Correspondence

Severe Lung Injury after Exposure to Chloramine Gas from Household Cleaners

N Engl J Med 1999; 341:848-849September 9, 1999

Article

To the Editor:

The inhalation of the noxious fumes associated with the mixing of household cleaners can lead to pulmonary irritation and pneumonitis. Household ammonia (3 to 10 percent aqueous NH₃) and bleach (5 percent NaOCl) are two of the most common cleaning agents. Combining them releases chloramine gas, which is a combination of monochloramines (NH₂Cl) and dichloramines (NHCl₂). When inhaled, chloramines react with the moisture of the respiratory tract to release ammonia (NH₃), hydrochloric acid (HCl), and oxygen free radicals. Typically, exposures to low concentrations of chloramines produce only mild respiratory tract irritation. In higher concentrations, the combination of hydrochloric acid, ammonia, and oxygen free radicals may cause corrosive effects and cellular injury, resulting in pneumonitis and edema.1-4

Emergency tracheostomy was required in a patient because of upper-airway compromise induced by chloramine gas. The patient, a previously healthy 53-year-old woman, was cleaning a walk-in freezer at her workplace with over-the-counter liquid ammonia and bleach. The door to the freezer was closed, and there was no air exchange with the outside. Approximately 30 minutes after beginning to clean, she noted shortness of breath and called 911. Over the next three hours, she had increased tightness of the throat and became unable to speak above a whisper. Despite aggressive use of nebulized albuterol, racepinephrine, and intravenous steroids, her symptoms progressively worsened. Rapid-sequence intubation was attempted but was unsuccessful because of swelling of the upper airway. Emergency tracheostomy was performed. The initial chest radiograph was unremarkable, but radiologic evidence of pneumonitis developed over the next four hours (Figure 1Figure 1Chest X-Ray Film Showing Changes Characteristic of Pneumonitis Four Hours after Exposure to Chloramine Gas from Household Cleaners.). At the time the second radiograph was obtained, the arterial-blood gas showed a pH of 7.23, partial pressure of carbon dioxide of 49 mm Hg, and partial pressure of oxygen of 102 mm Hg while the patient was breathing 100 percent oxygen with assisted ventilation. The patient received supportive care. Her tracheostomy was removed within five days, and she was discharged from the hospital within seven days.

Although it occurs infrequently, exposure to chloramine gas represents a substantial risk when household cleaners containing bleach and ammonia are mixed. As the course of our patient illustrates, upper-airway irritation can compromise the airway and require emergency tracheostomy.

David A. Tanen, M.D.
Kimberlie A. Graeme, M.D.
Robert Raschke, M.D.
Good Samaritan Regional Medical Center, Phoenix, AZ 85006

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Citing Articles (11)

Citing Articles

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   Paul D. Tourigny, Chris Hall. (2011) Diagnosis and Management of Environmental Thoracic Emergencies. Emergency Medicine Clinics of North America
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   Jan-Paul Zock, Estel Plana, Josep M. Antó, Geza Benke, Paul D. Blanc, Aurelia Carosso, Anna Dahlman-Höglund, Joachim Heinrich, Deborah Jarvis, Hans Kromhout, Linnéa Lillienberg, Maria C. Mirabelli, Dan Norbäck, Mario Olivieri, Michela Ponzio, Katja Radon, Argo Soon, Marc van Sprundel, Jordi Sunyer, Cecilie Svanes, Kjell Torén, Giuseppe Verlato, Simona Villani, Manolis Kogevinas. (2009) Domestic use of hypochlorite bleach, atopic sensitization, and respiratory symptoms in adults. Journal of Allergy and Clinical Immunology 124:4, 731-738.e1
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   A. A. Arif, P. C. Hughes, G. L. Delclos. (2008) Occupational exposures among domestic and industrial professional cleaners. Occupational Medicine 58:7, 458-463
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   A SAWALHA. (2007) Storage and utilization patterns of cleaning products in the home: Toxicity implications. Accident Analysis & Prevention 39:6, 1186-1191
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   Marc Nickmilder, Sylviane Carbonnelle, Alfred Bernard. (2007) House cleaning with chlorine bleach and the risks of allergic and respiratory diseases in children. Pediatric Allergy and Immunology 18:1, 27-35
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   Kenneth D. Rosenman. (2006) Cleaning Products-Related Asthma. Clinical Pulmonary Medicine 13:4, 221-228
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   Raghuraman Venkatapathy, June Weintraub, J. Michael Wright. 2005. Disinfectants. .
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   Kirsten P. Ernst, Wendy A. Wattigney, Wendy E. Kaye. (2005) Releases From Improper Chemical Mixing, Hazardous Substances Emergency Events Surveillance System, 1996???2001. Journal of Occupational and Environmental Medicine 47:3, 287-293
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   William W. Nazaroff, Charles J. Weschler. (2004) Cleaning products and air fresheners: exposure to primary and secondary air pollutants. Atmospheric Environment 38:18, 2841-2865
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    M. Giroux, F. Brémont, J.P. Salles, E. Rey, J.P. Della Massa, J. Ferrières. (2002) Exhaled NH3 and excreted NH4+ in children in unpolluted or urban environments. Environment International 28:3, 197-202
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    Sylviane Carbonnelle, Marc Francaux, Ian Doyle, Xavier Dumont, Claire de Burbure, Georges Morel, Olivier Michel, Alfred Bernard. (2002) Changes in serum pneumoproteins caused by short-term exposures to nitrogen trichloride in indoor chlorinated swimming pools. Biomarkers 7:6, 464-478
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