Chronic Carbon Monoxide Poisoning

What is Chronic CO2 Poisoning?

“Chronic” generally refers to a condition that persists over a long period of time; however, chronic carbon monoxide poisoning refers to the duration of exposure rather than that of the residual effects. The division between acute and chronic exposure is not distinct, but chronic cases generally involve multiple instances of exposure over a longer period.

CO concentrations experienced are relatively low, and exposure produces lower carboxyhemoglobin (COHb) levels in the bloodstream. Because the exposure is less intense, CO2 leak symptoms can be less severe at the onset than with cases of acute CO poisoning and possibly mistaken for other chronic conditions. However, the effects over time can still cause damage to the body, and even the more minor symptoms can disrupt one’s daily life. Additionally, a minor CO leak can precede a more drastic one, so identifying the condition can allow preventative measures to be taken.

Chronic CO poisoning usually involves lower levels of the gas in the air and lower blood CO (COHb) concentrations. Exposure usually continues for many days to months. The boundary limit between acute and chronic exposure is indistinct.

The word chronic should be reserved to describe the type of exposure, not the subsequent condition or effect! A damaging effect of CO poisoning, or in fact, any change which persists, should be referred to as a residual effect.

Chronic CO poisoning may not elicit the typical symptoms of (acute) CO poisoning such as a headache, nausea, weakness, dizziness, etc. Mucous membranes of the body will rarely be cherry pink. Chronic CO poisoning is often misdiagnosed as chronic fatigue syndrome, a viral or bacterial pulmonary or gastrointestinal infection, a “run-down” condition, immune deficiency, etc. Patients may occasionally present with polycythemia, increased hematocrit, etc.

Chronic CO poisoning is, in fact, difficult to diagnose by those not skilled in its presentation. As stated above, it is often mistaken for chronic fatigue syndrome, viral or bacterial pulmonary or gastrointestinal infection, excessive heat, etc. Similar symptoms are seen simultaneously in more than one person, and which disappear upon removal from an environment are tip-offs that CO is involved. COHb is usually not excessively elevated. More often than not, by the time air CO or blood CO levels are measured, the presence of CO in the environment has been corrected, making measurement impossible. Computed tomography (CT) and magnetic resonance imaging (MRI) generally show no lesion, even when psychological/psychiatric and neurologic evaluations may detect functional deficits.

This is a subject about which many exciting new data have become available during the past 2 years. Summaries of some of these dates are seen on this website. A body of animal data is also available which is of some value in understanding and predicting human responses. See the very useful British study by CO Support and the other studies contained in the section called Chronic CO Poisoning.

Definitions of Types of Co-Exposure

Acute CO Poisoning – Exposure to CO occurs only once and lasts no longer than 24 hrs.

Chronic CO Poisoning –

• Exposure to CO occurs more than once and lasts longer than 24 hrs.
• Usually involves lower CO levels / lower COHb saturations
• Exposure usually continues for many days to months
• Boundary limit between acute and chronic exposure indistinct

Definition of the Word ‘Chronic

Chronic –

(Gk.) Khronos = time

(Lat.) Chronicus

(Fr.) Chronique
1) Of long duration

2) Subject to a habit or disease for a lengthy period
Syn. continuing, lingering, persistent, prolonged, protracted

Webster’s New College Dictionary, Houghton Mifflin Co., 1986.

The term chronic is sometimes used as in definition #2 – “A history of CO inhalation and an awareness of the typical distributions of lesions are important for recognition of the effects of CO poisoning, especially when patients are in the chronic stage.” (Uchino et al., 1994, Neuroradiology, 36, 399-401)
Note: In this condition, ie. chronic CO poisoning, we are concerned with how long the insult (exposure) lasts, not how long the resulting effects last.

A Paradox of CO Physiology:

Deleterious:

• It limits oxygen delivery, binds to intracellular energy generating system, kills cells, causes damage to tissues and organs, and kills people.

Natural / Helpful:

• It is generated by the human body as a by-product of hemoglobin metabolism
• Along with NO (nitric oxide), it is an integral part of the vascular control mechanism.
• Most blood vessels dilate as COHb increases, allowing more blood to flow through.

Elevated CO Concentrations are More Likely in:

• Smaller multi-unit dwellings
• Households using gas ranges for cooking
• Dwellings heated by gas wall furnaces

Low(er) CO Concentrations are More Likely in:

• Single-family dwellings
• Homes with forced-air furnaces
• Residences with electric cooking appliances

Table of Indoor Air Pollutant Concentrations

Pollutant	Concentration	Location / Condition
Carbon Dioxide	860 ppm	Lecture Hall
Carbon Dioxide	600 – 2500 ppm	Schoolroom
Carbon Dioxide	9000 ppm	Nuclear submarines
Carbon Monoxide	2.04 +/- 2.55 ppm	U.S. homes
Carbon Monoxide	2.5 – 28 ppm	Offices, restaurants, bars, arenas
Carbon Monoxide	3.1 – 7.8 ppm	Home kitchens with gas stoves
Carbon Monoxide	1 – 5 ppm	median outdoor conc. in cities, 1979
Carbon Monoxide	0 – 3 -27 ppm	Max. 1 hr. average outdoor conc.
Carbon Monoxide	0 – 3 – 22 ppm	max. 1 hr. average indoor conc.
Carbon Monoxide	20 ppm	Room polluted with cigarette smoke
Hydrogen Cyanide	56 ppb	Room polluted with cigarette smoke
Nitric Oxide	1.05 ppm	Room polluted with cigarette smoke
Nitrogen Dioxide	5 – 110 ppb	U.S. homes with gas stoves
Nitrogen Dioxide	5 – 317 ppb	English homes with gas cookers
Nitrogen Dioxide	20 – 66 ppb	Median outdoor conc. in cities, 1979
Nitrogen Dioxide	25 – 177 ppb	Homes, 48 hr. average
Nitrogen Dioxide	200 ppb	Room polluted with cigarette smoke
Ozone	2 – 68 ppb	Photocopying room
Ozone	2 – 18 ppb	Homes with electrostatic air cleaner
Ozone	7 – 60 ppb	Median outdoor conc. in cities, 1979
Ozone	0 – 700 ppb	Using an electronic air cleaner
Sulfur Dioxide	8 – 37 ppb	Yearly averages in Chicago & NY
Methane	2 ppm	Atmospheric air

Non-Fatal vs. Fatal CO Poisonings

Condition	Ratio
All	4.6
Vehicular	3.0
Furnaces (non-vehicular)	19

Thus, for every CO death due to a malfunctioning furnace, there are 20 non-fatal CO poisonings.

Estimates Based on Statistical Data: 2

• 5,700 – 10,000 people seen in emergency rooms for suspected CO poisoning, 1992-94.
• 200 CO-related fatalities during the same period.
• 7850 / 200 = 39.25

Thus, for every CO death, this suggests 39.25 people present to the ER for CO poisoning. How many more people with CO poisoning don’t go to the ER, and thus are not found in the record?

Symptoms of Occult CO Poisoning

• Headache
• Fatigue
• Dizziness
• Paresthesias
• Chest pains
• Palpitations
• Visual Disturbances

Occult – “hidden from view, secret, concealed, not pulged”. Most chronic CO poisoning is of this type, at least at first.

Paresthesias – “abnormal or morbid sensation, as with burning, prickling, etc., but without objective symptoms.

Subjective Symptoms

Symptom	Frequency %
Fatigue	92
Headache	87
Dizziness	69
Sleep Disturbances	66
Cardiac Symptoms	62
Apathy	54
Nausea, vomiting	42
Memory Disturbances	40
Reduced Libido	22
Loss of Appetite	17

From: Jain, K.K. (1990) Carbon Monoxide Poisoning, Warren H. Green, Inc., St. Louis, MO

The symptoms of carbon monoxide poisoning cover a moderate range in cases of chronic exposure. Fatigue, headaches, and dizziness are most commonly reported, and these can be linked to cardiac symptoms and disruptions of normal sleep patterns.

Many people experience lethargy, apathy, and a sense of listlessness or irritability; memory or information processing issues can occur as well. More rarely, patients may suffer from nausea or experience weakened libido and a loss of appetite. The onset of these symptoms can be subtle at first, and without context, they resemble chronic fatigue syndrome or minor endocrine disorders.

Symptoms DURING CO Exposure, Study A Symptoms Symptoms Symptoms Agitation Anxiety Apathy Appet. loss Ataxia Attention, loss Back Pains Bal. Probl. Body Ache Bronchitis Chest Tghtn./pain Choking Chr. Fatigue Conc. Probl. Confusion Constipat. Coolness Coordin. Probl. Cough, spells Cramps Depression Diaphragm Pain Diarrhea Disorientation Dizziness Drop Things Dysarthria Ear Problems Emot. Probl. Energy Level Extremities Cold Eye Pain/Ache Fatigue Fibromyalgia Flu-like symptom Flushed Forgetful G.I. Probl. Hair Loss Hallucinations Handwrit. Probl. Headache Hearing Probl. Hypertension Hypoglycemia ILL, violently in Fog Incontinence Insomnia Iron Level Low Irritability Learning Probl. Lethargy Libido Loss Lightheadedness Lips Red Liver Pain Memory Loss Mood Chgs. Moodiness Muscle Ache/Pain Nausea Neck Pain Nerve Deafness Numbness Palpitations Panic Attack Paralysis Paresthesias Personality Chng. Press. in Head Shortness of breath Seasick Seizure Shoulder Pain Sick Feeling Sinusitis Skin, Cherry Red Skin, Dryness Sleep Probl. Sleepiness Smile, convulsive Speaking Probl. Spelling Probl. Suicidal Sweats Syncope, part/all Tachycardia Throat, burng. sore Tingling legs/arms Tingling Lips Tinnitus Tiredness Tongue, thickened Tremor Twitching fingers Vertigo Vision Probl. Vomiting Walk, inability to Weakness Weight Loss Word-Finding Probl.

Symptoms AFTER (Since) CO Exposure, Study A Symptoms Symptoms Symptoms Acad. Probl. ADD Aggression Altr’d Consciousn. Amnesia Anxiety Arthritis Ataxia Attention, loss Bal. Probl. Body Ache Body Temp. Contr. Chest Tghtn./pain Choking Concn. Probl. Confusion Coordin. Probl. Cramps Depression Disorientation Dizziness Dysarthria Dystonia Ear Problems Emot. Probl. Energy Level Executive Func. Eye feels puffy Fatigue Fatigue, Chronic Fear Flu-like symptom Forgetful G.I. Probl. Hand Control Headache Hearing Probl. Heart Murmur Hypertension Hyperactive. Hypersent./MCS I.Q. Loss Impulsiveness Info. Proc./Slow Irrational Behav. Itching Joint Pain Kidney Probl. Learning Probl. Libido Loss Math, difficulty Memory Loss Mood Chgs. Motivation, lack of Muscle Ache/Pain Nausea Neck Pain Nervous Numbness Palpitations Panic Attack Paraphasias, literal Paraphasias, verbal Parkinsonism Periph. Neuropath. Personality Chge. Phonophobia Photophobia PMS heightened Reading Probl. Shortness of breath Sinusitis Skin, Hypers/touch Sleep Probl. Spasm Speaking Probl. Spelling Probl. Staring Spells Stiffness Stroke Tachycardia Talkative Temper, short Thinking Probl. Tingling legs/arms Tingling, Hands Tinnitus Tiredness Tremor Vision Probl. Vocabul. down Vomiting Weakness Word-Findg. Probl. Writing Probl.

Characteristics

• Often goes long undetected
• Masquerades as flu, fatigue, etc.
• Often many people “sick” simultaneously
• May go away upon leaving the poisoning site (to work, on vacation, etc.)
• Nearly always misdiagnosed by physicians
• May involve pets “sick”, dead at the same time
• Rarely involves sinus congestion, cough (when present, it may be due to other compounds {eg. NO_x, SO₂} in exhaust gases)

Clues to Discovery

• Lethargy, headache, etc. of long duration
• Long-standing “illness” intractable to medical solutions
• “Illness” that suddenly improves when leaving a site
• Multiple cases at one location
• Morbidity/mortality of pets
• CO alarm sounding, once or repeatedly
• Presence of malfunctioning furnace, water heater, etc.

Differences From Acute Poisoning

• may not elicit the typical symptoms of (acute) CO poisoning:
  • headache
  • nausea
  • weakness
  • dizziness
  • mucous membranes rarely cherry pink
• COHb is usually not excessively elevated
• CT and MRI are generally not useful

Common Misdiagnoses

• Chronic fatigue syndrome
• Viral or bacterial pulmonary or GI infection
• “Run-down” condition
• Endocrine problem
• Immune deficiency
• Psychiatric/psychosomatic problem
• Allergies
• Bad/tainted food

Problems in Dealing With Chronic CO Poisoning

• Fact of exposure usually recognized only later
• Good COHb level measurements usually not obtained
• Air CO level measurements often not obtained
• Residual effects commonly occur, but often subtle; thus usually unrecognized by physicians.
• Less medical/scientific literature available than for acute CO poisoning
• Seldom produces damage recognizable by high-tech scanning techniques (MRI, CT, SPECT)
• Changes were seen by neuropsychological testing usually most useful
• Considerable variability of effects from one inpidual to the next

Why is CO Poisoning Not Better Recognized by the Medical Profession?

While acute poisoning is more immediately recognizable, carbon monoxide leak symptoms are often misdiagnosed until after the fact. This can be attributed to multiple factors:

• • The symptoms that manifest often appear to be non-specific or easily linked to other conditions that are more common and less hazardous. “Pattern recognition” methods of diagnosis usually fail when presented with these cases. Without specific training for handling carbon monoxide poisoning and similar indoor pollutants, even practiced physicians can misdiagnose this.
  • Chronic CO poisoning doesn’t present itself as needing immediate treatment – the telltale signs of acute CO poisoning, such as mucous membranes turning pink and more dramatic symptoms, don’t arise. Measuring COHb content also requires specific equipment, such that CO poisoning must already be suspected, and the readings may resemble normal COHb levels.
  • Studies in chronic CO poisoning are hampered by the fact that common animal test subjects such as rats are significantly more resistant to CO than humans. Thus, the physiological and chemical causes of symptoms are poorly understood.

• Chronic CO poisoning usually involves lower levels of the gas in the air and lower blood CO (COHb) concentrations. Exposure usually continues for many days to months. The boundary limit between acute and chronic exposure is indistinct.

Long-term Effects (Based on CO Support Data)

• Tiredness, weakness
• Pains, cramps
• Headaches
• Nausea, sickness
• Loss of Concentration
• Dizziness
• Digestive Problems
• Cardiac Problems
• Flu Symptoms
• Difficulty Breathing
• Pins & Needles, Stiffness
• Vision Problems
• Memory Loss
• Personality, Emotional Problems
• Sleep Disturbance
• Mouth/Throat Problems
• Unable to Walk / Work
• Clumsiness
• Hallucinations, Zombie-like State
• Depression
• Panic Attacks
• Loss of Hearing
• Trembling

Furnace Concerns – U.K. vs. U.S.

Chronic carbon monoxide problems are potentially worse in the U.K. than in the USA, because of the many very old buildings and the past and present construction approach which consists of building solid walls, floors, and ceilings. This usually precludes the use of ducted forced air heating/cooling. Instead, buildings are fitted with “gas fires”, ie. gas heaters that are usually located in old fireplaces, exhausting into the fireplace chimney.

Problems with Gas Fires/Fireplaces

• Most use air from within living space for combustion
• Inadequate installation / maintenance
• Possible exposure of inhabitants to heat, flame, and fumes
• Possible leakage of unburned heating gas into living space

Other Specific Problems With Gas Fires

• Chimney outlet too low
• Cold chimney, leading to water condensation, then rusting of metal parts
• Exhaust fan creating negative pressure in living/combustion space
• Unusual geography near a chimney
• Wind conditions around a chimney
• Doors/windows open, additions to a structure

Exhaust Gas Removal

• Leakage of fumes from flue – masonry/metal/plastic (lined/unlined)
• Partial/complete blockage of flue – cement, condensates, birds nests, etc.
• Age of fire/furnace, flue, and chimney

Hypothetical Case Report

Mrs. Betty Jones is a 35-year-old homemaker. She and her husband George, 37 years old, live in a city in the midwest. She has an Associates’s degree in accounting, while her husband has a Master’s degree in Business Administration. Neither of them are smokers.

In early 1995, they purchased a home in a suburban community through a real estate brokerage company. The home was built in 1958. It was inspected and major appliances in the home were guaranteed for 5 years. The home has three bedrooms, a living room, a family room, and a glassed-in back porch. It is heated by a forced-air, natural gas furnace in the basement. Hot water is provided by a gas-fired water heater, also in the basement.

Beginning in the autumn of 1995, Betty Jones began having headaches and feeling very tired. Her two children, John (12 years of age) and Cathy (9 years of age), and her husband George occasionally awoke in the morning with headaches, dizziness, and nausea. They believed that they all had a touch of “flu” or had eaten tainted food.

Mrs. Jones continued to feel “out of it” for the remainder of 1995 and into the spring of 1996. Her physician, Dr. Blackstone, gave her a “physical”, obtaining chest X-rays, blood for complete CBC, and samples for a Pap smear test. He found nothing wrong, saying that “flu” has been going around. A furnace company that regularly serviced the heating system found “everything in good working order.”

During the summer of 1996, Betty Jones and the whole family felt much better, although she and the children continued to have frequent headaches and to feel slightly fatigued. They felt better when they went away on vacation for two weeks.

In late October 1996, Betty Jones again began to have frequent severe headaches and to become extremely fatigued. She was becoming so lethargic that she could not accomplish her normal housework. She was forgetting tasks that needed doing and finding it increasingly difficult to maintain the family checkbook. She was also feeling depressed and defeated in her daily life.

On several visits to Dr. Blackstone, she was told that there was nothing wrong with her. He said her perceived state was psychosomatic, and that she should seek counseling or schedule regular visits with a psychiatrist.

By spring 1997, the Jones’ children John and Cathy, previously excellent students, were on academic probation at school. John, a 7th grader, was in danger of failing and being held back a year. Cathy was now getting C’s and D’s in her classes in elementary school and her teachers were concerned. Mr. Jones, who all his life had been an ambitious and successful employee at a national insurance company, believed he now was in danger of being fired.

To gain extra space in their modest 1300 square foot home, the Jones family contracted to have a fourth bedroom added during the summer of 1997. Because the old furnace in the home was the original unit and would not be adequate to heat the new larger house, the contractor installed a new one. In doing so, he discovered that the heat exchanger in the old furnace was badly rusted through, that the near horizontal run of flue pipe to the chimney was also rusted through, and that the old brick chimney was oversize, unlined, and partially blocked near the top.

Upon learning of these problems, Mr. Jones asked that the old furnace be fired up and measurements of CO made by the gas company. He had recently seen a program on TV about the dangers of CO and wanted to be sure. With the family safely outside, CO levels in the house were observed to attain 176 ppm after one hour. The whole family then went to see Dr. Blackstone, who drew blood for the measurement of carboxyhemoglobin. COHb levels came back at between 0.5% and 1.4%. The physician, not familiar with the effects of the gas, told them that since the CO was now out of their bodies, they would be well again.

Mrs. Jones continued to suffer from severe headaches, fatigue, depression, and irritability. She also continued to have cognitive and memory problems and began to develop muscle and joint pain, to hear a buzzing sound in her head (Tinnitus), and to have various visual problems. Mr. Jones continued to find it difficult to do his job. He could not make decisions (loss of executive functioning) and lost track of details in his work. The children continued to struggle academically and socially – cognitive testing at school suggested recent significant declines in I.Q. in both children.

As of early 1999, the Jones family is attempting to recover from the health problems caused by their old, leaking furnace. They have been seen by a number of health professionals with varying results: neurologists, toxicologists, and neuropsychologists. To the Jones, it appears that few people in the medical community have much understanding of the long-term health effects of chronic CO exposure. They have retained legal counsel and are discussing options that might lead to compensation from responsible parties. Fortuitously, they have kept the old furnace, flue, and other parts as evidence.

What Important Points does this Case Illustrate?

• Have a thorough inspection when you buy a house, especially an older house.
• The multiple symptoms reported (headache, dizziness, nausea) should have increased suspicion of CO poisoning.
• Similar symptoms in several people should also increase suspicion of CO poisoning.
• A CO detector should have been purchased and installed in a home.
• The physician should have been strongly encouraged to promptly order COHb tests.
• Furnace and “gas” inspectors should always test for CO.
• Fatigue and lethargy combined with a headache are strong indicators of CO presence.
• If you can’t get satisfaction with one physician, see another – a G.P. or a specialist with experience in CO poisoning.
• While the leaking furnace, flue ducts, and faulty chimney were discovered by chance, Mr. Jones did the right thing to immediately have the house tested for CO.
• Blood samples for COHb measurement were taken way too late, ie. they must be done within 2-4 hrs. after leaving the site of the poisoning).
• The residual effects elicited by all members of the Jones family are consistent with chronic CO poisoning.
• The health effects of CO poisoning continue at least 1-1/2 years after the CO poisoning was discovered/ended.
• Mr. Jones was wise to have kept the faulty furnace, flues, and other parts, should legal action be necessary.