dicative of subtle small-airway damage may have remained undetected.
Outbreaks of carbon monoxide intoxication in indoor ice arenas have occurred frequently20,21; however, outbreaks of nitrogen dioxide—induced respiratory illness in this setting are reported rarely. In addition to the current investigation, there are only two reports in the literature of illness compatible with nitrogen dioxide exposure in ice hockey players. In August 1969, a group of hockey players in Minnesota experienced chest tightness and difficulty breathing after playing a game.16 In February 1988, nine persons in Quebec, Canada, experienced cough, dyspnea, and “difficulty breathing” after attending a hockey game.22
Despite limited documentation of similar outbreaks, it is possible that the problem of nitrogen dioxide exposure in indoor ice arenas may be more common than is recognized currently. Although 800 indoor ice arenas are located in the United States, only three states monitor the air quality on a routine basis. In addition, because respiratory symptoms associated with exposure to nitrogen dioxide may be relatively mild and nonspecific, the correct diagnosis may remain unrecognized. To prevent future outbreaks from occurring, ice resurfacing equipment must be properly maintained and ice arenas must be adequately ventilated. In addition, regulations requiring routine exhaust emission checks of ice resurfacers may be necessary. When patients present with acute onset of pulmonary symptoms, particularly hemoptysis, with onset during or shortly after spending time in an indoor ice arena, physicians should consider the possibility of exposure to nitrogen dioxide.
We thank Jack A.Korlath, MPH, William W. Joy, RN, Ray W.Thron, PhD, Karen A.Casale, BSN, Eileen M.Rooney, BSN, and Karen A.Kavan, BSN, for assistance with data collection; Peter A.Bitterman, MD, and Guiermo Dopico, MD, for advice; Robert A.Gunn, MD, MPH, for manuscript review; and the Twin Cities (Minn) medical community for providing information on patients.
1. Criteria for a Recommended Standard… Occupational Exposure to Oxides of Nitrogen (Nitrogen Dioxide and Nitric Oxide). Washington, DC: National Institute for Occupational Safety and Health; 1976. Dept of Health, Education, and Welfare publication (NIOSH) 76–149.
2. Recommended Health-Based Occupational Exposure Limits for Respiratory Irritants. Geneva, Switzerland: World Health Organization; 1984. Technical report series 707.
3. Rosenstock L. Occupational Medicine: State of the Art Reviews . Philadelphia, Pa: Hanley & Belfus Inc; 1987;2:303–305.
4. Ramirez RJ, Dowell AR. Silo-fillers disease: nitrogen dioxide-induced lung injury. Ann Intern Med. 1971;74:569–576.
5. Milne JEH. Nitrogen dioxide inhalation and bronchiolitis obliterans. J Occup Med. 1969;11:538– 547.
6. Morgan WKC, Seaton A. Occupational Lung Disease. Philadelphia, Pa: WB Saunders Co; 1975.
7. Dorinsky PM, Davis WB, Lucas JG, Weiland JE, Gadek JE. Adult bronchiolitis: evaluation by bronchoalveolar lavage and response to prednisone therapy. Chest. 1985;88:58–63.
8. Kerr HD, Kulle TJ, McIlhany ML, Swidersky P. Effects of nitrogen dioxide on pulmonary function in human subjects: an environmental chamber study. Environ Res. 1979;19:392–404.
9. Melia RJW, Florey C, Morris RW, Goldstein BD, Clark D, John HH. Childhood respiratory illness and the home environment, I: relations between nitrogen dioxide, temperature and relative humidity. Int J Epidemiol. 1982;11:155–163.
10. Pearlman ME, Finklea JF, Creason JP, Shy CM, Young MM, Horton RJM. Nitrogen dioxide and lower respiratory illness. Pediatrics. 1971; 47:391–398.
11. Remijn B, Fischer P, Brunekreef B, Lebret E, Boliej JS, Noij D. Indoor air pollution and its effect on pulmonary function of adult non-smoking women, I: exposure estimates for nitrogen dioxide and passive smoking. Int J Epidemiol. 1985;2:215–220.
12. Detels R, Rokaw SN, Coulson AH, Tashkin DP, Sayre JW, Massey FJ. The UCLA population studies of chronic obstructive respiratory disease, I: methodology and comparison of lung function in areas of high and low pollution. Am J Epidemiol. 1979;109:33–58.
13. Wagner WD, Duncan BR, Wright PG, Stokinger HE. Experimental study of threshold limit of NO2. Arch Environ Health. 1965;10:455–466.
14. Shy CM, Creason JP, Pearlman ME, McClain KE, Benson FB. The Chattanooga school children study: effects of community exposure to nitrogen dioxide, I: methods, description of pullutant exposure and results of ventilatory function testing. J Air Pollut Control Assoc. 1970;20:539–545.
15. Shy CM, Creason JP, Pearlman ME, McClain KE, Benson FB. The Chattanooga school children study: effects of community exposure to nitrogen dioxide, II: incidence of acute respiratory illness. J Air Pollut Control Assoc. 1970;20:582–588.
16. Anderson DE. Problems created for ice arenas by engine exhaust. Am Ind Hyg Assoc J. 1971; 32:790–801.
17. Nie NH, Hull CH, Jenkins JG, Steinbrenner K, Bent DH. Statistical Package for the Social Sciences. 2nd ed. New York, NY: McGraw-Hill International Book Co; 1975.
18. Morris AH, Kanner RH, Crapo RO, Gardner RM. Clinical Pulmonary Function Testing. 2nd ed. Salt Lake City, Utah: Intermountain Thoracic Society; 1984.
19. Bauer MA, Utell MJ, Morrow PE, Speers DM, Gibb FR. Inhalation of 0.30 ppm nitrogen dioxide potentiates exercise-induced bronchospasm in asthmatics. Am Rev Respir Dis. 1986;134:1203– 1208.
20. Centers for Disease Control. Carbon monoxide intoxication associated with use of a gasoline-powered resurfacing machine at an ice-skating rink—Pennsylvania. MMWR. 1984;33:49–51.
21. Kwok PW. Evaluation and control of carbon monoxide exposure in indoor skating arenas . Can J Public Health. 1983;74:261–265.
22. Canadian Laboratory Centre for Disease Control. Nitrogen dioxide poisoning at a skating rink— Quebec. Can Dis Weekly Rep. 1988;14–15:61–62.