What is the appropriate management for acute inhalation of sodium‑hypochlorite vapour causing chemical respiratory irritation?

Management of Acute Bleach Fume Inhalation

Immediately remove the patient from exposure, administer humidified oxygen to maintain SpO2 >92%, and give nebulized bronchodilators (salbutamol 2.5-5 mg) for symptomatic respiratory distress. 1, 2

Immediate Decontamination and Supportive Care

• Remove the patient from the exposure source immediately and ensure fresh air ventilation to prevent ongoing inhalation injury 1, 2
• Administer warmed humidified oxygen to all symptomatic patients, targeting oxygen saturation >92% 2
• Do not attempt chemical decontamination of the airway - copious water irrigation is only appropriate for intact skin and soft tissues, and is contraindicated for respiratory tract exposure 3

Bronchodilator Therapy

• Administer nebulized salbutamol 2.5-5 mg (or terbutaline 5-10 mg) immediately for patients with cough, dyspnea, wheezing, or reduced peak expiratory flow 2
• Use compressed air (not oxygen) to drive the nebulizer at 6-8 L/min unless the patient is hypoxic, in which case oxygen-driven nebulization is appropriate 4, 5
• Repeat bronchodilator treatments as needed - only 38% of bleach inhalation patients show significant reversibility (≥15% PEFR improvement) after initial treatment, so multiple doses may be required 1

Corticosteroid Administration

• Add inhaled budesonide via nebulizer for symptomatic patients with persistent cough, dyspnea, or abnormal pulmonary function (FVC or PEF <80% predicted) 2
• Consider systemic corticosteroids (prednisolone 30-40 mg orally) for patients with severe respiratory distress, though evidence for efficacy in chemical pneumonitis remains limited 6

Adjunctive Therapy: Nebulized Sodium Bicarbonate

• Nebulized sodium bicarbonate may be beneficial as an adjunctive treatment for symptomatic patients, particularly when chlorine gas is the primary irritant (as occurs when bleach mixes with acids) 2
• This represents an emerging treatment approach with limited but promising clinical experience in mass casualty chlorine exposures 2

Objective Assessment and Monitoring

• Measure peak expiratory flow rate (PEFR) or spirometry (FEV1, FVC) at presentation to objectively assess airway obstruction severity 1
• Monitor oxygen saturation continuously - severe cases can present with SpO2 as low as 75% 7
• Assess for high-risk features including advanced age, initial low PEFR, exposure in small enclosed spaces, and prolonged exposure duration - these predict worse outcomes 1

Disposition Decisions

Hospitalize patients with:

• Persistent hypoxemia requiring supplemental oxygen 7, 8
• Severe respiratory distress or inability to maintain adequate oxygenation 7
• PEFR or FVC <80% predicted despite bronchodilator therapy 1
• Exposure in small enclosed spaces with prolonged duration 1

Discharge patients who:

• Achieve normal oxygen saturation on room air
• Show improvement in respiratory symptoms and pulmonary function after treatment
• Have reliable follow-up arrangements 1

Critical Monitoring for Complications

• Watch for delayed pulmonary edema developing hours after exposure - this can progress to ARDS requiring mechanical ventilation 6, 7, 8
• ARDS can develop rapidly (within 24-48 hours) and may require ICU admission with high-flow oxygen or mechanical ventilation 7, 8
• Mortality risk exists - one death has been reported in a series of 55 patients, with ARDS developing in 2 patients (13% deterioration rate) 1

Long-Term Sequelae and Follow-Up

• Arrange follow-up within 1-2 weeks to assess for reactive airways dysfunction syndrome (RADS), which can persist for months after acute exposure 1, 6
• RADS occurs in the majority of symptomatic bleach inhalation patients and manifests as persistent asthma-like symptoms with airway hyperreactivity 1, 6
• Other potential long-term complications include chronic airflow obstruction, bronchiolitis obliterans, and bronchiectasis, though most patients recover fully 6

Common Pitfalls to Avoid

• Never use water for nebulization as it may cause bronchoconstriction 4
• Do not dismiss patients with normal lung examination - absence of wheezing does not exclude significant airway injury 5
• Do not underestimate household bleach exposure - severe chemical pneumonitis and ARDS can occur from bleach alone, even without mixing with other chemicals 7
• Recognize that initial bronchodilator response is often poor (only 38% show significant reversibility), so lack of immediate improvement should not delay additional supportive care 1