Rads and irritant induced asthma

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Slide 1 : RADS and irritant induced asthma Dennis Nowak Institute and Outpatient Clinic for Occupational and Environmental Medicine Ludwig-Maximilians-University Munich, Germany
Slide 2 : RADS or iiA: Case report (1) 55 yr old pool attendant who had to add chlorine tablets to swimming pools several times per week No documented excesses of TLVs No accidental exposures documented Work-related respiratory symptoms Normal spirometry and bodyplethysmography Mild BHR, work-related PEF not conclusive
Slide 3 : 52 yr old chemical factory worker During smouldering fire unable to find door, approximately 10 min exposure to plastic pyrolysis products Previously healthy. Physician after accident saw conjunctivitis, nothing else. Starting this day, variable respiratory symptoms. Mild obstruction with 6 % reversibility, moderate BHR. RADS or iiA: Case report (2)
Slide 4 : RADS and Irritant Induced Asthma Overview RADS Irritant induced asthma Internet sources Summary
Slide 5 : OA and BHR: Definition (1) e.g., “Occupational asthma is a disease characterized by variable airflow limitation and / or airway hyper- responsiveness and / or inflammation due to causes and conditions attributable to a particular occupational environment and not to stimuli encountered outside the workplace.“ Bernstein, I.L., et al., Asthma in the workplace, 2006 (new versus 1993)
Slide 6 : OA and BHR: Definition (2) Generally: Inducers: cause airway inflammation and BHR Inciters: trigger airway narrowing in patients with BHR, increase frequency of symptoms in pts. with pre-existing asthma Thus, only inducers should be considered causal agents Bernstein, I.L., Asthma in the workplace, 2006
Slide 7 : OA and BHR: Pathogenesis, types of disease High molecular weight compounds: mostly IgE-mediated, latency period Low molecular weight compounds: some (e.g. acid anhydrides, platinum salts, reactive dyes) IgE-mediated mostly non-IgE mediated but may combine with airway proteins T-cells frequently involved
Slide 8 : OA and BHR: Types of disease Occupational asthma - immunological - non-immunological including RADS Work-aggravated asthma Variant syndromes - eosinophilic bronchitis - potroom asthma - asthma-like syndrome (e.g., organic dusts)
Slide 9 : OA and BHR: Pathogenesis, types of disease - typical agents High molecular weight agents flour, latex Low molecular weight agents platinum salts Irritants (RADS) chlorine, phosgen Potroom Asthma HF, SO2, (aluminium chloride? fluoride?) Asthma-like Syndrome endotoxin, NH3 Atopic asthma
Slide 10 : Workplace exposure Acute, high RADS Chronic, low?high Chronic bronchitis Asthma Asthma-like syndrome Sensitizer Atopic asthma Irritant Modified from do Pico 2004
Slide 11 : RADS and Irritant Induced Asthma Overview RADS Irritant induced asthma Internet sources Summary
Slide 12 : Criteria for the diagnosis of RADS (1) 1. Absence of preceding respiratory complaints 2. Onset of symptoms occurring after a single specific exposure incident or accident 3. Exposure was to a gas, smoke, fume or vapour that was present in very high concentrations and had irritant qualities 4. Onset of symptoms occuring within 24 hours after the exposure and persisting for at least three months 5. Symptoms consistend with asthma, with cough, wheezing and dyspnoea predominating 6. Pulmonary function tests may show airflow obstruction 7. Appropriate challenge testing showing increasing airway responsiveness 8. Other types of pulmonary diseases excluded modified from Brooks, 1985
Slide 13 : Criteria for the diagnosis of RADS (2) asthma-like syndrome abrupt start 12-24 h following end of exposure following high irritant exposure duration > 3 months no pre-existing airway disease obstruction and/or BHR do Pico 2004
Slide 14 : RADS: Historic exposures Chlorine gas exposure in industrial workers during world war I ? pulmonary edema, death ? persistent respiratory symptoms Winternitz, W., JAMA 73 (1919) 689 Weill, H., et al., ARRD 99 (1969) 374 Sulfur dioxide exposure ? longstanding obstruction Härkönen, H., et al., ARRD 128 (1983) 890
Slide 15 : RADS Epidemiology (1) - Onset at home possible - Typically occupational setting - Frequent with industrial accidents, e.g., Bhopal Nemery, B., ERJ 9 (1996) 1973 - Incidence? - Acetic acid in hospital: 8/51 within 2.5 h Kern, ARRD 144 (1991) 1058 - Chlorine: 53/75 developed BHR Bhérer, L., et al., OEM 51 (1994) 225
Slide 16 : RADS Epidemiology (2) - Chlorine: Follow up of 239 subjects for 3 yrs: BHR dose-dependent Gautrin, D., ERJ 8 (1995) 2046 - Mustard gas (Iran / Iraq war): 11 % von 197 developed asthma symptoms and variable obstruction, 68 % developed bronchitis and bronchiectasis Emad, A., Chest 112 (1997) 734
Slide 17 : RADS Clinical manifestation - Negative previous history - Mucosal symptoms, burning sensation in upper respiratory tract, thoracic pain, dyspnea, cough, wheezing < 24 h Patients can identify exact date Risk factors Dose Pre-existing BHR? Smoking?
Slide 18 : RADS Spirometry and therapy - BHR improves up to 3 yrs later - Obstruction often with low reversibility 6 out of 15 patients showed increase in FEV1 of > 15 % in Gautrin, D., et al., ERJ 8 (1995) 2046 Therapy: Steroids frequently used Steroids no substitute for environmental control
Slide 19 : RADS case reports of varieties - classic allergic isocyanate asthma following RADS - Metal fume fever with RADS
Slide 20 : History, questionnaire, SPT, specific IgE (if possible) Non-specific provocation challenge (e.g., MCh) if possible at the end of a working week after at least two weeks with relevant exposure Mostly no asthma (exception: e.g., isocyanate asthma) Specific challenge under laboratory conditions with suspected agent / extract Lung function monitoring by the patient for at least 3 wks with / without workplace exposure positive Probably occupational asthma Lung function monitoring at the workplace vs. non-exposure Probably non-occupational asthma negative suspicious un-suspicious suspicious un-suspicious and / or negative positive OA and BHR: Diagnostic approach Not true for RADS
Slide 21 : RADS and Irritant Induced Asthma Overview RADS Irritant induced asthma Internet sources Summary
Slide 22 : Distinguishing RADS and “classical“ irritant asthma (1) „Irritant asthma“ is broader wording Multiple exposures also possible with RADS RADS typically follows “big bang“ „Low-dose RADS“ (Kipen et al., JOM 36 (1994) 1133) is problematic wording since it suggests no excess over thresholds
Slide 23 : Distinguishing RADS and “classical“ irritant asthma (2)
Slide 24 :
Slide 25 : 1 2 3 POR (95% CI) 0 2 3 4 1 0 2 3 4 1 0 2 3 4 1 0 2 3 4 1 Shortness of breath Cough without sputum Wheeze Flu-like symptoms n = 4420 Work-related respiratory symptoms in relation to daily work in swine confinement house (in quartiles) Radon et al. 2001 Adjusted for study centre, age, sex and smoking history
Slide 26 : Cleaners
Slide 27 : OR for occupational asthma#: ECRHS #BHR + symptoms/medication *adjusted for study centre, age, sex and smkoking status Kogevinas et al. 1999
Slide 28 : Incidence of asthma (doctor’s diagnosis) in Finnish cleaners Karjalainen et al. 2002 5 % of all females working as cleaners 3.4 cases per 1.000 per year age adjusted RR vs office workers: 1.5 (1.4-1.6) Risk ? in all industrial areas Attributable fraction: 33 % (30-36 %)
Slide 29 : ECRHS OA cohort (n = 3543) Kaplan Meier curve for physician-diagnosed asthma according to the number of sprays used at least weekly Zock JP, … K Radon, … submitted
Slide 30 : Summary of new data on cleaners Enhanced risk for obstructive airway diseases High number of exposed people Job attributable fraction probably high Sprays at home seem to be risky
Slide 31 : mechanic electronic Mobile, onsite peak flow monitoring / spirometry
Slide 32 : Workplace provocation challenge
Slide 33 : Variant: potroom asthma
Slide 34 :
Slide 35 :
Slide 36 : 0-0,4 0,4-0,8 >0,8 mg/m3 fluoride 0 5 10 15 RR (95% CI) Variant: potroom asthma: RR for potroom asthma in relation to fluoride exposure Kongerud et al. 1994
Slide 37 : Spirometry in non-smoking potroom workers and controls Radon et al. 1999
Slide 38 : Don’t forget COPD! Case control study in occupational outpatient clinic Mastrangelo et al. 2003 0,1 1 10 100 1000 Farmers Welders Wood Textile Builders Foundry workers OR (95% CI) Adjusted for age, smoking, year starting work
Slide 39 : RADS and Irritant Induced Asthma Overview RADS Irritant induced asthma Internet sources Summary
Slide 40 : Internet sources www.asmanet.com http://www.remcomp.ft/asmanet/asmapro/asmawork.htm http://epa.gov/ttn/atw/urban/asthmatable.pdf http://www.occupationalasthma.com www.acgih.org www.cdc.gov/niosh/ipcs/cstart.html www.networm-online.net
Slide 41 : www.occupationalasthma.com
Slide 42 : www.acgih.org
Slide 43 : www.cdc.gov/niosh/ipcs/cstart.html
Slide 44 : www.mak-collection.com
Slide 45 :
Slide 46 : Computer-oriented case based e-learning Story Chief complaint History taking, Occupational history Medical and technical examinations Background information: Workplaces, legal aspects Medical estimate
Slide 47 :
Slide 48 : Bakers´Asthma Bronchus Carcinoma, Claim for compensation Occupational screening in miners Asbestosis Tuberculosis in a healthcare worker Latex allergy in a healthcare worker Needle stick injury (Hepatitis) in a healthcare worker Forestry worker with white fingers (Vasospastic Syndrom) Carpal Tunnel Syndrom Bladder cancer due to aromatic amines Nasal septum perforation due to Chromium Halogen hydrocarbonates/ liver cirrhosis Lead intoxication Occupational accident Flight attendant with Diabetes mellitus Radiation protection Epidemiologic study Preventive medical check-up Cases so far available Lung Healthcare worker Musculosceletal „Classical“ OM Methods
Slide 49 : Mr. Bun, a 52-year old patient, attends your outpatient clinic. For three years he has been suffering from sneezing, an itching and running nose, red, itching eyes, and swelling of eyelids. Since last year he has developed a cough with breathlessness and wheeze. What is the most likely diagnosis with these symptoms? Free text entry: Please type your answer in the box _________________________________________
Slide 50 : Worldwide participants of NetWoRM
Slide 51 : New cases Construction worker with skin carcinoma Workplace survey Protection of the unborn child Pleura mesothelioma Occupational health nurses Silicosis Psychosocial problems at work Hypersensitivity pneumonitis (HP) Welder with maculopathy Workplace accident due to alcohol Occupational asthma / HP Trichloroethanol intoxication Salt workers Surveillance programm for asbestos
Slide 52 : RADS and Irritant Induced Asthma Overview RADS Irritant induced asthma Internet sources Summary
Slide 53 : Summary: ATS Statement Occupational asthma 2003 RADS: RADS infrequent Magnitude of exposure probably most important risk factor
Slide 54 : Summary: ATS Statement Occupational asthma 2003 Organic Dust-induced Asthma-like Disorder: Workers chronically exposed to organic dust have increased risk for cough and sputum Magnitude of endotoxin exposure probably relevant
Slide 55 : Conclusion: Vandenplas, Malo ERJ 2003 Non immunological occupational asthma: Was attributed to multiple low-dose exposures. Evidence for “low-dose RADS“ or „not-so-sudden RADS“ very weak
Slide 56 : Conclusion: Bardana JACI 2003 There is a chronic occupational asthma induced by low to moderate irritant doses. Unprobable that new cases of asthma are induced by this.
Slide 57 : Conclusion: Banks Allergy Clin Immunol 2001 Low-level RADS has little to do with RADS and presents mostly as asthma-like syndrome. The role of non-sensitizing low level irritants in the development of asthma ist still unknown.
Slide 58 : Summary Occupational exposure to low level irritants is associated with obstructive airway diseases. This can be demonstrated in, e.g., primary aluminum industry, farmers, cleaning personell.
Slide 59 : Ilginiz için çok tesekkür ediyorum

 


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