Chronic Asthma

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AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 29:209-2 14 (1 996)

Chronic Lung Disease Secondary to Ammonia Inhalation Injury: A Report on Three Cases Rafael E. de la Hoz, MD, MPH, Donald P. Schlueter, MD, and William N. Rom, MD, MPH Inhalation of highly hydrosoluble toxicants, like ammonia, can be associated with chronic lung diseases, which have been partially characterized. We present the cases of three patients who were evaluated 2 years after massive exposure to ammonia in occupational settings. They presented with chronic dyspnea, and clinical pictures consistent with restrictive lung dysfunction, obstructive lung disease, and bronchial hyper-reactivity and small airways disease, respectively. The findings in 94 reported cases of inhalation injury due to massive exposure to ammonia are reviewed; in 35 cases follow-up for at least 1 year was available. The range of chronic pulmonary diseases associated with ammonia inhalation injury is reviewed, and suggestions for appropriate diagnostic evaluation are made. 0 1996 Wilev-Liss, Inc.

KEY WORDS: ammonia, lung diseases, occupational diseases, asthma

INTRODUCTION
Overexposure to ammonia in the occupational setting can be associated with a range of anatomic and functional abnormalities of the respiratory tract that have been sporadically reported in the medical literature [Slot, 1938; Caplin, 1941; Brille et al., 1957; Lepine and Soucy, 1962; Derobert et a]., 1964; Levy et a]., 1964; Sestier et al., 1969; Kass et al., 1972; Walton, 1973; Sobonya, 1977; Close et al., 1980; Hoeffleret al., 1982; Flury et al., 1983; Bernstein and Bemstein, 1989; Leduc et al., 19921. In those who survive an acute episode, the injury to the respiratory tract can result in disabling chronic pulmonary disease. In this paper we describe the cases of three men who were all evaluated ap-

proximately 2 years after exposure to large amounts of ammonia in occupational settings. They all presented with complaints of persistent respiratory symptoms, which in some cases are known to elude f r characterization by im routine testing [Close et al., 1980; Walton, 19731. After describing their clinical presentation, we discuss the different diagnostic means available to assess the long-term anatomic and physiopathological consequences of inhalation injuries.

CASE REPORTS

Case 1
Mr. A was a 30-year-old Afro-American man who was referred for evaluation in June 1983, 2% years after his exposure to a high concentration of anhydrous ammonia gas at a transportation equipment factory where he worked as an engine testing operator. The gas leaked from a refrigeration system in a room next to the one where he was working. He immediately noted burning of his eyes, upper airways, and skin, as well as cough and pleuritic chest pain. He tried to assist another employee, and he estimated his exposure duration to be approximately 15 rnin. He was admitted to a local hospital, where he was noted to have conjunctivitis and rhinopharyngitis. The chest radiograph was normal, and the resting room air arterial blood gas revealed a pH of 7.39,

Department of Environmental Medicine, New York University School of Medicine and Chest Service and Occupational Medicine Clinic, Bellevue Hospital, New York (R.E.D.). Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee (D.P.S.). Departments of Medicine and Environmental Medicine; New York University School of Medicine, and Chest Service, Bellevue Hospital, New York (W.N.R.). Address reprint requests to Rafael E. de la Hoz,M.D.,Bellevue Hospital Center, Occup. Med. Clin.-Room CD349, First Avenue at 27th Street, New York, NY 10016. Accepted for publication March 19, 1995.

0 1996 Wiley-Liss, Inc.

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d e la Hoz et al.

TABLE I . Pulmonary Function Tests in Three Patients Exposed to High Concentrations of Ammonia Case no.
No. 1 No. 2
06/83 (27) 2.82 (73%) 3.66 (78%) 77% 4.32 (66%) 0.83 (45%) 19% 27.2 (90%) 7.34 49 84 26 08/89 (30)...
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