The use of fractional exhaled nitric oxide in investigation of work-related cough in a hairdresser

Respiratory toxicity of persulphate salts and their adverse effects on airways in hairdressers: a systematic review

Objective

To review the literature on respiratory effects of persulfate salts (PS) or hair bleaches in hairdressers and animal models exploring mechanisms behind PS-induced asthma.

Methods

A systematic review according to the PRISMA guidelines was performed. Studies published from 2000 to July 2021 that fulfilled predefined eligibility criteria were retrieved. Data were not quantitatively synthesized due to the heterogeneity of study designs, outcomes and methods.

Results

Forty-two articles were included. PS are indicated as the main cause of occupational rhinitis and asthma in hairdressers, and one of the leading causes of occupational asthma in some European countries. Bleaching products are indicated as the most important factor for development of respiratory symptoms, lung function decline, and leaving the hairdressing profession. Risk estimates from a good quality prospective study showed up to 3.9 times higher risk for wheezing and breathlessness in hairdressers aged ≥ 40 years than in matched controls, and 20 times higher risk in hairdressers to develop respiratory symptoms from exposure to bleaching powder than controls. Pathophysiological mechanisms of the respiratory response to PS are not yet fully elucidated, but may include non-specific and specific immune responses.

Conclusions

Hairdressing is associated with a wide spectrum of respiratory adverse effects, of which bleaching products were indicated as the most hazardous. Preventive measures for reducing inhalatory exposure to PS in hair salons should be re-evaluated, including adopting occupational exposure limits at EU level, and encouraging use of safer bleach formulations.

PROSPERO registration number

CRD42021238118.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00420-022-01852-w.

Assessment and Management of Occupational Asthma

Exposures at work can give rise to different phenotypes of "work-related asthma." The focus of this review is on the diagnosis and management of sensitizer-induced occupational asthma (OA) caused by either a high- or low-molecular-weight agent encountered in the workplace. The diagnosis of OA remains a challenge for the clinician because there is no simple test with a sufficiently high level of accuracy. Instead, the diagnostic process combines different procedures in a stepwise manner. These procedures include a detailed clinical history, immunologic testing, measurement of lung function parameters and airway inflammatory markers, as well as various methods that relate changes in these functional and inflammatory indices to workplace exposure. Their diagnostic performances, alone and in combination, are critically reviewed and summarized into evidence-based key messages. A working diagnostic algorithm is proposed that can be adapted to the suspected agent, purpose of diagnosis, and available resources. Current information on the management options of OA is summarized to provide pragmatic guidance to clinicians who have to advise their patients with OA.

Characterization of Occupational Eosinophilic Bronchitis in a Multicenter Cohort of Subjects with Work-Related Asthma Symptoms

BACKGROUND

Occupational eosinophilic bronchitis (OEB) has been described only as anecdotal case reports.

OBJECTIVE

We investigated the clinical and inflammatory characteristics of subjects with OEB identified in a cohort of subjects who completed a specific inhalation challenge (SIC) with occupational agents.

METHODS

In this retrospective multicenter study, OEB was defined by (1) a fall in FEV1 less than 15% during the SIC and the absence of nonspecific bronchial hyperresponsiveness both before and after the SIC and (2) a postchallenge increase of 3% or more in sputum eosinophils. The subjects who fulfilled these criteria were compared with 226 subjects with a negative SIC and 30 subjects with a positive SIC who failed to show baseline nonspecific bronchial hyperresponsiveness.

RESULTS

An isolated increase in postchallenge sputum eosinophils was documented in 33 of 259 subjects (13%) with a negative SIC. These subjects reported significantly more often an isolated cough at work compared with the negative and positive SIC controls. When compared with positive SIC controls, the subjects with OEB experienced less frequently work-related wheezing and reported a shorter duration of symptoms at work. The sensitivity of the post-SIC increase in fractional exhaled nitric oxide in identifying OEB among subjects with a negative SIC was low, ranging from 43% to 24% using cutoff values of 8 ppb to 17.5 ppb, whereas the specificity was high (90%-97%).

CONCLUSIONS

This study highlights the relevance of induced sputum analysis in the investigation of work-related asthma symptoms to identify isolated increases in sputum eosinophils that are consistent with a diagnosis of OEB.

Occupational rhinitis and occupational asthma: Association or progression?

BACKGROUND

Occupational asthma is the most frequently reported occupational respiratory disease in registries, and is often co-diagnosed with occupational rhinitis. We undertook a systematic review of the English-language epidemiologic literature linking these two conditions, with emphasis on progression from occupational rhinitis to occupational asthma.

METHODS

PubMed and Embase were queried in a series of structured searches designed to identify studies comparing occupational asthma and occupational rhinitis incidence or prevalence in occupationally exposed individuals.

RESULTS

The searches yielded a total of 109 unique citations, 15 of which yielded inferential data on the occupational rhinitis-asthma relationship. Nine of fifteen studies showed statistically significant associations between the occurrence of occupational rhinitis and occupational asthma among individual workers.

CONCLUSIONS

Limited data support the notion that occupational rhinitis precedes the development of occupational asthma, particularly when high-molecular-weight (HMW) agents are involved. The relationship between the two conditions could not be evaluated in many relevant studies due to a lack of cross-tabulation of individual cases.

Diagnosing occupational asthma

Making an accurate diagnosis of occupational asthma (OA) is, generally, important. The condition has not only significant health consequences for affected workers, but also substantial socio-economic impacts for workers, their employers and wider society. Missing a diagnosis of OA may lead to continued exposure to a causative agent and progressive worsening of disease; conversely, diagnosing OA when it is not present may lead to inappropriate removal from exposure and unnecessary financial and social consequences. While the most accurate investigation is specific inhalation challenge in an experienced centre, this is a scarce resource, and in many cases, reliance is on other tests. This review provides a technical dossier of the diagnostic value of the available methods which include an appropriate clinical history, the use of specific immunology and measurement of inflammatory markers, and various methods of relating functional changes in airway calibre to periods at work. It is recommended that these approaches are used iteratively and in judicious combination, in cognizance of the individual patient's circumstances and requirements. Based on available evidence, a working diagnostic algorithm is proposed that can be adapted to the suspected agent, purpose of diagnosis and available resources. For better or worse, many of the techniques - and their interpretation - are available only in specialized centres and where there is room for doubt, referral to such a centre is probably wise. Accordingly, the implementation or development of such specialized centres with appropriate equipment and expertise should greatly improve the diagnostic evaluation of work-related asthma.

A Longitudinal Study of Association between Heavy Metals and Itchy Eyes, Coughing in Chronic Cough Patients: Related with Non-Immunoglobulin E Mediated Mechanism

The association between heavy metals exposure and respiratory diseases or allergic sensitization showing high serum immunoglobulin E (IgE) has been suggested. However, previous findings have been inconsistent and the mechanisms responsible remain unclear. We evaluated heavy metal exposure and its association with coughing, itchy eyes in chronic cough patients with different IgE levels. Ninety outpatients in Kanazawa University Hospital were recruited between January-June 2011. Subjects whose total IgE measured by radioimmunosorbent test were asked to record their daily symptoms. We collected daily total suspended particles (TSP) from which concentrations of calcium (Ca), cadmium (Cd), chromium (Cr), iron (Fe), manganese (Mn), nickel (Ni), and lead (Pb) were determined then divided into high and low level groups. Generalized estimating equations were applied to compute the relationship between concentrations of these metals and symptoms. All metals at high levels were significantly associated with itchy eyes compared with low levels, with exception of Ca, the six others were significant in patients with IgE < 250 IU/mL. Cd, Fe, Mn had association with coughing (odds ratio-OR (95% confidence interval-CI): 1.13 (1.03, 1.24), 1.22 (1.05, 1.42), and 1.13 (1.01, 1.27), respectively), this relationship remained significant for Cd (OR (95% CI): 1.14 (1.03, 1.27)) and Mn (OR (95% CI): 1.15 (1.00, 1.31)) in patients with lower IgE. Our findings demonstrate the relationship between aerial heavy metals and itchy eyes, coughing in chronic cough patients, suggesting these symptoms may be due to a non-IgE mediated mechanism.

Styrene-associated health outcomes at a windblade manufacturing plant

BACKGROUND

Health risks of using styrene to manufacture windblades for the green energy sector are unknown.

METHODS

Using data collected from 355 (73%) current windblade workers and regression analysis, we investigated associations between health outcomes and styrene exposure estimates derived from urinary styrene metabolites.

RESULTS

The median current styrene exposure was 53.6 mg/g creatinine (interquartile range: 19.5-94.4). Color blindness in men and women (standardized morbidity ratios 2.3 and 16.6, respectively) was not associated with exposure estimates, but was the type previously reported with styrene. Visual contrast sensitivity decreased and chest tightness increased (odds ratio 2.9) with increasing current exposure. Decreases in spirometric parameters and FeNO, and increases in the odds of wheeze and asthma-like symptoms (odds ratios 1.3 and 1.2, respectively) occurred with increasing cumulative exposure.

CONCLUSIONS

Despite styrene exposures below the recommended 400 mg/g creatinine, visual and respiratory effects indicate the need for additional preventative measures in this industry.

EAACI Position Paper on assessment of cough in the workplace

Cough is a nonspecific and relatively common symptom that can present difficulties in diagnosis and management, particularly when it is reported to be associated with the workplace. The present consensus document, prepared by a taskforce of the Interest Group on Occupational Allergy of the European Academy of Allergy and Clinical Immunology by means of a nonsystematic review of the current literature, is intended to provide a definition and classification of work-related chronic cough (WRCC) to assist the daily practice of physicians facing with this symptom. The review demonstrates that several upper and lower airway work-related diseases may present with chronic cough; hence, the possible link with the workplace should always be considered. Due to the broad spectrum of underlying diseases, a multidisciplinary approach is necessary to achieve a definite diagnosis. Nevertheless, more epidemiological studies are necessary to estimate the real prevalence and risk factors for WRCC, the role of exposure to environmental and occupational sensitizers and irritants in its pathogenesis and the interaction with both upper and lower airways. Finally, the best management option should be evaluated in order to achieve the best outcome without adverse social and financial consequences for the worker.

Non-IgE-mediated and irritant-induced work-related rhinitis

PURPOSE OF REVIEW

Recently there has been growing interest in non-IgE-mediated and irritant-induced occupational rhinitis due to old and new low-molecular-weight and irritant agents. The purpose of this review is to summarize the scientific evidence on agents and work activities responsible for non-IgE-mediated and irritant-induced occupational rhinitis and work-exacerbated rhinitis published in 2011 and 2012.

RECENT FINDINGS

Several epidemiological, surveillance and experimental studies, case reports and reviews showed that workers exposed to drugs, wood dust, chemicals, metals and biocides are at high risk of non-IgE-mediated and irritant-induced occupational rhinitis; among activities at risk are healthcare, antibiotic manufacturing and cleaning workers. Work-exacerbated rhinitis has not been specifically studied, but it is reasonable to expect that it is frequently associated with work-exacerbated asthma. Recently, work-related anosmia/microsmia, nasal polyps and sinusitis have also been described. Reducing or eliminating workplace exposure to the specific agent has been confirmed to be effective in preventing symptoms of nonallergic occupational rhinitis.

SUMMARY

In consideration of the relevance of non-IgE-mediated and irritant-induced work-related rhinitis, physicians should recognize work-related rhinitis symptoms due to old and new low-molecular-weight and irritant agents. The mechanisms of non-IgE-mediated and irritant-induced occupational rhinitis remain largely unclear and need to be studied further. Substitution of responsible agents, reduction or elimination of exposure at the workplace should be enforced as effective measures.

Induced sputum, exhaled NO, and breath condensate in occupational medicine

OBJECTIVE

Studies of fractional exhaled NO (FeNO) or induced sputum are now well standardized and the exponential increase in publications about exhaled breath condensate reflects growing interest in a noninvasive diagnosis of pulmonary diseases in occupational medicine.

METHODS

This review describes current techniques (FeNO, induced sputum, and exhaled breath condensate) for the study of inflammation and oxidative stress biomarkers.

RESULTS

These biomarkers are FeNO, cytokines, H2O2, 8-isoprostane, malondialdehyde, and nitrogen oxides. These techniques also include the study of markers of the toxic burden in the lungs (heavy metals and mineral compounds) that are important in occupational health exposure assessment.

CONCLUSIONS

In occupational medicine, the study of both volatile and nonvolatile respiratory biomarkers can be useful in medical surveillance of exposed workers, the early identification of respiratory diseases, or the monitoring of their development.

EAACI consensus statement for investigation of work-related asthma in non-specialized centres

Work-related asthma (WRA) is a relevant problem in several countries, is cause of disability and socioeconomic consequences for both the patient and the society and is probably still underdiagnosed. A correct diagnosis is extremely important to reduce or limit the consequences of the disease. This consensus document was prepared by a EAACI Task Force consisting of an expert panel of allergologists, pneumologists and occupational physicians from different European countries. This document is not intended to address in detail the full diagnostic work-up of WRA, nor to be a formal evidence-based guideline. It is written to provide an operative protocol to allergologists and physicians dealing with asthma useful for identifying the subjects suspected of having WRA to address them to in-depth investigations in a specialized centre. No evidence-based system could be used because of the low grade of evidence of published studies in this area, and instead, 'key messages' or 'suggestions' are provided based on consensus of the expert panel members.