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QJM Advance Access published online on July 22, 2006
QJM, doi:10.1093/qjmed/hcl065
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© The Author 2006. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: Journals.permissions@oxfordjournals.org
Received January 17, 2006
Accepted April 4, 2006

Original Papers

Respiratory failure in acute organophosphorus pesticide self-poisoning

M. Eddleston 1 *, F. Mohamed 2, J.O.J. Davies 3, P. Eyer 4, F. Worek 5, M.H.R. Sheriff 2, and N.A. Buckley 6

1 From the Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK; From the South Asian Clinical Toxicology Research Collaboration (www.sactrc.org), Sri Lanka; From the Ox-Col Collaboration, Department of Clinical Medicine, University of Colombo, Sri Lanka
2 From the South Asian Clinical Toxicology Research Collaboration (www.sactrc.org), Sri Lanka; From the Ox-Col Collaboration, Department of Clinical Medicine, University of Colombo, Sri Lanka
3 From the South Asian Clinical Toxicology Research Collaboration (www.sactrc.org), Sri Lanka; From the Department of Intensive Care, St Thomas's Hospital, London, UK
4 From the South Asian Clinical Toxicology Research Collaboration (www.sactrc.org), Sri Lanka; From the Walther Straub Institute of Pharmacology and Toxicology, Ludwig Maximilian's University, Munich, Germany
5 From the South Asian Clinical Toxicology Research Collaboration (www.sactrc.org), Sri Lanka; From the Bundeswehr Institute of Pharmacology and Toxicology, Munich, Germany
6 From the South Asian Clinical Toxicology Research Collaboration (www.sactrc.org), Sri Lanka; From the Department of Clinical Pharmacology & Toxicology, Canberra Clinical School, Canberra, Australia

* To whom correspondence should be addressed.
M. Eddleston, E-mail: eddlestonm{at}eureka.lk


  Abstract

Background: Acute organophosphorus (OP) pesticide poisoning is a major clinical problem in the developing world. Textbooks ascribe most deaths to respiratory failure occurring in one of two distinct clinical syndromes: acute cholinergic respiratory failure or the intermediate syndrome. Delayed failure appears to be due to respiratory muscle weakness, but its pathophysiology is unclear.

Aim: To describe the clinical patterns of OP-induced respiratory failure, and to determine whether the two syndromes are clinically distinct.

Design: Prospective study of 376 patients with confirmed OP poisoning.

Methods: Patients were observed throughout their admission to three Sri Lankan hospitals. Exposure was confirmed by butyrylcholinesterase and blood OP assays.

Results: Ninety of 376 patients (24%) required intubation: 52 (58%) within 2 h of admission while unconscious with cholinergic features. Twenty-nine (32%) were well on admission but then required intubation after 24 h while conscious and without cholinergic features. These two syndromes were not clinically distinct and had much overlap. In particular, some patients who required intubation on arrival subsequently recovered consciousness but could not be extubated, requiring ventilation for up to 6 days.

Discussion: Respiratory failure did not occur as two discrete clinical syndromes within distinct time frames. Instead, the pattern of failure was variable and overlapped in some patients. There seemed to be two underlying mechanisms (an early acute mixed central and peripheral respiratory failure, and a late peripheral respiratory failure) rather than two distinct clinical syndromes.


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