CARBON MONOXIDE TOXICITY - 2065
Book Review: Respiratory Care, July, 2002, vol. 47, No. 7
Carbon Monoxide Toxicity. David G. Penney, editor. Boca Raton, Florida: CRC Press, 2000. Hardcover, illustrated, 560 pages. $99.95
"This is the second book on carbon rnonoxide (CO) poisoning edited by Dr. David Penney. The first was Carbon Monoxide (Boca Raton, Florida: CRC Press; 1996), which covered CO analysis; formation, uptake, and elimination in humans; effects on the heart and lungs; effects on develpment in animals and humans; and how CO can impair learning, memory, neuropsychological function, and behavior. The first book also had a chapter dealing with delayed sequelae of and possible mechanisns of CO poisoning, as well as treatment of CO poisoning.
This new book, Carbon Monoxide Toxicity, which complements the first book, was released in 2000 by CRC Press. Most of the chapter contributors are different from those in tbe first text. There are chapters regarding the history of CO toxicology, the distribution af CO in various tissues and blood, and health-based standards for ambient CO levels. There are also chapters reviewing CO detectors, the effects of CO on exercise capacity, and the interacting effects of CO exposure with concomitant increased altitude exposure. Carbon monoxide can be associated with other toxic gases, and a chapter addresses that issue. There is a provocative chapter regarding the possibility that CO may be an unrecognized cause of neurasthenia. A series of chapters deals with the management of CO poisoning in the United States and other countries. The chapter about treatment of CO poisoning in the United States is wrinen by the same author as the similar chapter in tbe first text and updates that chapter. There is a discussion of scanning techniques to investigate brain damage from CO, as well as one on the effects of low-level CO exposure. Dr. Penney contributed a chapter on long-term CO poisoning, and there is a chapter regarding the Carbon Monoxide Support Study. The final chapters deal with neuropsychological evaluation of CO-poisoned patient, CO poisoning in children, CO's production, transport, and hazards in building fires, and approaches to dealing with CO in the livěng environrnent.
This text is 560 pages long und reviews CO toxicity in detail, but one needs to have both the 1996 book and this edition to have a foundation for understanding CO poisoning.
The intended readership is broad. Certainly, many health care providers would have an interest in this text, but, as well, patients suffering from CO-related sequelae, toxicologists, and even historians might find this book informative. Most of the book is written in language that respiratory therapists, nurses, and physiclans can understand.
As Dr. Penney states in the preface, one of the book's porposes was to discuss topics not covered by the first book, and in that he has been successful. The literature regarding CO poisoning is lengthy and complicated, but this text successfully organizes the infomation into a readable and well organized form, and each chapter is thorough and wel1 referenced. The material was apprapriately selected, and most of the data and arguments posed are clear and logical. Most of t'he conclusions posed by chapter authors are convincing, with the possible exception of the one regarding neurasthenia's relationship to CO poisoning. The text is relatively easy to read, although it is a lengthy text and takes some tlme to read in its entirety.
Regarding specific chapters, the first chapter is somewhat disorganized, but the information presented is difficult to find elsewhere, so this chapter is informative.
Chapter 2, regarding CO in breath, blood, and tissues, and the measurement, endogenous saurce, and biochemical effects of CO was interesting.
I found Chapter 3, regarding CO detectors and alarms, particularly informative and thought it well worth reading by anyone interested in the subject.
Although Chapter 4, which deals with the setting cf health-based standards for ambient CO and their unpact on atmospheric levels, presents substantial detail, I did not find this infomation particularly helpful as applied to understanding threshold levels for what should be considered toxic ambient CO exposures.
The chapter regarding CO on work and exercise capacity in humans is informative and very well referenced. The sentences are somewhat difficult to follow, but the information about how CO affects exercise was fascinating.
The information about interactions between altitude exposure and concomitant CO poisoning was of particular interest to me, since I have treated patients who suffered CO poisoning while residing at higher altitude.
Chapter 7, which deals with interactions among CO, hydrogen cyanide, low oxygen hypoxěa, carbon dioxide, and inhaled irritant gases, was stimulated by smoke-inhalation victims. Many assunnptions would have to be made to infer from such toxic exposures, which the author reviewed in detail. I was unaware of this information before reading this text and found this chapter helpful, although many of the assumptions may not necessarily be true with any given toxic inhalation. Nevertheless, the chapter is well thought out.
The review of CO poisoning and its management in the United States underscores how common CO poisoning is in this country and potentially how' under-recognized it is. This information is valuable and should help raise awareness of CO exposure and prevention, which is paramount.
The discussion about death by suicide (around the world) involving CO was interesting and sad. These suicide rates are linked to press events about suicide, and are also inversely related to improved emission standards in automobiles.
The chapter by Albert Donnay, regarding CO as a recognized cause of neurasthenia, is provocative, although I am not convinced that neurasthenia is linked to CO exposure. The neurasthenia hypothesis is intriguing and may be accurate, but it is difficult to prove conclusively. Donnay made reference to hand-held breathalyzers that can detect CO and might be a suitable screening method for CO poisoning, but those Breathalyzers have not been validated for that purpose, and the value of hand-held breath breathalyzers for determining CO poisoning remains to be determined.
For this book Suzanne R. White contributed a comprehensive update (to her chapter in the first text, Carbon Monoxide) on clinical treatment of CO paisoning. In the next few years, new infornation might modify current treatment recommendation, particularly regarding the role of hyperbaric oxygen therapy for CO poisoning.
Discussion about CO poisoning in other countries (including France, Poland, the United Kingdom, and major cities in China) encompasses the next several chapters. This information reminds us once again how common CO poisoning is and how it can adversely affect health. I.S. Saing Choi, who is well recognized in the field of neuroimaging and CO poisoning, offers a chapter on this subject and the role of magnetic resonance imaging and single photon emission computed Tomography. Dr. Choi makes an important point that the prognosis of CO poisoning depends an cerebtal white matter changes rather than those af the globus pallidus - that challenges same physicians' point of view. I agree with Dr Choi that brain MRI and spectroscopy are more sensitive than CT in detecting and evaluating brain damage due to CO poisoning.
The chapters by Robert D. Morris (low level CO and human health) and Dr. Penney (chronic CO poisoning) complement the chapter by Alistair W.M. Hay, Susan Jaffer, and Debbie Davis, '"Chronic Carbon Monoxide Exposure: The Catbon Monoxide Support Study." Studies of low-level CO exposure indicated that ambient CO levels may have an important adverse effects an persons with underlying heart disease. It is possible that sensitive subpopulations who are concurrently exposed to other stress factors, such as cold, may be affected by CO at concentrations previously thought to be safe. However, the exact CO levels that can cause disability in individual exposures remain unclear. Dr. Penney offers a working defimition for chronic CO poisoning, which is "an exposure to CO that occurs more than once and lasts longer than 24 hours." He also discusses the commonality of misdiagnosis of chronic CO poisoning. The information presented suggests that chronic CO poisoning could cause substantial morbidity. These points are somewhat substantiated by informnation presented by the chroric CO exposure study, in which questionnaires were distributed to patients following CO exposures.
Since CO is common and is associated wth permanent physical, cognětive, emotional, and psychological sequelae, the chapter regarding neuropsychological evaluation of the CO-poisoned patient is timely and helpful. This chapter reviews neuropsychological testing and the role of these tests in patients with CO-related sequelae. The chapter also includes sections regarding psychotherapy, psychiatric interventions, and neurocognitive rehabilitation, which can be potentially valuable for many patients suffering CO sequelae.
It is helpful that Dr White provided a chapter regarding pediatric CO poisoning. As expected, this chapter is thoroughly referenced.
There is a chapter that deals with C0 transport and flow patterns of gases within burning buildings. The final chapter discusses how CO exposure can be dealt with in the living environment. There are multiple possible sources of CO exposure all round us, and this chapter deals with those sources and how CO exposure can be minimized. The section regarding investigative techniques for identifying CO sources is also inforrnative, especially considering that CO exposure is common and may be under-recognized and and misdiagnosed.
Overall, the general appearance of the book is satisfactory. The incidence of typographical errors is low. The clarity of the Illustrations is appropriate. The index is thorough, and I found it relatively easy to use. The accuracy, timeliness, and coverage of the references, by all of the authors, are very good.
It is my opinion that this text complements the previous text, Carbon Monoxide, nicely. Sections within this text should be reviewed by physicians who see patients with CO poisoning or its sequelae. This text should also be available to emergency departments, respiratory therapists and nurses, and neuroscientists who may be seeing patients with CO poisoning. Patients who have had CO poisoning and its associated sequelae may also find chapters within this book helpful."
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