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A GUIDE TO THE
MANAGEMENT OF
OCCUPATIONAL ASTHMA
This booklet was written by Dr Chris Walls with assistance from the
OSH Departmental Medical Practitioners and Dr Julian Crane
(Physician, Wellington), Dr Margaret Wilsher (Physician, Auckland)
and Dr Colin Wong (Physician, Dunedin), members of the NODS
Asthma Panel.
Dr John Allen (Pukekohe), Dr Charles Skinner (Auckland) and Dr
Rob Stewart (Auckland) provided a critique from a general practice
view point and their assistance is greatly appreciated.
Published by:
Occupational Safety and Health Service
Department of Labour
Wellington
New Zealand
ISBN 0-477-03559-0
Contents
Foreword 4
Summary 5
Clinical History 11
Clinical Findings 12
References 19
Foreword
R Hill
General Manager
A GUIDE TO THE MANAGEMENT OF OCCUPATIONAL ASTHMA 5
Summary
* Industrial Injuries Advisory Council (UK) Asthma that develops after a variable
period of symptomless exposure to a sensitising agent at work.
A GUIDE TO THE MANAGEMENT OF OCCUPATIONAL ASTHMA 9
Occupational History
The occupational history attempts to establish the likely agent and the length
and degree of exposure.
The occupational history should record the work that the patient has done
since leaving school and the exposures that the patient had in these occupa-
tions. The intention is to identify the causative agent and whether the
symptoms are totally new or an aggravation of longstanding problems.
Particular attention should be paid to what these exposures (e.g. dusts, chemi-
cals) consisted of. For example, lots of dust needs some clarification as
dusts may be inert as in soil dusts, contain wood and chemicals as in wood
dust, biological material (animal protein and spores) as in dust from a poultry
shed, or dried chemicals (powder coating plants or timber treatment plants).
Chemicals are often only known by their commercial names or are a mixture
of other chemicals. OSH occupational hygienists are available to offer advice
as to the potential of materials or products to cause asthma or to research the
constituent parts of a product. They may be contacted at the OSH branch
offices listed in this guide.
A useful tool when trying to assess a product is to obtain the Material Safety
Data Sheet usually referred to as the MSDS. This can be obtained from the
manufacturer of the chemical product free of charge or from the Poisons
Centre in Dunedin. The MSDS presents information concerning the product
10 A GUIDE TO THE MANAGEMENT OF OCCUPATIONAL ASTHMA
Clinical History
The key questions to ask your patient
The clinical history is vital to making the diagnosis and is composed of several
parts. Usually, it is the clinical history that enables the diagnosis of occupa-
tional asthma to be made. There are four key screening questions to ask.
Although the actual pattern of asthma varies according to the substance and
the patient, these questions will help identify the majority of sufferers:
Does your asthma vary during the working week ?
Usually, occupational diseases including asthma worsen during the
working week so that by the end of the shift period there has been a
steady deterioration in symptoms and clinical measurements.
Often questioning reveals certain days and tasks where symptoms are
more pronounced helping to identify the cause of the asthma.
Is your asthma better or worse on days away from work ?
Patients may note a continued improvement away from work,
especially on long weekends or holidays. Identifying work/non-work
periods on peak flow charts gives a vital clue to occupational asthma.
Is your asthma better or worse on holidays ?
For those patients with severe asthma and who have a slow recovery,
the two- or three-day break may not be sufficient to allow a return to
the non-asthmatic state. Patients often report a dramatic improve-
ment of symptoms after several days away from the workplace and a
relapse of symptoms within 48 hours of returning to work.
In complex cases it is necessary to differentiate between holidays at
home or away from home because of the compounding effect of
irritants.
Is your sleep disturbed by cough or breathing problems ?
Occupational asthma often causes night cough or episodes of
wheezing or shortness of breath waking the patient from sleep. These
symptoms can be quite mild, are often initially misinterpreted
because they do not occur at work (e.g. the shift worker will blame the
light and noise outside for waking him or her or attribute the
symptoms to a recurrent cold).
12 A GUIDE TO THE MANAGEMENT OF OCCUPATIONAL ASTHMA
Smoking History
Burge12 notes that the prevalence of occupational asthma is higher in smokers
and smoking enhances the production of specific IgE in an occupational
setting. A variety of mechanisms have been postulated to explain this in-
creased prevalence including an increase in exposure to an occupational agent
by smoking in the at risk environment.
Smoking history is always relevant. Some employers or insurance companies
will attempt to blame smoking as the cause of the symptoms rather than
accepting that work can be a causative agent. It will be impossible to control
an occupational asthma while your patient continues to smoke in the
workplace in the presence of the causative exposure. Without a smoking
history you cannot properly advise the patient or their employer.
Clinical Findings
Measurements used to make the diagnosis
The NODS Asthma Panel tries to obtain the following information when
assessing a case:
Clinical evidence of reversible airways obstruction (peak flow
variability, response to inhaled beta-agonist such as an increased peak
flow or FEV1).
A peak flow pattern demonstrating a increased peak flow variability
associated with exposure. To measure this adequately the panel
recommends:
A minimum of four peak flows a day for two weeks.
The best of three (to ensure a consistent result) peak flows is
recorded. Before work, during work (mid shift), immediately after
work and as the patient goes to bed are the suggested times. A peak
flow chart is available in Appendix 2 and pads of this peak flow chart
are available from the local OSH branch office.
The patient must mark the time at work and not at work and, if
possible, periods when they were exposed to the suspected aetiological
agent, presuming the exposure was not continuous. They should also
A GUIDE TO THE MANAGEMENT OF OCCUPATIONAL ASTHMA 13
Specific inhalation challenges are not performed in New Zealand. They have
been described as the final arbiter of proof9 but they are exceedingly expensive
and are not without considerable risk to the patient. Furthermore, problems
arise in estimating the actual inhaled dose encountered in the workplace,
often of a mixture of substances and, in evaluating the results of artificial
doses given, in an artificial environment.
A number of exposures are the possible culprit(s) and include the welding
fumes composed of oxides of nitrogen, sulphur dioxide, metal fumes from the
metal, and the products of combustion from cutting isocyanate foam
insulation and ozone produced by the welding process.
This welder was using little in the way of personal protection and the welding
often took place in a confined space where the oxygen content of the inhaled
air could be reduced because of its consumption in the welding process.
A second peak flow chart is from an electronic worker referred by her general
practitioner with persistent and poorly controlled asthma. This patient was
exposed to solder fumes containing colophony and her peak flow values show
a steady deterioration during the working week and a recovery over the
weekend.
Elimination
In today's industrial climate substituting the hazard with another product or
material is often feasible. For example, the employer of the electronic worker,
whose peak flows are represented above, was able to purchase a riveting
machine which did away with the need to use solder in some of the circuit-
board manufacturing processes. OSH occupational hygienists can advise
doctors if alternative products or processes are available.
Isolation
By restricting the agent to some part of the factory or to specific times, it may
be possible to remove your patient from exposure to the asthma-causing
agent and relieve their symptoms. It should be remembered that for the
sensitised patient very small exposures will be sufficient to precipitate
symptoms.
18 A GUIDE TO THE MANAGEMENT OF OCCUPATIONAL ASTHMA
Minimisation
The minimisation of the risk from the asthma-causing agent can be achieved
by a number of measures. The first control measure to consider is adequate
ventilation (both local and environmental) and the last measure is personal
protection by means of respirators.
Ventilation is a complex solution and the employer is well advised to seek
some expert advice before purchasing equipment or approaching the problem
on a piecemeal basis.
Personal protection (a respirator) is not a cheap option. To be used success-
fully, the respirator must be appropriate for the agent or mixture in question,
be individually fitted, maintained correctly and, most importantly, worn
whenever the person is exposed to the agent or mixture. It should only be
used in conjunction with other measures and where substitution of the
offending agent is not practicable.
Most people find wearing a respirator a nuisance and compliance with rules to
wear a respirator is often poor because of a number of factors. Such protec-
tion may be suitable where the exposures are not heavy and are for only a
small portion of the working shift.
Respiratory protection is a subject in its own right and rather than cover it
inadequately in this booklet a copy of A Guide to Respirators and Breathing
Apparatus may be obtained from any OSH branch office.
Only as a last resort, and after consultation with a respiratory or occupational
medical specialist, should someone be advised to abandon their occupation.
The decision is obviously of great importance to the individual and has impli-
cations for compensation issues as well as the more obvious treatment issues.
Many other asthma sufferers have their condition made worse by workplace
factors, and the suggestions about control measures apply to them as well as
the pure occupational asthmas.
The most important difference in the treatment of occupational asthma is to
try and identify the causative exposure and control the patients exposure
to it.
As with most medical problems, this requires a team approach in which the
OSH health and technical services are able to play a part in protecting your
patients.
If you have any comments about this booklet, or suggestions for future
information booklets, please write to:
OSH Health Services
Occupational Safety and Health Service
Department of Labour
PO Box 3705
Wellington
References
1. Ramazzini B: De Morbus Artificum Diatriba (Wright WC, Trans Disease
of Workers). Chicago: University of Chicago Press, 1940.
2. Hunter D: The Diseases of Occupations (6th Ed) Hodder and Stoughton,
1978. ISBN 0-340-22084-8.
3. Gannon PF, Weir DC, Robertson AS, Burge PS: Health Employment
and Financial Outcomes in Workers with Occupational Asthma, Br J Ind
Med, 1993 50 (6) 491-6.
4. Garrett JE: Asthma and Employment Experience, N Z Med J, Aug 22
1990, 103 (896) 399-401.
5. Stenton S, Hendrick D: Occupational Asthma. Postgrad Med J (1991) 67,
271-277.
6. Tarlo S, Broder I: Outcome of Assessments for Occupational Asthma,
Chest, 1991, 100, 329-335.
7. Gannon P, Burge PS: The SHIELD scheme in the West Midlands Region,
United Kingdom. Br J Ind Med, 1993, 50 791-796.
8 Smith D: Medico-Legal Definition of Occupational Asthma, Chest, 1990,
98 1007-11.
9. Burge PS: Diagnosis of Occupational Asthma, Clinical and Experimental
Allergy, 1989, 19 649-52.
20 A GUIDE TO THE MANAGEMENT OF OCCUPATIONAL ASTHMA
Biologic enzymes
B subtilis Detergent industry
Trypsin Plastic, pharmaceutical
Pancreatin Pharmaceutical
Papain Laboratory
Pepsin Pharmaceutical
Flaviastase Pharmaceutical
Bromelin Pharmaceutical
Fungal amylase Manufacturing, bakers
Vegetables
Gum acacia Printers
Gum tragacanth Gum manufacturing
Other
Crab Fish processing
Prawn Fish processing
Hoya Oyster farming
22 A GUIDE TO THE MANAGEMENT OF OCCUPATIONAL ASTHMA
Fluxes
Aminoethyl ethanolamine Aluminium soldering
Colophony Electronic industries, welding
Drugs
Penicillins Pharmaceutical
Cephalosporins Pharmaceutical
Phenylglycine acid chloride Pharmaceutical
Piperazine HCL Chemist
Psyllium Pharmaceutical
Methyldopa Pharmaceutical
Spiramycin Pharmaceutical
Salbutamol Pharmaceutical
Amprolium HCL Poultry feed mixer
Tetracycline Pharmaceutical
Sulphone chloramides Manufacturer, brewer
A GUIDE TO THE MANAGEMENT OF OCCUPATIONAL ASTHMA 23
Aliphatic polyamines
Ethylene diamine Hardeners, particle board
Diethylene triamine
Triethylene tetramine
24 A GUIDE TO THE MANAGEMENT OF OCCUPATIONAL ASTHMA
Questions 1-41 of this form should be completed by 8. Name and address of family doctor?
the Occupational Health Nurse while interviewing the
person notified as a possible case. Questions 42-53
may be completed later.
Please return this form to the Regional Departmental
Medical Practitioner when complete. Smoking
Personal details of person investigated 9. Have you ever smoked for as long as a year?
4. Telephone numbers:
If you no longer smoke how old were you when
Home:
you stopped smoking?
Work:
Occupational History
14. Please list your past employers and the number of years worked for each employer (use additional
paper if needed).
Duration
Job title and employer from 19.. Please describe the nature of the work performed in this job
to 19..
Symptoms
19. Does the wheezing or tightness in your chest
15. Have you had wheezing or whistling in your improve when you are away from work such as
chest in the last twelve months? holidays or weekends?
No Yes No Yes
16. In the last 12 months have you been breathless 20. Have you woken up with a feeling of tightness in
when the wheezing was present? your chest at any time in the last twelve months?
No Yes No Yes
17. Have you had this wheezing or whistling when 21. Do you have a persistent cough?
you did not have a cold?
No Go to question 23
No Yes
Yes Go to question 22
18. Have you had wheezing or tightness in your
chest during or straight after work? 22. Do you tend to cough up phlegm on most days?
No Go to question 20 No Yes
Yes Go to question 19 23. Do you get short of breath walking on the flat?
No Yes
26 A GUIDE TO THE MANAGEMENT OF OCCUPATIONAL ASTHMA
24. Do you get short of breath walking up a slight 33. Are you currently taking any medicines for
incline? asthma (e.g. inhalers, aerosols or pills)?
No Yes No Go to question 34
25. Do you get short of breath more than other Yes Please specify below
people of the same age? Medication
No Yes
No Go to question 33
31. If you answered "yes" to Question 30, what are 36. Did you get asthma when you were a child
all the things that make you wheeze? (Mark the under 16?
appropriate boxes)
No Yes
Cold
37. Have you ever suffered from eczema?
Dusts
No Yes
Cigarette smoke
38. Have you ever suffered from hayfever?
Chemicals such as
solvent or isocyanate No Yes
fumes Go to question 32
39. Do you have a family history of asthma?
Other Go to question 32
No Yes
32. If you answered yes to chemicals or other
please specify. 40. Do you have a family history of eczema?
No Yes
No Yes
A GUIDE TO THE MANAGEMENT OF OCCUPATIONAL ASTHMA 27
42. Please complete the following table indicating: Predicted Sample Sample Sample Post
substances used in the workplace that could be 1 2 3 bronchodilator
implicated in this patient's problems; length of FEV1
exposure; intensity of exposure. Use extra paper FEC
if necessary. FEV1%
In order to assess whether this person's exposure
was heavy or moderate, take into account factors Attach the peak flow diary to this form. Peak flow
such as the percentage of the day that the person forms must record time away from work and time
was exposed and whether any protection was since last dose of bronchodilator was taken by the
used by the person. patient. (Peak flow forms are compulsory for this
diagnosis.)
Exposure estimate
Substance Months of (e.g. in your opinion was 48. When was the last dose of brochodilator taken by
exposure this person's exposure
heavy, moderate or light) the patient?
Yes If yes, please attach results. 53. Which of the following actions were initiated as a
result of this notification?
44. Does environmental monitoring need to be Discussion with management re safety
carried out? systems
No Yes Workplace health and safety assessment
Investigatory biological tests
45. What environmental monitoring have you and/
or the occupational hygienist done? Tests Education
ordered (attach a copy of the results to this Recommendation for consultation with
form). private sector health and safety providers
46. Is there a problem in the place of work? Investigation of other workers
Workplace improvements recommended
No Yes
Workplace improvements raised
Biological monitoring Enforcement action required
Environmental monitoring
47. Patient clinical data
Please use additional paper if you would like to
Age Height make any comments (e.g. justification for your
exposure estimate), and return with this form to
your regional DMP.
Signature (OHN)
Date ___ / ___ / ___
28 A GUIDE TO THE MANAGEMENT OF OCCUPATIONAL ASTHMA
At work ? At work At work Work Home Home Work Work Work Work Work Home Home Work Work Work Work
Before work
Before work
During work
During work
During work
Before work
After work
After work
After work
At home
At home
At home
Peak Flow Example Example Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10 Day 11 Day 12 Day 13 Day 14 Peak Flow
700 700
650 650
600 600
550 550
500 500
450 450
400 400
350 350
300 300
250 250
200 200
150 150
100 100