The Use of Portable Peak Flowmeters in the Surveillance of Occupational Asthma

doi:10.1378/chest.100.6.1515

Chest

Volume 100, Issue 6, December 1991, Pages 1515-1521

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The purpose of this study was to identify the strengths and limitations of using portable peak flowmeters to document suspected cases of occupational asthma that were reported to a statewide surveillance project. The New Jersey Department of Health conducts surveillance for occupational asthma as part of the federally sponsored Sentinel Event Notification System for Occupational Risks (SENSOR). Between May 1988 and January 1990, 70 cases were reported voluntarily by physicians. Subjects who were still employed in suspected work sites were requested to test themselves for at least 15 days, using portable peak flowmeters to generate serial measurements of their peak expiratory flow rate (PEFR). For each of the 14 subjects who were successfully tested, the PEFR data provided valuable information about their asthma-work association. However, a large number of subjects whose cases were reported (56) either could not be tested or were not successfully tested. The proportion of subjects completing the test would probably improve if it were conducted when their conditions were first diagnosed. Accordingly, the collection of serial peak flow measurements to document occupational asthma would best be initiated by the treating physician when the patient first sought care, rather than waiting until after the case was reported to the state health department.

Section snippets

METHODS AND MATERIALS

The suspected cases of occupational asthma were reported voluntarily by physicians between May 1, 1988, and December 31, 1989. (Starting in May 1990, physicians in New Jersey were required by state law to report cases of occupational lung disease to the state department of health.) During the study period, the New Jersey SENSOR surveillance staff included a project manager (M.J.S.), research assistant (L.S.T.), industrial hygienist, consulting physician (H.M.K.), and epidemiologist (P.K.H.).

RESULTS

Of the 70 suspected cases of occupational asthma that were reported during the study period, ten were reported anonymously by their physicians, and another three subjects were contacted but refused to be interviewed (Fig 1). All of the remaining 57 subjects were interviewed by SENSOR staff. Only one of the 57 had been examined by his private physician with pulmonary function testing in relation to work. None of the other subjects had any further documentation of the asthma-work association

Participation and Acceptance by Subjects

The reported cases of occupational asthma in subjects who were not successfully tested with the portable peak flowmeters fell into three categories. First, some cases were reported anonymously or the subjects refused to be interviewed. The New Jersey SENSOR surveillance project maintains strict confidentiality and will neither contact the employer nor reveal the identity of the subject without the individual's authorization. Despite these safeguards, the fear of reprisals by management may have

ACKNOWLEDGMENTS

This work was supported by funding to the New Jersey Department of Health from the National Institute for Occupational Safety and Health (Award Number U60-CCU-2-02994). The authors wish to thank Michael R. Lax, M.D., M.P.H., for his assistance with reviewing the manuscript.

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Cited by (29)

Diagnosis and management of work-related asthma: American College of Chest Physicians consensus statement
2008, Chest
Citation Excerpt :
The submission of appropriate reports to public health surveillance and regulatory systems can link clinical and public health approaches. Several voluntary reporting programs have been established in the United States (Sentinel Event Notification System for Occupational Risks [or SENSOR]21,105), the United Kingdom (Surveillance of Work-Related & Occupational Respiratory Disease [or SWORD]281,282), and South Africa (Surveillance of Work-related and Occupational Respiratory Diseases in South Africa [or SORDSA]283). Reports of suspected WRA may then encourage exposure control interventions.
A previous American College of Chest Physicians Consensus Statement on asthma in the workplace was published in 1995. The current Consensus Statement updates the previous one based on additional research that has been published since then, including findings relevant to preventive measures and work-exacerbated asthma (WEA).
A panel of experts, including allergists, pulmonologists, and occupational medicine physicians, was convened to develop this Consensus Document on the diagnosis and management of work-related asthma (WRA), based in part on a systematic review, that was performed by the University of Alberta/Capital Health Evidence-Based Practice and was supplemented by additional published studies to 2007.
The Consensus Document defined WRA to include occupational asthma (ie, asthma induced by sensitizer or irritant work exposures) and WEA (ie, preexisting or concurrent asthma worsened by work factors). The Consensus Document focuses on the diagnosis and management of WRA (including diagnostic tests, and work and compensation issues), as well as preventive measures. WRA should be considered in all individuals with new-onset or worsening asthma, and a careful occupational history should be obtained. Diagnostic tests such as serial peak flow recordings, methacholine challenge tests, immunologic tests, and specific inhalation challenge tests (if available), can increase diagnostic certainty. Since the prognosis is better with early diagnosis and appropriate intervention, effective preventive measures for other workers with exposure should be addressed.
The substantial prevalence of WRA supports consideration of the diagnosis in all who present with new-onset or worsening asthma, followed by appropriate investigations and intervention including consideration of other exposed workers.
Occupational asthma in the cotton textile industry: Assessment by bronchial hyperreactivity and peak expiratory flow recording
2002, Revista Portuguesa de Pneumologia
Introdução: Na indústria têxtil, a exposição a poeiras de algodão e outras fibras vegetais está na origem de várias doenças respiratórias, como a asma ocupacional (AO) e bissinose (B). A distinção clínica entre as duas é pouco específica, assentando, essencialmente, no agravamento dos sintomas no 1.º dia de trabalho após afastamento de alguns dias, podendo ser o restante quadro clínico muito semelhante.
Objectivos: Avaliar a importância do estudo de hiperreactividade brônquica (HRB) e registo de DEMI no diagnóstico diferencial entre asma ocupacional e bissinose na indústria têxtil.
População e métodos: 62 trabalhadores de uma fiação de algodão (32M, 30H), média de idades: 41,5±10,6 anos. Tempo de exposição a poeiras de algodão: 20,3±10,8 anos e sintomas respiratórios: 10,4±15,1 anos. Efectuada história clínica, testes cutâneos “prick”, provas de função respiratória, prova de metacolina (M), registo do DEMI e doseamento de IgE total. O diagnóstico inicial foi estabelecido com base em critérios exclusivamente clínicos e revisto, posteriormente, de acordo com os resultados da avaliação da HRB e dos registos do DEMI.
Resultados: Diagnóstico inicial (história clínica): B: 16, AO: 25 e asma não ocupacional (A): 21 trabalhadores. Cinquenta e dois trabalhadores (84%) apresentaram PC20M ≤ 16mg/ml (média: 1,9±3,2 mg/ml). Veri-ficaram-se variações do DEMI ≥ 20% em 25%, 68% e 100% dos trabalhadores e agravamento dos valores de DEMI em trabalho (impressão óptica) em 25%, 56% e 24% dos trabalhadores com B, AO e A, respectiva-mente. Diagnóstico final (história clínica, prova de metacolina e registo de DEMI): B: 20 (32%), AO: 23 (37%) e A: 19 (37%).
Dos 16 trabalhadores com B, 12 mantiveram diagnóstico e 4 foram classificados como AO (M positiva e agravamento do DEMI em trabalho). Dos 25 com AO, 14 mantiveram diagnóstico, enquanto 3 foram incluídos na A (DEMI sem variabilidade com exposição) e 8 na B (M negativa ou ausência de variabilidade do DEMI). Dos 21 com A, 16 mantiveram o diagnóstico e 5 foram reclassificados como AO (agravamento do DEMI em trabalho).
Diagnóstico final: B: 20, AO: 23 e A: 19 trabalhadores.
Conclusão: A caracterização da asma ocupacional na indústria têxtil necessita da avaliação da HRB e da confirmação da relação dos sintomas com a exposição, através do registo do DEMI.
REV PORT PNEUMOL 2002; VIII (2):
In the textile industry, exposure to cotton dust and other vegetable fibres, is responsible for respiratory diseases such as occupational asthma (OA) and byssinosis (B). The clinical distinction between them lacks specificity and is based essentially on the worsening of the symptoms on the first day back to work after a few days of absence. The rest of the clinical picture may be very similar.
Objective: To assess the importance of the bronchial hyperreactivity (BHR) and Peak Flow Metter recording (PFMR) in the differential diagnosis of OA and B.
Methods: We evaluated 62 workers from the cotton industry (30M, 32F), mean age 41.5±10.6 years with regards to clinical history, skin prick tests, respiratory function tests, bronchial hyperreactivity to methacholine, PFMR and total IgE measurement. Mean exposure time to dust cotton was 20.3±10.8 years and the history of respiratory symptoms 10.4±15.1 years. The initial diagnosis was based, exclusively, on clinical parameters and was later reviewed according to the results of HRB and PFMR.
Results: Initial diagnosis (clinical history): B: 16 (26%), OA: 25 (40%) and non-occupational asthma (A): 21 (34%). Fifty-two workers (84%) had PC20M ≤ 16mg/ml (mean: 1.9±3.2 mg/ml). We observed an impairment of PEF values during exposure (visual assessment) in 25%, 56% e 24% of the workers and PEF variation > 20% at work 25%, 68% e 100% of the workers with B, AO and A, respectively. Final diagnosis (clinical history, BHR and PFMR): B: 20 (32%), OA: 23 (37%) and A: 19 (37%).
From the 16 workers with B, 12 kept the diagnosis and 4 were classified as OA (positive M and PEF impairment at work). From the 25 with OA, 14 kept the diagnosis, 3 were included in A (PEF without variability at work) and 8 in B (PC20M > 16 mg/ml or PEF without variability). From the 21 workers with A, 16 kept the diagnosis and 5 were reclassified as OA (PEF impairment at work).
Final diagnosis: B: 20, OA: 23 and A: 19 workers.
Conclusion: The characterization of occupational asthma in the cotton textile industry needs bronchial hyperreactivity evaluation and confirmation of the relationship between symptoms and exposure by the Peak Flow Metter recording.
REV PORT PNEUMOL 2002; VIII (2)∝
Occupational asthma in 1997
1997, Revue Francaise d'Allergologie et d'Immunologie Clinique
L'asthme professionnel (A.P.) est défini comme une obstruction réversible des voies aériennes, causée par les gaz, les poussières et fumées rencontrés en milieu professionnel. L'A.P. est la maladie respiratoire professionnelle la plus fréquente des pays industrialisés. La prévalence de l'A.P. représente 10 p. cent de l'ensemble des asthmes. Environ 250 agents tels les isocyanates, la farine, les résines époxy, les formaldehydes, les produits capillaires peuvent provoquer des A.P. L'anamnèse, l'examen clinique et l'évaluation des expositions professionnelles constituent les données de base permettant de poser le diagnostic étiologique d'A.P. La mesure de l'hyperréactivité bronchique non spécifique, la réalisation de débitmétries de pointe étagées et la recherche d'anticorps spécifiques constituent des investigations complémentaires de choix. La surveillance médicale systématique des populations exposées, leur information des risques encourus et l'amélioration des conditions de travail, sont les éléments fondamentaux d'une prévention efficace.
Occupational asthma (O.A.) has been defined as variable airway narrowing causally related to exposure to airborne dusts, gases, vapors or fumes in the work environment. O.A. has become the commonest form of occupational lung disease in many industrialized countries. The prevalence of O.A. is about 10 per cent of all cases of asthma. About 250 agents such as isocyanates, flow, epoxy resin, formaldehyde or hairdressing chemicals can cause O.A. History, physical examination and assessment of occupational exposures are useful data in the identification of the occupational origin. Measurement of bronchial hyperresponsiveness, monitoring of peak expiratory flow, specific antibody testing are diagnostic tools. Medical surveillance programs are the keystone for prevention. Informing employees about the potential workplace hazards and proper training for safe work practices is of paramount importance.
Epidemiologic methods for the study of occupational asthma: Current problems and solutions
1996, Chest
Peak flow as a measure of airway dysfunction in swine confinement operators
1995, Chest
To evaluate the usefulness of a portable peak flow meter in predicting airway dysfunction in symptomatic swine confinement workers, we conducted a study using an established cohort of swine workers in Iowa. Participants were randomly selected from a group of 207 swine confinement workers and a group of nonconfinement farmers who had been followed longitudinally. Swine confinement workers with work-related symptoms were identified, and two control groups (swine confinement workers and nonconfinement workers) without work-related symptoms were frequency matched by age, sex, and smoking status to the symptomatic swine confinement workers. Peak flow measures were obtained for 7 days using a mini-Wright peak flow meter and comparisons were made between the symptomatic swine confinement farmers (n=24) and both groups of asymptomatic workers: swine confinement workers (n=21) and neighborhood farmer controls (n=25). Peak flow readings were recorded by subjects five times per day for 7 days, initially on awakening, then after chores, before lunch, before dinner, and before bedtime. The actual hour of day for each measurement of peak flow was similar between the three groups. Percent changes from initial am peak flow did not significantly differ between subject groups. However, symptomatic swine confinement workers consistently exhibited significantly lower initial and subsequent mean peak flow values compared with asymptomatic swine confinement workers and neighborhood control farmers, controlling for age, height, gender, and smoking status. These differences occurred on most of the measures of peak flow throughout the work day. The persistence of these lower values throughout the work day is remarkably consistent during the study period and is suggestive of airway disease in the symptomatic swine confinement workers. Our findings suggest that peak flow meters are a useful indicator of potential airway injury and offer an additional portable, diagnostic tool in the assessment of symptomatic workers.
The case for confirming occupational asthma: Why, how much, how far?
1993, The Journal of Allergy and Clinical Immunology

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: Manuscript received November 30; revision accepted April 4.

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Chest

Clinical InvestigationsThe Use of Portable Peak Flowmeters in the Surveillance of Occupational Asthma

Section snippets

METHODS AND MATERIALS

RESULTS

Participation and Acceptance by Subjects

ACKNOWLEDGMENTS

Lancet

J Allergy Clin Immunol

Sentinel event notification system for occupational risks

Scand J Environ Health

Occupational disease surveillance: occupational asthma

MMWR

Physiological patterns in early morning asthma

Thorax

Comparison of peak expiratory flow and FEV1 admission criteria for acute bronchial asthma

Ann Emerg Med

A procedure for using peak expiratory flow rate data to increase the predictability of asthma episodes

J Asthma Res

Clinical Investigations
The Use of Portable Peak Flowmeters in the Surveillance of Occupational Asthma