The guidelines developed by the New York State Workers Compensation Board are intended to assist healthcare professionals in managing work-related asthma.
Tailored for medical practitioners, these Workers Compensation Board guidelines offer support in determining the appropriate management strategies for individuals with asthma related to their work environment.
It’s important to emphasize that these guidelines do not replace clinical judgment or professional experience. The management of work-related asthma should be a collaborative effort, involving the patient and their healthcare provider, with a focus on identifying and addressing occupational factors contributing to the condition.
Work-Related Asthma
Asthma is a prevalent chronic condition affecting the airways, characterized by a intricate interplay of airflow obstruction, bronchial hyperresponsiveness, and underlying inflammation. Enhanced airway responsiveness to a range of stimuli is a characteristic feature.Work-related asthma (WRA) manifests with asthma symptoms that initiate or worsen in the workplace, often associated with exposure to new chemicals or environmental changes.
Work-related asthma (WRA) comprises both occupational asthma (OA) and work-exacerbated asthma (WEA).Occupational asthma (OA) encompasses sensitizer-induced asthma, triggered by sensitization to an antigen in the workplace, and irritant-induced asthma, caused by reactive airways disease provoked by exposure to irritants in the workplace.Both sensitizer-induced asthma and irritant-induced asthma have the potential for significant acute morbidity, long-term disability, and adverse social and economic impacts.
Occupational Asthma (OA)
Occupational Asthma (OA) is characterized by the onset of new asthma symptoms in the workplace. It can result from exposure to either a workplace sensitizer or an irritant.
OA With Latency
OA with latency is observed in all cases of immunologically mediated asthma, where sensitizers trigger an allergic response. The latency period, ranging from weeks to years, represents the time for the development of symptoms after the initial exposure. This period, crucial for the induction of an immunological response, is typically a few months. Sensitizers are categorized into high and low molecular weight chemicals, defining asthma mechanisms, symptoms, and latency. Prolonged exposure to low-level irritants can also lead to OA with latency.
OA Without Latency
OA without latency is characterized by an inflammatory, non-allergic response to irritant exposure, including gases, fumes, vapors, and aerosols. This form of OA can occur after exposure to irritants such as nitrogen oxide, ammonia, and chloride.
Work-Exacerbated Asthma (WEA)
Work-Exacerbated Asthma (WEA) affects individuals with pre-existing asthma, worsening due to specific workplace exposures to irritants like gases, fumes, vapors, and aerosols.
Etiology of Asthma
Asthma is primarily characterized by airway inflammation and reactivity. The key symptoms include episodic shortness of breath, wheezing, and cough.
Diagnosis of Work-Related Asthma
Signs and Symptoms of Work-Related Asthma
Asthma, primarily marked by airway inflammation and reactivity, manifests through episodic shortness of breath, wheezing, and cough. These symptoms contrast with the predominant features of bronchitis, which involve cough and sputum production. A specialized pulmonary and diagnostic history is necessary for diagnosing occupational asthma.
Criteria for Diagnosis
In 1995, the American College of Chest Physicians established criteria for diagnosing Work-Related Asthma (WRA), all of which are essential:
- History consistent with occupational asthma
- Presence of reversible airflow limitation
- In the absence of airflow limitation, the presence of nonspecific airway hyperresponsiveness
- Demonstration of work-relatedness through objective means.
Complications and Comorbid Conditions Relevant to Work
Asthma can present in complex ways, leading to various secondary symptoms and issues affecting daily life and work. Examples include chronic cough triggering secondary hoarseness, indirectly interfering with certain jobs (e.g., affecting voice or conversation abilities). Gastroesophageal Reflux Disease (GERD) is often linked with asthma, potentially exacerbated by bronchodilator medications affecting the lower esophageal sphincter and worsening asthma symptoms. Vocal cord dysfunction, distinct from asthma, may coexist with it or be triggered by GERD or exposure to irritants.
Occupational / Work-Related Asthma
History Taking and Physical Exam
The foundation for diagnosis and treatment plans is established through a comprehensive assessment of occupational exposure history, presentation, and diagnostic screening test results.
History of Present Illness
Occupational and Non-occupational Exposures
The History of Present Illness (HPI) should meticulously document various aspects, including:
- Occupational and non-occupational pulmonary exposures.
- Current and past occupations, specifying types of work activities.
- Duration of time spent in each job, even those held years to decades in the past.
Exposures
Details about exposures to:
- Dusts (grains, flours, wood).
- Metals (Platinum salts, aluminum).
- Chemicals or substances (gases, fumes, vapors like ammonia, isocyanates, solvents, smoke, and aerosols).
Intensity of Exposure
The intensity of exposure should ideally include environmental measurements (industrial hygiene data) or at least a qualitative description (e.g., daily, weekly, monthly).
Responsibilities and Symptoms
Include questions about individual responsibilities and exposure, covering symptoms such as:
- Throat tightness
- Shortness of breath
- Difficulty with inspiration or expiration
- Harsh breath sounds
- Cough
- Sputum production
- Recurrent bronchitis
- Chest tightness
Duration, Onset, and Frequency of Symptoms
Document details about the duration, onset, and frequency of symptoms, including:
- Aggravation and alleviation of symptoms in relation to the work environment.
- Changes in the work environment.
- Changes in symptoms in relation to days worked and not worked.
- Progression of symptoms.
- Seasonal patterns.
Specifics and Documentation
Document if symptoms began after a one-time, high-level workplace inhalation exposure to an irritant. Include information on pulmonary imaging, testing, previous treatments, and the relationship of the illness or injury to work. Assess the individual’s ability to perform job duties and daily activities, along with the workplace history of room size, ventilation, and past/current use of personal protective equipment (PPE).
Past Medical History
Inclusive Medical Background
Past medical history, encompassing prior pulmonary exposures and treatments, should include childhood asthma, susceptibility to bronchitis, hay fever, eczema, and pneumonia.
Systemic Review
The review of systems should encompass symptoms of various diseases, including rheumatologic, neurologic, endocrine, neoplastic, dermatologic, and other systemic conditions.
Smoking and Medication History
A detailed smoking history, considering marijuana and vaping, is essential. Additionally, gather a comprehensive medication history, including the use of pulmonary medications, angiotensin-converting enzyme inhibitors, and beta-blockers.
Vocational and Recreational Details
Explore vocational and recreational pursuits to understand potential exposures and risks.
Prior Studies and Surgical History
Consider prior imaging studies and surgical history in the assessment.
Allergy and Family History
Include an allergy history, particularly the history of atopy, and inquire about a family history of atopic disease.
Physical Examination
Elements of Occupational Pulmonary Physical Examination
- Vital signs, including measured respiratory rate and oxygen saturation.
- Overall functional abilities, assessing ease of movement, walking, changing positions, dressing/undressing, and signs of dyspnea.
Respiratory Status Assessment
- Evaluation of respiratory status, considering rate, depth, use of accessory muscles, and nasal flaring.
Inspection for Stigmata
Inspect for stigmata of pulmonary disease, including mucous membrane abnormalities, nasal polyps/swelling/discharge, clubbing, and anterior-posterior chest diameter.
Palpation and Percussion
- Palpation for chest wall abnormalities, adenopathy, and neck masses.
- Percussion for resonance to identify aeration, diaphragm level, and signs of fluid interface or consolidation.
Auscultation
- Auscultation for the inspiration-to-expiration ratio, adventitious breath sounds (crackles, wheeze, rales, rhonchi), and pleural rubs, considering timing, location, and persistence of lung findings.
Cardiac Examination
Conduct a cardiac examination, paying attention to findings related to cor pulmonale and heart failure.
Dermal Examination
Examine the skin for signs of disease, such as erythema nodosum (associated with Sarcoidosis).
