Dr BALAMUGESHT

Professor

Dept of Pulmonary Medicine

CMC Vellore

Scenario

33 yr

Nursing staff

Past ho allergic rhinitis

Itching skin lesions followed by cough chest tightness and breathlessness with wheeze in ward

Following handling Inj Piptaz

Occupational respiratory diseases

Occupational allergies

At risk population

Diagnosis

Smoke inhalation

Infections

Tuberculosis

Influenza

Occupational allergies Under recognized

Under diagnosed

Under treated

Under reported

Common Occupational allergies

Occupational asthma

Occupational dermatitis

Occupational rhinitis

Occupational conjunctivitis

Occupational asthma

Accounts for 5-10 of asthma in young adults

New‐onset asthma

Hospital technicians (RR 463 95 CI 187 to 115)

Those using ammonia andor bleach at work (RR 216 95 CI 103 to 453)

Kogevinas M et al Lancet 1999

Occupational asthma Of 182 cases of OA in HCWs over 10 years

75 - nursing operating theatre endoscopy and radiology staff

70 - glutaraldehyde latex and cleaning products

G I Walters et al Occupational Medicine 201363513ndash516

Definition ndash occupational asthma Occupational asthma (OA) refers to

de novo asthma or the recurrence of previously quiescent asthma

induced by

sensitization to a specific substance which is termed sensitizer-induced OA or

exposure to an inhaled irritant at work which is termed irritant-induced OA (reactive airways dysfunction syndrome)

Work related asthma

Work exacerbated asthma + OA

OA

Agents causing OA

NEJM July 1995

Risk factors Level and duration of exposure

Smoking

Atopy

Occupational rhinitis and conjunctivitis

Genetic factors

Irritant-induced OA

Exposure to airway irritants in the absence of sensitization

New-onset asthma after exposure to very high levels of alkaline dust from the collapse of the World Trade Center

16 of persons with high exposures at 1 year

At 9 years 36 of them recovered

Lower airway disease symptoms -WTC dust exposure Irritant-induced asthma (of subacute onset)

Nonspecific chronic bronchitis

Chronic bronchiolitis or

Aggravated preexistent obstructive pulmonary disease

Symptoms OA Cough

Breathlessness

Wheeze

Diagnosis History

Examination

PEFR

Spirometry

Serum IgE

Skin prick test

Methacholine challenge test

The Peak Flow Meter like a thermometer for asthma

Inexpensive clinic instrument

Monitoring

Builds confidence in treatment

One lsquohard fast blowrsquo

Occupational asthma diagnosis

bull Compatible history

bull Detailed exposure history

bull Spirometry with reversibility

bull Bronchoprovocation test

bull Establish the relationship

bull Serial peak flow BPT after exposure Skin tests Immunoassay

Environmental Health Perspectives August 2000

An estimated prevalence of sensitization among the general healthcare worker population - 121

4-7 powder-free gloves

It can be assumed that rates have decreased even further with the increased use of non-latex gloves

Latex allergy

Diagnostic tests for latex allergy

Skin testing

Extracts prepared with Hevea latex B and C serum proteins

Sensitivity 65 -96 and specificity ndash 88-94

Serology testing

Hevea latex-specific IgE antibody

Sensitivity ndash 70 specificity - gt95

Glutaraldehyde induced asthma

Cidex

Agent used for disinfection

The odour threshold of glutaraldehyde has been reported to be 004 parts per million (ppm)

Odour detection is a potential indicator that the engineering controls are inadequate

Odour detection - unreliable

Glutaraldemeter

United Kingdom Health and Safety Executive which also has established a 005 ppm Workplace Exposure Limit (WEL)

Prevention Primary prevention

reducing workplace exposure to potential causal agents

Substitution

Process modification

Respirator use

Engineering control with monitoring of airborne exposure levels

Secondary prevention identify early evidence of subclinical

disease periodic medical surveillance by using tools such as

questionnaires spirometry

Tertiary prevention minimize effects of the workplace

environment on clinically manifest disease

Control of specific factors responsible for disease onset or exacerbationaggravation

Change the person to another job

Treatment

Medical management of asthma

Controller inhalers

Rescue inhalers

Outcomes

Factors predicting a worse outcome

Smoking

Lower PC20 at baseline longer duration of exposure and the interval since removal of the patient from exposure

Subjects with OA to HMW agents

Typical plateau for improvement in spirometry is around 1 year whereas the plateau for improvement in BPT occurs around 2 years

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Scenario

33 yr

Nursing staff

Past ho allergic rhinitis

Itching skin lesions followed by cough chest tightness and breathlessness with wheeze in ward

Following handling Inj Piptaz

Occupational respiratory diseases

Occupational allergies

At risk population

Diagnosis

Smoke inhalation

Infections

Tuberculosis

Influenza

Occupational allergies Under recognized

Under diagnosed

Under treated

Under reported

Common Occupational allergies

Occupational asthma

Occupational dermatitis

Occupational rhinitis

Occupational conjunctivitis

Occupational asthma

Accounts for 5-10 of asthma in young adults

New‐onset asthma

Hospital technicians (RR 463 95 CI 187 to 115)

Those using ammonia andor bleach at work (RR 216 95 CI 103 to 453)

Kogevinas M et al Lancet 1999

Occupational asthma Of 182 cases of OA in HCWs over 10 years

75 - nursing operating theatre endoscopy and radiology staff

70 - glutaraldehyde latex and cleaning products

G I Walters et al Occupational Medicine 201363513ndash516

Definition ndash occupational asthma Occupational asthma (OA) refers to

de novo asthma or the recurrence of previously quiescent asthma

induced by

sensitization to a specific substance which is termed sensitizer-induced OA or

exposure to an inhaled irritant at work which is termed irritant-induced OA (reactive airways dysfunction syndrome)

Work related asthma

Work exacerbated asthma + OA

OA

Agents causing OA

NEJM July 1995

Risk factors Level and duration of exposure

Smoking

Atopy

Occupational rhinitis and conjunctivitis

Genetic factors

Irritant-induced OA

Exposure to airway irritants in the absence of sensitization

New-onset asthma after exposure to very high levels of alkaline dust from the collapse of the World Trade Center

16 of persons with high exposures at 1 year

At 9 years 36 of them recovered

Lower airway disease symptoms -WTC dust exposure Irritant-induced asthma (of subacute onset)

Nonspecific chronic bronchitis

Chronic bronchiolitis or

Aggravated preexistent obstructive pulmonary disease

Symptoms OA Cough

Breathlessness

Wheeze

Diagnosis History

Examination

PEFR

Spirometry

Serum IgE

Skin prick test

Methacholine challenge test

The Peak Flow Meter like a thermometer for asthma

Inexpensive clinic instrument

Monitoring

Builds confidence in treatment

One lsquohard fast blowrsquo

Occupational asthma diagnosis

bull Compatible history

bull Detailed exposure history

bull Spirometry with reversibility

bull Bronchoprovocation test

bull Establish the relationship

bull Serial peak flow BPT after exposure Skin tests Immunoassay

Environmental Health Perspectives August 2000

An estimated prevalence of sensitization among the general healthcare worker population - 121

4-7 powder-free gloves

It can be assumed that rates have decreased even further with the increased use of non-latex gloves

Latex allergy

Diagnostic tests for latex allergy

Skin testing

Extracts prepared with Hevea latex B and C serum proteins

Sensitivity 65 -96 and specificity ndash 88-94

Serology testing

Hevea latex-specific IgE antibody

Sensitivity ndash 70 specificity - gt95

Glutaraldehyde induced asthma

Cidex

Agent used for disinfection

The odour threshold of glutaraldehyde has been reported to be 004 parts per million (ppm)

Odour detection is a potential indicator that the engineering controls are inadequate

Odour detection - unreliable

Glutaraldemeter

United Kingdom Health and Safety Executive which also has established a 005 ppm Workplace Exposure Limit (WEL)

Prevention Primary prevention

reducing workplace exposure to potential causal agents

Substitution

Process modification

Respirator use

Engineering control with monitoring of airborne exposure levels

Secondary prevention identify early evidence of subclinical

disease periodic medical surveillance by using tools such as

questionnaires spirometry

Tertiary prevention minimize effects of the workplace

environment on clinically manifest disease

Control of specific factors responsible for disease onset or exacerbationaggravation

Change the person to another job

Treatment

Medical management of asthma

Controller inhalers

Rescue inhalers

Outcomes

Factors predicting a worse outcome

Smoking

Lower PC20 at baseline longer duration of exposure and the interval since removal of the patient from exposure

Subjects with OA to HMW agents

Typical plateau for improvement in spirometry is around 1 year whereas the plateau for improvement in BPT occurs around 2 years

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Occupational respiratory diseases

Occupational allergies

At risk population

Diagnosis

Smoke inhalation

Infections

Tuberculosis

Influenza

Occupational allergies Under recognized

Under diagnosed

Under treated

Under reported

Common Occupational allergies

Occupational asthma

Occupational dermatitis

Occupational rhinitis

Occupational conjunctivitis

Occupational asthma

Accounts for 5-10 of asthma in young adults

New‐onset asthma

Hospital technicians (RR 463 95 CI 187 to 115)

Those using ammonia andor bleach at work (RR 216 95 CI 103 to 453)

Kogevinas M et al Lancet 1999

Occupational asthma Of 182 cases of OA in HCWs over 10 years

75 - nursing operating theatre endoscopy and radiology staff

70 - glutaraldehyde latex and cleaning products

G I Walters et al Occupational Medicine 201363513ndash516

Definition ndash occupational asthma Occupational asthma (OA) refers to

de novo asthma or the recurrence of previously quiescent asthma

induced by

sensitization to a specific substance which is termed sensitizer-induced OA or

exposure to an inhaled irritant at work which is termed irritant-induced OA (reactive airways dysfunction syndrome)

Work related asthma

Work exacerbated asthma + OA

OA

Agents causing OA

NEJM July 1995

Risk factors Level and duration of exposure

Smoking

Atopy

Occupational rhinitis and conjunctivitis

Genetic factors

Irritant-induced OA

Exposure to airway irritants in the absence of sensitization

New-onset asthma after exposure to very high levels of alkaline dust from the collapse of the World Trade Center

16 of persons with high exposures at 1 year

At 9 years 36 of them recovered

Lower airway disease symptoms -WTC dust exposure Irritant-induced asthma (of subacute onset)

Nonspecific chronic bronchitis

Chronic bronchiolitis or

Aggravated preexistent obstructive pulmonary disease

Symptoms OA Cough

Breathlessness

Wheeze

Diagnosis History

Examination

PEFR

Spirometry

Serum IgE

Skin prick test

Methacholine challenge test

The Peak Flow Meter like a thermometer for asthma

Inexpensive clinic instrument

Monitoring

Builds confidence in treatment

One lsquohard fast blowrsquo

Occupational asthma diagnosis

bull Compatible history

bull Detailed exposure history

bull Spirometry with reversibility

bull Bronchoprovocation test

bull Establish the relationship

bull Serial peak flow BPT after exposure Skin tests Immunoassay

Environmental Health Perspectives August 2000

An estimated prevalence of sensitization among the general healthcare worker population - 121

4-7 powder-free gloves

It can be assumed that rates have decreased even further with the increased use of non-latex gloves

Latex allergy

Diagnostic tests for latex allergy

Skin testing

Extracts prepared with Hevea latex B and C serum proteins

Sensitivity 65 -96 and specificity ndash 88-94

Serology testing

Hevea latex-specific IgE antibody

Sensitivity ndash 70 specificity - gt95

Glutaraldehyde induced asthma

Cidex

Agent used for disinfection

The odour threshold of glutaraldehyde has been reported to be 004 parts per million (ppm)

Odour detection is a potential indicator that the engineering controls are inadequate

Odour detection - unreliable

Glutaraldemeter

United Kingdom Health and Safety Executive which also has established a 005 ppm Workplace Exposure Limit (WEL)

Prevention Primary prevention

reducing workplace exposure to potential causal agents

Substitution

Process modification

Respirator use

Engineering control with monitoring of airborne exposure levels

Secondary prevention identify early evidence of subclinical

disease periodic medical surveillance by using tools such as

questionnaires spirometry

Tertiary prevention minimize effects of the workplace

environment on clinically manifest disease

Control of specific factors responsible for disease onset or exacerbationaggravation

Change the person to another job

Treatment

Medical management of asthma

Controller inhalers

Rescue inhalers

Outcomes

Factors predicting a worse outcome

Smoking

Lower PC20 at baseline longer duration of exposure and the interval since removal of the patient from exposure

Subjects with OA to HMW agents

Typical plateau for improvement in spirometry is around 1 year whereas the plateau for improvement in BPT occurs around 2 years

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Occupational allergies Under recognized

Under diagnosed

Under treated

Under reported

Common Occupational allergies

Occupational asthma

Occupational dermatitis

Occupational rhinitis

Occupational conjunctivitis

Occupational asthma

Accounts for 5-10 of asthma in young adults

New‐onset asthma

Hospital technicians (RR 463 95 CI 187 to 115)

Those using ammonia andor bleach at work (RR 216 95 CI 103 to 453)

Kogevinas M et al Lancet 1999

Occupational asthma Of 182 cases of OA in HCWs over 10 years

75 - nursing operating theatre endoscopy and radiology staff

70 - glutaraldehyde latex and cleaning products

G I Walters et al Occupational Medicine 201363513ndash516

Definition ndash occupational asthma Occupational asthma (OA) refers to

de novo asthma or the recurrence of previously quiescent asthma

induced by

sensitization to a specific substance which is termed sensitizer-induced OA or

exposure to an inhaled irritant at work which is termed irritant-induced OA (reactive airways dysfunction syndrome)

Work related asthma

Work exacerbated asthma + OA

OA

Agents causing OA

NEJM July 1995

Risk factors Level and duration of exposure

Smoking

Atopy

Occupational rhinitis and conjunctivitis

Genetic factors

Irritant-induced OA

Exposure to airway irritants in the absence of sensitization

New-onset asthma after exposure to very high levels of alkaline dust from the collapse of the World Trade Center

16 of persons with high exposures at 1 year

At 9 years 36 of them recovered

Lower airway disease symptoms -WTC dust exposure Irritant-induced asthma (of subacute onset)

Nonspecific chronic bronchitis

Chronic bronchiolitis or

Aggravated preexistent obstructive pulmonary disease

Symptoms OA Cough

Breathlessness

Wheeze

Diagnosis History

Examination

PEFR

Spirometry

Serum IgE

Skin prick test

Methacholine challenge test

The Peak Flow Meter like a thermometer for asthma

Inexpensive clinic instrument

Monitoring

Builds confidence in treatment

One lsquohard fast blowrsquo

Occupational asthma diagnosis

bull Compatible history

bull Detailed exposure history

bull Spirometry with reversibility

bull Bronchoprovocation test

bull Establish the relationship

bull Serial peak flow BPT after exposure Skin tests Immunoassay

Environmental Health Perspectives August 2000

An estimated prevalence of sensitization among the general healthcare worker population - 121

4-7 powder-free gloves

It can be assumed that rates have decreased even further with the increased use of non-latex gloves

Latex allergy

Diagnostic tests for latex allergy

Skin testing

Extracts prepared with Hevea latex B and C serum proteins

Sensitivity 65 -96 and specificity ndash 88-94

Serology testing

Hevea latex-specific IgE antibody

Sensitivity ndash 70 specificity - gt95

Glutaraldehyde induced asthma

Cidex

Agent used for disinfection

The odour threshold of glutaraldehyde has been reported to be 004 parts per million (ppm)

Odour detection is a potential indicator that the engineering controls are inadequate

Odour detection - unreliable

Glutaraldemeter

United Kingdom Health and Safety Executive which also has established a 005 ppm Workplace Exposure Limit (WEL)

Prevention Primary prevention

reducing workplace exposure to potential causal agents

Substitution

Process modification

Respirator use

Engineering control with monitoring of airborne exposure levels

Secondary prevention identify early evidence of subclinical

disease periodic medical surveillance by using tools such as

questionnaires spirometry

Tertiary prevention minimize effects of the workplace

environment on clinically manifest disease

Control of specific factors responsible for disease onset or exacerbationaggravation

Change the person to another job

Treatment

Medical management of asthma

Controller inhalers

Rescue inhalers

Outcomes

Factors predicting a worse outcome

Smoking

Lower PC20 at baseline longer duration of exposure and the interval since removal of the patient from exposure

Subjects with OA to HMW agents

Typical plateau for improvement in spirometry is around 1 year whereas the plateau for improvement in BPT occurs around 2 years

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Occupational asthma

Accounts for 5-10 of asthma in young adults

New‐onset asthma

Hospital technicians (RR 463 95 CI 187 to 115)

Those using ammonia andor bleach at work (RR 216 95 CI 103 to 453)

Kogevinas M et al Lancet 1999

Occupational asthma Of 182 cases of OA in HCWs over 10 years

75 - nursing operating theatre endoscopy and radiology staff

70 - glutaraldehyde latex and cleaning products

G I Walters et al Occupational Medicine 201363513ndash516

Definition ndash occupational asthma Occupational asthma (OA) refers to

de novo asthma or the recurrence of previously quiescent asthma

induced by

sensitization to a specific substance which is termed sensitizer-induced OA or

exposure to an inhaled irritant at work which is termed irritant-induced OA (reactive airways dysfunction syndrome)

Work related asthma

Work exacerbated asthma + OA

OA

Agents causing OA

NEJM July 1995

Risk factors Level and duration of exposure

Smoking

Atopy

Occupational rhinitis and conjunctivitis

Genetic factors

Irritant-induced OA

Exposure to airway irritants in the absence of sensitization

New-onset asthma after exposure to very high levels of alkaline dust from the collapse of the World Trade Center

16 of persons with high exposures at 1 year

At 9 years 36 of them recovered

Lower airway disease symptoms -WTC dust exposure Irritant-induced asthma (of subacute onset)

Nonspecific chronic bronchitis

Chronic bronchiolitis or

Aggravated preexistent obstructive pulmonary disease

Symptoms OA Cough

Breathlessness

Wheeze

Diagnosis History

Examination

PEFR

Spirometry

Serum IgE

Skin prick test

Methacholine challenge test

The Peak Flow Meter like a thermometer for asthma

Inexpensive clinic instrument

Monitoring

Builds confidence in treatment

One lsquohard fast blowrsquo

Occupational asthma diagnosis

bull Compatible history

bull Detailed exposure history

bull Spirometry with reversibility

bull Bronchoprovocation test

bull Establish the relationship

bull Serial peak flow BPT after exposure Skin tests Immunoassay

Environmental Health Perspectives August 2000

An estimated prevalence of sensitization among the general healthcare worker population - 121

4-7 powder-free gloves

It can be assumed that rates have decreased even further with the increased use of non-latex gloves

Latex allergy

Diagnostic tests for latex allergy

Skin testing

Extracts prepared with Hevea latex B and C serum proteins

Sensitivity 65 -96 and specificity ndash 88-94

Serology testing

Hevea latex-specific IgE antibody

Sensitivity ndash 70 specificity - gt95

Glutaraldehyde induced asthma

Cidex

Agent used for disinfection

The odour threshold of glutaraldehyde has been reported to be 004 parts per million (ppm)

Odour detection is a potential indicator that the engineering controls are inadequate

Odour detection - unreliable

Glutaraldemeter

United Kingdom Health and Safety Executive which also has established a 005 ppm Workplace Exposure Limit (WEL)

Prevention Primary prevention

reducing workplace exposure to potential causal agents

Substitution

Process modification

Respirator use

Engineering control with monitoring of airborne exposure levels

Secondary prevention identify early evidence of subclinical

disease periodic medical surveillance by using tools such as

questionnaires spirometry

Tertiary prevention minimize effects of the workplace

environment on clinically manifest disease

Control of specific factors responsible for disease onset or exacerbationaggravation

Change the person to another job

Treatment

Medical management of asthma

Controller inhalers

Rescue inhalers

Outcomes

Factors predicting a worse outcome

Smoking

Lower PC20 at baseline longer duration of exposure and the interval since removal of the patient from exposure

Subjects with OA to HMW agents

Typical plateau for improvement in spirometry is around 1 year whereas the plateau for improvement in BPT occurs around 2 years

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Occupational asthma Of 182 cases of OA in HCWs over 10 years

75 - nursing operating theatre endoscopy and radiology staff

70 - glutaraldehyde latex and cleaning products

G I Walters et al Occupational Medicine 201363513ndash516

Definition ndash occupational asthma Occupational asthma (OA) refers to

de novo asthma or the recurrence of previously quiescent asthma

induced by

sensitization to a specific substance which is termed sensitizer-induced OA or

exposure to an inhaled irritant at work which is termed irritant-induced OA (reactive airways dysfunction syndrome)

Work related asthma

Work exacerbated asthma + OA

OA

Agents causing OA

NEJM July 1995

Risk factors Level and duration of exposure

Smoking

Atopy

Occupational rhinitis and conjunctivitis

Genetic factors

Irritant-induced OA

Exposure to airway irritants in the absence of sensitization

New-onset asthma after exposure to very high levels of alkaline dust from the collapse of the World Trade Center

16 of persons with high exposures at 1 year

At 9 years 36 of them recovered

Lower airway disease symptoms -WTC dust exposure Irritant-induced asthma (of subacute onset)

Nonspecific chronic bronchitis

Chronic bronchiolitis or

Aggravated preexistent obstructive pulmonary disease

Symptoms OA Cough

Breathlessness

Wheeze

Diagnosis History

Examination

PEFR

Spirometry

Serum IgE

Skin prick test

Methacholine challenge test

The Peak Flow Meter like a thermometer for asthma

Inexpensive clinic instrument

Monitoring

Builds confidence in treatment

One lsquohard fast blowrsquo

Occupational asthma diagnosis

bull Compatible history

bull Detailed exposure history

bull Spirometry with reversibility

bull Bronchoprovocation test

bull Establish the relationship

bull Serial peak flow BPT after exposure Skin tests Immunoassay

Environmental Health Perspectives August 2000

An estimated prevalence of sensitization among the general healthcare worker population - 121

4-7 powder-free gloves

It can be assumed that rates have decreased even further with the increased use of non-latex gloves

Latex allergy

Diagnostic tests for latex allergy

Skin testing

Extracts prepared with Hevea latex B and C serum proteins

Sensitivity 65 -96 and specificity ndash 88-94

Serology testing

Hevea latex-specific IgE antibody

Sensitivity ndash 70 specificity - gt95

Glutaraldehyde induced asthma

Cidex

Agent used for disinfection

The odour threshold of glutaraldehyde has been reported to be 004 parts per million (ppm)

Odour detection is a potential indicator that the engineering controls are inadequate

Odour detection - unreliable

Glutaraldemeter

United Kingdom Health and Safety Executive which also has established a 005 ppm Workplace Exposure Limit (WEL)

Prevention Primary prevention

reducing workplace exposure to potential causal agents

Substitution

Process modification

Respirator use

Engineering control with monitoring of airborne exposure levels

Secondary prevention identify early evidence of subclinical

disease periodic medical surveillance by using tools such as

questionnaires spirometry

Tertiary prevention minimize effects of the workplace

environment on clinically manifest disease

Control of specific factors responsible for disease onset or exacerbationaggravation

Change the person to another job

Treatment

Medical management of asthma

Controller inhalers

Rescue inhalers

Outcomes

Factors predicting a worse outcome

Smoking

Lower PC20 at baseline longer duration of exposure and the interval since removal of the patient from exposure

Subjects with OA to HMW agents

Typical plateau for improvement in spirometry is around 1 year whereas the plateau for improvement in BPT occurs around 2 years

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Definition ndash occupational asthma Occupational asthma (OA) refers to

de novo asthma or the recurrence of previously quiescent asthma

induced by

sensitization to a specific substance which is termed sensitizer-induced OA or

exposure to an inhaled irritant at work which is termed irritant-induced OA (reactive airways dysfunction syndrome)

Work related asthma

Work exacerbated asthma + OA

OA

Agents causing OA

NEJM July 1995

Risk factors Level and duration of exposure

Smoking

Atopy

Occupational rhinitis and conjunctivitis

Genetic factors

Irritant-induced OA

Exposure to airway irritants in the absence of sensitization

New-onset asthma after exposure to very high levels of alkaline dust from the collapse of the World Trade Center

16 of persons with high exposures at 1 year

At 9 years 36 of them recovered

Lower airway disease symptoms -WTC dust exposure Irritant-induced asthma (of subacute onset)

Nonspecific chronic bronchitis

Chronic bronchiolitis or

Aggravated preexistent obstructive pulmonary disease

Symptoms OA Cough

Breathlessness

Wheeze

Diagnosis History

Examination

PEFR

Spirometry

Serum IgE

Skin prick test

Methacholine challenge test

The Peak Flow Meter like a thermometer for asthma

Inexpensive clinic instrument

Monitoring

Builds confidence in treatment

One lsquohard fast blowrsquo

Occupational asthma diagnosis

bull Compatible history

bull Detailed exposure history

bull Spirometry with reversibility

bull Bronchoprovocation test

bull Establish the relationship

bull Serial peak flow BPT after exposure Skin tests Immunoassay

Environmental Health Perspectives August 2000

An estimated prevalence of sensitization among the general healthcare worker population - 121

4-7 powder-free gloves

It can be assumed that rates have decreased even further with the increased use of non-latex gloves

Latex allergy

Diagnostic tests for latex allergy

Skin testing

Extracts prepared with Hevea latex B and C serum proteins

Sensitivity 65 -96 and specificity ndash 88-94

Serology testing

Hevea latex-specific IgE antibody

Sensitivity ndash 70 specificity - gt95

Glutaraldehyde induced asthma

Cidex

Agent used for disinfection

The odour threshold of glutaraldehyde has been reported to be 004 parts per million (ppm)

Odour detection is a potential indicator that the engineering controls are inadequate

Odour detection - unreliable

Glutaraldemeter

United Kingdom Health and Safety Executive which also has established a 005 ppm Workplace Exposure Limit (WEL)

Prevention Primary prevention

reducing workplace exposure to potential causal agents

Substitution

Process modification

Respirator use

Engineering control with monitoring of airborne exposure levels

Secondary prevention identify early evidence of subclinical

disease periodic medical surveillance by using tools such as

questionnaires spirometry

Tertiary prevention minimize effects of the workplace

environment on clinically manifest disease

Control of specific factors responsible for disease onset or exacerbationaggravation

Change the person to another job

Treatment

Medical management of asthma

Controller inhalers

Rescue inhalers

Outcomes

Factors predicting a worse outcome

Smoking

Lower PC20 at baseline longer duration of exposure and the interval since removal of the patient from exposure

Subjects with OA to HMW agents

Typical plateau for improvement in spirometry is around 1 year whereas the plateau for improvement in BPT occurs around 2 years

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Agents causing OA

NEJM July 1995

Risk factors Level and duration of exposure

Smoking

Atopy

Occupational rhinitis and conjunctivitis

Genetic factors

Irritant-induced OA

Exposure to airway irritants in the absence of sensitization

New-onset asthma after exposure to very high levels of alkaline dust from the collapse of the World Trade Center

16 of persons with high exposures at 1 year

At 9 years 36 of them recovered

Lower airway disease symptoms -WTC dust exposure Irritant-induced asthma (of subacute onset)

Nonspecific chronic bronchitis

Chronic bronchiolitis or

Aggravated preexistent obstructive pulmonary disease

Symptoms OA Cough

Breathlessness

Wheeze

Diagnosis History

Examination

PEFR

Spirometry

Serum IgE

Skin prick test

Methacholine challenge test

The Peak Flow Meter like a thermometer for asthma

Inexpensive clinic instrument

Monitoring

Builds confidence in treatment

One lsquohard fast blowrsquo

Occupational asthma diagnosis

bull Compatible history

bull Detailed exposure history

bull Spirometry with reversibility

bull Bronchoprovocation test

bull Establish the relationship

bull Serial peak flow BPT after exposure Skin tests Immunoassay

Environmental Health Perspectives August 2000

An estimated prevalence of sensitization among the general healthcare worker population - 121

4-7 powder-free gloves

It can be assumed that rates have decreased even further with the increased use of non-latex gloves

Latex allergy

Diagnostic tests for latex allergy

Skin testing

Extracts prepared with Hevea latex B and C serum proteins

Sensitivity 65 -96 and specificity ndash 88-94

Serology testing

Hevea latex-specific IgE antibody

Sensitivity ndash 70 specificity - gt95

Glutaraldehyde induced asthma

Cidex

Agent used for disinfection

The odour threshold of glutaraldehyde has been reported to be 004 parts per million (ppm)

Odour detection is a potential indicator that the engineering controls are inadequate

Odour detection - unreliable

Glutaraldemeter

United Kingdom Health and Safety Executive which also has established a 005 ppm Workplace Exposure Limit (WEL)

Prevention Primary prevention

reducing workplace exposure to potential causal agents

Substitution

Process modification

Respirator use

Engineering control with monitoring of airborne exposure levels

Secondary prevention identify early evidence of subclinical

disease periodic medical surveillance by using tools such as

questionnaires spirometry

Tertiary prevention minimize effects of the workplace

environment on clinically manifest disease

Control of specific factors responsible for disease onset or exacerbationaggravation

Change the person to another job

Treatment

Medical management of asthma

Controller inhalers

Rescue inhalers

Outcomes

Factors predicting a worse outcome

Smoking

Lower PC20 at baseline longer duration of exposure and the interval since removal of the patient from exposure

Subjects with OA to HMW agents

Typical plateau for improvement in spirometry is around 1 year whereas the plateau for improvement in BPT occurs around 2 years

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Risk factors Level and duration of exposure

Smoking

Atopy

Occupational rhinitis and conjunctivitis

Genetic factors

Irritant-induced OA

Exposure to airway irritants in the absence of sensitization

New-onset asthma after exposure to very high levels of alkaline dust from the collapse of the World Trade Center

16 of persons with high exposures at 1 year

At 9 years 36 of them recovered

Lower airway disease symptoms -WTC dust exposure Irritant-induced asthma (of subacute onset)

Nonspecific chronic bronchitis

Chronic bronchiolitis or

Aggravated preexistent obstructive pulmonary disease

Symptoms OA Cough

Breathlessness

Wheeze

Diagnosis History

Examination

PEFR

Spirometry

Serum IgE

Skin prick test

Methacholine challenge test

The Peak Flow Meter like a thermometer for asthma

Inexpensive clinic instrument

Monitoring

Builds confidence in treatment

One lsquohard fast blowrsquo

Occupational asthma diagnosis

bull Compatible history

bull Detailed exposure history

bull Spirometry with reversibility

bull Bronchoprovocation test

bull Establish the relationship

bull Serial peak flow BPT after exposure Skin tests Immunoassay

Environmental Health Perspectives August 2000

An estimated prevalence of sensitization among the general healthcare worker population - 121

4-7 powder-free gloves

It can be assumed that rates have decreased even further with the increased use of non-latex gloves

Latex allergy

Diagnostic tests for latex allergy

Skin testing

Extracts prepared with Hevea latex B and C serum proteins

Sensitivity 65 -96 and specificity ndash 88-94

Serology testing

Hevea latex-specific IgE antibody

Sensitivity ndash 70 specificity - gt95

Glutaraldehyde induced asthma

Cidex

Agent used for disinfection

The odour threshold of glutaraldehyde has been reported to be 004 parts per million (ppm)

Odour detection is a potential indicator that the engineering controls are inadequate

Odour detection - unreliable

Glutaraldemeter

United Kingdom Health and Safety Executive which also has established a 005 ppm Workplace Exposure Limit (WEL)

Prevention Primary prevention

reducing workplace exposure to potential causal agents

Substitution

Process modification

Respirator use

Engineering control with monitoring of airborne exposure levels

Secondary prevention identify early evidence of subclinical

disease periodic medical surveillance by using tools such as

questionnaires spirometry

Tertiary prevention minimize effects of the workplace

environment on clinically manifest disease

Control of specific factors responsible for disease onset or exacerbationaggravation

Change the person to another job

Treatment

Medical management of asthma

Controller inhalers

Rescue inhalers

Outcomes

Factors predicting a worse outcome

Smoking

Lower PC20 at baseline longer duration of exposure and the interval since removal of the patient from exposure

Subjects with OA to HMW agents

Typical plateau for improvement in spirometry is around 1 year whereas the plateau for improvement in BPT occurs around 2 years

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Irritant-induced OA

Exposure to airway irritants in the absence of sensitization

New-onset asthma after exposure to very high levels of alkaline dust from the collapse of the World Trade Center

16 of persons with high exposures at 1 year

At 9 years 36 of them recovered

Lower airway disease symptoms -WTC dust exposure Irritant-induced asthma (of subacute onset)

Nonspecific chronic bronchitis

Chronic bronchiolitis or

Aggravated preexistent obstructive pulmonary disease

Symptoms OA Cough

Breathlessness

Wheeze

Diagnosis History

Examination

PEFR

Spirometry

Serum IgE

Skin prick test

Methacholine challenge test

The Peak Flow Meter like a thermometer for asthma

Inexpensive clinic instrument

Monitoring

Builds confidence in treatment

One lsquohard fast blowrsquo

Occupational asthma diagnosis

bull Compatible history

bull Detailed exposure history

bull Spirometry with reversibility

bull Bronchoprovocation test

bull Establish the relationship

bull Serial peak flow BPT after exposure Skin tests Immunoassay

Environmental Health Perspectives August 2000

An estimated prevalence of sensitization among the general healthcare worker population - 121

4-7 powder-free gloves

It can be assumed that rates have decreased even further with the increased use of non-latex gloves

Latex allergy

Diagnostic tests for latex allergy

Skin testing

Extracts prepared with Hevea latex B and C serum proteins

Sensitivity 65 -96 and specificity ndash 88-94

Serology testing

Hevea latex-specific IgE antibody

Sensitivity ndash 70 specificity - gt95

Glutaraldehyde induced asthma

Cidex

Agent used for disinfection

The odour threshold of glutaraldehyde has been reported to be 004 parts per million (ppm)

Odour detection is a potential indicator that the engineering controls are inadequate

Odour detection - unreliable

Glutaraldemeter

United Kingdom Health and Safety Executive which also has established a 005 ppm Workplace Exposure Limit (WEL)

Prevention Primary prevention

reducing workplace exposure to potential causal agents

Substitution

Process modification

Respirator use

Engineering control with monitoring of airborne exposure levels

Secondary prevention identify early evidence of subclinical

disease periodic medical surveillance by using tools such as

questionnaires spirometry

Tertiary prevention minimize effects of the workplace

environment on clinically manifest disease

Control of specific factors responsible for disease onset or exacerbationaggravation

Change the person to another job

Treatment

Medical management of asthma

Controller inhalers

Rescue inhalers

Outcomes

Factors predicting a worse outcome

Smoking

Lower PC20 at baseline longer duration of exposure and the interval since removal of the patient from exposure

Subjects with OA to HMW agents

Typical plateau for improvement in spirometry is around 1 year whereas the plateau for improvement in BPT occurs around 2 years

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Lower airway disease symptoms -WTC dust exposure Irritant-induced asthma (of subacute onset)

Nonspecific chronic bronchitis

Chronic bronchiolitis or

Aggravated preexistent obstructive pulmonary disease

Symptoms OA Cough

Breathlessness

Wheeze

Diagnosis History

Examination

PEFR

Spirometry

Serum IgE

Skin prick test

Methacholine challenge test

The Peak Flow Meter like a thermometer for asthma

Inexpensive clinic instrument

Monitoring

Builds confidence in treatment

One lsquohard fast blowrsquo

Occupational asthma diagnosis

bull Compatible history

bull Detailed exposure history

bull Spirometry with reversibility

bull Bronchoprovocation test

bull Establish the relationship

bull Serial peak flow BPT after exposure Skin tests Immunoassay

Environmental Health Perspectives August 2000

An estimated prevalence of sensitization among the general healthcare worker population - 121

4-7 powder-free gloves

It can be assumed that rates have decreased even further with the increased use of non-latex gloves

Latex allergy

Diagnostic tests for latex allergy

Skin testing

Extracts prepared with Hevea latex B and C serum proteins

Sensitivity 65 -96 and specificity ndash 88-94

Serology testing

Hevea latex-specific IgE antibody

Sensitivity ndash 70 specificity - gt95

Glutaraldehyde induced asthma

Cidex

Agent used for disinfection

The odour threshold of glutaraldehyde has been reported to be 004 parts per million (ppm)

Odour detection is a potential indicator that the engineering controls are inadequate

Odour detection - unreliable

Glutaraldemeter

United Kingdom Health and Safety Executive which also has established a 005 ppm Workplace Exposure Limit (WEL)

Prevention Primary prevention

reducing workplace exposure to potential causal agents

Substitution

Process modification

Respirator use

Engineering control with monitoring of airborne exposure levels

Secondary prevention identify early evidence of subclinical

disease periodic medical surveillance by using tools such as

questionnaires spirometry

Tertiary prevention minimize effects of the workplace

environment on clinically manifest disease

Control of specific factors responsible for disease onset or exacerbationaggravation

Change the person to another job

Treatment

Medical management of asthma

Controller inhalers

Rescue inhalers

Outcomes

Factors predicting a worse outcome

Smoking

Lower PC20 at baseline longer duration of exposure and the interval since removal of the patient from exposure

Subjects with OA to HMW agents

Typical plateau for improvement in spirometry is around 1 year whereas the plateau for improvement in BPT occurs around 2 years

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Symptoms OA Cough

Breathlessness

Wheeze

Diagnosis History

Examination

PEFR

Spirometry

Serum IgE

Skin prick test

Methacholine challenge test

The Peak Flow Meter like a thermometer for asthma

Inexpensive clinic instrument

Monitoring

Builds confidence in treatment

One lsquohard fast blowrsquo

Occupational asthma diagnosis

bull Compatible history

bull Detailed exposure history

bull Spirometry with reversibility

bull Bronchoprovocation test

bull Establish the relationship

bull Serial peak flow BPT after exposure Skin tests Immunoassay

Environmental Health Perspectives August 2000

An estimated prevalence of sensitization among the general healthcare worker population - 121

4-7 powder-free gloves

It can be assumed that rates have decreased even further with the increased use of non-latex gloves

Latex allergy

Diagnostic tests for latex allergy

Skin testing

Extracts prepared with Hevea latex B and C serum proteins

Sensitivity 65 -96 and specificity ndash 88-94

Serology testing

Hevea latex-specific IgE antibody

Sensitivity ndash 70 specificity - gt95

Glutaraldehyde induced asthma

Cidex

Agent used for disinfection

The odour threshold of glutaraldehyde has been reported to be 004 parts per million (ppm)

Odour detection is a potential indicator that the engineering controls are inadequate

Odour detection - unreliable

Glutaraldemeter

United Kingdom Health and Safety Executive which also has established a 005 ppm Workplace Exposure Limit (WEL)

Prevention Primary prevention

reducing workplace exposure to potential causal agents

Substitution

Process modification

Respirator use

Engineering control with monitoring of airborne exposure levels

Secondary prevention identify early evidence of subclinical

disease periodic medical surveillance by using tools such as

questionnaires spirometry

Tertiary prevention minimize effects of the workplace

environment on clinically manifest disease

Control of specific factors responsible for disease onset or exacerbationaggravation

Change the person to another job

Treatment

Medical management of asthma

Controller inhalers

Rescue inhalers

Outcomes

Factors predicting a worse outcome

Smoking

Lower PC20 at baseline longer duration of exposure and the interval since removal of the patient from exposure

Subjects with OA to HMW agents

Typical plateau for improvement in spirometry is around 1 year whereas the plateau for improvement in BPT occurs around 2 years

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Diagnosis History

Examination

PEFR

Spirometry

Serum IgE

Skin prick test

Methacholine challenge test

The Peak Flow Meter like a thermometer for asthma

Inexpensive clinic instrument

Monitoring

Builds confidence in treatment

One lsquohard fast blowrsquo

Occupational asthma diagnosis

bull Compatible history

bull Detailed exposure history

bull Spirometry with reversibility

bull Bronchoprovocation test

bull Establish the relationship

bull Serial peak flow BPT after exposure Skin tests Immunoassay

Environmental Health Perspectives August 2000

An estimated prevalence of sensitization among the general healthcare worker population - 121

4-7 powder-free gloves

It can be assumed that rates have decreased even further with the increased use of non-latex gloves

Latex allergy

Diagnostic tests for latex allergy

Skin testing

Extracts prepared with Hevea latex B and C serum proteins

Sensitivity 65 -96 and specificity ndash 88-94

Serology testing

Hevea latex-specific IgE antibody

Sensitivity ndash 70 specificity - gt95

Glutaraldehyde induced asthma

Cidex

Agent used for disinfection

The odour threshold of glutaraldehyde has been reported to be 004 parts per million (ppm)

Odour detection is a potential indicator that the engineering controls are inadequate

Odour detection - unreliable

Glutaraldemeter

United Kingdom Health and Safety Executive which also has established a 005 ppm Workplace Exposure Limit (WEL)

Prevention Primary prevention

reducing workplace exposure to potential causal agents

Substitution

Process modification

Respirator use

Engineering control with monitoring of airborne exposure levels

Secondary prevention identify early evidence of subclinical

disease periodic medical surveillance by using tools such as

questionnaires spirometry

Tertiary prevention minimize effects of the workplace

environment on clinically manifest disease

Control of specific factors responsible for disease onset or exacerbationaggravation

Change the person to another job

Treatment

Medical management of asthma

Controller inhalers

Rescue inhalers

Outcomes

Factors predicting a worse outcome

Smoking

Lower PC20 at baseline longer duration of exposure and the interval since removal of the patient from exposure

Subjects with OA to HMW agents

Typical plateau for improvement in spirometry is around 1 year whereas the plateau for improvement in BPT occurs around 2 years

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

The Peak Flow Meter like a thermometer for asthma

Inexpensive clinic instrument

Monitoring

Builds confidence in treatment

One lsquohard fast blowrsquo

Occupational asthma diagnosis

bull Compatible history

bull Detailed exposure history

bull Spirometry with reversibility

bull Bronchoprovocation test

bull Establish the relationship

bull Serial peak flow BPT after exposure Skin tests Immunoassay

Environmental Health Perspectives August 2000

An estimated prevalence of sensitization among the general healthcare worker population - 121

4-7 powder-free gloves

It can be assumed that rates have decreased even further with the increased use of non-latex gloves

Latex allergy

Diagnostic tests for latex allergy

Skin testing

Extracts prepared with Hevea latex B and C serum proteins

Sensitivity 65 -96 and specificity ndash 88-94

Serology testing

Hevea latex-specific IgE antibody

Sensitivity ndash 70 specificity - gt95

Glutaraldehyde induced asthma

Cidex

Agent used for disinfection

The odour threshold of glutaraldehyde has been reported to be 004 parts per million (ppm)

Odour detection is a potential indicator that the engineering controls are inadequate

Odour detection - unreliable

Glutaraldemeter

United Kingdom Health and Safety Executive which also has established a 005 ppm Workplace Exposure Limit (WEL)

Prevention Primary prevention

reducing workplace exposure to potential causal agents

Substitution

Process modification

Respirator use

Engineering control with monitoring of airborne exposure levels

Secondary prevention identify early evidence of subclinical

disease periodic medical surveillance by using tools such as

questionnaires spirometry

Tertiary prevention minimize effects of the workplace

environment on clinically manifest disease

Control of specific factors responsible for disease onset or exacerbationaggravation

Change the person to another job

Treatment

Medical management of asthma

Controller inhalers

Rescue inhalers

Outcomes

Factors predicting a worse outcome

Smoking

Lower PC20 at baseline longer duration of exposure and the interval since removal of the patient from exposure

Subjects with OA to HMW agents

Typical plateau for improvement in spirometry is around 1 year whereas the plateau for improvement in BPT occurs around 2 years

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Occupational asthma diagnosis

bull Compatible history

bull Detailed exposure history

bull Spirometry with reversibility

bull Bronchoprovocation test

bull Establish the relationship

bull Serial peak flow BPT after exposure Skin tests Immunoassay

Environmental Health Perspectives August 2000

An estimated prevalence of sensitization among the general healthcare worker population - 121

4-7 powder-free gloves

It can be assumed that rates have decreased even further with the increased use of non-latex gloves

Latex allergy

Diagnostic tests for latex allergy

Skin testing

Extracts prepared with Hevea latex B and C serum proteins

Sensitivity 65 -96 and specificity ndash 88-94

Serology testing

Hevea latex-specific IgE antibody

Sensitivity ndash 70 specificity - gt95

Glutaraldehyde induced asthma

Cidex

Agent used for disinfection

The odour threshold of glutaraldehyde has been reported to be 004 parts per million (ppm)

Odour detection is a potential indicator that the engineering controls are inadequate

Odour detection - unreliable

Glutaraldemeter

United Kingdom Health and Safety Executive which also has established a 005 ppm Workplace Exposure Limit (WEL)

Prevention Primary prevention

reducing workplace exposure to potential causal agents

Substitution

Process modification

Respirator use

Engineering control with monitoring of airborne exposure levels

Secondary prevention identify early evidence of subclinical

disease periodic medical surveillance by using tools such as

questionnaires spirometry

Tertiary prevention minimize effects of the workplace

environment on clinically manifest disease

Control of specific factors responsible for disease onset or exacerbationaggravation

Change the person to another job

Treatment

Medical management of asthma

Controller inhalers

Rescue inhalers

Outcomes

Factors predicting a worse outcome

Smoking

Lower PC20 at baseline longer duration of exposure and the interval since removal of the patient from exposure

Subjects with OA to HMW agents

Typical plateau for improvement in spirometry is around 1 year whereas the plateau for improvement in BPT occurs around 2 years

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Environmental Health Perspectives August 2000

An estimated prevalence of sensitization among the general healthcare worker population - 121

4-7 powder-free gloves

It can be assumed that rates have decreased even further with the increased use of non-latex gloves

Latex allergy

Diagnostic tests for latex allergy

Skin testing

Extracts prepared with Hevea latex B and C serum proteins

Sensitivity 65 -96 and specificity ndash 88-94

Serology testing

Hevea latex-specific IgE antibody

Sensitivity ndash 70 specificity - gt95

Glutaraldehyde induced asthma

Cidex

Agent used for disinfection

The odour threshold of glutaraldehyde has been reported to be 004 parts per million (ppm)

Odour detection is a potential indicator that the engineering controls are inadequate

Odour detection - unreliable

Glutaraldemeter

United Kingdom Health and Safety Executive which also has established a 005 ppm Workplace Exposure Limit (WEL)

Prevention Primary prevention

reducing workplace exposure to potential causal agents

Substitution

Process modification

Respirator use

Engineering control with monitoring of airborne exposure levels

Secondary prevention identify early evidence of subclinical

disease periodic medical surveillance by using tools such as

questionnaires spirometry

Tertiary prevention minimize effects of the workplace

environment on clinically manifest disease

Control of specific factors responsible for disease onset or exacerbationaggravation

Change the person to another job

Treatment

Medical management of asthma

Controller inhalers

Rescue inhalers

Outcomes

Factors predicting a worse outcome

Smoking

Lower PC20 at baseline longer duration of exposure and the interval since removal of the patient from exposure

Subjects with OA to HMW agents

Typical plateau for improvement in spirometry is around 1 year whereas the plateau for improvement in BPT occurs around 2 years

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

An estimated prevalence of sensitization among the general healthcare worker population - 121

4-7 powder-free gloves

It can be assumed that rates have decreased even further with the increased use of non-latex gloves

Latex allergy

Diagnostic tests for latex allergy

Skin testing

Extracts prepared with Hevea latex B and C serum proteins

Sensitivity 65 -96 and specificity ndash 88-94

Serology testing

Hevea latex-specific IgE antibody

Sensitivity ndash 70 specificity - gt95

Glutaraldehyde induced asthma

Cidex

Agent used for disinfection

The odour threshold of glutaraldehyde has been reported to be 004 parts per million (ppm)

Odour detection is a potential indicator that the engineering controls are inadequate

Odour detection - unreliable

Glutaraldemeter

United Kingdom Health and Safety Executive which also has established a 005 ppm Workplace Exposure Limit (WEL)

Prevention Primary prevention

reducing workplace exposure to potential causal agents

Substitution

Process modification

Respirator use

Engineering control with monitoring of airborne exposure levels

Secondary prevention identify early evidence of subclinical

disease periodic medical surveillance by using tools such as

questionnaires spirometry

Tertiary prevention minimize effects of the workplace

environment on clinically manifest disease

Control of specific factors responsible for disease onset or exacerbationaggravation

Change the person to another job

Treatment

Medical management of asthma

Controller inhalers

Rescue inhalers

Outcomes

Factors predicting a worse outcome

Smoking

Lower PC20 at baseline longer duration of exposure and the interval since removal of the patient from exposure

Subjects with OA to HMW agents

Typical plateau for improvement in spirometry is around 1 year whereas the plateau for improvement in BPT occurs around 2 years

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Diagnostic tests for latex allergy

Skin testing

Extracts prepared with Hevea latex B and C serum proteins

Sensitivity 65 -96 and specificity ndash 88-94

Serology testing

Hevea latex-specific IgE antibody

Sensitivity ndash 70 specificity - gt95

Glutaraldehyde induced asthma

Cidex

Agent used for disinfection

The odour threshold of glutaraldehyde has been reported to be 004 parts per million (ppm)

Odour detection is a potential indicator that the engineering controls are inadequate

Odour detection - unreliable

Glutaraldemeter

United Kingdom Health and Safety Executive which also has established a 005 ppm Workplace Exposure Limit (WEL)

Prevention Primary prevention

reducing workplace exposure to potential causal agents

Substitution

Process modification

Respirator use

Engineering control with monitoring of airborne exposure levels

Secondary prevention identify early evidence of subclinical

disease periodic medical surveillance by using tools such as

questionnaires spirometry

Tertiary prevention minimize effects of the workplace

environment on clinically manifest disease

Control of specific factors responsible for disease onset or exacerbationaggravation

Change the person to another job

Treatment

Medical management of asthma

Controller inhalers

Rescue inhalers

Outcomes

Factors predicting a worse outcome

Smoking

Lower PC20 at baseline longer duration of exposure and the interval since removal of the patient from exposure

Subjects with OA to HMW agents

Typical plateau for improvement in spirometry is around 1 year whereas the plateau for improvement in BPT occurs around 2 years

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Glutaraldehyde induced asthma

Cidex

Agent used for disinfection

The odour threshold of glutaraldehyde has been reported to be 004 parts per million (ppm)

Odour detection is a potential indicator that the engineering controls are inadequate

Odour detection - unreliable

Glutaraldemeter

United Kingdom Health and Safety Executive which also has established a 005 ppm Workplace Exposure Limit (WEL)

Prevention Primary prevention

reducing workplace exposure to potential causal agents

Substitution

Process modification

Respirator use

Engineering control with monitoring of airborne exposure levels

Secondary prevention identify early evidence of subclinical

disease periodic medical surveillance by using tools such as

questionnaires spirometry

Tertiary prevention minimize effects of the workplace

environment on clinically manifest disease

Control of specific factors responsible for disease onset or exacerbationaggravation

Change the person to another job

Treatment

Medical management of asthma

Controller inhalers

Rescue inhalers

Outcomes

Factors predicting a worse outcome

Smoking

Lower PC20 at baseline longer duration of exposure and the interval since removal of the patient from exposure

Subjects with OA to HMW agents

Typical plateau for improvement in spirometry is around 1 year whereas the plateau for improvement in BPT occurs around 2 years

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

The odour threshold of glutaraldehyde has been reported to be 004 parts per million (ppm)

Odour detection is a potential indicator that the engineering controls are inadequate

Odour detection - unreliable

Glutaraldemeter

United Kingdom Health and Safety Executive which also has established a 005 ppm Workplace Exposure Limit (WEL)

Prevention Primary prevention

reducing workplace exposure to potential causal agents

Substitution

Process modification

Respirator use

Engineering control with monitoring of airborne exposure levels

Secondary prevention identify early evidence of subclinical

disease periodic medical surveillance by using tools such as

questionnaires spirometry

Tertiary prevention minimize effects of the workplace

environment on clinically manifest disease

Control of specific factors responsible for disease onset or exacerbationaggravation

Change the person to another job

Treatment

Medical management of asthma

Controller inhalers

Rescue inhalers

Outcomes

Factors predicting a worse outcome

Smoking

Lower PC20 at baseline longer duration of exposure and the interval since removal of the patient from exposure

Subjects with OA to HMW agents

Typical plateau for improvement in spirometry is around 1 year whereas the plateau for improvement in BPT occurs around 2 years

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Glutaraldemeter

United Kingdom Health and Safety Executive which also has established a 005 ppm Workplace Exposure Limit (WEL)

Prevention Primary prevention

reducing workplace exposure to potential causal agents

Substitution

Process modification

Respirator use

Engineering control with monitoring of airborne exposure levels

Secondary prevention identify early evidence of subclinical

disease periodic medical surveillance by using tools such as

questionnaires spirometry

Tertiary prevention minimize effects of the workplace

environment on clinically manifest disease

Control of specific factors responsible for disease onset or exacerbationaggravation

Change the person to another job

Treatment

Medical management of asthma

Controller inhalers

Rescue inhalers

Outcomes

Factors predicting a worse outcome

Smoking

Lower PC20 at baseline longer duration of exposure and the interval since removal of the patient from exposure

Subjects with OA to HMW agents

Typical plateau for improvement in spirometry is around 1 year whereas the plateau for improvement in BPT occurs around 2 years

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Prevention Primary prevention

reducing workplace exposure to potential causal agents

Substitution

Process modification

Respirator use

Engineering control with monitoring of airborne exposure levels

Secondary prevention identify early evidence of subclinical

disease periodic medical surveillance by using tools such as

questionnaires spirometry

Tertiary prevention minimize effects of the workplace

environment on clinically manifest disease

Control of specific factors responsible for disease onset or exacerbationaggravation

Change the person to another job

Treatment

Medical management of asthma

Controller inhalers

Rescue inhalers

Outcomes

Factors predicting a worse outcome

Smoking

Lower PC20 at baseline longer duration of exposure and the interval since removal of the patient from exposure

Subjects with OA to HMW agents

Typical plateau for improvement in spirometry is around 1 year whereas the plateau for improvement in BPT occurs around 2 years

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Secondary prevention identify early evidence of subclinical

disease periodic medical surveillance by using tools such as

questionnaires spirometry

Tertiary prevention minimize effects of the workplace

environment on clinically manifest disease

Control of specific factors responsible for disease onset or exacerbationaggravation

Change the person to another job

Treatment

Medical management of asthma

Controller inhalers

Rescue inhalers

Outcomes

Factors predicting a worse outcome

Smoking

Lower PC20 at baseline longer duration of exposure and the interval since removal of the patient from exposure

Subjects with OA to HMW agents

Typical plateau for improvement in spirometry is around 1 year whereas the plateau for improvement in BPT occurs around 2 years

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Tertiary prevention minimize effects of the workplace

environment on clinically manifest disease

Control of specific factors responsible for disease onset or exacerbationaggravation

Change the person to another job

Treatment

Medical management of asthma

Controller inhalers

Rescue inhalers

Outcomes

Factors predicting a worse outcome

Smoking

Lower PC20 at baseline longer duration of exposure and the interval since removal of the patient from exposure

Subjects with OA to HMW agents

Typical plateau for improvement in spirometry is around 1 year whereas the plateau for improvement in BPT occurs around 2 years

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Treatment

Medical management of asthma

Controller inhalers

Rescue inhalers

Outcomes

Factors predicting a worse outcome

Smoking

Lower PC20 at baseline longer duration of exposure and the interval since removal of the patient from exposure

Subjects with OA to HMW agents

Typical plateau for improvement in spirometry is around 1 year whereas the plateau for improvement in BPT occurs around 2 years

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Outcomes

Factors predicting a worse outcome

Smoking

Lower PC20 at baseline longer duration of exposure and the interval since removal of the patient from exposure

Subjects with OA to HMW agents

Typical plateau for improvement in spirometry is around 1 year whereas the plateau for improvement in BPT occurs around 2 years

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Smoke inhalation

Three types of injuries

Thermal injury to the upper airways

Chemical injury to the tracheobronchial tree and

Systemic poisoning due to carbon monoxide andor cyanide

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

95 people including members of the staff

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Thermal injury airway compromise

Intubation is justified if any of the following signs are present

Stridor

Use of accessory respiratory muscles

Respiratory distress

Hypoventilation

Deep burns to the face or neck or blistering or edema of the oropharynx

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Oropharygeal examination -if erythema

Do Larygoscopy

Upper airway edema or blistering seen during laryngoscopic exam should prompt intubation

Bronchoscopy instead of laryngoscopy

if there is a history of inhalation

of superheated particles or steam

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Carbon monoxide poisoning

Headache nausea malaise altered cognition dyspnea angina seizures coma cardiac dysrhythmias heart failure or bright cherry red lips

Detected by co-oximetry

Treatment

100 oxygen

Hyperbaric oxygen

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Cyanide poisoning

Burning of certain compounds (eg polyurethane acrylonitrile nylon wool and cotton)

Clinical suspicion for cyanide poisoning should be high

Unexplained lactic acidosis low arterial carbon dioxide tension

Treatment

high flow oxygen

use of antidotes ( eg sodium thiosulfate PLUS hydroxocobalamin)

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Prevention

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Influenza in HCW

Olga Anikeeva et al Am J Public Health 2009

Additional benefits of vaccination Prevent sickness absenteeism

Protect transmission to patients

SUMMARY

High index of suspicion required for occupational respiratory diseases

Preparedness for smoke inhalation management

THANK YOU

Cleveland clinic Nov 2013

Features of Irritant-Induced Occupational Asthma

ASSOCIATIONS BETWEEN OCCUPATIONAL EXPOSURES AND ASTHMA AMONG TEXAS HEALTH CARE WORKERS

SUMMARY

High index of suspicion required for occupational respiratory diseases

Preparedness for smoke inhalation management

THANK YOU

Cleveland clinic Nov 2013

Features of Irritant-Induced Occupational Asthma

ASSOCIATIONS BETWEEN OCCUPATIONAL EXPOSURES AND ASTHMA AMONG TEXAS HEALTH CARE WORKERS

THANK YOU

Cleveland clinic Nov 2013

Features of Irritant-Induced Occupational Asthma

ASSOCIATIONS BETWEEN OCCUPATIONAL EXPOSURES AND ASTHMA AMONG TEXAS HEALTH CARE WORKERS

Cleveland clinic Nov 2013

Features of Irritant-Induced Occupational Asthma

ASSOCIATIONS BETWEEN OCCUPATIONAL EXPOSURES AND ASTHMA AMONG TEXAS HEALTH CARE WORKERS

Features of Irritant-Induced Occupational Asthma

ASSOCIATIONS BETWEEN OCCUPATIONAL EXPOSURES AND ASTHMA AMONG TEXAS HEALTH CARE WORKERS

ASSOCIATIONS BETWEEN OCCUPATIONAL EXPOSURES AND ASTHMA AMONG TEXAS HEALTH CARE WORKERS