Chest
Volume 108, Issue 4, October 1995, Pages 1084-1117
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ACCP Consensus Statement: Articles
Assessment of Asthma in the Workplace

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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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References (159)

  • HennebergerPK et al.

    The use of portable peak flowmeters in the surveillance of occupational asthma

    Chest

    (1991)
  • ShapiroSM et al.

    An evaluation of the accuracy of Assess and Mini-Wright peak flowmeters

    Chest

    (1991)
  • BérubéD et al.

    Comparison of peak expiratory flow rate and FEV1 in assessing bronchomotor tone after challenges with occupational sensitizers

    Chest

    (1991)
  • TarloSM et al.

    Outcome of assessments for occupational asthma

    Chest

    (1991)
  • CockcroftDW et al.

    Sensitivity and specificity of histamine PC20 determination in a random selection of young college students

    J Allergy Clin Immunol

    (1992)
  • BanksDE et al.

    Absence of hyper-responsiveness to methacholine in a worker with methylene diphenyl diisocyanate (MDI)-induced asthma

    Chest

    (1986)
  • LamS et al.

    Nonspecific bronchial reactivity in occupational asthma

    J Allergy Clin Immunol

    (1979)
  • CartierA et al.

    Exposure to a sensitizing occupational agent can cause a long-lasting increase in bronchial responsiveness to histamine in the absence of significant changes in airway caliber

    J Allergy Clin Immunol

    (1986)
  • HudsonP et al.

    Follow-up of occupational asthma caused by crab and various agents

    J Allergy Clin Immunol

    (1985)
  • ChaiH et al.

    Standardization of bronchial inhalation challenge procedures

    J Allergy Clin Immunol

    (1975)
  • BrooksSM et al.

    Cold air challenge and platinum skin reactivity in platinum refinery workers: bronchial reactivity precedes skin prick response

    Chest

    (1990)
  • RamsdaleEH et al.

    Differences in bronchial responsiveness in asthma and chronic airflow obstruction

    Med Clin North Am

    (1990)
  • TownleyRG et al.

    Methacholine inhalation challenge studies

    J Allergy Clin Immunol

    (1979)
  • Gervais, P, Rosenberg, N, Occupational respiratory allergy: epidemiological and medicolegal aspects., Proceedings of...
  • PickeringCAC

    A 7 year survey of allergic occupational lung disease in the United Kingdom

    Eur J Respir Dis

    (1980)
  • KeskinenH et al.

    Occupational asthma in Finland

    Clin Allergy

    (1978)
  • LagierF et al.

    Statistiques médico légals sur l'asthme professionnel au Québec de 1986 á 1988

    [English abstract]. Rev Mal Respir

    (1990)
  • MeredithSK et al.

    Occupational respiratory disease in the United Kingdom 1989: a report to the British Thoracic Society and the Society of Occupational Medicine by the SWORD project group

    Br J Ind Med

    (1991)
  • DuffyDL et al.

    Genetics of asthma and hay fever in Australian twins

    Am Rev Respir Dis

    (1990)
  • BrooksSM

    Bronchial asthma of occupational origin

    Scand J Work Environ Health

    (1977)
  • MitchellCA et al.

    Respiratory symptoms and skin reactivity in workers exposed to proteolytic enzymes in the detergent industry

    Am Rev Respir Dis

    (1971)
  • NIOSH Criteria for a Recommended Standard. Occupational exposure to diisocyanates. US Dept of Health, Education and...
  • Chan-YeungM et al.

    A respiratory survey of cedar mill workers: I

    Prevalence of symptoms and pulmonary function abnormalities. J Occup Med

    (1978)
  • Bernstein, IL, Bernstein, DI, Malo, J-L, Definition and classification of asthma., Asthma in the workplace., Bernstein,...
  • MaloJ-L et al.

    Is the clinical history a satisfactory means of diagnosing occupational asthma

    Am Rev Respir Dis

    (1991)
  • AmericanThoracic Society

    Guidelines for the evaluation of impairment/disability in patients with asthma

    Am Rev Respir Dis

    (1993)
  • BascomR

    Occupational and environmental respiratory disease: a medico-legal primer for physicians

    Occup Med

    (1992)
  • BarnhartS

    Evaluation of impairment and disability in occupational lung disease

    Occup Med

    (1987)
  • Chan-YeungM

    Evaluation of impairment/disability in patients with occupational asthma

    Am Rev Respir Dis

    (1987)
  • RenzettiAD Jr et al.

    American Thoracic Society Ad Hoc Committee on Impairment/Disability Criteria: evaluation of impairment/disability secondary to respiratory disorders

    Am Rev Respir Dis

    (1986)
  • WiseRA et al.

    Evaluation of lung function: determination of pulmonary impairment

    Current pulmonology

    (1985)
  • DoegeTC et al.

    Guides to the evaluation of permanent impairment

    (1993)
  • VedalS et al.

    Symptoms and pulmonary function in western red cedar workers related to duration of employment and dust exposure

    Arch Environ Health

    (1986)
  • HuyT et al.

    Grain dust and lung function: dose-response relationships

    Am Rev Respir Dis

    (1991)
  • Chan-Yeung, M, Malo, J-L, Table of the major inducers of occupational asthma., Asthma in the workplace., Bernstein, IL,...
  • Taking the occupational history

    Ann Intern Med

    (1983)
  • BascomR et al.

    Don't just 'do spirometry'-closing the loop in workplace spirometry programs

    Occup Med

    (1992)
  • Brooks, S, Occupational and environmental diseases., Comprehensive textbook of pulmonary medicine., Bone, R, Dantzger,...
  • WeinerM et al.

    Adverse reactions to drug formulation agents: a handbook of excipients

    (1989)
  • Grammer, LC, Patterson, R, Immunologic evaluation of occupational asthma., Asthma in the workplace., Bernstein, IL,...
  • Cited by (0)

    A list of consensus conference participants is provided in the appendix at the end of the article.

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