Smoke and Fire—1977

circulation press. Any academic or economic force which threatens the well-being of biomedical communication represents a crisis situation for all and should elicit the urgent concern of both the scientific community and controlled cirrulation publications. There are fundamental differences of purpose between controlled circulation periodicals and scholarly journals. Each type of publication pedorms important functions. Yet, scientific priorities exist and we dare not weaken the primacy of journals of clinical investigation. Their pages provide the material which is used by physician-interpreters and science writers in the formulation of clinical essays for the practitioner. The scienti6c editor, isolated from institutional pressures, is the guardian of the investigator, the teacher, and the practitioner. Editorial peer review associated with final independent judgment by the editor constitutes our best and most consistent protection of intellectual freedom and scientific integrity. I Alfred Soffer, M.D., F.C.C.P.

Park Ridge lb:FERENCE 1 Soffer A: 11le medical editor-a democratic despot. Arch Intern Med 137:149-150, 1977

Smoke and Rre-1977 This month's issue contains two reports which should be of interest to all physicians, partirularly those involved in pulmonary, critical care, and industrial medicine. The first, by Genovesi et al (see page 441 ) , is a study of a group of firemen in Los Angeles following their acute exposure to smoke and emphasizes the dangers of the asymptomatic and unexpected occurrence of hypoxemia and carboxyhemoglobinemia in individuals exposed to toxic products of combustion, partirularly in fires involving materials made of polyvinyl chloride. 1 All physicians should be aware of these two potential problems when treating victims of fires, making sure that oxygen is routinely administered as soon as possible and that the patient is observed carefully for ( 1 ) cerebral complications of the inhalation of carbon monoxide2 and ( 2) the respiratory insufficiency which may ensue after a deceptively tranquil interval.3 Cardiac, as well as pulmonary, systems are affected by the altered physiology which results from this toxic exposure, especially during early critical periods. This requires that the physicians involved know and be prepared to practice all of the

438 EDITORIALS

techniques for evaluation and treatment of the adult respiratory distress syndrome, noncardiac pulmonary edema, cardiac failure, airway injury, sepsis, lactic acidosis due to carboxyhemoglobinemia with tissue hypoxia, 4 and so forth. The second report, by Tashkin et al (see page 445), discusses the respiratory status of this group of firemen one month after their acute exposure. They concluded that there was no evidence of development of subsequent chronic respiratory impairment. These findings are somewhat at variance with the results from other investigators who have reported an increased prevalence of chronic nonspecific respiratory symptoms in firemen and have concluded that fighting fires is a risk factor for the development of chronic pulmonary problems. 5 Welldesigned prospective studies should provide data for settling this issue, but it is encouraging to note that while fighting fires may be a high-risk job, it seems to have low morbidity. Final resolution of these differences may have implications for other occupational groups besides firemen. The increasing interest in and the importance of the effects of inhalation of the toxic products of combustion are appropriate to the hazards surrounding us in today's plastic and toxic environment. A final caveat: we, as physicians, must remember that the most dangerous smoke to which the majority of our patients are chronically exposed is from cigarettes and that this is the great challenge of preventive medicine in lf176. ]ames R. Webster, ]r., M.D., F.C.CP. • Chicago •Chief of Medicine, Wesley Pavilion, Northwestern Memorial Hospital. and Associate Professor of Medicine, Northwestern U Diversity Medical School. Reprint requests: Dr. Webster, 250 East Superior Street, Chicago 60611 REFEREN~

1 Dyer RF, Esch VH: Polyvinyl chloride toxicity in 6res. JAMA 235:393-399, 1976 2 Zarem M Rattenborg CC, Harmel MH: Carbon monoxide toxicity in human fire victims. Arch Surg 107:851-853, 1973 3 Webster JR, McCabe MM, Karp M: Recognition and management of smoke inhalation. JAMA 201:287-290, 1967 4 Buehler JH, Berns AS, Webster JR. et al: Lactic acidosis from carboxyhemoglobinemia after smoke inhalation. Ann Intern Med 82:803-805, 1975 5 Peters JM, Theriault GP, Fine LJ, et al: Chronic effect of 6re fighting on pulmonary function. N Engl J Med 291: 1320-1322, 1974

CHEST, 71: 4, APRIL, 1977