What is the management for a patient with vomiting and dry cough after inhaling fumes from mixing acid and bleaching powder?

Management of Acute Toxic Fume Inhalation from Acid-Bleach Mixture

This patient requires immediate oxygen supplementation, close monitoring for delayed pulmonary edema over the next 48-72 hours, and consideration of systemic corticosteroids given the high risk of developing acute respiratory distress syndrome (ARDS) from chlorine gas exposure. 1, 2, 3

Immediate Management (First 30 Minutes to 2 Hours)

Airway and Breathing Assessment

• Administer 100% oxygen immediately via non-rebreather mask or high-flow nasal cannula, regardless of current oxygen saturation, as toxic gas inhalation causes direct alveolar injury 1, 2
• Monitor for signs of upper airway edema (stridor, hoarseness, difficulty swallowing) which may necessitate early intubation before complete airway obstruction develops 2
• Assess respiratory rate, work of breathing, and oxygen saturation continuously for the first 2-4 hours 3

Bronchospasm Management

• Administer nebulized beta-2 agonists (albuterol 2.5-5mg) immediately for the dry cough and any wheezing, even if not clinically apparent on exam 2, 3
• Consider adding ipratropium bromide 0.5mg to the nebulizer treatment for additional bronchodilation 2
• Document peak expiratory flow rate (PEFR) before and 15 minutes after bronchodilator treatment—improvement <15% predicts worse outcomes 3

Corticosteroid Administration

• Initiate systemic corticosteroids early (hydrocortisone 200mg IV or prednisone 40-60mg orally) to prevent delayed toxic pulmonary edema that can develop 24-72 hours after exposure 1, 2
• The mixing of acid and bleach produces chlorine gas, which causes direct chemical injury to airways and alveoli, making corticosteroids a critical preventive measure despite limited controlled trial data 1, 3

Critical Monitoring Period (First 48-72 Hours)

Observation for Delayed Complications

• Admit for observation or arrange very close outpatient follow-up within 24 hours, as noncardiogenic pulmonary edema and ARDS can develop after a symptom-free interval lasting up to 48-72 hours 1, 2, 3
• The patient's single vomiting episode and dry cough are early warning signs—87% of patients in the largest case series improved, but 13% deteriorated with 2 developing ARDS and 1 death 3
• Obtain chest radiograph now and repeat at 24 hours even if initial film is normal, as radiographic changes lag behind clinical deterioration 4, 5

Risk Stratification

This patient has several concerning features predicting potential deterioration: 3

• Exposure in an enclosed space (bathroom/kitchen most common)
• Immediate symptom onset (vomiting, cough within 30 minutes)
• Young female (housewives represent the highest risk group for this specific exposure)

Symptomatic Treatment

Cough Management

• Prescribe codeine linctus 15-30mg every 4-6 hours or codeine phosphate tablets for distressing cough to suppress the irritant-induced cough reflex 6
• Avoid lying supine, which worsens cough—encourage semi-recumbent positioning 6
• Simple measures like humidified air and adequate hydration help thin secretions 7

Antiemetic Therapy

• Administer antiemetic (ondansetron 4-8mg IV/PO) for the vomiting, which may recur with coughing paroxysms 3

Disposition and Follow-Up

Admission Criteria

Admit to hospital if any of the following are present: 3, 5

• Oxygen saturation <92% on room air
• Respiratory rate >24 breaths/minute
• PEFR <70% predicted with <15% improvement after bronchodilators
• Abnormal chest radiograph
• Continued vomiting or inability to tolerate oral intake
• Advanced age or significant comorbidities

Outpatient Management (If Stable)

• Discharge only if oxygen saturation ≥95% on room air, normal respiratory rate, and patient can return within 2 hours if symptoms worsen 3
• Prescribe prednisone 40mg daily for 5-7 days to prevent delayed pulmonary edema 1, 2
• Continue albuterol inhaler (2 puffs every 4-6 hours as needed) for persistent cough or bronchospasm 2
• Mandatory follow-up within 24 hours with repeat clinical assessment and chest radiograph 3

Long-Term Considerations

Reactive Airways Dysfunction Syndrome (RADS)

• This patient is at risk for developing persistent asthma-like symptoms (RADS) that can last months to years after acute chlorine gas exposure 1, 3
• If cough persists beyond 2-3 weeks, initiate inhaled corticosteroids (fluticasone 250mcg twice daily) and continue bronchodilators 3
• Consider pulmonary function testing at 3 months to document any residual airflow obstruction or bronchial hyperreactivity 1, 3

Critical Pitfalls to Avoid

• Do not discharge without ensuring 24-hour follow-up capability—delayed ARDS can be fatal and develops after an initial asymptomatic period 2, 3, 5
• Do not withhold corticosteroids based on lack of definitive evidence—the risk of toxic pulmonary edema outweighs theoretical concerns about infection or delayed healing 1, 2
• Do not assume the patient is stable based on initial presentation—one case report documented severe respiratory distress requiring ICU admission and high-flow oxygen from household bleach alone 5
• Do not prescribe antibiotics unless secondary bacterial pneumonia develops (fever, purulent sputum, infiltrate on chest radiograph)—this is chemical pneumonitis, not infection 1, 4