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RADS and the Bhopal Disaster

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RADS and the Bhopal Disaster Eur Respir J, 1996, 9, 1973–1976 Copyright ERS Journals Ltd 1996 DOI: 10.1183/09031936.96.09101973 European Respiratory Journal Printed in UK - all rights reserved ISSN 0903 - 1936 EDITORIAL Late consequences of accidental exposure to inhaled irritants: RADS and the Bhopal disaster B. Nemery Pulmonary physicians occasionally have to evaluate tims of civil disasters, such as explosions, fires or major patients some time after an acute inhalation injury and chemical spills, which involved a few tens of subjects to make a judgement about the existence of residual at most. Although these studies provided evidence of lung lesions, the possible causal relationship of such persistent obstructive defects in some subjects, until the lesions with the accident, and their prognosis. This has early 1980s, the prevailing opinion, judging from two been a difficult and often contentious issue, ever since leading textbooks [2, 3], was that "complete recovery" former servicemen who had been gassed in the first was the rule for most individuals surviving acute expo- world war, claimed compensation for late respiratory sure. As late as 1987, an extensive review article [4] effects. Thus, in a review and opinion article published considered that "the chronic effects of acute exposures 35 yrs after the large scale use of war gases [1], it is to toxic inhalants have not been clearly characterized". stated that "the physical impact on men exposed to these Although this is still true to a large extent, significant substances has been a source of interest to, and spe- progress has been made over the past 10 yrs, mainly as culation by, the medical profession, and amidst the a result of the "discovery" of the reactive airways dys- emotional and sentimental miasma which may cloud function syndrome (RADS). medical opinion, much controversy and many conflict- ing hypotheses have been nurtured and flourished". From RADS to irritant-induced asthma According to the same source, leading British medical opinion in the 1930s had concluded that, although there In 1985, the issue of the late consequences of inhala- were "cases of recurrent bronchitis, bronchiectasis and tion injury received a new impetus with publication by emphysema which appeared to have a clear association BROOKS et al. [5], of a retrospective analysis of 10 pre- with severe pulmonary effects at the time of gas expo- viously healthy subjects, who had developed persistent sure... only a comparatively small percentage of gas airway hyperreactivity after a single, high level expo- casualties suffered from such ill effects and the greater sure to a chemical irritant. The authors called the condi- bulk of men, including those with minor symptoms, re- tion "reactive airways dysfunction syndrome" or RADS, ceived no permanent damage". Similarly, a US Board presumably as an oblique reference to the adult res- of Medical Officers found that "the most significant piratory distress syndrome (ARDS). The acronym RADS observation was that the major proportion (of gas casu- has proved to be very successful and has rapidly gained alties evacuated to field medical units) exhibited com- wide acceptance in the medical community, even though plete recovery" [1]. the "reactive airways dysfunction syndrome" is a some- Reading the early literature with today's eyes, it is what nondescript (and grammatically suspect) phrase. striking that the assessment of possible sequelae of past Indeed, dysfunction because of reactive airways is a fea- inhalation injury consisted solely of a clinical judge- ture of any asthma and, in this sense, the term RADS ment based on the documentation of a severe (i.e. inca- is not particularly helpful to indicate that the syndrome pacitating) lung or bronchial injury, followed within a originates from a single inhalation. Perhaps "postin- short time by an unbroken train of signs and symptoms halation injury hyperreactivity" or a similar term would indicative of bronchitis or emphysema, and the absence have been more appropriate. The great merit of RADS of a more plausible cause (e.g. influenza or tuberculo- is that a respectable and "marketable" name had, at last, sis). Thus, in the review article published in 1954 [1], been given to a clinical entity, with which practising no mention is made of "asthma" or "pulmonary func- pneumologists were regularly faced but for which little tion measurements", or even smoking. Over the follow- or no published evidence had hitherto been available to ing decades, relatively little progress was made in the sustain the claim that asthma symptoms could be the debate about the occurrence of sequelae in survivors of consequence of an inhalation incident. Until the RADS acute inhalational injury. There were occasional reports era, victims of inhalation incidents were considered to of bronchiectases, bronchiolitis obliterans or obstruc- have recovered completely if no structural alterations tive lung disease following massive exposures to am- were demonstrated by radiology or bronchoscopy, or if monia, oxides of nitrogen, sulphur dioxide, chlorine or their pulmonary function values were "within normal phosgene, as well as limited follow-up studies of vic- limits". Henceforth, the presence of bronchial hyperre- Correspondence: B. Nemery, Laboratorium voor Pneumologie (Eenheid activity, which can be demonstrated by a low provoca- voor longtoxicologie), K.U. Leuven, Herestraat 49, B-3000 Leuven, tive concentration or dose of histamine or methacholine Belgium. causing a 20% fall in forced expiratory volume in one 1974 B. NEMERY second (PC20 or PD20), must be taken into considera- pathogenesis, the concept of RADS also involves a tion as a possible consequence of severe inhalation in- number of other very practical issues, mainly with jury. regard to diagnostic criteria, prognosis, treatment and Since the seminal publication of BROOKS et al. [5], compensation. A particular, and often difficult, problem many authors have published case reports, case series concerns the "reactivation" of latent asthma (e.g. in an and, so far, a single cohort study [6] demonstrating the asymptomatic individual with a history of asthma in reality of RADS. Several recent editorials, reviews or childhood) or the worsening of pre-existing asthma fol- textbook chapters have been devoted to the condition, lowing an accidental inhalational exposure. Although, and these have indicated that, far from being a simple on the basis of the strictest criteria [5], a diagnosis of curiosity, RADS does occur in a proportion of sur- RADS should not be made in subjects with prior res- vivors of inhalation trauma [7–11]. The exact incidence piratory complaints, it appears perfectly reasonable to of RADS, either in the community or among victims of consider that persistent exacerbation of asthma is a pos- inhalation accidents, is still unknown. An evaluation sible consequence of acute inhalation injury. Several based on data from poison control centres indicated authors seem to have adopted this view [13, 18]. In fact, that RADS is uncommon, with only 6% of victims of it is conceivable (and there is some evidence to support (generally mild) inhalation injury exhibiting symptoms this hypothesis [12]) that asthmatics or "ex-asthmatics" for more than 2 weeks [12]. On the other hand, 3 out or, more generally, subjects with less than optimal air- of 14 health workers "highly" exposed to vapours of ways (e.g. smokers) are at greater risk of suffering long- spilled acetic acid were later found to fit the diagnos- term effects of inhalation injury than perfectly healthy tic criteria for RADS, although none of these subjects people. In other words, compensation should not be seems to have experienced very serious respiratory in- denied to a victim of inhalation injury simply on the jury [6]. There is clearly a need for a better confirmation grounds that there was evidence of pre-existing asthma and reporting of this condition. or smoking-related lung disease, although, admittedly, RADS has been described as a possible consequence the documentation and quantification of the contribu- of inhalation accidents in the most varied settings, includ- tion of the accident will be more complicated in such ing many sectors of industry, in agriculture and the cases. health sector [6], the home and the community [13]. An important practical consequence is that adequate The causal exposures have been generally described as documentation of pulmonary status, which includes at "high levels of irritants", with the incriminated agents least simple spirometry, should be available for the lar- varying from well-known and defined gases or vapours, gest possible number of people. This is a task for school such as chlorine or ammonia, to complex and ill-defined medical services, general practitioners, occupational mixtures, such as fire smoke, paints, pesticide degra- physicians and all those involved in preventive or pri- dation products [13], or swine confinement gases [14]. mary health care. For those at special risk of inhalation For obvious reasons, quantitative exposure assessments injury, such as some chemical workers, firefighters and have generally been lacking, but surrogate measures, other emergency personnel, etc., it is reasonable to rec- such as distance from the source and/or duration of ommend that a measure of bronchial responsiveness be exposure [6, 13], have been used to estimate exposure obtained at the onset of their career (although not for levels, with, however, mixed success in establishing ex- the purpose of excluding subjects with bronchial hyper- posure-response relationships. responsiveness from such jobs). At present, the main question is no longer whether The recognition that asthma may be caused by a sin- RADS does or does not exist as a clinical entity, but gle exposure to high levels of irritants has naturally led what the determinants are for its occurrence in some to extending this notion to the possibility that other victims of inhalation injuries. Indeed, the recognition types of irritant injury to the airways would have simi- that persistent airway hyperreactivity may accompany lar effects.
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