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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.


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