Korean J Crit Care Med.  2016 May;31(2):146-151. 10.4266/kjccm.2016.31.2.146.

Lung Transplantation for Chronic Humidifier Disinfectant-Associated Lung Injury

Affiliations
  • 1Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. sbhong@amc.seoul.kr
  • 2Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
  • 3Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Abstract

In the spring of 2011, a cluster of lung injuries caused by humidifier disinfectant (HD) usage were reported in Korea. Many patients required mechanical ventilation, extracorporeal membrane oxygenation, and even lung transplantation (LTPL). However, the long-term course of HD-associated lung injury remains unclear because the majority of survivors recovered normal lung function. Here we report a 33-year-old woman who underwent LTPL approximately four years after severe HD-associated lung injury. The patient was initially admitted to the intensive care unit and was supported by a high-flow nasal cannula. Although she had been discharged, she was recurrently admitted to our hospital due to progressive lung fibrosis and a persistent decline in lung function. Finally, sequential double LTPL was successfully performed, and the patient's clinical and radiological findings showed significant improvement. Therefore, we conclude that LTPL can be a therapeutic option for patients with chronic inhalation injury.

Keyword

disinfectants; humidifiers; inhalation exposure; lung transplantation; oxygen inhalation therapy

MeSH Terms

Adult
Catheters
Disinfectants
Extracorporeal Membrane Oxygenation
Female
Fibrosis
Humans
Humidifiers*
Inhalation
Inhalation Exposure
Intensive Care Units
Korea
Lung Injury*
Lung Transplantation*
Lung*
Oxygen Inhalation Therapy
Respiration, Artificial
Survivors
Disinfectants

Figure

  • Fig. 1. The three stages of humidifier disinfectant-associated lung injury in a 33-year-old woman. (A) Initial computed tomography (CT) scan revealing diffuse, centrilobular ground-glass opacity (GGO) nodules with patchy multifocal consolidations. (B) On the CT obtained on the day of admission to our hospital, the consolidations disappeared, but diffuse GGO nodules became more distinct (lower), with newly appeared GGOs in both upper lobes (upper). (C) Follow-up CT scan obtained two weeks after exhibited improved GGOs in both upper lobes (upper), but diffuse GGO nodules and pneumomediastinum remained (lower). A small amount of left pneumothorax is also visible (upper).

  • Fig. 2. The patient’s disease course after discharge. (A-C) Follow-up computed tomography (CT) scans exhibited residual diffuse centrilobular ground-glass opacity nodules and multiple air cysts with parenchymal distortion and fibrosis. (D) Normal CT scans two months after lung transplantation.

  • Fig. 3. Serial pulmonary function test findings showing a decline that persisted during follow-up. After the lung transplantation, these findings were significantly improved. LTPL: lung transplantation; FVC: forced vital capacity; FEV1: forced expiratory volume in 1 s; DLCO: diffusing capacity of lung for carbon monoxide.

  • Fig. 4. Pathology of the explanted lungs. (A) Centrilobular and patchy fibrosis with honeycomb changes (H&E stain, ×10). Characteristically, the lung architecture was destroyed and replaced by irregular cystic sacs with dense fibrotic walls. (B) Patchy, interstitial lymphoid cellular infiltration with fibrosis of the bronchioles (H&E stain, ×40).


Reference

References

1. Tredget EE, Shankowsky HA, Taerum TV, Moysa GL, Alton JD. The role of inhalation injury in burn trauma. A Canadian experience. Ann Surg. 1990; 212:720–7.
Article
2. Suzuki M, Aikawa N, Kobayashi K, Higuchi R. Prognostic implications of inhalation injury in burn patients in Tokyo. Burns. 2005; 31:331–6.
Article
3. Hong SB, Kim HJ, Huh JW, Do KH, Jang SJ, Song JS, et al. A cluster of lung injury associated with home humidifier use: clinical, radiological and pathological description of a new syndrome. Thorax. 2014; 69:694–702.
Article
4. Kim HJ, Lee MS, Hong SB, Huh JW, Do KH, Jang SJ, et al. A cluster of lung injury cases associated with home humidifier use: an epidemiological investigation. Thorax. 2014; 69:703–8.
Article
5. Kim KW, Ahn K, Yang HJ, Lee S, Park JD, Kim WK, et al. Humidifier disinfectant-associated children’s interstitial lung disease. Am J Respir Crit Care Med. 2014; 189:48–56.
6. Lee JH, Kim YH, Kwon JH. Fatal misuse of humidifier disinfectants in Korea: importance of screening risk assessment and implications for management of chemicals in consumer products. Environ Sci Technol. 2012; 46:2498–500.
Article
7. Suda T, Sato A, Ida M, Gemma H, Hayakawa H, Chida K. Hypersensitivity pneumonitis associated with home ultrasonic humidifiers. Chest. 1995; 107:711–7.
Article
8. Kim YB, Choi SJ, Yang YS, Kim YH, Song CW, Cho JW, et al. Comparative pulmonary response to aerosolized humidifier disinfectants by intratracheal instillation and inhalation exposure. In : 2013 Annual Meeting Poster #207; 2013.
9. Christie JD, Edwards LB, Aurora P, Dobbels F, Kirk R, Rahmel AO, et al. The registry of the international society for heart and lung transplantation: twenty-sixth official adult lung and heart-lung transplantation report-2009. J Heart Lung Transplant. 2009; 28:1031–49.
Article
10. Barrio J, Sánchez C, Vicente R, Ramos F, Montero R, Morales P, et al. Successful sequential double-lung transplantation for adult respiratory distress syndrome after long-term mechanical ventilation. Eur J Anaesthesiol. 2004; 21:326–7.
Article
11. Hayes D Jr. Lung transplantation for bronchiectasis due to smoke inhalation. Burns. 2011; 37:e24–8.
Article
12. Pirjavec A, Kovic I, Lulic I, Zupan Z. Massive anhydrous ammonia injury leading to lung transplantation. J Trauma. 2009; 67:E93–7.
Article
13. Millar J, Lutton S, O’Connor P. The use of high-flow nasal oxygen therapy in the management of hypercarbic respiratory failure. Ther Adv Respir Dis. 2014; 8:63–4.
Article
14. Nilius G, Franke KJ, Domanski U, Rühle KH, Kirkness JP, Schneider H. Effects of nasal insufflation on arterial gas exchange and breathing pattern in patients with chronic obstructive pulmonary disease and hypercapnic respiratory failure. Adv Exp Med Biol. 2013; 755:27–34.
Article
15. Sztrymf B, Messika J, Bertrand F, Hurel D, Leon R, Dreyfuss D, et al. Beneficial effects of humidified high flow nasal oxygen in critical care patients: a prospective pilot study. Intensive Care Med. 2011; 37:1780–6.
Article
16. Frat JP, Thille AW, Mercat A, Girault C, Ragot S, Perbet S, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med. 2015; 372:2185–96.
Article
17. Kang BJ, Koh Y, Lim CM, Huh JW, Baek S, Han M, et al. Failure of high-flow nasal cannula therapy may delay intubation and increase mortality. Intensive Care Med. 2015; 41:623–32.
Article
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