Prof. Metin Gorguner

Atatürk University Medical FacultyDepartment of Pulmonary Diseases

gorguner@atauni.edu.tr

Terminology*Terminology*

• Cleaning• Cleaning Worker• Cleanliness• Clean

* T.L.F. Dictionary

Cleaning IndustryCleaning Industry

Cleaning Agents and Other Household Products

Inhaled Toxic SubstancesInhaled Toxic Substances• Gas• Aerosol

– Stable suspended solid or liquid particles with in gas environment

• Vapor– Gas condition of solid or liquid

substances in normal• Fume

– Solid particles aerosol < 0,1 m• Duman

– Volatile gas or particles formed by burning

Inhalation of Toxic Inhalation of Toxic SubstanceSubstance

inhalation of toxic substance

chronic pulmonary disease

systemic diseasesudden respiratory

distress

pathologic changes developing with in seconds

Factors Affecting ToxicityFactors Affecting Toxicity

• Particles diameter• Solubility in water• Consantration• Exposure time• Ventilation• Personal characteristics

– Age, cigarette, comorbid disease, prevention, genetic predisposition

Most Important FactorsMost Important Factors

solubility in water particles diameter

region of damage – heavy of damage

Characteristics of Solubilitiy in Characteristics of Solubilitiy in Water Water

High Solubility in WaterHigh Solubility in Water

sudden onset of symptoms

excitement of irritant receptors

environment away from or exposition source of deactivation

bronchospasm

prevention of distal transition of toxic substance

Low Solubility in WaterLow Solubility in Water

no irritation

prolonged exposure time

not removed from the environmentno bronchospasm

increased exposure amount

Particles DiameterParticles Diameter

Localization – DamagesLocalization – Damages

• Upper airways– Acute– Chronic

• Conducting airways– Acute– Chronic (RADS, Vocal cord dysfunction)

• Distal airways - parenchymal– Acute– Chronic (BO, BOOP)

Upper AirwaysUpper Airways

• Sudden and short-term toxic effect• Typical symptoms

– Burning in throat– Sticky mucus– Cough and sneeze

• Extrapulmonary symptoms– Burning eyes– Headache and dizziness

Upper AirwaysUpper Airways

• Most important risk: airway obstruction– Reflex laryngospasm or bronchospasm– Mucosal edema– Increased secretion– Epithelial damage

• If hoarseness or stridor;– Careful observation in terms of respiratory insufficiency

• Non-sequelaous improvement in general

Conducting AirwaysConducting Airways

• Acute Damage– Epithelial damage like upper airways– Life-threatening edema, inflammation,

bronchospasm– Wheezing, reduction in air flow with PEF-meter or

spirometer, abnormal chest X-ray, dyspnea, chest tightness

Conducting AirwaysConducting Airways

• Chronic damage

– Vocal Cord Dysfunction

– Reaktif Airway Dysfunction Syndrome (RADS)

Distal Airways - Distal Airways - ParenchymalParenchymal

• Acute damage– Cellular toxicity increased alveolo-capillary

membran permeability ARDS– Typically; a latent period after the first exposition– Minimum 24 hours of observation period should

be done in terms of respiratory distress

Slight dyspneaCough ARDS

Distal Airways - Distal Airways - ParenchymalParenchymal

• Chronic damage– BO (Bronchiolitis obliterans)

– BOOP (Bronchiolitis obliterans organized pneumonia)

• Work related asthma

Mesleksel HastalıkMesleksel Hastalık

1. SKIN

2. RESPIRATORY SYSTEM

1. Airway disease

2. Parenchymal disease

3. Pleural disease

AHR

Variant• Industrial bronchitis• Asthma-like syndrome

Persistent

Work Related AsthmaWork Related Asthma

WORK RELATED ASTHMA

Work Exacerbated Asthma

Work Exacerbated Asthma

Occupational Asthma

Occupational Asthma

Occupational AsthmaOccupational Asthma

Immunological (IgE)

Non-immunological

High Molecular Weight

Low Molecular Weight

Non-immunologicalNon-immunological

• İrritants “İrritant induced asthma”– Multiple exposure– Single exposure (RADS)

• Organic dusts and microbial agents “Asthma-like syndrome”

Mapp CE, et al. Occupational Asthma AJRCCM 2005

Work Related AsthmaWork Related Asthma

Population Attributable RiskPopulation Attributable Risk

• Population attributable risk (PAR) for asthma due to occupational exposures: median 15 %

(21 studies: 4% to 58%)

Balmes J, et al. AJRCCM 2003

Asthma and Cleaning Asthma and Cleaning AgentsAgents

• In female cleaners• Use of bleach • Reported inhalation incident• Use of cleaning sprays

High risk of asthma

Karjalainen et al. ERJ 2002, Medina-Ramon et al. OEM 2005, Zock et al. AJRCCM 2007

• 43 female cleaners with recent history of asthma and/or chronic bronchitis

• 2-week diary (symptoms, PEF 3/d, exposures)• Upper respiratory symptoms:

– no association with exposure

• Lower respiratory symptoms: associations with;– exposure to bleach (O.R. 2.5)– degreasing sprays (O.R. 2.6) – air refreshing sprays (O.R. 6.5)

Medina-Ramon et al. OEM 2005

• USA (CA, MA, MI, NJ), 1993 – 1995 • SENSOR (Sentinel Event Notification System for Occupational Risks) program• Work related RADS (123 cases)• 18 (15 %) of the RADS cases• Most common class of agents was cleaning materials

Henneberger PK, et al. J Occup Environ Med 2003

Reactive Airways Dysfuntion Reactive Airways Dysfuntion SyndromeSyndrome

• 10 clinical case;– Önceden solunum sistemi semptomu olmayan– Yüksek düzeyde kimyasal iritana maruziyet sonrası

dakikalar-saatler içerisinde solunumsal semptomlar

– Persistan astım (>1yıl): öksürük, vizing, dispne, FEV1’de , havayolu aşırı duyarlılığı

– Biyopside nonspesifik havayolu inflamasyonu

• Re-maruziyet yokBrooks SM, et al. Reactive airways dysfunction syndrome (RADS). Chest 1985

• Acute inhalational damage • after• new onset • asthma

Brooks SM, et al. Reactive airways dysfunction syndrome (RADS). Chest 1985

Reactive Airways Dysfuntion Reactive Airways Dysfuntion SyndromeSyndrome

RADS-PathophysiologyRADS-Pathophysiology

Epithelial Damage

Inflammation

AHR

Inflammation – RemodellingInflammation – Remodelling

Acut Period

Chronic Period

RADS – RADS – Criteria for DiagnosisCriteria for Diagnosis

1. Absence of preceeding respiratory complaints2. The oncet of symptoms occured after a single

spesific exposure3. The exposure was to a gas, smoke, fume which was

present in very high concentrations4. The onset of symptoms occurred within 24 hours5. Symptoms persisted for at least 3 months6. Symptoms simulated asthma (cough, wheezing,

dyspnea)7. Pulmonary function tests may show airflow

obstruction8. Positive Methacholine/histamine challenge testing9. Other types of pulmonary diseases were ruled out

Brooks SM, et al. Reactive airways dysfunction syndrome (RADS). Chest 1985Nemery B, Leuven – 2009

Substances that can make Substances that can make RADSRADSAcetic acid Diesel fuel Spray paint

Sulfuric acid Diethilaminethanol Sulfur dioxide

Chloridric acid Epichlorohydrine Gas (chlorine, mustard, phosgene)

Heated acid Ethylene oxide Fire smoke

Ammonia Isocyanates Grouting

Laundry bleach Metal cleaners Formalin

Chlorine Oxyde Spray Cleaner

Chloropicrine Heated paint Hydrazine

Cleaning supplies Phthalic anhydride

• Inhalation accidents and RADS occuring;– Workplace

• Petrochemistry, fire-fighting, industrial cleaning

– Home• Indoor cleaning*

– Daily life• Transportation accidents• Fire & Explosion

* Akkoçlu, A., et al. The effect of hydrochloric acid and hypochlorite as the cause of RADS Dokuz Eylul Univ. Med. J. 1990

BleachBleach – – Hydrochloric Acid MixtureHydrochloric Acid Mixture

Gorguner M, et al. Inhal Toxicol 2004

Gorguner M, et al. Inhal Toxicol 2004

• A lower age, higher initial PEFR, higher initial paO2, • Exposure in the kitchen or bathroom, • Exposure after waiting 10–15 min after mixing the

solutions • Shorter duration of the acute exposure• Less long-term use of the mixture

were associated with a better response to therapy• Smoking status was not related to differing responses to treatment

Gorguner M, et al. Inhal Toxicol 2004

TreatmentTreatment

• Prevention is more important• Treated like asthma when sypmtoms develop• Steroid therapy in early stage can prevent

RADS do ? • Nebulized Sodium-Bicarbonate treatment

Nebulize Sodyum – Nebulize Sodyum – Bikarbonat Bikarbonat

Kandiş H, et al. Inhalation Toxicology 2006

Sodium – Bicarbonate Sodium – Bicarbonate TreatmentTreatment

• 44 patients• Patients were divided into two groups• Bronchdilator + steroid given to all• In addition; nebulized 4,2 % sodium

bicarbonate solution given to one group (NSB), and placebo to other group (NP)

Kandiş H, et al. Inhalation Toxicology 2006

• In NSB group;– NSB group had

significantly higher FEV1 values (p<0,05)

– Significantly more improvement in QoL questionnaire scores occurred in the NSB group (p<0,01)

Kandiş H, et al. Inhalation Toxicology 2006

Thank you for your attention…