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DESCRIPTION
- Cadmium fume fever is a transient febrile illness that occurs after inhalation of cadmium oxide fumes.
- Cadmium fume pneumonitis is a serious complication leading to hypoxia and occassionally death.
- Ingestion and inhalation of cadmium can produce other toxicity that is distinct from cadmium fume fever (see SECTION IV, Cadmium chapter).
FORMS AND USES
- Cadmium has broad industrial uses, ranging from the electroplating of steel, to antifriction bearings, to solder used in welding and brazing.
- Cadmium oxide is odorless. Poisoning can occur at concentrations too low to cause respiratory irritation.
- Cadmium oxide fumes result from burning cadmium in processes such as welding, heat-cutting, brazing, silver-soldering cadmium-plated or cadmium-containing metals, smelting, and refining.
TOXIC DOSE
Inhalation of cadmium oxide at a concentration of 40 mg/m3 may be lethal.
PATHOPHYSIOLOGY
- Fumes of cadmium oxide cause direct injury to the lung.
- Symptoms typically develop over several hours as inflammation develops.
EPIDEMIOLOGY
- Poisoning is uncommon.
- Toxic effects following inhalation are typically mild to moderate, with death occurring in high-concentration exposures.
CAUSES
Toxicity usually results from occupational exposure.
WORKPLACE STANDARDS
NIOSH. IDLH is 9 mg/m3.
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Toxic causes of delayed pulmonary injury after inhalation exposure include phosgene, phosphine, other types of metal fume fever, oxides of nitrogen, and various types of metals.
SIGNS AND SYMPTOMS
- The physical examination may be initially unremarkable.
- The patient usually presents several hours after the initial inhalation exposure with flulike complaints such as upper airway irritation (cough, shortness of breath) headaches, nausea, chills, fever, and weakness.
- The onset of chest pain and dyspnea is often delayed for 24 to 36 hours.
- Severe cases. Within 72 hours and continuing up to 10 days, chest pain, dyspnea, cough, hemoptysis, wheezing, tracheobronchitis, pulmonary edema, and respiratory failure may occur. Approximately 20% of all cases are fatal.
Vital Signs
Tachycardia, tachypnea, and hypoxia may develop.
HEENT
Anosmia has been reported following chronic exposure.
Pulmonary
After an initial asymptomatic period, the effects range from mild sore throat irritation to severe dyspnea associated with hemorrhagic pulmonary edema that may be fatal.
PROCEDURES AND LABORATORY TESTS
Essential Tests
Arterial blood gases or pulse oximetry, chest radiograph, and pulmonary function tests should be performed in symptomatic patients.
Recommended Tests
- Analysis of the fumes or the material being used is the best method for determining the cause of the pneumonitis.
- Blood or urine cadmium levels above 5 µg/L suggest excessive exposure.
- Urinary beta-2-microglobulin levels may be elevated.
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Treatment should focus on supportive care with appropriate airway management.
DIRECTING PATIENT COURSE
The health-care professional should call the poison control center when:
- Severe or persistent effects develop.
- Drug interaction or underlying disease presents an unusual problem.
The patient should be referred to a health-care facility when:
- Patient or caregiver seems unreliable.
- Toxic effects develop.
- Drug interaction or underlying disease presents an unusual problem.
Admission Considerations
Inpatient management is warranted for any patient with a history of possible cadmium fume inhalation or who presents with dyspnea, cough, chest pain, hemoptysis, wheezing, tracheobronchitis, pulmonary edema, or respiratory distress.
DECONTAMINATION
- The patient should be moved to fresh air and 100% oxygen should be administered.
- Exposed skin and eyes should be copiously flushed with water.
ANTIDOTES
- There is no specific antidote available for cadmium poisoning.
- Chelation. There are no clear data to support the use of chelation therapy for acute inhalation of cadmium.
- Some investigators propose that immediate treatment with ethylenediaminetetraacetic acid (CaNa EDTA)may be effective.
- Adult dose is 75 mg/kg/day in 3 to 4 divided doses for 5 days, not to exceed 500 mg/kg. The course is repeated once after a drug-free period of 2 days.
ADJUNCTIVE TREATMENT
- If bronchospasm is evident, treatment with inhaled sympathomimetic agents should be considered.
- Aggressive pulmonary care for pneumonitis should be provided.
- Adequate ventilation and oxygenation should be maintained with close monitoring of arterial blood gases.
- Positive end-expiratory pressure in intubated patients or continuous positive airway pressure in nonintubated patients may be necessary.
- Based on anecdotal experience, some clinicians recommend early administration of methylprednisolone, 1 g intravenously as a single dose, in an attempt to prevent the later development of pulmonary edema.
- An antibiotic is indicated when there is evidence of infection.
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PATIENT MONITORING
- Continuous cardiac and respiratory monitoring should be performed in symptomatic patients.
- Long-term follow-up including pulmonary function tests may be required.
EXPECTED COURSE AND PROGNOSIS
- If the patient survives the acute exposure, a restrictive ventilatory defect may persist.
- The restrictive impairment improves over time with the greatest improvement in the first 3 months.
DISCHARGE CRITERIA/INSTRUCTIONS
Asymptomatic patients may be discharged after a 12 hour observation period and documentation of normal or baseline pulmonary function.
Section Outline:
ICD-9-CM 985.5Toxic effect of other metals: cadmium and its compounds.
See Also: SECTION III, Ethylenediaminetetraacetic Acid chapter; SECTION IV, Metal Fume Fever.
RECOMMENDED READING
Barnhart S, Rosenstoele L. Cadmium chemical pneumonitis. Chest 1984;86:789-791.
Author: Luke Yip
Reviewer: Ed Kuffner