Clinical Features And Literature Review Of Acute Severe Ammonia Poisoning And Its Late Lung Injury

Objective:The clinical data of 1 cases of acute severe ammonia poisoning were analyzed and literature were reviewed in order to understand more about the acute and late lung injury of severe ammonia poisoning.Methods:One case which was diagnosed as severe ammonia poisoning at The First Affiliated Hospital of Guangxi Medical University in 2016 had been reported.Retrospective analysis this disease and analyze clinical features of lung injury in this case.A literature rearch was performed with“severe ammonia poisoning,injury of lungs" as the key in China Knowledge Resource Integrated Database,Wanfang Database,Chinese VIP Journal Database and Pubmed.The time interval was from 1990 to May 2017.Because the retrieved foreign literature is in 70s,it can not obtain abstract or full text,so it is not included in the foreign literature.After screening,after excluding a total of 15 cases of acute ammonia poisoning and follow-up case.Related articles of the lung injury of severe ammonia poisoning were retrieved and the clinical manifestation,blood gas analysis,pulmonary function,imaging,fiberoptic bronchoscope and treatment.Results:Firstly,The results of our hospital case were as follows:(1)The early stages of the disease:The main symptoms were cough,coughing up phlegm,persistent dyspnea,acute respiratory distress syndrome and the need for endotracheal intubation assisted ventilation.The blood gas analysis showed type I respiratory failure,and could not be separated from the ventilator.It was associated with carbon dioxide retention after a half month of onset.Fiberoptic bronchoscopy showed erosion of the trachea and bilateral bronchial mucosa,congestion,edema,luminal obstruction,and gray purulent discharge.After repeated fiberoptic bronchoscopy,bronchial mucosa congestion,edema,erosion gradually improved,luminal purulent secretions gradually decreased.Simple lung function test showed obstructive ventilation dysfunction after February.The patients with ammonia poisoning 4 days after the check two chest CT showed lung scattered patchy shadows,as signs of pulmonary edema,with the lower lobe of the left lung atelectasis;After the treatment,repeated chest CT showed two lung scattered patchy shadows significantly reduce the absorption of left lower lobe atelectasis and bronchiectasis,partial bronchial wall thickening,left in a few scattered patchy,patchy shadows of high density,suspected "mosaic sign".The treatment included short-term intravenous corticosteroids,active anti infection,ventilator assisted respiration,and fiberoptic bronchoscopy for the treatment of respiratory secretions and alveolar lavage.(2)Follow up 1 years later:For the performance of the patients with recurrent cough,coughing up phlegm and continued breathing difficulties.The blood gas analysis showed hypoxemia accompanied by persistent carbon dioxide retention.The patient suffered from dyspnea and failed to perform the pulmonary function test.Fiberoptic bronchoscopy showed the bronchoscopic findings of left lung upper lobe bronchus opening mucosal rough,local small nodule formation.The patency of the lumen at all levels,a few serous secretions.The right main bronchus,right upper lobe anterior segmental bronchus,right middle lobe bronchus,right lower lobe anterior bronchial lumen distortion,which right middle lobe bronchus,right lower lobe anterior bronchial stenosis is obvious,but still unobstructed.The chest CT showed two lung touliangdu increased significantly,there are still a few scattered patchy,patchy shadows of high density,suspected "mosaic sign",a local bronchiectasis,bronchial wall thickening.The main therapy for oral hormone,erythromycin,anti infection,continuous noninvasive ventilator assisted ventilation.Secondly,The results of literature review were as follows:A total of 57 cases of acute severe ammonia intoxication were retrieved after the literature search.15 cases were followed up(followed by 1 to 9 years after the onset of the disease).After screening,the data were relatively complete,10 cases were reported,and a total of 2 cases were reported.(1)Clinical manifestations:acute onset mainly manifested as cough,cough pink frothy sputum,chest tightness,dyspnea.Late follow-up manifestations were cough,sputum,dyspnea.(2)Blood gas analysis:acute onset and late follow-up blood gas analysis were basically consistent with acute onset,9 cases showed hypoxemia,8 cases showed normal PaC02,1 cases showed partial pressure of carbon dioxide increased.Late follow-up 11 cases showed hypoxemia,10 cases showed normal partial pressure of carbon dioxide.1 cases showed partial pressure of carbon dioxide increased.(3)Lung function:there are 4 cases of acute onset of pulmonary function showed mixed ventilatory dysfunction,1 cases showed obstructive ventilatory dysfunction,1 cases showed diffuse function decline.Late follow-up there were 8 cases of lung function showed mixed ventilatory dysfunction,5 cases showed obstructive ventilation dysfunction,3 cases performance for the diffusion function decline.(4)Imaging:acute onset of 13 cases pulmonary edema,bronchiectasis to learn late follow-up image(10 cases),interstitial changes(6 cases),small airway lesions(2 cases).(5)Fiberoptic bronchoscopy:2 cases of acute onset of bronchial congestion,edema,large airway secretions,followed by late 2 cases of bronchial scarring and bronchial opening stenosis.(6)the treatment plan included tracheotomy,ventilator assisted ventilation,oxygen inhalation,anti infection and hormone therapy at the onset of the disease.The main treatment regimen was anti infection at the end of the follow-up period,and the lung transplantation could be done at the end of the period.Conclusions:According to our hospital severe ammonia poisoning case,combined with literature analysis,draw the following conclusions:(1)The severe pulmonary edema caused by severe ammonia intoxication is mainly caused by chemical pulmonary edema,acute respiratory distress syndrome and pulmonary infection.The later stage of infection is characterized by repeated infection and persistent dyspnea,and the quality of life of the patients is poor.(2)Characteristics of this case:onset of half month to follow-up 1,the average annual performance of carbon dioxide retention,pulmonary function,obstructive ventilatory dysfunction,pulmonary CT manifestations,bronchiectasis,emphysema and suspicious mosaic sign.(3)In this case,clinical diagnosis of severe ammonia poisoning complicated bronchiolitis obliterans,the possibility of diagnosis is to be pathological.