Document RpKRbzOdgwxGZe3w5MGgVMoa

jj$vr ' '/7< . .'-VY, ;i M I*"..,*''- 1 * m,i.- - m.\s V; :* y\\ ^ a>. Polyvinyl Chloride Toxicity in Fires r ; : V^ Hydrogen Chloride Toxicity,.In Fire Fighters' . : ?> ;. ,, ... v; j.Jl' v Robert F. Dyer, MD, VictorH. Esch.MO JJVJ-, Ewfys-Myvlnyl chloride, ol all the plastic polymers, has been Implicated prl- In causing the most ser.ous problem In fire fighting today because It jllsair*' hydrogen chloride .gas when burning. One hundred seventy fire - Ugh**** wh0 experienced symptoms from Its toxicity have been studied from ^tnto 1975, One died. .. .j ^{iUU 235:393-397, 1878) VV:! REPORT OF A CASE Approximately 24 hour* after 0 fire, a > ' 33-year-old fire fighter fainted in the sit- -' ting room of the truck company. Iteraa - also reported that he had a muscle spasm . similar to an epileptic seizure, but recov-. ered. was fully conscious, nnd got up im f-Jt RECENTLY identified hazard that ipjirf paramount importance to prac- aViiemg physicians is that of chemical ff''jqjury incurred by persons exposed to mediately. Hie superior officer aakod how. the smoke was so excessive as to pre- - he felt, and he replied that he was "fine" vent entry without masks. The fire, ' - and walked into, the kitchen. Following which was confined to an office copy lunch, the acting sergeant on duty looked ing machine constructed of plastic . for the man to check his condition for dnv- from fires. Specifically, such in- ~ ` and Teflon parts, was quickly extin . ing and found him lying on the floor next injuries are caused by the inhalation of created by the thermal degra- Ej dslien of polyvinyl chloride, a plastic . ^^tyreer, Such substances have now famine widely used in the construc- . Saa alto p 390. , fr-r-------------------------------------- ,iihB #f homes, furnishings, office vsqatpaent, electric wire, telephone ijlfij able covering, and vehicles. A pr'jerlfcular hazard exists in the case of fire fighter, although it could be ' ;Jaquafiy serious in any circumstance in |,'Tkidi an individual might be exposed .'tosueh plastic combustion products. THE FIRE l.'At 10:30 am on Jan 6.1970, an alarm guished. \ . The fire companies entered `the building via the elevator, placed aev-. era! portable fans for ventilation, and left the building about 20 minutes later. On returning to their quarters, many of the fire fighters experienced unusual and unexplainable symp toms, including a constricting tight ness localized to the anterior part of the chest. This chest discomfort was described as a searing, burning sensa tion accompanied by dyspnea as well as a "hunting sensation appearing to close off the throat." These symptoms were in addition to the usual head ache, dizziness or vertigo, and nausea, which, in our experience, is fre , to his bed. He was cyanotic and, deaprte aU ' reauscitotive efforts by an ambulance crew ` and the rescue squad, waa pronounced .dead on irrival by a Are surgeon at the George Washington University Hospital nt 1:10 PM. Postmortem examination by the i .District of Columbia Department of Public Health Medical Examiner ihowed severe ' pulmonary hemorrhage and edema due to chemical pneumonitis secondary to expo sure to chemical' smoke and fire. The pathologist : also - reported - eoronary. atherosclerosis. . EFFECT OF FUMES It has been suspected for several', year* that the smoke and fumes from electrical fires produced greater in jury now than similar fires in the ' ^.minded for a fire reported to be on ^tteaixtb floor of Building 213 at the quently seen in cases of nonchemical smoke inhalation. Some symptoms past." It was strongly suspected that hydrogen chloride released by ther- VjWlulhington, DC, Navy Yard. Units persisted over a course of several mal degradation of PVC, a common 'ef the District of Columbia Fire De* days following exposure to the fumes. electrical wiring insulation material, iyjfaltalent arriving on the scene found The dyspnea was noted on mild exer was the lethal product causing death ijfc floor filled with a heavy concen- tion and was associated with moder in this instance. The medical exam Mftf toxic fumes. Although all of ate apprehension by all of the af iner's report and the microscopic 'y.m ire fighters carried masks, none f gw used. since neither the fire nor fected fire fighters. A number of the fire fighters exposed at this fire exj>erienced severe conjunctivitis, lacrima- findings subsequently confirmed our original. clinical impreasion ,of the cause of death. th* Pole* *ni3 Fif*m*ni Clinic, Wash* . .] CC to Chairman of th Board of a***. Suita 1445. Chevy Chase Bldfl, 5530 NW. Washington, DC 20015 (Dr tion, and dyspnea persisting for 24 hours after the fire. An intense head ache, localized anteriorly and persist ing about 24 hours, was also common. Hydrogen chloride, inhaled either. in the gaseous state or combined with . water vapor, acts as an irritant to the mucous membranes of the eyes and 26 1976-Vol 235, No 4 * jy&- Polyvinyl Chloride--Dyer a Esch 393 *1WllWqw l -- ................. ---- ucc 008728 iD Table 2. In the group of firemen,' spirometric val ues were normal in all but four subjects (firemen 2,9, 11, and 18) who had mild to moderate abnormalities in FEF25-752; in addition, fireman 11 also had a slight reduction in FEVi. The Caw/VL was moder ately reduced in two of these four firemen and mild ly reduced in two additional subjects. Single-breath nitrogen washout was normal in all subjects, whereas CV was abnormally increased in two subjects, nei ther of whom demonstrated spirometric abnormali ties but both of whom were currently cigarette smok ers. Two of the subjects with abnormal spirometric values were heavy smokers who had worked 5 and 12 years as firemen; the other two subjects were only occasional cigarette smoker but had served as fire men for 14 and 28 years. The fireman who com plained of a chronic nonproductive cough and the fireman who complained of definite wheezing both had significant reductions in FEF25-75S and Caw/ Vl Comparing the results of studies of pulmonary function in the firemen with those obtained in the computer-matched sample of individuals residing in the same area, spirometric and plethysmographic indices and single-breath nitrogen washout were comparable in the two groups, but CV was signifi cantly lower in the firemen than their matched con trols (P < 0.05); however, the latter difference may not be real since values for CV obtained in the lab oratory at the University of California, Los Angeles, were poorly correlated with those obtained in the field laboratory on the population from which the matched sample was drawn (r " 0.06). There was no apparent relationship between the degree of hypoxemia which developed following an episode of smoke inhalation one month previously* and the presence or absence of chronic cough, pro duction of sputum, wheezing, or abnormalities od pulmonary function testing. Discussion Comparison of symptoms elicited by a standard ized questionnaire from the present small group of firemen who had a mean of 16 years (range, 2 to 33 years) of exposure to fighting fires with those obtained in a group of healthy nonfiremen residing in Los Angeles matched for race, height, age, sex, and smoking history revealed the same frequency of respiratory symptoms among the nonfiremen. More over, results of tests of pulmonary function, includ ing FEF23-75S and CV, which are considered rel atively sensitive indicators of early obstructive air way disease,1*'50 were no worse in the firemen, com pared with their matches. These findings suggest that, at least in the small sample evaluated, fighting ' fires did not lead to clinically apparent respirat ,'.scase or functional respiratory impairment. Tw ly of the 21 firemen studied had normal values FEVi, and 17 of the 21 had statistically normal vnl for FEF25-75S, based on published predicted vale It is of interest that all four firemen with nbnon values for FEF25-752 were cigarette smokers, sgesting that smoking is an important contributor pulmonary abnormalities noted in firemen, as a suggested by previous studies.1"* The paucity of respiratory symptoms and abm malities of pulmonary function noted in this gro. of firemen is surprising for two reasons. First, the firemen were selected for study because one moi. earlier, they had developed significant liypoxerr (arterial oxygen pressure [PaOi], 71 13 mm 1 [SD]), despite hyperventilation (PaO- 31 4 ti. Hg), following exposure to the combusted prodm of polyvinylchloride.* Secondly, our findings are variance with the results of a questionnaire a studies of pulmonary function performed in Bos'. firemen,1"* which suggested that fighting fires ct tributed to the development of chronic pulmona. disease. The discrepancy between the findings in th present group of firemen and those reported f< Boston firemen could be related to the small size o our sample, which may not be representative of LoAngeles firemen as a whole, to geographic differ ences, to ethnic differences,51 or to the difference; between the prevalence of current cigarette smoking in the Los Angeles and Boston firemen (33 percent vs 48 percent, respectively). Since more than half of our sample of Los Angeles firemen had more than tea years of experience fighting fires, it is not likely that ' the minimal respiratory symptoms which we noted ' were due lo an insufficient length of exposure for the clinical exhibition of respiratory disease. These findings in an admittedly small sample of Los Angeles firemen suggest that fighting fires may result in discrete episodes of bronchopulmonary in jury secondary to repeated bouts of inhalation of dense smoke without resulting in sustained function al impairment or chronic respiratory symptoms. Our data do not support the hypothesis that the occupa tion of fighting fires poses a significant risk for (ho ' development of chronic obstructive pulmonary dis ease and are in agreement with recent findings of a three-year follow-up study of Boston firemen;4 how ever, longitudinal studies of respiratory symptoms and pulmonary function in a representative and much larger sample of firemen and a suitably matched group of nonfiremen are required to answer the question of whether or not fighting fires in itself contributes to the development of chronic pulmo nary disease. 448 TASHKIN ET AL CHEST, 71; 4, APRIL, lW UCC 008729 *CKN0WLEDCMENT: We are grateful for the invaluable ^itince of tlie Loi Angeles Fire Department in the conduc* pm of this study. References I Sidor R, Peters JM: Prevalence rates of cltronie non-spe cific respiratory disease in firefighters. Am Rev Respir Dis J09:255-261,1974 i Sidor R, Peters JM: Firefighting and pulmonary function. Am Rev Respir Dis 109:249-254,1974 3 Peters JM, Theriault CP, Fine LJ. et ah Chronic effect of fire fighting on pulmonary function. N Engl J Med 291: 1320-1322,1974 4 Musk AW, Peters JM: Firefighting end pulmonary func tion: A three-year follow-up. Am Rev Respir Dis 113:99, 1976 (abstract) 3 Cuthrie LC: Los Angeles Firemen Cardiovascular Dis ease Survey. Los Angeles, American Heart Association, Creater Los Angeles Affiliate, 1970 6 Ccnovesi MC, Tashkin DP, Chopra S, et al: Transient hypoxemia in firemen following inhalation of smoke. Chest 71:441-444, 1977 7 Medical Research Council's Committee on the Aetiology of Chronic Bronchitis: Standardized questionnaire On res piratory symptoms. Br Med J 2:1665,1960 t Dubois AB, Botelho SY, Cotnroe JH Jr: A new method for measuring airway resistance in man using a body plethystnograph; Values in normal subjects and in pa tients with respiratory disease. J Clin Invest 35:327-335, 1950 9 Dubois AB, Botelho SY, Bedell CN, et al: A rapid plethysmogntphic method for measuring, thoracic gas volume. J Clin Invest 35:322,1956 10 Anthonisen NR, Danson J, Robertson PC, et al: Airway closure as a function of age. Respir Physiol 8:58-65, 1969-70 ' 11 Ogilvie CM, Forster RE, Blakemore WS, et al: A stan dardized breath holding technique for the clinical mea surement of the diffusing capacity of the lung for carbon monoxide. J Clin Invest 36:1-17,1957 12 Morris JF, Koski A, Johnson LC: Spirometric standards for healthy non-smoking adults. Am Rev Respir Dis 103: 57-67,1971 13 Berglund E, Birath C, Bjure J, et al: Spirometric studies in normal subjects: 1. Forced spirograms in subjects be tween 7 end 70 yean of age. Acta Med Scand 173:185- 192,1963 14 Kory RC, Callahan R, Boren HG, et al: The Veterans Administration-Army cooperative study of pulmonary function: 1. Clinical spirometry in normal men. Am J Med 30:243-258,1961 15 Cote, JE: Lung Function. Philadelphia, FA Davis Co, 1965 16 Fowler WS: Lung function studies; 3. Uneven pulmonary ventilation in normal subjects and in patients with pul monary disease. J Appl Physiol 2:283-295,1949 17 Buist AS, Ross BB: Predicted values for dosing volumes using a modified single breath nitrogen test- Am Rev Respir Dis 107:744-752,1973 18 Detels R, Coulson A, Tashkin DP, et al: Reliability of plethysmography, the single breath oxygen test, and spi rometry in population studies. Bull Physiopathol Respir 11:9-30,1975 19 McFadden ER Jr, Linden DA: A reduction in maximum mid-expiratory flow rate: A spirographic manifestation of small airway disease. Am J Med 52:723-737,1972 20 McCarthy DS, Spencer R, Greene R, et al: Measurement of "dosing volume" as a simple end sensitive test for early detection of small airway disease. Am J Med 52:747-753, 1972 21 Sidor R, Peters JM; Differences in ventilatory capacities of Irish and Italian firefighters. Am Rev Respir Dis 108: 669-671,1973 A NOTE OF APPRECIATION Space nt the end of articles has frequently been used for the inclusion of "filler material." We have been for tunate to have had the skillful and dedicated partiripalion of Dr. Andrew L. Banyai in the last decade cir-n-cis such material. Dr. Banyai, a distinguished teacher, is Uo a noted bibliophile and has shared with us a variety of his own interests in medicine, history and the arts. We wish to express via this "filler" our gratitude to Dr. Banyai for the many pages of Chest his comments have graced. Alfred Soffer, M.D. EllitOr-iii-Chief CHFRT 71. A soon 1077 RESPIRATORY STATUS OF LOS ANGELES FIREMEN 449 UCC 008730