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Lommatzsch M, Criée CP, de Jong CCM, Gappa M, Geßner C, Gerstlauer M, Hämäläinen N, Haidl P, Hamelmann E, Horak F, Idzko M, Ignatov A, Koczulla AR, Korn S, Köhler M, Lex C, Meister J, Milger-Kneidinger K, Nowak D, Pfaar O, Pohl W, Preisser AM, Rabe KF, Riedler J, Schmidt O, Schreiber J, Schuster A, Schuhmann M, Spindler T, Taube C, Christian Virchow J, Vogelberg C, Vogelmeier CF, Wantke F, Windisch W, Worth H, Zacharasiewicz A, Buhl R. [Diagnosis and treatment of asthma: a guideline for respiratory specialists 2023 - published by the German Respiratory Society (DGP) e. V.]. Pneumologie 2023; 77:461-543. [PMID: 37406667 DOI: 10.1055/a-2070-2135] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
The management of asthma has fundamentally changed during the past decades. The present guideline for the diagnosis and treatment of asthma was developed for respiratory specialists who need detailed and evidence-based information on the new diagnostic and therapeutic options in asthma. The guideline shows the new role of biomarkers, especially blood eosinophils and fractional exhaled NO (FeNO), in diagnostic algorithms of asthma. Of note, this guideline is the first worldwide to announce symptom prevention and asthma remission as the ultimate goals of asthma treatment, which can be achieved by using individually tailored, disease-modifying anti-asthmatic drugs such as inhaled steroids, allergen immunotherapy or biologics. In addition, the central role of the treatment of comorbidities is emphasized. Finally, the document addresses several challenges in asthma management, including asthma treatment during pregnancy, treatment of severe asthma or the diagnosis and treatment of work-related asthma.
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Affiliation(s)
- Marek Lommatzsch
- Zentrum für Innere Medizin, Abt. für Pneumologie, Universitätsmedizin Rostock
| | | | - Carmen C M de Jong
- Abteilung für pädiatrische Pneumologie, Abteilung für Pädiatrie, Inselspital, Universitätsspital Bern
| | - Monika Gappa
- Klinik für Kinder und Jugendliche, Evangelisches Krankenhaus Düsseldorf
| | | | | | | | - Peter Haidl
- Abteilung für Pneumologie II, Fachkrankenhaus Kloster Grafschaft GmbH, Schmallenberg
| | - Eckard Hamelmann
- Kinder- und Jugendmedizin, Evangelisches Klinikum Bethel, Bielefeld
| | | | - Marco Idzko
- Abteilung für Pulmologie, Universitätsklinik für Innere Medizin II, Medizinische Universität Wien
| | - Atanas Ignatov
- Universitätsklinik für Frauenheilkunde, Geburtshilfe und Reproduktionsmedizin, Universitätsklinikum Magdeburg
| | - Andreas Rembert Koczulla
- Schön-Klinik Berchtesgadener Land, Berchtesgaden
- Klinik für Innere Medizin Schwerpunkt Pneumologie, Universitätsklinikum Marburg
| | - Stephanie Korn
- Pneumologie und Beatmungsmedizin, Thoraxklinik, Universitätsklinikum Heidelberg
| | - Michael Köhler
- Deutsche Patientenliga Atemwegserkrankungen, Gau-Bickelheim
| | - Christiane Lex
- Klinik für Kinder- und Jugendmedizin, Universitätsmedizin Göttingen
| | - Jochen Meister
- Klinik für Kinder- und Jugendmedizin, Helios Klinikum Aue
| | | | - Dennis Nowak
- Institut und Poliklinik für Arbeits-, Sozial- und Umweltmedizin, LMU München
| | - Oliver Pfaar
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Hals-Chirurgie, Sektion für Rhinologie und Allergie, Universitätsklinikum Marburg, Philipps-Universität Marburg, Marburg
| | - Wolfgang Pohl
- Gesundheitszentrum Althietzing, Karl Landsteiner Institut für klinische und experimentelle Pneumologie, Wien
| | - Alexandra M Preisser
- Zentralinstitut für Arbeitsmedizin und Maritime Medizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Klaus F Rabe
- Pneumologie, LungenClinic Großhansdorf, UKSH Kiel
| | - Josef Riedler
- Abteilung für Kinder- und Jugendmedizin, Kardinal Schwarzenberg Klinikum Schwarzach
| | | | - Jens Schreiber
- Universitätsklinik für Pneumologie, Universitätsklinikum Magdeburg
| | - Antje Schuster
- Klinik für Allgemeine Pädiatrie, Neonatologie und Kinderkardiologie, Universitätsklinikum Düsseldorf
| | | | | | - Christian Taube
- Klinik für Pneumologie, Universitätsmedizin Essen-Ruhrlandklinik
| | | | - Christian Vogelberg
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, Dresden
| | | | | | - Wolfram Windisch
- Lungenklinik Köln-Merheim, Lehrstuhl für Pneumologie, Universität Witten/Herdecke
| | - Heinrich Worth
- Pneumologische & Kardiologische Gemeinschaftspraxis, Fürth
| | | | - Roland Buhl
- Klinik für Pneumologie, Zentrum für Thoraxerkrankungen, Universitätsmedizin Mainz
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Schwab AD, Poole JA. Mechanistic and Therapeutic Approaches to Occupational Exposure-Associated Allergic and Non-Allergic Asthmatic Disease. Curr Allergy Asthma Rep 2023; 23:313-324. [PMID: 37154874 PMCID: PMC10896074 DOI: 10.1007/s11882-023-01079-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2023] [Indexed: 05/10/2023]
Abstract
PURPOSE OF REVIEW Occupational lung disease, including asthma, is a significant cause of disability worldwide. The dose, exposure frequency, and nature of the causal agent influence the inflammatory pathomechanisms that inform asthma disease phenotype and progression. While surveillance, systems engineering, and exposure mitigation strategies are essential preventative considerations, no targeted medical therapies are currently available to ameliorate lung injury post-exposure and prevent chronic airway disease development. RECENT FINDINGS This article reviews contemporary understanding of allergic and non-allergic occupational asthma mechanisms. In addition, we discuss the available therapeutic options, patient-specific susceptibility and prevention measures, and recent scientific advances in post-exposure treatment conception. The course of occupational lung disease that follows exposure is informed by individual predisposition, immunobiologic response, agent identity, overall environmental risk, and preventative workplace practices. When protective strategies fail, knowledge of underlying disease mechanisms is necessary to inform targeted therapy development to lessen occupational asthma disease severity and occurrence.
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Affiliation(s)
- Aaron D Schwab
- Division of Allergy and Immunology, Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Jill A Poole
- Division of Allergy and Immunology, Department of Internal Medicine, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
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van Kampen V, Eisenhawer C, Brüning T, Merget R. Serial fractional exhaled nitric oxide measurements at and off work may help to identify immunologic occupational asthma in cases with complex exposures. Respir Physiol Neurobiol 2023; 313:104068. [PMID: 37100218 DOI: 10.1016/j.resp.2023.104068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 04/18/2023] [Accepted: 04/23/2023] [Indexed: 04/28/2023]
Abstract
Serial measurements of fractional exhaled nitric oxide (FeNO) at home and at work have been described to provide complementary information for the diagnosis of occupational asthma (OA) when specific inhalation challenge (SIC) is missing or doubtful. We describe two cases in which serial FeNO measurements enabled the detection of probable OA after complex exposures. A 25-year-old industrial painter with exposure to a variety of paints suffered from work-related airway symptoms for five years. Lung function was normal, and he was not atopic. SIC with hexamethylene diisocyanate was negative. A 47-year-old sign maker (screen printing, foils) suffering from work-related dyspnoea for seven years. Moderate airway obstruction, but no atopy was detectable. Due to the complex exposures SIC was not performed. Both patients performed FeNO measurements once daily during a 2-week-holiday and a subsequent 2-week-work period. In both cases elevated baseline FeNO decreased to normal (25 ppb) during holidays and increased after resuming work (case 1: 125 ppb, case 2: 45 ppb).
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Affiliation(s)
- V van Kampen
- Institute for Prevention and Occupational Medicine of the German Social Accident Insurance, Institute of the Ruhr-University Bochum (IPA), Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Germany.
| | - C Eisenhawer
- Institute for Prevention and Occupational Medicine of the German Social Accident Insurance, Institute of the Ruhr-University Bochum (IPA), Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Germany
| | - T Brüning
- Institute for Prevention and Occupational Medicine of the German Social Accident Insurance, Institute of the Ruhr-University Bochum (IPA), Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Germany
| | - R Merget
- Institute for Prevention and Occupational Medicine of the German Social Accident Insurance, Institute of the Ruhr-University Bochum (IPA), Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Germany
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Marques-da-Silva D, Videira PA, Lagoa R. Registered human trials addressing environmental and occupational toxicant exposures: Scoping review of immunological markers and protective strategies. ENVIRONMENTAL TOXICOLOGY AND PHARMACOLOGY 2022; 93:103886. [PMID: 35598754 DOI: 10.1016/j.etap.2022.103886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/11/2022] [Accepted: 05/15/2022] [Indexed: 06/15/2023]
Abstract
Exposure to pollution is a worldwide societal challenge participating in the etiology and progression of different diseases. However, the scarce information hinders our understanding of the actual level of human exposure and its specific effects. Inadequate and excessive immune responses underlie diverse chronic diseases. Yet, it is unclear which and how toxicant exposures affect the immune system functions. There is a multiplicity of immunological outcomes and biomarkers being studied in human trials related to exposure to different toxicants but still without clear evidence of their value as biomarkers of exposure or effect. The main aim of this study was to collect scientific evidence and identify relevant immunological biomarkers used at the clinical level for toxicant exposures. We used the platform clinical trials.gov as a database tool. First, we performed a search combining research items related to toxicants and immunological parameters. The resulting117 clinical trials were examined for immune-related outcomes and specific biomarkers evaluated in subjects exposed to occupational and environmental toxicants. After categorization, relevant immunological outcomes and biomarkers were identified related to systemic and airway inflammation, modulation of immune cells, allergy and autoimmunity. In general, the immune markers related to inflammation are more frequently investigated for exposure to pollutants, namely IL-6, C-reactive protein (CRP) and nitric oxide (NO). Nevertheless, the data also indicated that prospective biomarkers of effect are gaining ground and a guiding representation of the established and novel biomarkers is suggested for upcoming trials. Finally, potential protective strategies to mitigate the adverse effects of specific toxicants are underlined for future studies.
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Affiliation(s)
- Dorinda Marques-da-Silva
- School of Technology and Management, Polytechnic Institute of Leiria, Morro do Lena, Alto do Vieiro, 2411-901 Leiria, Portugal; LSRE-LCM - Laboratory of Separation and Reaction Engineering - Laboratory of Catalysis and Materials, Escola Superior de Tecnologia e Gestão, Instituto Politécnico de Leiria, 2411-901 Leiria, Portugal; ALiCE - Associate Laboratory in Chemical Engineering, Faculty of Engineering, University of Porto, Rua Dr. Roberto Frias, 4200-465 Porto, Portugal.
| | - Paula Alexandra Videira
- UCIBIO - Applied Molecular Biosciences Unit, NOVA School of Science and Technology, NOVA University of Lisbon, 2819-516 Caparica, Portugal; Associate Laboratory i4HB - Institute for Health and Bioeconomy, NOVA School of Science and Technology, NOVA University of Lisbon, 2819-516 Caparica, Portugal
| | - Ricardo Lagoa
- School of Technology and Management, Polytechnic Institute of Leiria, Morro do Lena, Alto do Vieiro, 2411-901 Leiria, Portugal; UCIBIO - Applied Molecular Biosciences Unit, NOVA School of Science and Technology, NOVA University of Lisbon, 2819-516 Caparica, Portugal; Associate Laboratory i4HB - Institute for Health and Bioeconomy, NOVA School of Science and Technology, NOVA University of Lisbon, 2819-516 Caparica, Portugal
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Barber CM, Cullinan P, Feary J, Fishwick D, Hoyle J, Mainman H, Walters GI. British Thoracic Society Clinical Statement on occupational asthma. Thorax 2022; 77:433-442. [DOI: 10.1136/thoraxjnl-2021-218597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Merget R, van Kampen V. Should measurements of exhaled nitric oxide before and after specific inhalation testing with occupational allergens be performed? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:888. [PMID: 35272792 DOI: 10.1016/j.jaip.2021.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/07/2021] [Indexed: 06/14/2023]
Affiliation(s)
- Rolf Merget
- Institute for Prevention and Occupational Medicine of the German Social Accident Insurance, Institute of the Ruhr University Bochum (IPA), Bochum, Germany
| | - Vera van Kampen
- Institute for Prevention and Occupational Medicine of the German Social Accident Insurance, Institute of the Ruhr University Bochum (IPA), Bochum, Germany.
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Betancor D, Sastre J. Reply to "Should measurements of exhaled nitric oxide before and after specific inhalation test with occupational allergens be performed?". THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:888-889. [PMID: 35272791 DOI: 10.1016/j.jaip.2021.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 12/07/2021] [Indexed: 06/14/2023]
Affiliation(s)
- Diana Betancor
- Servicio de Alergología, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain; CIBER de Enfermedades Respiratorias, Madrid, Spain.
| | - Joaquin Sastre
- Servicio de Alergología, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain; CIBER de Enfermedades Respiratorias, Madrid, Spain
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Gautier C, Lecam MT, Basses S, Pairon JC, Andujar P. [A definition of work-related asthma and its social and occupational consequences in adults and teenagers]. Rev Mal Respir 2021; 38:914-935. [PMID: 34711451 DOI: 10.1016/j.rmr.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 09/07/2021] [Indexed: 10/20/2022]
Abstract
Work-related asthma (WRA) accounts for 10-25% of all adult asthma. It therefore seems important to raise questions regarding an asthmatic's approach to occupational or job training activities. WRA takes on two forms: work-exacerbated asthma (WEA) and occupational asthma (OA), which encompasses different subtypes of heterogeneous mechanisms. It currently represents a major challenge for occupational medicine in terms of detailed diagnosis, social care, the economic repercussions for workers and employers and, last but not least, social insurance. This review aims to sensitize health care practitioners to the peculiarities of WRA management in routine practice. More specifically, prognosis depends on early diagnosis, medical care and work adjustment measures. WEA and OA are explained in detail in view of identifying causative agents and at-risk occupations and defining adapted medical strategy. Relevant lines of questioning and complementary exams are presented. In addition, the key role of the occupational physician, especially as regards recognition and identification of occupational disease, is underlined, the objective being to facilitate optimal professional and social management. In future studies, the key role of counseling and orientation mechanisms should be highlighted as means of preventing WRA occurrence.
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Affiliation(s)
- C Gautier
- Centre hospitalier intercommunal de Créteil, service de pathologies professionnelles et de l'environnement, 94000 Créteil, France
| | - M T Lecam
- Centre hospitalier intercommunal de Créteil, service de pathologies professionnelles et de l'environnement, 94000 Créteil, France
| | - S Basses
- Centre hospitalier intercommunal de Créteil, service de pathologies professionnelles et de l'environnement, 94000 Créteil, France
| | - J C Pairon
- Centre hospitalier intercommunal de Créteil, service de pathologies professionnelles et de l'environnement, 94000 Créteil, France; INSERM, unité 955, équipe 4, 94000 Créteil, France; Université Paris-Est Créteil, faculté de santé, 94000 Créteil, France
| | - P Andujar
- Centre hospitalier intercommunal de Créteil, service de pathologies professionnelles et de l'environnement, 94000 Créteil, France; INSERM, unité 955, équipe 4, 94000 Créteil, France; Université Paris-Est Créteil, faculté de santé, 94000 Créteil, France.
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Olivieri M, Malerba M, Spiteri G, Torroni L, Biscardo CA, Valenza D, Malinovschi A. Fractional exhaled nitric oxide levels in relation to work-related respiratory burden and sensitization to wheat flour and multigrain in bakers. Clin Transl Allergy 2021; 11:e12018. [PMID: 34708942 PMCID: PMC8694179 DOI: 10.1002/clt2.12018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 01/25/2021] [Accepted: 03/17/2021] [Indexed: 01/26/2023] Open
Abstract
Background Work‐related lower airway symptoms (WR‐LAS), rhinitis (WRR), and asthma (WRA) are very common among bakers, due to airborne exposure to wheat flour and multigrain. Limited data is available regarding fractional exhaled nitric oxide (FeNO) in bakers in relation to respiratory burden and occupational sensitization in a real‐life situation. Objective To analyze FeNO levels in relation to WRR, WR‐LAS, and WRA with regard to allergic sensitization to occupational allergen in bakers. Methods Cross‐sectional, observational study of 174 bakers employed in traditional small bakeries in the Verona District. Subjects did FeNO measurements, spirometry, methacholine challenge, and skin prick test to common inhalant aeroallergens and bakeries occupational allergens. Results FeNO levels were higher in subjects sensitized to occupational allergens compared with bakers not sensitized to occupational allergens (22.8 ppb (18.9, 27.6) vs. 12.0 ppb (9.9, 14.5), p < 0.05). FeNO levels were higher in bakers with WRR and occupational sensitization (25.4 (20.6, 31.3)) than in bakers with WRR without occupational sensitization compared and bakers without respiratory burden (13.4 (9.6, 18.6) and 11.9 (9.8, 14.5), both p < 0.001). Similar findings were found for WR‐LAS with regard to the same categories (31.2 (24.1, 40.4) vs 13.3 (11.4, 15.6) and 15.3 (8.5, 27.5), p < 0.001 and p = 0.005). Bakers with WRA, with or without occupational allergic sensitization, had higher levels of FeNO than bakers without respiratory burden (both p ≤ 0.001). These findings were consistent after adjustments for gender, age, height, weight, smoking, and sensitization to common inhalant aeroallergens and lung function. Conclusions WRR and lower airway symptoms in bakers sensitized to occupational allergens relate to increased FeNO. Our study suggests that FeNO is associated with work‐related allergic inflammation in occupational sensitized bakers, but future studies are needed to assess how FeNO should be integrated in the diagnostic work‐up of occupational disease in bakers.
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Affiliation(s)
- Mario Olivieri
- Unit of Occupational Medicine, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Mario Malerba
- Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Gianluca Spiteri
- Unit of Occupational Medicine, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Lorena Torroni
- Unit of Epidemiology and Medical Statistics, Department of Diagnostic and Public Health, University of Verona, Verona, Italy
| | - Carlo Alberto Biscardo
- Unit of Occupational Medicine, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Dario Valenza
- Unit of Occupational Medicine, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Andrei Malinovschi
- Department of Medical Sciences Clinical Physiology, Uppsala University, Uppsala, Sweden
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Preisser AM, Koschel D, Merget R, Nowak D, Raulf M, Heidrich J. Workplace-related inhalation test - Specific inhalation challenge: S2k Guideline of the German Society for Occupational and Environmental Medicine e.V. (DGAUM), the German Society for Pneumology and Respiratory Medicine e.V. (DGP) and the German Society for Allergology and Clinical Immunology e.V. (DGAKI). Allergol Select 2021; 5:315-334. [PMID: 34646977 PMCID: PMC8507414 DOI: 10.5414/alx02280e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 10/01/2021] [Indexed: 11/25/2022] Open
Abstract
Not available.
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Affiliation(s)
- Alexandra M. Preisser
- Institute for Occupational and Maritime Medicine, University Medical Center Hamburg-Eppendorf, Hamburg
- Mandated representative of the German Society for Occupational and Environmental Medicine e. V. (DGAUM)
- Coordinator of the guideline
| | - Dirk Koschel
- Department of Internal Medicine and Pneumology, Fachkrankenhaus Coswig, Lung Center, Coswig, Division of Pneumology, Medical Department I, University Hospital Carl Gustav Carus, Dresden
- Mandated representative of the German Society for Allergology and Clinical Immunology (DGAKI)
| | - Rolf Merget
- Institute for Prevention and Occupational Medicine of the German Social Accident Insurance, Institute of the Ruhr University Bochum (IPA), Bochum, and
- Mandated representative of the German Society for Occupational and Environmental Medicine e. V. (DGAUM)
| | - Dennis Nowak
- Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, CPC Comprehensive Pneumology Center Munich, DZL, Deutsches Zentrum für Lungenforschung Munich, Germany
- Mandated representative of the German Society for Pneumology and Respiratory Medicine e. V. (DGP) , and
| | - Monika Raulf
- Institute for Prevention and Occupational Medicine of the German Social Accident Insurance, Institute of the Ruhr University Bochum (IPA), Bochum, and
- Mandated representative of the German Society for Allergology and Clinical Immunology (DGAKI)
| | - Jan Heidrich
- Institute for Occupational and Maritime Medicine, University Medical Center Hamburg-Eppendorf, Hamburg
- Coordinator of the guideline
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Taylor LW, French JE, Robbins ZG, Nylander-French LA. Epigenetic Markers Are Associated With Differences in Isocyanate Biomarker Levels in Exposed Spray-Painters. Front Genet 2021; 12:700636. [PMID: 34335698 PMCID: PMC8318037 DOI: 10.3389/fgene.2021.700636] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/21/2021] [Indexed: 12/30/2022] Open
Abstract
Isocyanates are respiratory and skin sensitizers that are one of the main causes of occupational asthma globally. Genetic and epigenetic markers are associated with isocyanate-induced asthma and, before asthma develops, we have shown that genetic polymorphisms are associated with variation in plasma and urine biomarker levels in exposed workers. Inter-individual epigenetic variance may also have a significant role in the observed biomarker variability following isocyanate exposure. Therefore, we determined the percent methylation for CpG islands from DNA extracted from mononuclear blood cells of 24 male spray-painters exposed to 1,6-hexamethylene diisocyanate (HDI) monomer and HDI isocyanurate. Spray-painters’ personal inhalation and skin exposure to these compounds and the respective biomarker levels of 1,6-diaminohexane (HDA) and trisaminohexyl isocyanurate (TAHI) in their plasma and urine were measured during three repeated industrial hygiene monitoring visits. We controlled for inhalation exposure, skin exposure, age, smoking status, and ethnicity as covariates and performed an epigenome-wide association study (EWAS) using likelihood-ratio statistical modeling. We identified 38 CpG markers associated with differences in isocyanate biomarker levels (Bonferroni < 0.05). Annotations for these markers included 18 genes: ALG1, ANKRD11, C16orf89, CHD7, COL27A, FUZ, FZD9, HMGN1, KRT6A, LEPR, MAPK10, MED25, NOSIP, PKD1, SNX19, UNC13A, UROS, and ZFHX3. We explored the functions of the genes that have been published in the literature and used GeneMANIA to investigate gene ontologies and predicted protein-interaction networks. The protein functions of the predicted networks include keratinocyte migration, cell–cell adhesions, calcium transport, neurotransmitter release, nitric oxide production, and apoptosis regulation. Many of the protein pathway functions overlap with previous findings on genetic markers associated with variability both in isocyanate biomarker levels and asthma susceptibility, which suggests there are overlapping protein pathways that contribute to both isocyanate toxicokinetics and toxicodynamics. These predicted protein networks can inform future research on the mechanism of allergic airway sensitization by isocyanates and aid in the development of mitigation strategies to better protect worker health.
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Affiliation(s)
- Laura W Taylor
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - John E French
- Nutrition Research Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Zachary G Robbins
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Leena A Nylander-French
- Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Abstract
PURPOSE OF REVIEW Baker's allergy and asthma continue to represent an important contributor of occupational asthma globally. This review identified recent studies related to the prevention of baker's allergy and asthma. RECENT FINDINGS Studies with respect to regulatory exposure standards, workplace control measures aimed at reduction of flour dust exposures, surveillance programmes (exposure monitoring, medical surveillance) and workplace information, education and training programmes were identified. SUMMARY Detailed knowledge on risk factors and detection methods to assess exposure and early identification of high-risk workers exist, but workplace control measures remain sub-optimal because they are rarely multifaceted. This is compounded by the lack of health-based exposure standards globally. Exposure level monitoring and medical surveillance are integral to assessing effectiveness of preventive strategies. Triage systems for optimizing the efficiency of medical surveillance programmes show promise, but need replication in different contexts. Future studies need to focus on evaluating the relevance and quantification of peak exposures in increasing risk; developing standardized respiratory questionnaires for medical surveillance; and further exploration of serial fractional exhaled nitric oxide (FeNO) measurements as an adjunct to allergic sensitization for the early identification of baker's asthma and assessing the long-term impact of interventions.
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van Kampen V, Mertens H, Brüning T, Merget R. Serial measurements of fractional exhaled nitric oxide at home and at work: A useful tool for monitoring workers with platinum salt allergy after exposure reduction. Health Sci Rep 2021; 4:e299. [PMID: 34136658 PMCID: PMC8190558 DOI: 10.1002/hsr2.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 04/12/2021] [Accepted: 04/25/2021] [Indexed: 11/08/2022] Open
Affiliation(s)
- Vera van Kampen
- Institute for Prevention and Occupational Medicine of the German Social Accident InsuranceInstitute of the Ruhr University Bochum (IPA)BochumGermany
| | | | - Thomas Brüning
- Institute for Prevention and Occupational Medicine of the German Social Accident InsuranceInstitute of the Ruhr University Bochum (IPA)BochumGermany
| | - Rolf Merget
- Institute for Prevention and Occupational Medicine of the German Social Accident InsuranceInstitute of the Ruhr University Bochum (IPA)BochumGermany
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Abstract
PURPOSE OF REVIEW Finding suitable biomarkers to phenotype asthma, identify individuals at risk of worsening and guide treatment is highly prioritized in asthma research. We aimed to provide an analysis of currently used and upcoming biomarkers, focusing on developments published in the past 2 years. RECENT FINDINGS Type 2 inflammation is the most studied asthma mechanism with the most biomarkers in the pipeline. Blood eosinophils and fractional exhaled nitric oxide (FeNO) are those most used clinically. Recent developments include their ability to identify individuals at higher risk of exacerbations, faster decline in lung function and more likely to benefit from anti-IL-5 and anti-IL-4/-13 treatment. Certain patterns of urinary eicosanoid excretion also relate to type 2 inflammation. Results of recent trials investigating the use of serum periostin or dipeptidyl peptidase-4 to guide anti-IL-13 therapy were somewhat disappointing. Less is known about non-type 2 inflammation but blood neutrophils and YKL-40 may be higher in patients with evidence of non-type 2 asthma. Volatile organic compounds show promise in their ability to distinguish both eosinophilic and neutrophilic asthma. SUMMARY The ultimate panel of biomarkers for identification of activated inflammatory pathways and treatment strategies in asthma patients still lies in the future, particularly for non-type 2 asthma, but potential candidates are available.
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15
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Occupational Respiratory Allergy: Risk Factors, Diagnosis, and Management. Handb Exp Pharmacol 2021; 268:213-225. [PMID: 34031758 DOI: 10.1007/164_2021_472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Occupational allergies are among the most common recorded occupational diseases. The skin and the upper and lower respiratory tract are the classical manifestation organs. More than 400 occupational agents are currently documented as being potential "respiratory sensitizers" and new reported causative agents are reported each year. These agents may induce occupational rhinitis (OR) or occupational asthma (OA) and can be divided into high-molecular weight (HMW) and low-molecular weight (LMW) agents. The most common occupational HMW agents are (glycol)proteins found in flour and grains, enzymes, laboratory animals, fish and seafood, molds, and Hevea brasiliensis latex. Typical LMW substances are isocyanates, metals, quaternary ammonium persulfate, acid anhydrides, and cleaning products/disinfectants. Diagnosis of occupational respiratory allergy is made by a combination of medical history, physical examination, positive methacholine challenge result or bronchodilator responsiveness, determination of IgE-mediated sensitization, and specific inhalation challenge tests as the gold standard. Accurate diagnosis of asthma is the first step to managing OA as shown above. Removal from the causative agent is of central importance for the management of OA. The best strategy to avoid OA is primary prevention, ideally by avoiding the use of and exposure to the sensitizer or substituting safer substances for these agents.
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Betancor D, Villalobos V, Valverde-Monge M, Barroso B, Sastre J. Exhaled nitric oxide is of limited value in the diagnosis of occupational asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1726-1727.e2. [PMID: 33242627 DOI: 10.1016/j.jaip.2020.09.068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/27/2020] [Accepted: 09/28/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Diana Betancor
- Allergology Service, Hospital Universitario Fundación Jiménez Díaz and Instituto de Investigación Sanitaria (IIS) Fundación Jiménez Díaz, Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
| | - Victoria Villalobos
- Allergology Service, Hospital Universitario Fundación Jiménez Díaz and Instituto de Investigación Sanitaria (IIS) Fundación Jiménez Díaz, Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Marcela Valverde-Monge
- Allergology Service, Hospital Universitario Fundación Jiménez Díaz and Instituto de Investigación Sanitaria (IIS) Fundación Jiménez Díaz, Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Blanca Barroso
- Allergology Service, Hospital Universitario Fundación Jiménez Díaz and Instituto de Investigación Sanitaria (IIS) Fundación Jiménez Díaz, Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Joaquin Sastre
- Allergology Service, Hospital Universitario Fundación Jiménez Díaz and Instituto de Investigación Sanitaria (IIS) Fundación Jiménez Díaz, Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
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17
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Tiotiu AI, Novakova S, Labor M, Emelyanov A, Mihaicuta S, Novakova P, Nedeva D. Progress in Occupational Asthma. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E4553. [PMID: 32599814 PMCID: PMC7345155 DOI: 10.3390/ijerph17124553] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/20/2020] [Accepted: 06/22/2020] [Indexed: 01/12/2023]
Abstract
Occupational asthma (OA) represents one of the major public health problems due to its high prevalence, important social and economic burden. The aim of this review is to summarize current data about clinical phenotypes, biomarkers, diagnosis and management of OA, a subtype of work-related asthma. Most studies have identified two phenotypes of OA. One is sensitizer-induced asthma, occuring after a latency period and caused by hypersensitivity to high- or low-molecular weight agents. The other is irritant-induced asthma, which can occur after one or more exposures to high concentrations of irritants without latency period. More than 400 agents causing OA have been identified and its list is growing fast. The best diagnostic approach for OA is a combination of clinical history and objective tests. An important tool is a specific inhalation challenge. Additional tests include assessments of bronchial hyperresponsiveness to methacholine/histamine in patients without airflow limitations, monitoring peak expiratory flow at- and off-work, sputum eosinophil count, exhaled nitric oxide measurement, skin prick tests with occupational allergens and serum specific IgE. Treatment of OA implies avoidance of exposure, pharmacotherapy and education. OA is a heterogeneous disease. Mechanisms of its different phenotypes, their diagnosis, role of new biomarkers and treatment require further investigation.
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Affiliation(s)
- Angelica I. Tiotiu
- Department of Pulmonology, University Hospital of Nancy, 54000 Nancy, France
- Development, Adaptation and Disadvantage, Cardiorespiratory Regulations and Motor Control (EA 3450 DevAH), University of Lorraine, 54000 Nancy, France
| | - Silviya Novakova
- Allergy Unit, Internal Consulting Department, University Hospital “St. George”, 4000 Plovdiv, Bulgaria;
| | - Marina Labor
- Department of Pulmonology, University Hospital Centre Osijek, 31000 Osijek, Croatia;
- Medical Faculty Osijek, J.J. Strossmayer University, 31000 Osijek, Croatia
| | - Alexander Emelyanov
- Department of Respiratory Medicine, North-Western Medical University, 191015 Saint-Petersburg, Russia;
| | - Stefan Mihaicuta
- Victor Babes University of Medicine and Pharmacy, 300120 Timisoara, Romania
| | - Plamena Novakova
- Clinic of Clinical Allergy, Medical University, 1000 Sofia, Bulgaria;
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Abstract
PURPOSE OF REVIEW This review focuses on new findings in the clinical and inflammatory aspects that can help to better identify the different phenotypes of work-related asthma and the development of specific biomarkers useful in diagnosis and follow-up. RECENT FINDINGS Studies on phenotyping of occupational asthma, a subtype of work-related asthma, have mainly compared the clinical, physiological, and inflammatory patterns associated with the type of agent causing occupational asthma, namely, high-molecular-weight and low-molecular-weight agents. Most of this research has found that patients with occupational asthma due to high-molecular-weight agents have an associated presence of rhinitis, conjunctivitis, atopy, and a pattern of early asthmatic reactions during specific inhalation challenge. The inflammatory profile (blood eosinophils, sputum cell count, or exhaled nitric oxide) may be similar when occupational asthma is caused by either type of agent. In some studies, severity of asthma and exacerbations have been associated with exposure to low-molecular-weight agents. The most reliable biomarkers in diagnosis and follow-up are eosinophilia in induced sputum and exhaled nitric oxide. SUMMARY There are several phenotypes, characterized by its pathogenesis and inflammatory profile. Avoidance of the causative agents does not warrant complete recovery of occupational asthma. Treatment with biologic agents may be considered in severe occupational asthma.
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Kampen V, Brüning T, Merget R. Serial fractional exhaled nitric oxide measurements off and at work in the diagnosis of occupational asthma. Am J Ind Med 2019; 62:663-671. [PMID: 31168929 DOI: 10.1002/ajim.22996] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Fractional exhaled nitric oxide (FeNO) before and after specific inhalation challenge has been postulated as an additional tool in the diagnosis of occupational asthma (OA), but little is known about serial FeNO measurements at home and at work. The aim of the present study was to assess the contribution of serial measurements of FeNO off and at work toward the diagnosis of OA. METHODS Forty-one subjects with suspected (n = 35) or diagnosed (n = 6) OA performed FeNO measurements once daily during a 2-week holiday and a subsequent 2-week work period. A work-related increase in FeNO by 20 ppb (parts per billion) or more was considered positive. Subjects with negative or doubtful specific inhalation challenge but a FeNO increase of 20 ppb or more were evaluated individually by an overall expert rating taking into account all available information. RESULTS Seven of 35 subjects (20%) with suspected and three of six subjects (50%) with diagnosed OA showed a work-related FeNO increase of 20 ppb or more. Six of the seven with suspected OA were reclassified as having an OA diagnosis by the overall expert rating which also considered these FeNO changes. CONCLUSIONS Serial FeNO measurements off and at work provide complementary information in the diagnosis in about one-fifth of cases with suspected OA, especially if specific inhalation challenges are negative or cannot be performed.
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Affiliation(s)
- Vera Kampen
- Institute for Prevention and Occupational Medicine of the German Social Accident Insurance (IPA)Institute of the Ruhr UniversityBochum Germany
| | - Thomas Brüning
- Institute for Prevention and Occupational Medicine of the German Social Accident Insurance (IPA)Institute of the Ruhr UniversityBochum Germany
| | - Rolf Merget
- Institute for Prevention and Occupational Medicine of the German Social Accident Insurance (IPA)Institute of the Ruhr UniversityBochum Germany
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20
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Non-invasive tools beyond lung function before and after specific inhalation challenges for diagnosing occupational asthma. Int Arch Occup Environ Health 2019; 92:1067-1076. [PMID: 31144109 DOI: 10.1007/s00420-019-01439-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 05/09/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Increases of fractional exhaled nitric oxide (FeNO), sputum eosinophils, and methacholine responsiveness have been described after specific inhalation challenges (SIC) with occupational allergens, but limited information is available about their comparative performance. It was the aim of the study to assess the diagnostic accuracy of these non-invasive tests before and after SIC for the diagnosis of occupational asthma (OA). METHODS A total of 122 subjects with work-related shortness of breath were included. The 'gold standard' was defined as airway obstruction (pulmonary responders) and/or an increase of FeNO of at least 13 ppb after SIC. The results were compared with those obtained using the pulmonary responder status alone as 'gold standard'. RESULTS If the pulmonary responder status and/or an increase of FeNO was used as 'gold standard' for SIC, 28 out of 39 positives (72%), but also 20 out of 83 negatives (24%) showed an increase of sputum eosinophils and/or bronchial hyperresponsiveness after SIC. If the pulmonary responder status alone was used as 'gold standard', an increase of FeNO with a sensitivity of 0.57 and a specificity of 0.82 showed a higher accuracy than increases of sputum eosinophils (0.52/0.75) or bronchial hyperresponsiveness (0.43/0.87). Individual case analyses suggest that a few cases of OA may be detected by increases of sputum eosinophils or bronchial hyperresponsiveness alone, but probably false-positive tests dominate. CONCLUSION It is recommended to use both lung function and increase of FeNO as primary effect parameters of SIC. Changes of sputum eosinophils and bronchial hyperresponsiveness after SIC have a low additional diagnostic value, but may be useful in individual cases.
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21
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Lau A, Tarlo SM. Update on the Management of Occupational Asthma and Work-Exacerbated Asthma. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2019; 11:188-200. [PMID: 30661311 PMCID: PMC6340795 DOI: 10.4168/aair.2019.11.2.188] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 10/25/2018] [Accepted: 10/28/2018] [Indexed: 12/16/2022]
Abstract
Work-related asthma is the most common occupational lung disease encountered in clinical practice. In adult asthmatics, work-relatedness can account for 15%-33% of cases, but delays in diagnosis remain common and lead to worse outcomes. Accurate diagnosis of asthma is the first step to managing occupational asthma, which can be sensitizer-induced or irritant-induced asthma. While latency has traditionally been recognized as a hallmark of sensitizer-induced asthma and rapid-onset a defining feature of irritant-induced asthma (as in Reactive Airway Dysfunction Syndrome), there is epidemiological evidence for irritant-induced asthma with latency from chronic moderate exposure. Diagnostic testing while the patient is still in the workplace significantly improves sensitivity. While specific inhalational challenges remain the gold-standard for the diagnosis of occupational asthma, they are not available outside of specialized centers. Commonly available tests including bronchoprovocation challenges and peak flow monitoring are important tools for practicing clinicians. Management of sensitizer-induced occupational asthma is notable for the central importance of removal from the causative agent: ideally, removal of the culprit agent; but if not feasible, this may require changes in the work process or ultimately, removal of the worker from the workplace. While workers' compensation programs may reduce income loss, these are not universal and there can be significant socio-economic impact from work-related asthma. Primary prevention remains the preferred method of reducing the burden of occupational asthma, which may include modification to work processes, better worker education and substitution of sensitizing agents from the workplace with safer compounds.
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Affiliation(s)
- Ambrose Lau
- Respiratory Division, Department of Medicine, Toronto Western Hospital and St. Michael's Hospital, Toronto, Ontario, Canada
| | - Susan M Tarlo
- Respiratory Division, Department of Medicine, Toronto Western Hospital and St. Michael's Hospital, Toronto, Ontario, Canada.
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