Chest
ACCP Consensus Statement: ArticlesAssessment of Asthma in the Workplace
Section snippets
Classification of Types of Asthma Found in the Workplace
Asthma in the workplace is classified as (1) occupational asthma or asthma caused by exposure to specific agents in the workplace, and (2) work-aggravated asthma or concurrent asthma worsened by workplace exposure.
Diagnostic Criteria for Occupational Asthma
The diagnosis of occupational asthma should include the diagnosis of asthma and the establishment of work relatedness. The features include a compatible history and the following: (1) the presence of airflow limitation and its reversibility; (2) in the absence of airflow limitation, the presence of nonspecific bronchial hyperresponsiveness; and (3) the demonstration of work relatedness of asthma by objective means. How many of these features are necessary to establish the diagnosis in a
History and Physical Examination
The history is a key element of the clinical assessment. It often guides the timing of diagnostic tests and leads to the identification of the etiologic agent. The physical examination is less useful because it is an insensitive measure of work-related asthma. Objective documentation of asthma and its relationship to the work environment is necessary and should usually begin with the first office visit. As a general guideline, patients with possible occupational asthma should have serial peak
Exposure Assessment
The assessment of exposures is a critical step in evaluating the contribution of the workplace and environment to a patient's asthma. The goals of the exposure assessment are to identify the causative agents, minimize future exposures, and prevent the development of further cases of occupational asthma. In this context, “exposure” means likely contact of the respiratory system with an airborne chemical or biologic agent. Industrial hygienists may interpret the word exposure as a synonym for
PEF Monitoring in the Diagnosis of Occupational Asthma
The diagnosis of occupational asthma requires objective evidence that there is a relationship between work exposure and the development of airflow limitation and/or bronchial hyperresponsiveness. Malo and coworkers15 reported that the questionnaire used for epidemiologic assessment of occupational asthma is a sensitive but generally not a specific tool for detecting occupational asthma. Only 8 to 52% of those with a suggestive history were shown to have occupational asthma using objective
Nonspecific Challenge Testing
Bronchial hyperresponsiveness, so-called twitchy airways, can be defined as the tendency of the airways to narrow upon exposure to relatively small concentrations of nonspecific stimuli that do not provoke such a response in normal persons. Bronchial hyperresponsiveness is a characteristic feature of asthma but is also present in a substantial number of asymptomatic persons without asthma. In population surveys, the prevalence of NSBH among asymptomatic children and adults ranges between 3 and
Laboratory and Workplace Challenge Tests
Jack Pepys113 was the first to suggest challenging suspected asthma patients with occupational agents in a controlled manner. Specific inhalation challenge tests, using occupational agents in the laboratory, are more widely used in Europe and in Canada than in the United States. Workplace challenges can be done by asking a technician to go to the workplace and perform spirometry serially on the patient.
Treatment of Patients with Occupational Asthma
The confirmation of the diagnosis is only the first step in the treatment of patients with occupational asthma. Once the diagnosis has been confirmed, a hierarchy of events should ensue.
ALGORITHM
The diagnosis and management of occupational asthma can be conducted in an orderly manner. Occupational asthma concerns are common; a recent survey of ACCP members suggested that chest physicians frequently see patients with possible occupational and environmental airway effects.127 This section outlines a general algorithm for recognizing and treating the disorder. Specific details are shown in other sections. Figure 10 summarizes the algorithm. There are four phases of involvement.
1. Initial
RESEARCH NEEDS, VITAL STATISTICS
Despite the increased prevalence, increased recognition, and enhancement of our knowledge base, a very fundamental problem exists in establishing the enormity of the health care impact of occupational asthma compared with other occupational medical conditions. Although occupational asthma has been defined by various investigators, the book Asthma in the Workplace provides a consensus definition by the editors of the book stating that “occupational asthma is a disease characterized by variable
Appendix
Consensus conference participants:
Moira Chan-Yeung, MD, FCCP, Vancouver, British Columbia, Canada; Stuart Brooks, MD, FCCP, Tampa, Fla; W. Michael Alberts, MD, FCCP, Tampa; John R. Balmes, MD, FCCP, San Francisco; Scott Barnhart, MD, Seattle; Rebecca Bascom, MD, MPH, Baltimore; I. Leonard Bernstein, MD, Cincinnati; Leslie C. Grammer, MD, FCCP, Chicago; Philip Harber, MD, FCCP, Los Angeles; Jean-Luc Malo, MD, Montreal, Quebec, Canada; Cecile Rose, MD, MPH, Denver; David A. Schwartz, MD, MPH,
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2022, Journal of Allergy and Clinical Immunology: In PracticeCitation Excerpt :After the screening, only those patients identified as possibly having “occupational asthma” were chosen for the next step of exhaustive data collection. According to the consensus of the American College of Chest Physicians,13 the inclusion criteria for occupational asthma were defined as follows: (a) a compatible history with a positive NSBH test result or a positive postbronchodilator test result, (b) onset of asthma after entering the workplace, (c) a history of association between asthmatic symptoms and work, and (d) at least 1 of the following criteria to help in the diagnosis of OA: (d1) workplace exposure to an agent known to induce OA, or (d2) work-related changes in Forced Expiratory Volume in 1 second (FEV1) or PEF, or (d3) work-related changes in bronchial responsiveness, or (d4) positive response to SIC. The sociodemographic data, clinical presentation, results of pulmonary function and laboratory tests, and occupational exposure data were extracted via chart review based on a structured format (see Table E1 in this article’s Online Repository at www.jaci-inpractice.org).
Target sites: respiratory
2020, Information Resources in Toxicology, Volume 1: Background, Resources, and ToolsReactive airways dysfunction syndrome after hydrofluoric acid inhalation
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2011, Immunology and Allergy Clinics of North AmericaCitation Excerpt :The preexisting asthma criterion (criterion C1 in Box 1) for defining WEA may result in misdiagnosis of true immunologic OA occurring in subjects with preexisting asthma. The case definitions97,98 and diagnostic algorithms for OA4,99 that have been proposed to date have not formally incorporated the predictive value of the various diagnostic procedures. The authors propose a clinical case definition based on the posttest probability of OA derived from the systematic review conducted by the Agency for Health care Research and Quality,100 which provides estimates of the sensitivity and specificity of diagnostic procedures compared with those of specific inhalation challenges.100
A list of consensus conference participants is provided in the appendix at the end of the article.