Pulmonary Agent Treatment

Chlorine exposures may lead to copious secretions and laryngospasm shortly following exposure, therefore providers should be prepared for airway management and possibly emergent surgical airway control. It is important to remember that phosgene-exposed patients, despite being asymptomatic, need to be treated as casualties.  Such casualties should be kept at rest, as exertion is associated with pulmonary edema and worse outcomes in phosgene-exposed patients.  If an advanced airway is placed, a large-bore endotracheal tube will facilitate pulmonary toilet as toxic gas exposures can cause sloughing of mucosa and clogging of the airway with debris.

Intravenous fluids may be necessary in the setting of volume depletion, but should not be given empirically.  Fluid overload can contribute to pulmonary edema and should be avoided. Laryngoscopy and/or bronchoscopy may be necessary, and preparations for advanced airway management must be in place should airway compromise occur.  Portable ventilators with simplified automated setting (e.g. SAVe ventilators) may not be adequate for ventilation management in these patients.  Because of the associated pulmonary edema, bronchospasm, and risk of ARDS, the ability to manipulate ventilator settings is crucial. Additionally, suction is a key component of maintaining patent airways, bulb suction is unlikely to be adequate and mechanical suction with the ability to do inline suction is preferred.

Advanced interventions and the supporting evidence is described in the table below.  Much of the available evidence is based upon animal studies and human data is limited.