The Role of Bronchoscopy in Pulmonary Complications due to Mustard Gas Inhalation

doi:10.1378/chest.100.5.1436

Chest

Volume 100, Issue 5, November 1991, Pages 1436-1441

https://doi.org/10.1378/chest.100.5.1436 Get rights and content

Over the last five years we have repetitively treated a group of 21 Iranian soldiers who developed pulmonary complications as a result of severe inhalation injury due to mustard gas during the Iran-Iraq war. Early respiratory manifestations included hemorrhagic inflammation of the tracheobronchial tree accompanied by severe erosions. Secondary complications consisted of chronic infections, suppurative bronchitis, and extensive stenotic process of the entire tracheobronchial tree with life-threatening sequelae. After a delay of up to 15 months, scars, ulcers, and strictures developed in the central airways. Progressive deterioration of gas exchange was common. At this point, bronchoscopy, both diagnostic and therapeutic, was invaluable in evaluating the conditions in these patients since many required multiple therapeutic bronchoscopies. Repeated bougienage of the stenotic tracheobronchial lesions and laser photoresection of scarring tissue was life-saving. The recurrence rate of stenosis was very high, with intervals of less than six months on the average. One pneumonectomy was necessary, with the excised lung showing bronchiectasis and chronic pneumonia. To this date we have performed 146 therapeutic bronchoscopies. In four patients, silicone stents had to be implanted. One patient received brachytherapy and external beam radiation therapy in an effort to prevent continued scarring and life-threatening stenoses of the tracheobronchial tree. Our experience demonstrates the extreme usefulness of bronchoscopy in the diagnosis and treatment of pulmonary complications due to inhalation of poisonous gases.

Section snippets

Clinical Features

Several agents might have been used because recently we have seen patients with different symptoms suggestive of involvement of peripheral airways only. According to the reports, many soldiers died immediately on the battle field, probably due to acute chemical-induced pulmonary edema. Besides respiratory problems,^1,² the mustard gas damages multiple organs by local and systemic effects.^3,⁴ Eye and skin burns are severe and require long healing periods.^5,⁶ Many men have become infertile and

Treatment

Initial treatment included various types of physiotherapy, including postural drainage and chest percussion.^9,¹⁰ Therapeutic lavages with isotonic sodium solution via fiberbronchoscopes were frequently performed, sometimes supported by internal airway-vibrations.¹¹ These measures usually improved the gas exchange, but only for limited periods. The administration of antibiotics and systemic corticosteroids seemed to have little success in preventing the next stage of the disease.

Scars and

Discussion

The history of chemical weapons can be traced back to ancient times. According to Thukydides, smoke of sulfur-impregnated wood was used by Spartan soldiers during the Peloponnesian War to drive the enemies out of their field fortifications. The fall of Delion in 424 BC has been attributed to the use of smoke-conducting hollow tree trunks. Over the centuries, a countless number of scientists has collaborated to create more effective chemical weapons. In 763 BC, Callinicus divulged the recipe of

Acknowledgment

We thank our skilled nursing staff, our colleagues from the Department of Anesthesiology, and Professor Hartung, Pathological Institute, Bochum, FRG, for preparation of the slice of the excised lung.

REFERENCES (26)

WadaS et al.
Mustard gas as a cause of respiratory neoplasms in man.
Lancet
(1968)
CarlinBW et al.
The treatment of endobronchial stenosis using balloon catheter dilatation.
Chest
(1988)
DumonJF et al.
Treatment of tracheobronchial lesions by laser photoresection.
Chest
(1982)
CavaliereS et al.
Nd:YAG Bronchoscopy: a five-year experience with 1,396 applications in 1,000 patients.
Chest
(1988)
CooperJD et al.
Use of silicone stents in the management of airway problems.
Ann Thorac Surg
(1989)
DumonJF.
A dedicated tracheobronchial stent.
Chest
(1990)
OrlowskiTM.
Palliative intubation of the tracheobronchial tree.
J Thorac Cardiovasc Surg
(1987)
WinternitzW.
Chronic lesions of the respiratory tract initiated by inhalation of irritant gases.
JAMA
(1919)
SohrabpourH et al.
Late complications of sulfur mustard in respiratory system.
Med J Islamic Rep Iran
(1988)
SomaniSM et al.
Toxicodynamics of sulfur mustard.
Int J Clin Pharmacol Ther Toxicol
(1989)

SohrabpourH.

Observation and clinical manifestation of patients injured with mustard gas.

Med J Islamic Rep Iran

(1987)

DörffelI et al.

Veränderungen der Haut nach Ätzung mit Dichloräthyldisulfid.

Virchows Arch

(1935)

NeameN.

Late results after mustard gas burn of the eyes.

Proc R Soc Med

(1928)

Cited by (78)

Chemical Agents in Disaster: Care and Management in the Intensive Care Unit
2019, Critical Care Clinics
Evaluation of bronchiectasis in war chemically-injured patients via high resolution computed tomography
2017, Egyptian Journal of Radiology and Nuclear Medicine
Sulfur mustard (SM) gas as a vesicant chemical warfare was used in the Iran-Iraq war (1981–1989) against the Iranian warriors.
This alkylating agent with the potential of producing chemical injury in the skin, eyes and lung, may damage both upper and lower respiratory tract, which in turn can cause different types of sequels such as asthma, bronchiectasis, chronic bronchitis and lung fibrosis.
This study was performed on 274 patients with documented history of SM gas exposure. All of the participants complained of respiratory problems. Patients with positive history of cigarette smoking, respiratory problems before the exposure to SM gas, cardiovascular problems, surgery of the lung, and exposure to occupational toxic chemicals were excluded from the study. Results of all chest HRCTs were evaluated by a radiologist.
HRCT findings showed that bronchiectasis involved 53 patients (19.34%) of all cases. Varicose bronchiectasis and cystic bronchiectasis was observed in 10 (18.9%) and 6 cases (11.3%) respectively. Among patients with bronchiectasis, the involvement rate of different lobes was as follows: Right upper lobe (RUL) 7.5%, right middle lobe (RML) 11.3%, left upper lobe (LUL) 15.1%, left lower lobe (LLL) 26.4% and right lower lobe (RLL) 39.6%.
Findings of chest HRCT demonstrated tubular bronchiectasis was the most frequent type of this disease that involve the chemically injured patients and RLL had been the most frequently involved lobe of the lung with bronchiectasis.
Mustard Lung: Diagnosis and Treatment of Respiratory Disorders in Sulfur-Mustard Injured Patients
2016, Mustard Lung: Diagnosis and Treatment of Respiratory Disorders in Sulfur-Mustard Injured Patients
Iraq-Iran chemical war: Calendar, mortality and morbidity
2014, Chinese Journal of Traumatology - English Edition
Objectives To review the calendar, mortality and morbidity of Iraq-Iran chemical war among Iranians based on researchers’ reports.
We used national and international databanks such as PubMed, ISI, Scopus, Irandoc and Iranmedex and studied 350 articles related to chemical agents and their effects on different organs. The main criteria for qualification of articles were relevancy orientation and being published in approved medical journals.
The Iraqi army invaded to west and southwest Iran using chemical weapons such as nerve agents (NAs) and sulfur mustard (SM). Most victims were civilians including women and children. These attacks had imposed more than 150 types of diseases and complications on Iranians and the frequency of death was 2%-3%. Most reports were about respiratory problems and a few were in the domain of socio-economic damages.
At present, 25 years after the end of war, the victims are faced with different complications induced by chemical agents and it is estimated that they will be continuously troubled by these problems in future.
Endoscopic treatment of tracheal stenosis
2014, Thoracic Surgery Clinics
Citation Excerpt :
With less elastin and more collagen, stenoses become rigid and cannot be passed with flexible instruments. The most serious mucosal damage we have seen was in patients who had inhaled mustard gas.19 However, any injury, whether physical or chemical, can result in severe airway narrowing.
Historical perspective on effects and treatment of sulfur mustard injuries
2013, Chemico-Biological Interactions
Citation Excerpt :
If upper airway obstruction from laryngospasm is suspected (stridor, hoarseness), early tracheostomy is also warranted [13]. Bronchoscopy with lavage of isotonic saline may also be beneficial in the early stages of respiratory management of SM-inhalation injury to remove tracheobronchial debris that accumulates from necrosis and sloughing of membranous tissue [70,71]. Mucolytics such as N-acetyl-cysteine may also benefit patients where secretions are difficult to remove because of decreased ciliary function or increased thickness of secretions [8,72].
Sulfur mustard (2,2′-dichlorodiethyl sulfide; SM) is a potent vesicating chemical warfare agent that poses a continuing threat to both military and civilian populations. Significant SM injuries can take several months to heal, necessitate lengthy hospitalizations, and result in long-term complications affecting the skin, eyes, and lungs. This report summarizes initial and ongoing (chronic) clinical findings from SM casualties from the Iran–Iraq War (1980–1988), with an emphasis on cutaneous injury. In addition, we describe the cutaneous manifestations and treatment of several men recently and accidentally exposed to SM in the United States.
Common, chronic cutaneous problems being reported in the Iranian casualties include pruritis (the primary complaint), burning, pain, redness, desquamation, hyperpigmentation, hypopigmentation, erythematous papular rash, xerosis, multiple cherry angiomas, atrophy, dermal scarring, hypertrophy, and sensitivity to mechanical injury with recurrent blistering and ulceration. Chronic ocular problems include keratitis, photophobia, persistent tearing, sensation of foreign body, corneal thinning and ulceration, vasculitis of the cornea and conjunctiva, and limbal stem cell deficiency. Chronic pulmonary problems include decreases in lung function, bronchitis with hyper-reactive airways, bronchiolitis, bronchiectasis, stenosis of the trachea and other large airways, emphysema, pulmonary fibrosis, decreased total lung capacity, and increased incidences of lung cancer, pulmonary infections, and tuberculosis.
There are currently no standardized or optimized methods of casualty management; current treatment strategy consists of symptomatic management and is designed to relieve symptoms, prevent infections, and promote healing. New strategies are needed to provide for optimal and rapid healing, with the goals of (a) returning damaged tissue to optimal appearance and normal function in the shortest period of time, and (b) ameliorating chronic effects. Further experimental research and clinical trials will be needed to prevent or mitigate the acute clinical effects of SM exposure and to reduce or eliminate the long-term manifestations.

View all citing articles on Scopus

View full text

Chest

BronchoscopyThe Role of Bronchoscopy in Pulmonary Complications due to Mustard Gas Inhalation

Section snippets

Clinical Features

Treatment

Discussion

Acknowledgment

Lancet

Chest

Chest

Chest

Ann Thorac Surg

Chest

J Thorac Cardiovasc Surg

Chronic lesions of the respiratory tract initiated by inhalation of irritant gases.

JAMA

Late complications of sulfur mustard in respiratory system.

Med J Islamic Rep Iran

Toxicodynamics of sulfur mustard.

Int J Clin Pharmacol Ther Toxicol

Observation and clinical manifestation of patients injured with mustard gas.

Med J Islamic Rep Iran

Veränderungen der Haut nach Ätzung mit Dichloräthyldisulfid.

Virchows Arch

Late results after mustard gas burn of the eyes.

Proc R Soc Med

Bronchoscopy
The Role of Bronchoscopy in Pulmonary Complications due to Mustard Gas Inhalation