Importance of smoking and the occurrence of acute poisoning due to waterproof spray

Abstract

A search of the database Ichushi (Japana Centra Revuo Medicana), which collects summaries of Japanese medical articles, was undertaken to identify articles published between 1983 and 2013, using the key word “waterproof”. There was one original article and 19 case reports describing acute poisoning due to inhalation of waterproof spray gas, and providing information about the patient's smoking habit. Twenty‐three of the 25 cases (92% of male patients, 71% of female patients) had a smoking habit. The one female case who did not have a smoking habit was in an environment exposed to secondhand smoke, because her husband had smoking habit. All cases had respiratory symptoms, and 24 cases had lung edema confirmed by computed tomography. There were no fatal cases among these patients. The one original article reported that 93% of males and 49% of females among a total of 104 cases with acute poisoning due to inhalation of waterproof spray gas had a smoking habit. Accordingly, people with a smoking habit tend to be vulnerable to exposure to waterproof spray gas.

Introduction

In Japan, a waterproof spray containing fluororesin is commercially available, and acute poisoning due to the waterproof spray occurs approximately 10 times per year.1 The main complaints are due to respiratory disturbance, such as lung edema. We herein report that a smoking habit may make patients more vulnerable to acute poisoning due to the waterproof spray.

Methods

A search of the Ichushi database (http://login.jamas.or.jp/) (Japana Centra Revuo Medicana), which collects summaries of Japanese medical articles, was undertaken to identify articles published between 1983 and 2013 using the key word “waterproof”. The exclusion criterion was that the article did not report whether the patient had a smoking habit. The age, sex, Brinkman index, type of spray, spraying indoors or not, spraying while smoking or not, chief complaints, PaO₂/FiO₂ on arrival, the radiological findings, contents of treatment, duration of treatment and survival rate were investigated. For measurement of PaO₂/FiO₂ on arrival, the following calculation was used: when the value of the SpO₂ is 90 + α%, then the PaO₂ is equal to 60 + 4 × α mmHg; when the oxygenation is β L/min, then the FiO₂ is equal to 0.2 + 0.04 × β. The relationship between the Brinkman index and PaO₂/FiO₂ on arrival or the duration of treatment was also analyzed.

Results

We found 46 articles about waterproof spray intoxication. Of these, there were seven experimental studies and six review articles that were excluded because they did not report whether the patient had a smoking habit. Among five original articles, only one article2 described the smoking habits of the patients, so the other four articles were also excluded. Among the remaining 28 case reports, 19 reports that described acute poisoning due to inhalation of waterproof spray gas and the smoking habit of the patient were analyzed. These cases, and our own, are summarized in Table 1.3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 Surprisingly, 23 cases out of 25 (92% of all men, and 71% of all women) had a smoking habit. The one female case who did not have a smoking habit was in an environment where she was exposed to secondhand smoke, because her husband was a smoker.13 There was no significant correlation between the Brinkman index and PaO₂/FiO₂ on arrival or duration of treatment. All cases had respiratory symptoms, and 24 cases had lung edema confirmed by computed tomography. There were no fatalities among the analyzed articles, however, there was one fatal case induced by suicidal inhalation,22 which did not have data available concerning the smoking habit.

Table 1.

Findings of published reports of acute poisoning due to inhalation of waterproof spray gas

No.	Reporter, year	Smoking habit	BI	Age	Sex	Type of spray	Indoor use	Spraying while smoking	Complaint(s) and CT findings	P/F	Treatment	Duration of treatment (h)
1	Fukui, 20113	Yes	200	33	F	?	Yes	No	Fe, D, LE	460	St, Amy, Anti	103
2	Fuseya, 20114	Yes	200	29	M	?	Yes	IA	D, LE	469	St	4
3	Fuseya, 20114	Yes	1840	66	M	?	Yes	No	Fe, D, LE	148	St	8
4	Hashimoto, 20095	Yes	600	57	M	Fluorine	?	IA	D, LE	407	St	7
5	Hashimoto, 20095	Yes	1600	59	M	Fluorine	Yes	IA	D, LE	416	None	28
6	Nakamura, 20086	Yes	940	67	M	?	Yes	Yes	D, LE	320	Anti	10
7	Nakamura, 2008.	Yes	200	21	M	?	Yes	No	Fe, pain, D, LE	480	St, Anti	80
8	Nakamura, 20086	Yes	200	42	M	?	?	No	Cough, LE	440	St	Lost†
9	Kajiwara, 20087	Yes	1600	59	M	?	Yes	No	D, LE	?	None	7
10	Saito, 20088	Yes	?	4?	M	?	Yes	No	D	320	St, sivelestat	11
11	Hayashi, 20089	Yes	90	24	F	?	Yes	20 min A	D, LE	392	None	10
12	Ito, 200710	Yes	1050	51	M	Fluorine	Yes	IA	D, LE	290	Oxygen only	7
13	Sanno, 200711	Yes	80	22	F	?	Yes	No	D, LE	245	St	7
14	Endo, 200712	Yes	600	46	M	?	Yes	30 min A	D, LE	375	St, Anti	7
15	Kobayashi, 200613	Yes	150	28	M	?	Yes	IA	Fe, D, LE	289	St	7
16	Kobayashi, 200613	No	0	27	F	?	Yes	No	Nausea, LE	470	None	7
17	Tagawa, 200314	Yes	1220	55	M	?	Yes	No	D, LE	385	None	4
18	Tanaka, 200215	Yes	195	33	M	?	Yes	No, Stove +	Fe, D, LE	240	St, Anti	24
19	Takeda, 200016	Yes	200	40	F	Fluorine	Yes	No	Fe, D, LE	301	St, Amy, Anti	21
20	Tanino, 199917	Yes	25	25	F	?	Yes	1 h A	Fe, D, LE	252	St	10
21	Hoashi, 199818	Yes	200	40	F	?	Yes	No	Fe, D, LE	300	St, Amy, Anti	>3 days
22	Aoki, 199619	Yes	1200	42	M	?	No	No	D, LE	330	?	8
23	Nakazawa, 199520	Yes	200	25	M	Fluorine	Yes	No	Coma, LE	34	St, MV	20
24	Nakatani, 199521	No	0	49	M	?	Yes	No	D, LE	355	Antitussive	7
25	This study	Yes	720	50	M	Fluorine	Yes	No	Fe, D, LE	205	Oxygen only	6

†Patient who did not go to the hospital who need the follow‐up. ?, Not specified; A, after spraying; Amy, amynophyline; Anti, antibiotics; BI, Brinkman index; CT, computed tomography; D, dyspnea; F, female; Fe, fever; IA, immediately after spraying; LE, lung edema; M, male; MV, mechanical ventilation; St, steroid.

Ishizawa et al. reported 219 cases of acute poisoning due to inhalation of waterproof spray gas, and they investigated the smoking habit of 104 cases.2 Among them, 93% of males and 49% of females had a smoking habit. They reported that there was no relationship between the smoking habit and severity of acute poisoning.

Discussion

The Ministry of Health, Labor and Welfare of Japan reported that incidence of smoking decreased from 50% to 30% in men, and decreased in women to approximately 10% (of the population), from 1989 to 2011 (http://www.health-net.or.jp/tobacco/product/pd100000.html). Given the high incidence of smoking in the patients treated for waterproof spray intoxication, the present study indicated that people who have a smoking habit are more vulnerable to exposure to waterproof spray gas in a confined space.

When fluororesin is heated, it becomes a gas at 425–450°C, perfluoroisobutylene is released at 475°C and carbonyl fluoride is produced at 500–650°C. These products resulting from heat decomposition have toxic effects on the lungs.2, 23 The temperature of the lit end of a cigarette can reach up to 850–900°C, which may lead to the production of more toxic cases that can induce acute poisoning due to waterproof spray.6 However, all but one case with acute poisoning among the people who had smoking habits in our study were not smoking while using the waterproof spray. In mice, inhalation of the waterproofing agent alone was proved to induce pulmonary collapse and pneumonia.24 The fact that most cases of acute poisoning due to waterproof spray occurred indoors suggested that there could be a positive correlation between inhalation volume of waterproofing agent and severity of lung injury.

Smoking itself induces a disturbance of the epithelial membrane due to inflammation or apoptosis, and endothelial injury due to oxidative stress, and leads to the subsequent disruption of the air–blood barrier and foaming lung edema.25, 26, 27 The fluorine waterproof spray also induces lung edema and hemorrhage.28 Accordingly, the lung injury induced by the waterproof spray may be more extensive in patients who already have chronic disturbance of the air–blood barrier due to a smoking habit. Furthermore, smoking increases the activity of leukocytes, so that the “two hit” mechanism or “neutrophil priming” may occur when smoking and exposure to the waterproof spray gas are combined.29, 30 As there have been no reports investigating whether lungs of former smokers had vulnerability for exposure of the waterproof spray or not, further study is required.

Conclusion

People with a smoking habit tend to be vulnerable to exposure to waterproof spray gas in a confined space.

Conflict of Interest

None.