Stratify chlorine toxic patients into no symptoms, mild, moderate and severe. Treatment and observation periods can be tailored based on the severity of symptoms.

1. No symptoms. If no symptoms, then may be discharged if initial assessment (respiratory examination, vital signs, and pulse oximetry) is normal.
2. Mild (minimal symptoms, coughing, normal pulse oximetry, and no increased respiratory effort). Obtain chest radiograph, administer inhaled beta agonists, and observe for up to 6 hours. Most patients can be discharged.
3. Moderate (hypoxia, increased respiratory effort, normal chest radiograph) - Obtain chest radiograph, administer beta agonists, and admit for at least 12 hours. Consider inhaled steroids (fluticasone 200 mcg or similar agent) twice a day, early endotracheal intubation for increased respiratory effort, and inhaled ipratropium.
4. Severe (hypoxia, respiratory distress, often require intubation). Perform early endotracheal intubation with 8.0 tube to allow for bronchoscopy, obtain chest radiograph, administer beta agonists, and admit to ICU. Administer humidified oxygen and inhaled steroids (fluticasone 200 mcg or similar agent) twice a day. Consider inhaled ipratropium if not improving. If unable to administer inhaled steroids or if patient has significant bronchoconstriction consider intravenous steroids.

ARDS. Perform similar ventilation strategies for ARDS, including increased PEEP and low tidal volumes. Evaluate daily for barotrauma. The patient may require high doses of sedatives to maintain synchrony with the ventilator.

Important caveats

A patient who is close to a large, dense chlorine exposure (IED detonated chlorine tank) or suffers a sustained exposure (unconscious in a chlorine filled room) may develop upper airway edema. In these cases, perform early intubation. Examine all exposed patients for eye, mucosal, and skin contamination which is manifested by corneal burns/abrasions, mucosal swelling, and skin erythema, blister, or burns. Decontaminate all symptomatic skin surfaces. Remove all exposed clothing. The trauma evaluation and treatment takes priority over the chlorine toxicity. Nebulized bicarbonate has not been reliably effective. It is made by mixing 1 ml of 8.5% sodium bicarbonate in 3 ml saline to create a 2% solution.

Post discharge follow-up

If available, obtain pulmonary function tests with lung volume assessment and DLCO. If the PFT is abnormal, obtain high resolution pulmonary CT scan to assess or pulmonary fibrosis.

Background and clinical effects

Chlorine is a gas with intermediate water solubility. It will induce mild irritant symptoms (tearing, pungent smell, upper airway irritation), but will also induce delayed pulmonary edema following a dense or sustained exposure. Chlorine dissolution into lung water generates hydrochloric acid and hypochlorous acid. The hypochlorous acid decomposes to HCl and nascent oxygen (O-). The nascent O- produces additional lung damage by free-radical formation. Chlorine was used in World War I as a chemical warfare agent.

- Early effects. Irritation of the eyes, nasal mucosa, upper airway, coughing, shortness of breath, and chest pain or burning
- Late effects. Pulmonary congestion and edema and then ARDS.