What is the treatment for inhaling chlorine gas?

Treatment for Chlorine Gas Inhalation

Immediately remove the patient from exposure, provide humidified oxygen, and administer nebulized bronchodilators (salbutamol 5 mg or terbutaline 10 mg) combined with ipratropium bromide (500 µg) for symptomatic patients with dyspnea or bronchospasm. 1

Immediate Management

Scene Safety and Decontamination

• Remove the patient from the chlorine source immediately, as pre-hospital exposure cessation is the single most effective intervention for survival 2
• Ensure healthcare workers use acid-gas filters on air-purifying respirators when managing ongoing chlorine exposure, as these provide appropriate protection against chlorine gas 3
• Irrigate eyes thoroughly if conjunctival injection or chemical conjunctivitis is present 4

Oxygen Therapy

• Administer humidified oxygen for all patients with dyspnea or hypoxemia 1, 2
• Humidified oxygen has moderate quality evidence for effectiveness and should be started immediately 2

Bronchodilator Therapy

Standard Regimen

• Nebulize salbutamol 5 mg (or terbutaline 10 mg) combined with ipratropium bromide 500 µg for patients with bronchospasm or airway irritation 1
• This combination effectively reverses bronchoconstriction, airway irritation, and increased airway resistance in chlorine exposure 1
• Use air-driven nebulizers at 6-8 L/min flow rate, not oxygen-driven, unless the patient has documented hypoxemia requiring supplemental oxygen 3

Frequency

• Repeat nebulized treatments every 4-6 hours for mild-to-moderate exposures 5
• For severe bronchospasm, treatments may be repeated more frequently based on clinical response 1

Corticosteroid Administration

• Administer intravenous dexamethasone or prednisolone for moderate-to-severe exposures, particularly when pulmonary edema or significant airway inflammation is present 6, 1
• While corticosteroids are commonly used, evidence quality is low as they have not been studied in isolation; however, they are standard practice for severe exposures 1, 2
• Avoid routine prophylactic corticosteroids for mild exposures without significant respiratory symptoms 4

Sodium Bicarbonate Inhalation

• Consider nebulized sodium bicarbonate (typically 4% solution) as an adjunct therapy, though evidence is limited 1
• One randomized controlled trial showed sodium bicarbonate increased forced expiratory volume at 2 and 4 hours post-administration when added to standard therapy 1
• This remains controversial and should not replace standard bronchodilator therapy 4

Risk Stratification and Monitoring

Mild Exposure (Discharge within 6 hours)

• Presenting symptoms: cough, nausea, vomiting, conjunctival hyperemia only 5
• No specific treatment needed beyond symptomatic management or observation 5
• Pulse oximetry should be normal 4

Moderate Exposure (24-hour observation)

• Presenting symptoms: mild exposure symptoms plus dyspnea 5
• Requires humidified oxygen, bronchodilators, and close monitoring 5
• Obtain arterial blood gases if respiratory distress is present 4

Severe Exposure (Hospitalization required)

• Presenting symptoms: moderate exposure symptoms plus palpitations, weakness, chest tightness, or progressive respiratory distress 5, 6
• Monitor for development of acute respiratory distress syndrome (ARDS), toxic pneumonitis, or pulmonary edema 6, 4
• Obtain EKG and cardiac enzymes if retrosternal pain is present 4
• Perform chest x-ray only if pulmonary edema is suspected, not routinely 4

Airway Management

Indications for Advanced Airway

• Perform laryngoscopy if glottis edema or laryngospasm is suspected 4
• Intubate immediately for progressive respiratory distress, stridor, complete voice loss, inability to maintain airway patency, or SpO2 <90% on room air 7
• Prepare for difficult airway management, as caustic injury may distort anatomy 7

Mechanical Ventilation

• Use continuous positive airway pressure (CPAP) or high positive end-expiratory pressure (PEEP) if mechanical ventilation is required 4
• Consider prone positioning for severe ARDS 6
• In refractory severe ARDS, extracorporeal membrane oxygenation (ECMO) may be considered 4

Additional Therapies for Severe Cases

• Inhaled epoprostenol may be used for severe pulmonary edema or ARDS 6
• Sevoflurane has been reported in one case to decrease peak inspiratory pressure in intubated patients, though its specific role is unclear 1

What NOT to Do

• Do not administer prophylactic antibiotics unless there is documented secondary infection, as studies have failed to demonstrate benefit 1, 4
• Do not perform routine chest x-rays in asymptomatic or mildly symptomatic patients 4
• Do not use water for nebulization, as it may cause bronchoconstriction; use 0.9% sodium chloride instead 3

Prognosis

• Most patients with mild-to-moderate exposure recover fully with supportive care 5
• Even patients with severe ARDS and poor initial prognostic markers can make excellent recoveries with aggressive standard ARDS management 6
• Mortality is rare with appropriate early management 5