Accident Analysis and Prevention 39 (2007) 624–628

Breathing difficulty and tinnitus among children exposed

to airbag deployment
Manoj K. Mittal a,∗ , Michael J. Kallan b , Dennis R. Durbin a,b
a Division of Emergency Medicine, The Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard,
Philadelphia, PA 19104, United States
b Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine,

Philadelphia, PA 19104, United States

Received 16 May 2006; received in revised form 2 September 2006; accepted 10 October 2006

Abstract
Objective: To assess the incidence of breathing difficulty and tinnitus in children involved in motor vehicle crashes with and without passenger
airbag (PAB) deployment, and its relationship to seating position and to whether the airbag deployed was first versus second-generation.
Methods: We studied motor vehicle crashes with child passengers, over a 3-year period, in three large regions of the United States, by means
of telephone interviews with the driver/parent. The crashes were classified into those with and without a PAB deployment. Complete data were
collected on 7383 children in 4817 crashes, who, because of the sample design of the study, represent an estimated 120,987 children in 83,267
crashes.
Results: Among children involved in crashes with PAB deployment, 6.6% complained of breathing difficulty versus 1.4% without airbag deployment
(OR 5.2, 95% CI 3.3–8.2). The corresponding figures for tinnitus were 5.0% versus 0.7% (OR 7.4, 95% CI 4.0–13.7).
Analysis of data for children exposed to PABs indicated that 14.1% of children in the front seat versus 1.1% in the rear complained of tinnitus
(OR 14.4, 95% CI 5.9–34.7). Seating row did not significantly affect the incidence of breathing difficulty. The type of airbag deployed did not
significantly affect the incidence of breathing difficulty or of tinnitus.
Conclusion: Breathing difficulty and tinnitus were much more common among children in crashes with PAB deployment as against those without
PAB deployment. Among children in crashes with PAB deployment, tinnitus was about 14 times more likely for those sitting in the front versus
rear seat. The incidence of breathing difficulty was not affected significantly by seating row. Introduction of second-generation airbags has not
affected the incidence of breathing difficulty or of tinnitus.
© 2006 Elsevier Ltd. All rights reserved.

Keywords: Passenger airbag; Tinnitus; Breathing difficulty; First-generation airbag; Second-generation airbag; Seating row

1. Introduction Besides traumatic injuries, airbag exposure has also been

Passenger airbags (PAB) began appearing in vehicles in the
United States in the mid-1990s (Durbin et al., 2003). Their use
has been linked with an overall reduction in deaths and severe
injuries amongst front seat passengers (Braver et al., 1997).
Deploying PABs, however, may increase the risk of death in
exposed children (Braver et al., 1997). They have also been
linked to a wide variety of injuries of all severities in exposed
adults and children (Boyd, 2002; Durbin et al., 2003).
∗
Corresponding author. Tel.: +1 215 590 1944; fax: +1 215 590 4454.
E-mail addresses: mittal@email.chop.edu, manojmital@yahoo.com
(M.K. Mittal), mkallan@cceb.upenn.edu (M.J. Kallan),
durbind@email.chop.edu (D.R. Durbin).
linked to breathing difficulty and audiologic abnormalities.
Experimental studies have confirmed that aerosol particles
released with airbag deployment can cause bronchospasm in
susceptible people (Gross et al., 1994). There have been several
case reports of breathing difficulty and asthma exacerbation
associated with airbag deployment among drivers and passen-
gers with and without a past history of asthma (Epperly et al.,
1997; Mazieres et al., 2002; Perez-Camareo et al., 2000). These
episodes tend to respond to usual treatment for asthma exacer-
bation. Sound impulses generated with airbag deployment can
result in noise induced hearing loss (Banglmaier and Rouhana,
2003). As experience with airbags has grown, multiple case
reports and case series have indicated that airbag deployment can
result in persistent tinnitus and permanent hearing impairment

0001-4575/$ – see front matter © 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.aap.2006.10.005
 M.K. Mittal et al. / Accident Analysis and Prevention 39 (2007) 624–628
in some individuals (Buckley et al., 1999; Chao and Pomerantz,
2004; Mattox and Price, 1995; Mcfeely et al., 1999; Morris
and Borja, 1998; Saunders et al., 1998; Yaremchuk and Dobie,
2001). Presence of tinnitus causes discomfort in its own right
and is also a marker for the presence of hearing impairment.
In 1997, the US National Highway Traffic Safety Admin-
istration issued a change to airbag regulations, which led to
a reduction in the power of the airbags during inflation by
20–35% (Kiuchi, 1998). These new airbags are referred to as
second-generation airbags. They were introduced in most US
automobiles beginning with the 1998 model year.
While previous case reports have identified the nature of
breathing difficulty and tinnitus/hearing impairment resulting
from airbag deployment, no study has determined the incidence
of these conditions in a large population of children exposed to
airbags. Therefore, the aim of this study was to determine the
incidence of breathing difficulty and tinnitus in children involved
in crashes with PAB deployment versus no PAB deployment. In
addition, we examined the effect of seating row and the intro-
duction of second-generation airbags on the incidence of both
conditions among children in PAB-deployment crashes.
2. Methods
2.1. Study population and data collection
Data for this study were drawn from the Partners for Child
Passenger Safety (PCPS) program over a 3-year period from
January 2003 through December 2005. A detailed description
of the study methods has been published previously (Durbin et
al., 2001). Because of the aforementioned case reports linking
breathing and hearing problems with airbag deployment, ques-
tions regarding breathing difficulty and ringing in the ears (tinni-
tus) were added to the survey instrument in January, 2003 PCPS
consists of a large scale, child-specific crash surveillance system.
Insurance claims from State Farm Insurance Co. (Bloomington,
IL) function as the source of subjects, with telephone survey
and on-site crash investigations serving as the primary sources
of data. The study has been approved by the Institutional Review
Boards at the University Of Pennsylvania School Of Medicine
(Penn) and The Children’s Hospital of Philadelphia (CHOP).
Vehicles qualifying for inclusion were State Farm-insured,
model year 1990 or newer, and involved in a crash with at least
one child occupant 4–15 years of age. We excluded children
under the age of 4 years from the study because history of
breathing difficulty or tinnitus could not be reliably obtained
from them and very few were sitting in the front seat of the
vehicle at the time of the crash. Qualifying crashes were those
that occurred in any of 15 states and the District of Columbia,
representing three large regions of the United States (East: New
York, Pennsylvania, Delaware, Maryland, Virginia, West Vir-
ginia, North Carolina, District of Columbia; Midwest: Ohio,
Michigan, Indiana, Illinois; and West: California, Nevada, Ari-
zona, Texas [starting 6/03]).
A stratified cluster sample was designed with a vehicle as
the unit of sampling. Vehicles were stratified on whether they
were towed from the scene or not, as well as the level of medical
625
treatment received by child occupant(s). A probability sample
was selected at random with a higher probability of selection
for vehicles in which a child occupant died, was admitted to
the hospital or evaluated in a physician’s office or emergency
department. In this way, the majority of injured children would
be selected while maintaining the representativeness of the over-
all population. If a vehicle was sampled, the “cluster” of all child
occupants in that vehicle was included in the survey. Surveys
were conducted in English with the driver of the vehicle and
parent(s) of the involved children.
Separate verbal consent was obtained from eligible partici-
pants for the transfer of claim information from State Farm to
CHOP/Penn, and for conducting the telephone survey.
The data collected included age and sex of child passengers,
their restraint status, PAB/DAB (driver air bag) deployment, type
and model year of vehicle involved, position of the child in the
vehicle with respect to seating row, and whether the child passen-
ger complained of breathing difficulty and/or ringing in the ears
(tinnitus) following the crash in answer to the following ques-
tions: (1) Did the child passenger, XYZ in your car complain of
difficulty in breathing following the crash? (2) Did the child pas-
senger, XYZ in your car complain of ringing in one or both ears
following the crash? The type of airbag, first-generation versus
second-generation was determined from the type and model year
of the vehicle.
2.2. Statistical methods
Initial analyses determined the incidence of breathing diffi-
culty and tinnitus for all children involved in crashes with or
without PAB deployment. Among children in PAB deployment
crashes, the incidence of each condition was then stratified by the
seating row of the child and by whether the airbag was a first ver-
sus second-generation system. Logistic regression modeling was
then used to separately compute the unadjusted odds ratio (OR)
of (1) breathing difficulty and (2) tinnitus for children in vehicles
equipped with second versus first-generation airbags, both over-
all, and also stratified by seating row. To compute p-values and
95% confidence intervals while taking into account the stratifi-
cation of subjects by medical treatment, clustering of subjects by
vehicle, and the disproportional probability of selection, Taylor
Series linearization estimates of the logistic regression param-
eter variance were calculated using SAS-callable SUDAAN:
Software for the Statistical Analysis of Correlated Data, Ver-
sion 9.0 (Research Triangle Institute, Research Triangle Park,
NC, 2005). Results of logistic regression modeling are expressed
as unadjusted and adjusted odds ratios with corresponding 95%
confidence intervals. Because of the relative rarity of the out-
comes of interest, the odds ratio and relative risk measures are
assumed equivalent.
3. Results
3.1. Sample characteristics
Complete interview data were obtained on 7383 children
in 4817 vehicles representing an estimated 120,987 children
in 83,267 vehicles in the overall PCPS population. Of these,
626 M.K. Mittal et al. / Accident Analysis and Prevention 39 (2007) 624–628

Table 1
Characteristics of the study subjects (as a whole) and of those exposed to deploying PABs
Total population: unweighted N Those exposed to deploying PABs:
(total N = 7383) (weighted %) unweighted N (total N = 1476) (weighted %)

Male 3449 (47.4) 668 (41.8)

Restrained 6869 (97.2) 1354 (96.1)
Front row seated 2296 (26.9) 502 (30.0)
Back row seated 5088 (73.1) 974 (70.0)
Second row 4473 (63.8) 887 (63.0)
Third row 615 (9.3) 87 (7.0)
Age-group
4–8 years 2748 (43.8) 486 (39.8)
9–12 years 2343 (31.5) 476 (32.6)
13–15 years 2292 (24.7) 514 (27.6)
Type of vehicle
Passenger car 3560 (43.2) 903 (54.9)
SUV 1693 (24.8) 267 (21.5)
Minivan 1399 (21.9) 238 (19.3)
Pickup truck 577 (8.2) 53 (2.9)
Cargo van 154 (1.8) 15 (1.4)
Model year of vehicles
1990–1993 906 (9.3) 6 (0.2)
1994–1997 1831 (20.8) 490 (28.4)
1998–2005 4646 (69.9) 980 (71.4)

111,636 children [unweighted (U) = 5 565], were estimated to
be in vehicles without airbag deployment, 1512 (U = 342), in
vehicles with only a driver airbag (DAB) deployment while 7839
children (U = 1476) were estimated to be in vehicles with PAB
deployment as well. Of the children involved in crashes with
no airbag deployment, 7.7% were in vehicles with no airbag
installed, while 6.8% were in vehicles with DAB only. The
median length of time between the date of the crash and the
completion of the interview was 8 days.
The characteristics of the study subjects (as a whole) and of
those exposed to deploying PABs on which much of the further
analysis has been done, are listed in Table 1.
3.2. Incidence of breathing difficulty and tinnitus related to
PAB deployment
Of the estimated 7839 children involved in crashes with PAB
deployment, 521 (6.6%) complained of breathing difficulty ver-
sus 1614 of 113,148 children (1.4%) in crashes without PAB
deployment, yielding an OR of 5.2 (95% CI 3.3–8.2, p < 0.001).
Tinnitus was reported by an estimated 394 (5.0%) children in
crashes with PAB deployment, as opposed to 802 (0.7%) chil-
dren in crashes without PAB deployment, yielding an OR of 7.4
(95% CI 4.0–13.7, p < 0.001).
Data for children in crashes with PAB deployments were
further analyzed to examine the association between breathing
difficulty and tinnitus with seating row and the type of airbag
deployed.
3.3. Effect of seating row
Breathing difficulty was reported by 195 of 2350 (8.3%) chil-
dren in the front seat as compared to 326 of 5489 (5.9%) in
the rear, yielding an OR of 1.4 (95% CI 0.7–2.8). Tinnitus was
reported by 332 of 2350 (14.1%) children in the front seat, ver-
sus 62 of 5489 (1.1%) in the rear, yielding an OR of 14.4 (95%
CI 5.9–34.7, p < 0.001).
3.4. Effect of type of airbag
Breathing difficulty was reported by 362 out of 5525 (6.6%)
children exposed to second-generation airbags versus 159 out of
2314 (6.9%) of those exposed to first-generation airbags, yield-
ing an OR of 0.9 (95% CI 0.5–1.9). Tinnitus occurred in 231
children out of 5 525 (4.2%) in vehicles with second-generation
versus 163 out of 2314 (7.0%) of those in vehicles with first-
generation airbags, yielding an OR of 0.6 (95% CI 0.2–1.5).
4. Discussion
Breathing difficulty and tinnitus were more common among
children in crashes with PAB deployment as opposed to those
without PAB deployment. Among children exposed to PAB
deployment, the incidence of breathing difficulty was not sig-
nificantly affected by seating row. Tinnitus, on the other hand
was predominantly a problem for front seat passengers, and was
about 14 times more likely for children sitting in the front ver-
sus rear seat. Introduction of second-generation airbags did not
affect the incidence of breathing difficulty or of tinnitus in a
significant manner.
4.1. Tinnitus/hearing difficulty
The peak sound pressure in a vehicle exposed to a barrier
crash without an airbag deployment is about 145 decibels (dB)
(Banglmaier and Rouhana, 2003), whereas addition of a rapid
 M.K. Mittal et al. / Accident Analysis and Prevention 39 (2007) 624–628
airbag deployment leads to the generation of a much louder
impulse noise of 165–175 dB (Price and Kalb, 1999). Exposure
to noise of 140 dB or more for more than 5 ms may lead to per-
manent hearing loss. Levels in excess of 165 dB, even for shorter
durations, are likely to cause cochlear damage, potentially caus-
ing tinnitus and hearing impairment (International Programme
on Chemical Safety, 1980).
Tests run when airbags were first proposed for automotive use
indicated negligible auditory hazard (Nixon, 1969). As experi-
ence with airbags has grown, however, multiple case reports
and case series have indicated that airbag deployment can result
in tinnitus and permanent hearing impairment in some individ-
uals. Huelke et al. (1999) found that 1.7% (3 of 177) of car
occupants complained of hearing-related problems following a
crash. In the largest case series of its kind published so far,
members of the American Academy of Otolaryngology, Head
and Neck Surgery submitted case reports on 71 patients, aged
4–81 years, with audiologic problems, chiefly hearing loss and
tinnitus, after being involved in a crash with airbag deployment.
Fifty-two patients complained of persistent tinnitus, while 47
had a confirmed unilateral hearing loss (Yaremchuk and Dobie,
2001). The vast majority of cases did not involve any physical
contact between the airbag and the subject’s ear. The disability
is mostly due to the cochlear damage resulting from the noise
impulse. Results from this and other studies (Buckley et al.,
1999; Mattox and Price, 1995; Mcfeely et al., 1999; Morris and
Borja, 1998; Saunders et al., 1998; Yaremchuk and Dobie, 2001)
suggest that tinnitus and hearing impairment usually coexist, so
that presence of tinnitus should warrant formal hearing assess-
ment.
Studies with ear models and airbag deployment have previ-
ously suggested that the occupants in the second row and beyond
may be at less risk of noise induced hearing loss, the risk reduc-
tion being ∼30% for each seating row away from the frontal
airbag system (Banglmaier and Rouhana, 2003). This is related
to attenuation of high frequency noise with increasing distance
from the source of the sound impulse. In our study, tinnitus was
reported 14 times more often by children sitting in the front pas-
senger seat than those in the back seat. Most case reports linking
hearing impairment with airbag deployment have also been in
driver or front seat passengers (Buckley et al., 1999; Chao and
Pomerantz, 2004; Mattox and Price, 1995; Mcfeely et al., 1999;
Morris and Borja, 1998; Saunders et al., 1998; Yaremchuk and
Dobie, 2001). Thus our study adds more data in support of cur-
rent recommendations for children to sit in the rear seat.
4.2. Breathing difficulty
An estimated 9 million children aged <18 years have had
asthma diagnosed at some time in their lives (Dey and Bloom,
2005). Inhalation of the aerosol produced by airbag deployment
can result in significant bronchospasm in 40% of asthmatics
(Gross et al., 1994). The asthmatic response is induced by
inhaled particulates dissolving in the airway fluids and changing
osmolarity (Gross et al., 1995). Most of the cases of breathing
difficulty associated with exposure to a deploying airbag are
likely related to induction of an asthmatic attack.
627
Nearly 7% of children in our study complained of breathing
difficulty after being involved in a crash with PAB deployment
as opposed to only 1.4% of those without an airbag deployment.
Similar proportions of children sitting in the front passenger
seat had symptoms of breathing difficulty (8%) as those in the
rear seat (6%). This is consistent with experimental observa-
tions showing that the aerosol exposure for people sitting in
the front or back rows of a vehicle is similar (Gross et al.,
1994). Serious airbag-related injuries have decreased signifi-
cantly in children since the introduction of second-generation
airbags (Arbogast et al., 2005). Our study shows that introduc-
tion of second-generation airbags has not affected the incidence
of breathing difficulty or of tinnitus, however, in a significant
manner.
4.3. Limitations
The data for this study were obtained via telephone interview
with the driver/parent of the child and therefore are subject to
potential misclassification. However, on-going comparison of
several driver-reported variables including child restraint use
and seating position with evidence from crash investigations
performed as part of this research project have demonstrated
a high degree of agreement (κ-statistic = 0.99 for seat row,
0.77 for restraint use). In addition, our results on age-specific
restraint use and seating position are similar to those of other
recently reported population-based studies of child occupants
(Glassbrenner et al., 2004; Wittenberg et al., 1999).
The information obtained in this study does not tell us about
the severity or the duration of breathing difficulty or tinnitus.
Further studies need to be done to assess these issues. The
study does, however, show significant association between PAB
deployment and breathing difficulty and tinnitus. Considering
the biologic plausibility, and multiple case reports showing these
associations, this study provides crucial hypotheses which need
to be tested further.
4.4. Implications for prevention
Future research should assess the degree of breathing diffi-
culty and include follow-up regarding the duration of tinnitus
and formal hearing assessment of affected patients. As newer
model year vehicles are equipped with additional airbags like
front side airbags and side curtain airbags, deployment of more
of these airbags in a crash may increase the amount of particulate
matter and noise generated, and may thus further increase the
chance of precipitating asthmatic attacks/breathing difficulty,
and noise-induced tinnitus/hearing loss among the affected pop-
ulation.
Airbag suppliers and auto manufacturers need to continue
efforts to improve airbag design to reduce noise levels and the
release of particulate matter at the time of deployment. In the
meantime, emergency medicine physicians, EMT technicians
and other physicians treating trauma patients should be aware
of the potential for both tinnitus and breathing difficulty follow-
ing exposure of children to deployed airbags and should ensure
appropriate initial treatment and follow-up.
628 M.K. Mittal et al. / Accident Analysis and Prevention 39 (2007) 624–628
Acknowledgments
The authors would like to acknowledge the commitment and
financial support of State Farm Mutual Automobile Insurance
Company for the creation and ongoing maintenance of the Part-
ners for Child Passenger Safety (PCPS) program, the source of
data for this study. The authors also thank the many State Farm
policyholders who consented to participate in PCPS. The results
presented in this report are the interpretation solely of the authors
and are not necessarily the views of State Farm. We thank Kristy
Arbogast, PhD for reviewing the manuscript.
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