Evaluation of the inhalation technique in asthmatic children visiting a specialised outpatient clinic

Background and objective: Asthma is one of the most frequent chronic diseases affecting children and adolescents. Good compliance is indispensable for effective treatment since a suboptimal use of inhalation devices can result in decreased therapeutic efficacy and increased morbidity. The objective of this work was to evaluate the inhalation technique of paediatric patients visiting a specialized consultation clinic of a university hospital. Design: Observational prospective study during a 3-month period. Setting Specialized consultation clinic of a university hospital. Main outcome measures: This study involved 40 outpatient infants, children and adolescents visiting alone or with their parent(s). Patients' data (age, sex, weight, diagnostic, reason for consulting, previous consultations) and their medicines were compiled using an ad hoc form. Filmed sequences of the inhalation procedure used by each child were reviewed independently by members of an interdisciplinary team consisting in a physician, a pharmacist, a nurse and a physiotherapist. A score of 1 was assigned to each correct step in the procedure, and a score of 0 to an incorrect step. A perfect procedure implied 12 correct steps. Results: Thirty patients were treated with a metered-dose inhaler and an inhalation chamber (Babyhaler or AeroChamber Plus); ten other patients were treated with a dry powder inhaler (Diskus or Turbuhaler). The agreement between the members of the interdisciplinary team was considered satisfactory. Nine patients (22.5%) reached an average score lower than 7, 18 patients (45%) a score between 7 and 10 and 13 (32.5%) a score equal to or better than 10. No patient reached the maximum score of 12. Users of the metered-dose inhalers (average score = 9.2) showed a better technique than users of the dry powder inhalers (average score = 7.4). Disappointingly, the score was not improved during a second consultation or following regular consultations. Conclusions: Video recording is a simple method to evaluate the degree of mastery of an inhalation procedure in paediatric patients. The method allows a convenient and efficient identification of suboptimal procedure steps by the hospital staff, and opens the way to patient-specific teaching. In two-thirds of juvenile patients, their inhalation technique was suboptimal despite initial training. This study shows conclusively that the inhalation technique in paediatric patients must be monitored during each examination, and teaching measures taken to improve it when necessary.

Human inhalation exposure to iron oxide particles

In the past decade, many studies have been conducted to determine the health effects induced by exposure to engineered nanomaterials (NMs). Specifically for exposure via inhalation, numerous in vitro and animal in vivo inhalation toxicity studies on several types of NMs have been published. However, these results are not easily extrapolated to judge the effects of inhaling NMs in humans, and few published studies on the human response to inhalation of NMs exist. Given the emergence of more industries utilizing iron oxide nanoparticles as well as more nanomedicine applications of superparamagnetic iron oxide nanoparticles (SPIONs), this review presents an overview of the inhalation studies that have been conducted in humans on iron oxides. Both occupational exposure studies on complex iron oxide dusts and fumes, as well as human clinical studies on aerosolized, micron-size iron oxide particles are discussed. Iron oxide particles have not been described to elicit acute inhalation response nor promote lung disease after chronic exposure. The few human clinical studies comparing inhalation of fine and ultrafine metal oxide particles report no acute changes in the health parameters measured. Taken together existing evidence suggests that controlled human exposure to iron oxide nanoparticles, such as SPIONs, could be conducted safely.

Acute respiratory syndrome after inhalation of waterproofing sprays: a posteriori exposure-response assessment in 102 cases

Waterproofing agents are widely used to protect leather and textiles in both domestic and occupational activities. An outbreak of acute respiratory syndrome following exposure to waterproofing sprays occurred during the winter 2002-2003 in Switzerland. About 180 cases were reported by the Swiss Toxicological Information Centre between October 2002 and March 2003, whereas fewer than 10 cases per year had been recorded previously. The reported cases involved three brands of sprays containing a common waterproofing mixture, that had undergone a formulation change in the months preceding the outbreak. A retrospective analysis was undertaken in collaboration with the Swiss Toxicological Information Centre and the Swiss Registries for Interstitial and Orphan Lung Diseases to clarify the circumstances and possible causes of the observed health effects. Individual exposure data were generated with questionnaires and experimental emission measurements. The collected data was used to conduct numeric simulation for 102 cases of exposure. A classical two-zone model was used to assess the aerosol dispersion in the near- and far-field during spraying. The resulting assessed dose and exposure levels obtained were spread on large scales, of several orders of magnitude. No dose-response relationship was found between exposure indicators and health effects indicators (perceived severity and clinical indicators). Weak relationships were found between unspecific inflammatory response indicators (leukocytes, C-reactive protein) and the maximal exposure concentration. The results obtained disclose a high interindividual response variability and suggest that some indirect mechanism(s) predominates in the respiratory disease occurrence. Furthermore, no threshold could be found to define a safe level of exposure. These findings suggest that the improvement of environmental exposure conditions during spraying alone does not constitute a sufficient measure to prevent future outbreaks of waterproofing spray toxicity. More efficient preventive measures are needed prior to the marketing and distribution of new waterproofing agents.

An unusual case of accidental poisoning: fatal methadone inhalation.

In this report, the authors present a case of unusual, accidental methadone intoxication in a 40-year-old man, who had inhaled methadone powder. The drug dealer was a pharmacy technician; methadone had been stolen from a pharmacy and sold as cocaine. After having inhaled methadone powder, he suffered cardiopulmonary arrest. He was admitted to hospital where he died after 24 h of intensive care. The autopsy revealed congestion of internal organs and cerebral and pulmonary edema. Microscopically, the heart showed no changes. The toxicological analyses performed on blood and urine taken at the hospital revealed methadone, cannabinoids, and ethanol. The blood methadone concentration was 290 μg/L. The urine methadone concentration was 160 μg/L. Midazolam and lidocaine, which were administered to the patient at the hospital, were also detected in the blood. The cause of death was determined to be methadone intoxication. The literature has been reviewed and discussed. To date, and to our knowledge, only very few cases of accidental death resulting from methadone inhalation have been described up to the case presented herein.

Suicide par sulfure d'hydrogène et délai post mortem long : à propos d'un cas. [Suicide by hydrogen sulfide inhalation and significant post mortem delay: A case report].

L'hydrogène sulfuré (H2S) est un gaz toxique retrouvé à l'état naturel et dans certains milieux industriels, à l'origine d'intoxication accidentelle, mais pouvant être également et facilement synthétisé de manière domestique. Des cas de suicide par hydrogène sulfuré ont ainsi été décrits à partir de produits ménagers dans la littérature depuis 2009, aux États-Unis et au Japon. La plupart présentait des délais post mortem (DPM) courts (moins de 72 heures). En France, les intoxications aiguës à l'H2S demeurent rares et sont le plus souvent liées à des accidents du travail. Nous rapportons ici le cas d'un homme âgé de 37 ans découvert à son domicile, en état de décomposition avancée avec un DPM de deux mois. Compte tenu de la présence d'une importante signalétique avisant du danger potentiel d'exposition à l'H2S, des mesures de précaution ont été mises en oeuvre dès la découverte du corps et poursuivies jusqu'aux opérations d'autopsie. Les analyses toxicologiques ont confirmé la présence d'H2S au niveau des prélèvements de cerveau et de muscle. Le cas présenté constitue le premier cas de suicide avec un délai post mortem long à l'H2S rapporté en France. Dans la littérature, les constatations macroscopiques à l'autopsie ne sont pas spécifiques tandis que les analyses toxicologiques reposent essentiellement sur la recherche et la quantification d'H2S. En raison de leur redistribution post mortem, les résultats de ces analyses doivent être interprétés avec prudence, et encore plus en cas de délai post mortem long et de phénomènes de putréfaction qui peuvent également être une source de génération d'H2S post mortem. Hydrogen sulfide (H2S) which is a poisonous gas found either in the natural state or in industrial environments and potentially linked with accidental intoxication, can also be easily handmade. Several cases of suicide by inhaling H2S produced by mixing household products have been reported in the literature since 2009 in USA and Japan. Most of them involved short post mortem delays up to 72 hours. In France, acute H2S poisoning remains rare and mostly accidental. We report the case of a 37-year-old man found at home, in an advanced stage of decomposition with a 2-month post mortem delay. As numerous warning signs about a high risk of H2S exposure were present, some precautionary measures were taken from the discovery of the cadaver to the autopsy. Toxicological analyses confirmed the presence of H2S in brain and muscle samples. This observation is the first French case with a long post mortem delay. As macroscopic findings in such cases are described to be unspecific in literature, toxicological analysis must focus on the detection and the quantification of H2S. However, due to the phenomena of post mortem drug redistribution and neo-formation, their results should be interpreted with much more caution when the post mortem delay is long. The potential increase in such voluntary-intoxication-related-deaths in France, similar to the recent Japanese and American waves of suicides, requires for forensic scientists, a good knowledge of both thanatological and toxicological pictures, and precautionary measures to adopt in such situations.

Démonstration d'une séance d'inhalation à l'inhalatorium de la rue Erlanger : [photographie de presse] / [Agence Rol]

Référence bibliographique : Rol, 60178

Une des salles d'inhalation avec tube projecteur de vapeurs médicamenteuses de l'inhalatorium [de la rue Erlanger] : [photographie de presse] / [Agence Rol]

Référence bibliographique : Rol, 60179

Chaudière à haute pression avec tuyaux de distribution pour les salles d'inhalation de l'inhalatorium de la rue Erlanger : [photographie de presse] / [Agence Rol]

Référence bibliographique : Rol, 60180

Évaluation des niveaux d’éthanolémie résultant de l’exposition à l’éthanol par inhalation : études chez des volontaires et modélisation toxicocinétique

Un modèle pharmacocinétique à base physiologique (PBPK) d’exposition par inhalation à l’éthanol a antérieurement été développé en se basant sur des données provenant d’une étude chez des volontaires exposés par inhalation à plus de 5000 ppm. Cependant, une incertitude persiste sur la capacité du modèle PBPK à prédire les niveaux d’éthanolémie pour des expositions à de faibles concentrations. Ces niveaux sont fréquemment rencontrés par une large partie de la population et des travailleurs suite à l’utilisation de produits tels que les vernis et les solutions hydroalcooliques (SHA). Il est ainsi nécessaire de vérifier la validité du modèle existant et de déterminer l’exposition interne à l’éthanol dans de telles conditions. Les objectifs du mémoire sont donc 1) de documenter les niveaux d’éthanolémie résultant de l’exposition par inhalation à de faibles concentrations d’éthanol (i.e., ≤ 1000 ppm) et de valider/raffiner le modèle PBPK existant pour ces concentrations ; et 2) de déterminer les concentrations d’éthanol atmosphérique provenant d’utilisation de SHA et de vernis et de prédire les niveaux d’éthanolémie découlant de leur utilisation. Les données toxicocinétiques récoltées chez des volontaires nous suggèrent qu’il est insuffisant de limiter au foie la clairance métabolique de l’éthanol lors d’exposition à de faibles niveaux d’éthanol, contrairement aux expositions à de plus forts niveaux. De plus, il a clairement été démontré qu’un effort physique léger (50 W) influençait à la hausse (2-3 fois) l’éthanolémie des volontaires exposés à 750 ppm. L’ajout au modèle PBPK d’une clairance métabolique de haute affinité et de faible capacité associée aux tissus richement perfusés a permis de simuler plus adéquatement la cinétique de l’éthanolémie pour des expositions à des concentrations inférieures à 1000 ppm. Des mesures de concentrations d’éthanol dans l’air inhalé générées lors d’utilisation de SHA et de vernis ont permis de simuler des expositions lors de l’utilisation de ces produits. Pour l’utilisation de 1,5 g et 3 g de SHA dans un local peu ventilé, des concentrations sanguines maximales (Cmax) de 0.383 et 0.366 mg.L-1 ont été respectivement simulées. Dans un local bien ventilé, les Cmax simulées étaient de 0.264 et 0.414 mg.L-1. Selon les simulations, une application de vernis résulterait en une Cmax respectivement de 0.719 mg.L-1 et de 0.729 mg.L-1, chez les hommes et femmes. Les Cmax sanguines d’éthanol estimées suites aux différentes simulations sont inférieures à la concentration toxique pour les humains (100 mg.L-1). Ainsi, de telles expositions ne semblent pas être un danger pour la santé. Les résultats de cette étude ont permis de mieux décrire et comprendre les processus d’élimination de l’éthanol à faibles doses et permettront de raffiner l’évaluation du risque associé à l’inhalation chronique de faibles niveaux d’éthanol pour la population, particulièrement chez les travailleurs.