Diagnosis and Initial Treatment of Occupational Asthma

DIAGNOSIS AND INITIAL TREATMENT
OF OCCUPATIONAL ASTHMA
I.
BACKGROUND
A.
Asthma is an airways disease of the lungs characterized by the following:

1.
Airway inflammation
2.
Increased airway responsiveness to a variety of stimuli; and
3.
Airway obstruction that is partially or completely reversible, either
spontaneously or with treatment.
The two essential clinical elements for the diagnosis of asthma are
airways obstruction which is partially or totally reversible with treatment, and/or airways
hyperreactivity. Occupational asthma is asthma that has its onset in association with
workplace exposure(s). Occupationally-aggravated asthma is asthma that is aggravated
by workplace exposure(s).
B.
Causative agents are classified as sensitizers (including but not limited to
the appended list) or irritants. Sensitizers cause inflammation through one or more
immunologic mechanisms, whereas irritants directly inflame the airway. Occupational
environments are often complex, and it may be difficult to identify a single specific
causal agent.
C.
A delay in diagnosis resulting in continued exposure of the worker to even
minute amounts of sensitizers can lead to permanent and irreversible airways disease or
death.
D.
An acute high level inhalation exposure to an irritant may result in a
permanent asthmatic condition known as Reactive Airways Dysfunction Syndrome
(RADS).
E.
This guideline is meant to cover the majority of tests and treatments that
may be used to diagnose and initially stabilize occupational and occupationallyaggravated asthma. This guideline does not include parameters of care for long term
management of either occupational or occupationally-aggravated asthma. It is expected
that approximately 10% of cases will fall outside this guideline and require review on a
case-by-case basis.
II.
Criteria for Diagnosis:

A.
Diagnosis of Occupational Asthma

1.
Diagnosis of asthma within these guidelines by a medical doctor,
using the appended algorithm
2.
Historical association between the onset of asthma and work,
AND
3.
At least one of the following criteria:
a.
Documentation (see Occupational History, Section III.B) of
workplace exposure to a category of agents or processes associated with asthma;
b.
Work-related change in FEV1 or in peak expiratory flow
(PEF);
c.
Onset of respiratory signs and/or symptoms within hours
after an acute high level occupational inhalation exposure to an irritant (RADS)
B.
Diagnosis of Occupationally-Aggravated Asthma: There must be a
history of asthma prior to the occupational exposure in question. Other diagnostic criteria
are the same as for new onset occupational asthma.
III.
Medical Diagnosis and Initial Stabilization:
Physician Visits Allowed. The number of physician visits needed to diagnose and
stabilize cases of occupational and occupationally-aggravated asthma is likely to vary
from patient to patient. Physicans must use their judgment to determine the number of
physician visits necessary for diagnosis and initial stabilization.
IV.
Establishing the Diagnosis:

A.
Medical History:
1.
Characteristic symptoms: wheeze, cough, chest tightness,
shortness of breath
2.
Past respiratory history: prior diagnosis of asthma, allergies,
eczema, rhinitis, bronchitis, sinusitis, hayfever, chest colds, and respiratory symptoms
upon exertion, exposure to minor irritants, or exposure to cold air
3.
Review of systems: history of other diseases with symptoms that
could mimic or precipitate asthma; e.g., cardiovascular disease with left ventricular
dysfunction; gastroesophageal reflux
4.
Family history: asthma, atopy
5.
Smoking history: average # packs of cigarettes per day x # years
smoked (pack years of smoking)
6.
List of current medications
7.
Home, hobby, and environmental exposure history to exclude other
causal or contributing factors
B.
Occupational History:
1.
Description of the patients work tasks, exposures and related
processes, both past and present
2.
Effect(s) of workplace exposures on respiratory symptoms, with
emphasis on temporal associations. Note whether symptoms change on weekends and/or
vacation.
3.
Documentation of workplace exposures where possible: e.g.,
Material Safety Data Sheets (MSDS); employer records; industrial hygiene monitoring
data from government agencies or private consultants
4.
Where data for characterizing exposures is inadequate, worksite
evaluation by an appropriate health care provider or industrial hygienist may be necessary
and is encouraged.
C.
Physical Examination:
1.
Examination of head for rhinitis, nasal polyps, conjunctivitis, and
sinusitis
2.
Chest percussion and auscultation
3.
Cardiovascular exam to rule out cardiogenic explanation for
respiratory symptoms
4.
Skin exam for atopic dermatitis
D.
Diagnostic Tests Allowed:
1.
A total of 11 spirometry studies is allowed. For purposes of this
guideline, each study shall consist of a minimum of 3 and a maximum of 8 maneuvers,
with at least the initial study pre- and post-inhaled bronchodilator.
a.
Up to 2 follow-up spirometry studies will be allowed to
establish a diagnosis of asthma.
b.
Up to 8 pre- and post-shift spirometry studies will be
allowed at the beginning and end of each work week for 2 weeks.
c.
When PEF diary and spirometric monitoring are equivocal,
a longer absence from work may be needed to establish or rule out the diagnosis, with
(i)
1 repeat spirometry study allowed at the beginning
of the absence from work and 1 repeat spirometry study allowed at the end of the absence
from work, and
(ii)
the PEF diary monitoring repeated.
2.
One Non-Specific Inhalation Challenge Test Allowed:

If there is no significant improvement in FEV1 in response to
inhaled bronchodilator, and if the existence of airways hyperreactivity remains in
question (see appended algorithm), but only when:
a.
Consistent with this guidelines Appended Algorithm, and
b.
Under supervision of a medical doctor experienced in this
type of procedure.
3.
Ten Specific Skin Tests with relevant antigens allowed, but only
when:
a.
Performed by a medical doctor experienced in this type of
procedure, and
b.
In a hospital-based outpatient setting.
WARNING: SKIN TESTS ARE NON-EMERGENT PROCEDURES, WITH

SIGNIFICANT RISK OF SEVERE REACTION, INCLUDING DEATH.
4.
Chest radiograph 1 postero-anterior and 1 lateral view allowed
5.
Latex and laboratory animal dander RAST test(s) for specific
work-related exposure 1 allowed for each antigen.
V.
Initial Treatment Program:

A.
Prevention of further exposure to causal or precipitating agent(s):
1.
When caused by a sensitizing agent, all further exposure to the
causal agent must be eliminated because of the increased risk for irreversible airways
obstruction, severe bronchospasm and/or death. A statement of the physicians
discussion of these and other risks with the patient must be documented in the medical
record.
2.
When caused by an irritant, elimination of exposure is desirable
but significant reduction of exposure may be sufficient.
3.
When elimination of exposure is not possible, alternative
approaches may include, in order of preference:
a.
Engineering controls such as local exhaust ventilation
b.
Appropriate use of respiratory protection provided by the
employer
B.
Where these approaches fail and the clinical condition warrants, removal
of the workers from the workplace may be necessary.
C.
Medications:
1.
Medications should only be used in conjunction with prevention of
further exposure as outlined in Section V. A. above.
2.
Spirometric testing is allowed as needed to monitor effectiveness
of therapy, not to exceed a maximum of 11 spirometry studies allowed in Section IV. D.
above. Due to its unique nature, Occupational Asthma often requires a more aggressive
therapeutic approach than Non-Occupational Asthma. The recommended therapeutic
approach is as follows:
a. Step 1:
Rapid-onset B-agonist as needed for control of
symptoms of asthma occurring less than three times per week. If this fails, then:
b. Step 2:
Inhaled low-to- medium dose corticosteroids to treat
underlying inflammation, combined with a rapid-onset inhaled B-agonist as needed to
control symptoms of asthma. If this fails, then:
c. Step 3:
Increase inhaled corticosteroids to high dose, plus
long-acting inhaled B-agonist, and/or theophylline with continued use of rapid-onset
inhaled B-agonist as needed to control symptoms of asthma. If this fails, then:
d. Step 4:
Add an oral corticosteroid.
D.
Patient Education
(The following shall be discussed with the patient at
the initial physician visit and repeated thereafter as necessary):
1.
Key points about signs and symptoms of asthma and characteristic
airway changes in asthma.
2.
Asthma triggers and how to avoid them.
3.
How medications work and their potential adverse effects;
instruction and demonstration in the correct use of all medications (e.g., proper use of
MDIs).
4.
Techniques of monitoring status of asthma, such as PEF readings.
5.
Indications for emergency care.
VI.
Discharge Plan:
A.
Future medical care will depend upon the outcome of initial medical
management. This guideline is meant to address only the diagnosis and initial
stabilization of occupational and occupationally-aggravated asthma.
B.
If causal or aggravating exposure is eliminated or reduced and asthma
symptoms resolve without medication, no further medical management is needed. If
symptoms have resolved with medication, a period of medical follow-up will be needed
to determine the necessity for continued medication and to establish an effective
maintenance regimen. Practitioners should consult other guidelines, practice parameters
and/or standards of care for guidance in the long-term management of persistent
symptoms of asthma.
PROTOCOL HISTORY:
Passed:
4/20/2004
Revised:
1/31/2011
DIAGNOSISOFASTHMAALGORITHM
SYMPTOMS OF ASTHMA
SPIROMETRY: BEFORE AND AFTER INHALED
BETA-ADRENERGIC
AGONIST
REVERSIBILITY OF FEV1>OR= 12%

REVERSIBILITY OF FEV1 <12%
AND/OR ABSOLUTE VALUE > OR=
AND/OR ABSOLUTE VALUE
<200ML
L
200ML
BASELINE
FEV1> 70%
METHACHOLINE OR HISTAMINE
CHALLENGE
# PC20 < 8MGM/ML OR EQUIVALENT
DIAGNOSIS OF ASTHMA
Note:FEV1improvementaftersteroidtrialmaysuggestasthma;however,otherpulmonary
etiologiesalsomayresultinsimilareffectandimprovementinpulmonaryfunction.Froma
diagnosticstandpoint,therefore,apositiveresponseisnotnecessarilydiagnosticofasthma.

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DIAGNOSIS AND INITIAL TREATMENT

Asthma is an airways disease of the lungs characterized by the following:

Criteria for Diagnosis:

Diagnosis of Occupational Asthma

Medical Diagnosis and Initial Stabilization:

Establishing the Diagnosis:

Examination of head for rhinitis, nasal polyps, conjunctivitis, and

Diagnostic Tests Allowed:

One Non-Specific Inhalation Challenge Test Allowed:

WARNING: SKIN TESTS ARE NON-EMERGENT PROCEDURES, WITH

Initial Treatment Program:

Prevention of further exposure to causal or precipitating agent(s):

SPIROMETRY: BEFORE AND AFTER INHALED

REVERSIBILITY OF FEV1>OR= 12%

# PC20 < 8MGM/ML OR EQUIVALENT

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