Steam Vaporizer Injuries

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PEDIATRICS Vol. 67 No. 5 May 1 981 661

Steam

Vaporizer

Injuries

John

L. Colombo,

MD,

Robert

L. Hopkins,

MD,

and

William

W. Waring,

MD

From the Department of Pediatrics, Section of Pulmonary Diseases, Tulane University School of Medicine, New Orleans

ABSTRACT. There were an estimated 656 cases of Va-porizer-related injuries seen in hospital emergency de-partments in 1979. Two cases of burns with respiratory

involvement are described. Both children were directly exposed to steam from commercial vaporizers and

suf-fered cutaneous and respiratory burns. These cases

em-phasize the hazards ofsteam vaporizers, devices that have

no proven therapeutic benefits. Pediatrics 67:661-663, 1981; steam vaporizers, burns, accidents, respiratory tract burns, inhalation injury.

The use of steam and cool-air vaporizers for symptomatic therapy in upper airway infections is

quite common, but there is little evidence to support their efficacy.’ There are also few reports of acci-dents involving these devices.2 However, the Con-sumer Product Safety Commission estimates that 656 cases of vaporizer-related injuries were seen in hospital emergency departments in 1979. This a!-most certainly underestimates the total number of such injuries. The following two cases ifiustrate the hazards of steam vaporizers. The apparent

respira-tory tract injury is emphasized.

CASE REPORTS

Case 1

A 13-month-old black girl was admitted for treatment

of burns on the face, neck, and shoulders (Figure). She

had had a one-week history of symptoms of upper respi-ratory tract infection including cough and nasal

conges-tion. On the night of admission, the mother had placed a

steam vaporizer next to the child’s crib for treatment of her upper respiratory tract symptoms. The child

over-Received for publication April 21, 1980’, accepted Aug 27, 1980. Reprint requests to (J.L.C.) Department of Pediatrics, Section

of Pulmonary Diseases, Tulane University School of Medicine,

1430 Tulane Aye, New Orleans, LA 70112.

American Academy of Pediatrics.

turned the vaporizer, spilling the hot water on herself.

The only significant past medical history was a heart murmur. There was no history of congestive heart failure

or pulmonary disease.

Taking of vital signs revealed a temperature (rectal) of

38.4 C; pulse, 200 beats per minute; and respiratory rate, 60/mm. There were second-degree burns of the face and left shoulder. The child’s cry was quite hoarse. There was a grade 4/6 holosystolic heart murmur. Mild intercostal retractions were present, and auscultation revealed

sup-pression of breath sounds over thc superior segment of

the right lower lobe. Inspiratory crackles were heard in

the right lower lobe, and inspiratory and expiratory wheezes were heard over all bronchopulmonary

seg-ments. A chest roentgenogram showed atelectasis of the

posterior segment of the right upper lobe and atelectasis

with infiltration of the superior segment of the right lobe. The cardiac silhouette was enlarged. Arterial blood gas

measurements on room air were pH 7.40, Pao, 81 mm

Hg; and Paco2, 37 mm Hg.

The patient became afebrile 12 hours after admission and remained so for the duration of hospitalization. Med-ical treatment consisted of chest percussion and postural

drainage, administration ofaerosolized isoproterenol, oral

theophylline, and intravenous penicillin, and topical burn therapy. Wheezing worsened during the first 36 hours and then resolved over the next 72 hours. The crackles and

suppression resolved five days after admission. After

three weeks the child was discharged in good condition.

Case 2

A 2-year-old black boy was admitted because of facial burns that had occurred after his mother told him to hold

his face near the outlet of a steam vaporizer. The

vapor-izer was being used to treat his symptoms of an upper respiratory tract infection. The child began to cry and the mother noted erythema of the face and neck. There was a history ofasthma, but according to the mother the child had not wheezed during this illness.

Vital signs taken on admission included temperature of 38.4 C; pulse, 160 beats per minute; and respiratory rate, 34/mm. The child had second-degree burns of the face, and third-degree burns of the neck. His voice was hoarse and he had a croup-like cough. Expiratory wheezes were heard but there were no retractions.

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Figure. Burns from steam vaporizer.

662 STEAM

VAPORIZER

INJURIES

Results of the chest roentgenogram were normal.

Ar-terial blood gas measurements on room air were pH 7.44;

Paco2, 36 mm Hg; and Pao2, 62 mm Hg. When the patient

was given supplemental oxygen (fractional inspiratory

oxygen = 0.30) the arterial blood gas values were pH 7.47;

Pao2, 77 mm Hg; and Paco2, 35 mm Hg.

The patient became afebrile the morning after admis-sion and remained afebrile for the rest of the

hospitali-zation. Therapy with intravenous aminophylline,

dexa-methasone, and cephalothin was administered. On the

second hospital day the child had difficulty in swallowing, and this difficulty persisted for approximately 48 hours. The wheezing worsened 36 to 48 hours after admission,

was most pronounced on the third hospital day, and then

gradually resolved over the next four days. A thorough investigation by a child protection agency failed to

dem-onstrate malicious intent by the mother.

DISCUSSION

Since the time of these patients’ admission, two more children have been admitted to Charity Hos-pita! of New Orleans with severe burns from

vapor-izer accidents, a total of four such mishaps in a three-month period. The latter two children

in-curred cutaneous burns as a result of spilling Va-porizer contents on themselves. They had no facial burns or respiratory symptoms.

The two patients in this report were especially interesting because of the respiratory tract involve-ment. Both children had a history of

cardiopulmo-nary problems but neither had had audible

wheez-ing, hoarseness, or symptoms of congestive heart

failure immediately prior to the accidents. The first

patient had had no other known episodes of

wheez-ing, which makes it unlikely that this episode was

only an isolated attack of asthma. Clinical findings

and results of chest roentgenograms were not con-sistent with bronchiolitis in either patient.

Actual thermal injury to the lungs from flame or

dry hot air is rare. The upper respiratory tract is

usually able to protect the lungs from this type of

insult. Thus, injury with dry heat is usually limited to the upper tract. Inhalation of steam, however, which has a greater heat-carrying capacity than dry air, can produce severe pulmonary injury.4 Reports

ofsteam inhalation in human beings are rare. Brink-man and P#{252}schel5 reported severe thermal lung injury in 27 men secondary to steam inhalation following the explosion of a ship’s boiler. They found pathologic changes of coagulation necrosis of tracheal and bronchial walls, and lung parenchymal edema, desquamation, and hyaline membranes.

The second patient also illustrates the danger of cutaneous burns even from only brief exposure to steam. These burns can be extensive and can occur quite rapidly. Moritz et a!4 showed epithelial

necro-sis in dogs with one second exposure of the skin to

steam at 100 C.

Vaporizer therapy for pediatric respiratory

infec-tions is still quite common, although modem pedi-atric textbooks either do not mention it or mention only briefly the use of mist tent therapy for thinning

of mucus and for relief of spasmodic croup.8 To our knowledge there is no study that demonstrates the value of this form of therapy for upper respira-tory tract infections. Ultrasonic nebulizers have been shown to have both beneficial and detrimental effects on disease of the lower respiratory tract.8’9 Home vaporizers have no demonstrated benefits and may indeed have deleterious effects on airway resistance and flow rates. These effects are caused by aerosol stimulation of irritant receptors in the

upper irw#{176}’ A recent editorial9 reviewed the controversy surrounding the use of mist and aerosol therapy. With the exclusion of thermal injuries, controversial points include ( 1) site and volume of

particle deposition in the respiratory tract, (2) ef-fects of aerosolized water on mucociiary clearance, (3) adverse effects of aerosols on airway function,

and (4) bacterial contamination of humidifiers and other cool mist-producing equipment.

Despite the controversy surrounding the benefits

of vaporizer therapy, certain hazards are clear.

These include (1) burns, (2) electrical shock, and

(3) exposure to devices that may serve as a reservoir

for pathogenic bacteria.

In our opinion, the use of steam vaporizers is not

justified in view of their risk/benefit ratio, and

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ARTICLES 663

physicians caring for children should urge parents

not to use them.

ACKNOWLEDGMENTS

This work was supported in part by a Pediatric

Pul-monary Center grant from the Office of Maternal and

Child Health, Public Health Service and a Care, Teaching

and Research Center grant from the Cystic Fibrosis Foun-dation.

The authors thank Gillian Brown, PhD, Darlene

Blan-chard, RN, MS, Diana M. Joseph, and Holly A. Brandon

for their help in the preparation of this manuscript.

REFERENCES

1. Parks CR: Mist therapy: Rationale and practice. J Pediatr

76:305, 1970

2. Barich DP: Steam vaporizers-Therapy or tragedy?

Pedi-atrics 49:131, 1972

3. US Consumer Product Safety Commission, National Injury

Information: 1979 Annual Report, Part 1, 1979, p 27

4. Moritz AR, Henriques FC, McLean R: The effects of inhaled

heat on the air passage and lungs. Am J Pathol 21:31 1, 1945 5. Brinkman B, P#{252}schel K: Heat injuries to the respiratory

system. Virchows Arch Pathol Anat 379:299, 1978

6. Stern RC: Acute spasmodic laryngotracheobronchitis, in

Vaughan VC III, McKay Ri, Behrman RE (eds): Nelson

Textbook of Pediatrics, ed 1 1. Philadelphia, WB Saunders Co, 1979, pp 1195-1196

7. Frick OL: Bronchial asthma, in Rudolph AM (ed):

Pediat-rics, ed 16. New York, Appleton-Century-Crofts. 1977, p 351

8. Tooley WH, Lipow HW: Spasmodic croup, in Rudolph AM

(ed): Pediatrics, ed 16. New York, Appleton-Century-Crofts,

1977, p 1556

9. Taussig LM: Mists and aerosols: New studies, new thoughts,

editorial. J Pediatr 84:619, 1974

10. Josenhans WT, Melvill GN, Ulmer WT: Effects of humidity

in inspired air on airway resistance and functional residual

capacity in patients with respiratory diseases. Respiration

26:435,1969

11. Kaufman J, Wright GW: The effect of nasal and

naso-pharyngeal irritation on airway resistance in man. Am Rev

Respir Dis 100:626, 1969

SECRETION OF ANTIDIURETIC HORMONE (ADH) IN MENINGITIS

Cerebral edema contributes significantly to morbidity and mortality in men-ingitis. Of 124 children with bacterial meningitis 72 had serum sodium <135 mEq/liter on admission. This was likely due to inappropriate ADH. Sequelae of meningitis (abnormal postmeningitis neurologic examination, seizures, subdural effusions) were more common in low sodium group, and the longer the serum sodium remained low the more common the sequelae as well as the longer the level of consciousness was depressed. Careful attention to fluid balance may minimize these sequelae.

Comment: Vigorous rehydration of infants and children with meningitis is contraindicated. The dangers of cerebral edema exceed the dangers of mild to moderate dehydration and rehydration should proceed cautiously. (R.H.R.)

I Abstracted from Feigin RD, et al: Inappropriate secretion ofantidiuretic hormone (ADH) in children

with bacterial meningitis (Am J Cliii Nutr 30:1482, 1977).

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1981;67;661

Pediatrics

John L. Colombo, Robert L. Hopkins and William W. Waring