Thermal injury after “huffing” compressed air duster: a case report

Abstract

Recreational abuse of compressed air duster has been associated with cardiac toxicity, central nervous system depression, local tissue damage, seizures, and death. We describe a 30-year-old man who reported huffing four bottles of canned air duster to “get high.” In addition to blistering on his dominant hand, he developed pain and swelling of the lips and tongue, followed by difficulty speaking and swallowing. He underwent endotracheal intubation for anticipated airway failure and was treated for an allergic reaction. Fiberoptic bronchoscopy and computed tomography scan of the neck demonstrated unaffected posterior oropharynx and airways. He was extubated on hospital day 2 and subsequently made a full recovery. Patients with oropharyngeal and dermal injury after abuse of compressed air duster are likely suffering a thermally-mediated injury. Outcomes are generally good with minimal intervention. Routine treatment for an allergic reaction is unnecessary.

Keywords:

• Angioedema
• compressed air
• 1,1 difluoroethane
• inhalant
• huffing
• thermal injury
• case report

Background

Abuse of hydrocarbons such as household canned air dusters (e.g. Dust-off^™) is common in the United States. A recent National Survey on Drug Use and Health (NSDUH) report found a rise in respondents reporting abuse of inhalants such as canned air duster from 1.8 million in 2015 to 2.2 million in 2021. In 2021, one-third of inhalant users were adolescent males (ages 12 to 17 years), and 2.4% of adolescent respondents to the NSDUH admitted to abuse of inhalants in the previous year [1,2]. These data may underestimate the scope of this problem as inhalant abuse is difficult to assess given the young age of typical users, the broad availability of products, and stigma associated with reporting usage.

Inhalation of volatile gasses found in common household computer dust cleaners is performed as a means to achieve a brief euphoric effect, or “get high.” Abuse by inhalation can involve spraying contents of the container directly into mouth or nares (“dusting”) or inhaling the contents of the container after first transferring the aerosol to a bag or other container (“bagging”). These methods vary the concentration and potential hazards associated with inhaling hydrocarbons.

Fluorinated hydrocarbon (e.g. 1,1 difluoroethane, 1,1,1,2 tetrafluoroethane) propellants found in computer dusters may produce euphoria when abused. These effects may involve the stimulation of gamma-amino-butyric acid (GABA) receptors or antagonism of central N-methyl-D-aspartate (NMDA) receptors [3].

Serious consequences of abusing fluorinated hydrocarbons may include local skin irritation/dermatitis, arrhythmias (due to sensitization of the myocardium), and death [4]. Orofacial edema and airway compromise have occasionally followed abuse of compressed air. Currently there is no consensus on the pathophysiology of this process. Some authors have proposed a thermal mechanism of this injury for this while others suggest bradykinin-mediated angioedema [5–7].

We describe a case of a young man who developed swelling and ulceration of his lips and tongue, with similar injuries affecting his dominant hand, after abuse of a compressed air duster. The patient gave consent for this case report.

Case report

A 30-year-old man with a history of alcohol use disorder presented to an ED with progressive swelling of the tongue and lips that had begun 12 h previously. He admitted to inhalational abuse of four cans of Walmart^™ brand compressed air duster (1,1 difluoroethane) five hours prior to “get high.” The patient had pain, swelling and blistering of the lips and progressive difficulty breathing, speaking and swallowing. The history was obtained with assistance from the patient’s mother as he had difficulty speaking.

His initial vital signs were normal. On physical examination, he had marked edema and blistering of both upper and lower lips with associated intraoral edema and tongue swelling (Figure 1). He spoke with a muffled voice but was tolerating secretions and had no inspiratory stridor or wheezing. He had ulceration of the middle finger of his dominant hand (Figure 2). Comprehensive metabolic panel and complete blood count were normal except for hemoglobin 10.3 g/dL, platelet count 430 cells/mm³, and elevated activities of AST (103 IU/L), ALT (65 IU/L), and alkaline phosphatase (103 IU/L).

Figure 1. Angioedema of lips.

Figure 2. Ulceration of finger.

The ED physician had immediate concern for airway compromise. The patient received diphenhydramine 50 mg, epinephrine 0.3 mg, famotidine 20 mg and methylprednisolone 125 mg with no improvement in symptoms or examination. General surgery and anesthesia teams were called to the bedside for intubation. Video laryngoscopy showed no abnormality of the upper airway or posterior oropharynx. The patient transferred to an intensive care unit (ICU) where he underwent same day laryngoscopy and bronchoscopy again showing a normal posterior oropharynx and airways. A computed tomography (CT) scan of the neck showed only swelling of the soft tissue of the lips. CT of the thorax revealed a left lower lobe opacity consistent with atelectasis.

The patient was extubated on hospital day 2 without complication. He was continued on oral dexamethasone and mouthwash comprising diphenhydramine, lidocaine, Maalox^® for his oral edema. He required opioid analgesics for painful lips and tongue. Over several days his swelling and pain improved, and at the time of discharge on hospital day 5 he had passed a speech and swallow evaluation, had adequate oral intake, and had satisfactory pain control with oral analgesics. He went home with an additional three-day prescription for dexamethasone. On follow-up one week later, the patient was doing well with no additional complaints, and he ultimately made a full recovery.

Discussion

Our patient’s history, physical exam findings and clinical course are similar to prior reports of soft tissue injury after inhalation abuse of canned air duster. We believe that blistering on his dominant hand, and swelling and blistering of oral mucosa and lips are more consistent with a thermal injury pattern than an allergic or bradykinin-mediated reaction. Several prior reports of dermal and mucosal injuries after abuse of air duster describe similar injury patterns that are likewise localized and geographic [5,6,8–12]. One would expect a more diffuse or generalized effect from a bradykinin- or allergy-mediated process. Four of six previously reported cases also note focal bullae and blistering of hand or digits, presumably due to direct exposure to the abused substance [8–11]. Additionally, one patient in our literature search had a biopsy of a lesion performed and the microscopy was most consistent with thermal injury [10]. Altogether, these findings suggest that the mechanism of injury in these cases is thermally-mediated.

As in previous cases, our patient received steroids, epinephrine and antihistamines out of concern for an allergic process. His early, aggressive intubation ultimately proved unnecessary. Most similar patients will not require invasive airway maneuvers, with only one of six cases sustaining injuries that truly required invasive ventilation [5].

One previous patient did not receive common treatments for an allergic reaction and recovered fully without complications [10]. It is therefore unclear that these patients benefit from steroids, antihistamines and epinephrine.

Several cases describe dermal effects after exposure to other compressed gasses. Three cases described abuse of airbrush propellant (fluorinated and/or chlorinated hydrocarbons), and these patients demonstrated more severe injuries [13–15]. One patient had injuries isolated to the anterior oropharynx and required wound care only [15], but two patients suffered extensive injury to the posterior oropharynx and proximal airways and required endotracheal intubation [13,14]. The latter patients required extensive wound care and debridement, and one of them required tracheostomy and gastric tube placement [13,14]. The patient with the most severe injuries had experienced loss of consciousness from the inhalant, resulting in the entire contents of the canister being released into his oropharynx [13]. One possible explanation for more severe injuries in these cases may be the greater flow and/or pressure of compressed gas that air-brushing tools can produce.

One patient abused chlorodifluoromethane, or “Freon^®” gas, from an air conditioning unit [16]. His injuries were isolated to the lips, cheeks, and gums. He did well after treatment with steroids and antibiotics. A patient abusing liquefied nitrous oxide (used for automotive combustion engines) developed edema and blistering of hands and face [7]. He also developed swelling of the posterior oropharynx and upper airways resulting in hypoxemia and requiring fiberoptic orotracheal intubation. The authors suggested that factors contributing to his severe presentation were the high pressure of the canister (950 psi or 6550 kPa) resulting in barotrauma and the sulfur dioxide additive which may have caused bronchoconstriction and airway edema.

Most oropharyngeal injuries in patients who are “huffing” canned air duster will resolve after basic wound care and analgesia (Table 1). In contrast to patients abusing spray paint propellant or “Freon^®” gas, patients who are “huffing” canned air duster are unlikely to experience severe airway-threatening effects. The one patient who experienced severe effects from “huffing” demonstrated extensive burns to his external face and neck associated with underlying soft tissue swelling. External findings of more complex cutaneous burns may indicate more severe underlying soft tissue injuries. Fiberoptic endoscopy is useful to assess for significant airway involvement.

Table 1. Primary literature case reports describing airway injury after abuse of compressed air duster.

Reference	Patient	Route of exposure	Clinical presentation	Interventions	Complications	Outcome
Winston et al. [5]	40 y/o M	Inhalational abuse of air duster (1,1 difluoroethane)	Severe swelling of upper and lower lip, blistering of oral mucosa and posterior oropharyngeal edema.	Antibiotics, steroids, and antihistamines.	Emergency intubation in the OR	Recovered
Kurniali et al. [6]	25 y/o M	Inhalational abuse of aerosolized difluoroethane computer air duster	Syncope, upper and lower lip swelling with inspiratory stridor, hypoxia, and QT prolongation.	Racemic epinephrine, and supplemental oxygen.	None	Recovered
Koehler et al. [8]	20 y/o M	Inhalational abuse of HFC 134a (tetrafluoroethane) computer air duster	Pain, edema and blistering of the lips, cheeks and tongue. Extensive geographic circumferential bullae of the digits of the left hand.	Steroids, antihistamines, epinephrine, lancing of bullae, topical clobetasol and bacitracin.	None	Recovered
Lasala et al. [9]	15 y/o M	Inhalational abuse of computer air duster (unspecified)	Edema and bullae of the lips, hand and thigh.	Steroids, antihistamines and epinephrine.	None	Recovered
Honari et al. [10]	15 y/o M	Inhalational abuse of air duster (1,1 difluoroethane)	Edema of the lips and tongue with bullae on the lips and fingers.	None	Intubation	Recovered
Trautman et al. [11]	22 y/o M	Inhalational abuse of computer air duster (unspecified)	Swelling and blistering of lips and hand.	Steroids, antihistamines and epinephrine.	ICU admission, plastic surgery consultation for wound care	Recovered

Conclusion

Our patient had swelling and blistering of the lips and tongue after “huffing” canned air duster. These injuries are most likely thermally mediated. Routine treatment of allergic reaction or angioedema in these patients is not necessary. Most patients will do well with basic wound care and pain control, and severe airway injury appears rare.

Author contributions

Both Dr. Dorey and Mr. Katz contributed significantly to the concept and design of this article, the review of relevant literature, and the drafting and revising of the paper. Both Dr. Dorey and Mr. Katz have given final approval for publication of this draft and are accountable for all aspects of the report herein.

Acknowledgments

The authors would like to thank the staff of the University of Utah Eccles Health Sciences Library for their assistance with the literature review. The authors would also like to thank our colleagues at the Utah Poison Control Center for their interest in and support of this project.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data which support the findings in this article are available from the corresponding author upon reasonable request [AD]. These data are not publicly available as they contain protected patient information.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.