J Korean Med Sci.  2016 Dec;31(12):1857-1862. 10.3346/jkms.2016.31.12.1857.

Inhalation Lung Injury Associated with Humidifier Disinfectants in Adults

• Huh JW
• Hong SB
• Do KH
• Koo HJ
• Jang SJ
• Lee MS
• Paek D
• Park DU
• Lim CM
• Koh Y

• KMID: 2355611
• DOI: http://doi.org/10.3346/jkms.2016.31.12.1857

Abstract

We recently established a novel disease entity presented as progressive respiratory failure associated with the inhalation of humidifier disinfectants. In April 2011, we encountered a series of peripartum patients with complaints of respiratory distress of unknown etiology, which was an uncommon phenomenon. Accordingly, we created a multidisciplinary team comprising intensivists, radiologists, pathologists, epidemiologists, and the Korea Centers for Disease Control and Prevention (KCDC). Further, we defined the disease entity and performed a case-control study, epidemiologic investigation, and animal study to determine the etiology. The study findings indicated that the lung injury outbreak was related to the inhalation of humidifier disinfectants and showed that household chemical inhalation can cause severe respiratory failure. Following the withdrawal of humidifier disinfectants from the Korean market in 2012, no such cases were reported. This tragic event is a warning that appropriate safety regulations and monitoring for potential toxic household chemicals are critical to protect public health.

Keyword

Respiratory Failure; Humidifier Disinfectants; Chemicals; Lung Injury; Adults

MeSH Terms

Adult*
Animals
Case-Control Studies
Centers for Disease Control and Prevention (U.S.)
Disinfectants*
Family Characteristics
Humans
Humidifiers*
Inhalation*
Korea
Lung Injury*
Lung*
Peripartum Period
Public Health
Respiratory Insufficiency
Social Control, Formal
Disinfectants

Figure

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  Fig. 1 Lung histology in a typical case. The main pathology included a fibroinflammatory process predominantly involving bronchioles and centrilobular lung parenchyma without notable granuloma (arrow, panel A). Bronchiolar lesions were characterized by epithelial sloughing and replacement by flatten regeneration cells (arrow, panel B), and subepithelial fibroblastic proliferation resulting in bronchiolar obliteration (panel B). Parenchymal lesions showed histological patterns from the early exudative phase to the extensive fibrosing phase (panel C). Moreover, subpleural and paraseptal airspaces were relatively preserved, even in the end-stage explanted lung (arrow, panel D).

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  Fig. 2 Typical lung radiographs at the early and late stage. (A-D) A 30-year-old woman who was not admitted to the intensive care unit. (A) An axial computed tomography image showing irregular patchy consolidation and ill-defined centrilobular nodules approximately 1 week after the onset of respiratory symptoms including cough, sputum, and dyspnea. (B) After 2 months, the consolidation decreased and progressed to diffuse centrilobular nodules and ground-glass opacity; moreover, focal pneumomediastinum was noted. (C) The attenuation of the centrilobular nodules gradually diminished at the early chronic stage approximately 6 months after symptom onset. (D) The diffuse centrilobular nodule attenuation had decreased, but it persisted in the lungs even after 5 years. (E-H) A 35-year-old woman was admitted to the intensive care unit. (E, F) Computed tomography images showed diffuse dense centrilobular nodules with a ground-glass opacity, spontaneous pulmonary interstitial emphysema, and pneumomediastinum at 2 months after severe dyspnea. (G, H) The attenuation of the diffuse ill-defined centrilobular nodules and ground-glass opacity had decreased, but it persisted even after 8 years. This patient died after 9 years due to recurrent infection and deteriorated pulmonary function.

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  Fig. 3 Chronological changes in the computed tomography findings. (A) Proportion of extent by duration. (B) Number (%) of patients by duration.

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