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Oțelea MR, Fell AKM, Handra CM, Holm M, Filon FL, Mijakovski D, Minov J, Mutu A, Stephanou E, Stokholm ZA, Stoleski S, Schlünssen V. The value of fractional exhaled nitric oxide in occupational diseases - a systematic review. J Occup Med Toxicol 2022; 17:14. [PMID: 35879723 PMCID: PMC9317127 DOI: 10.1186/s12995-022-00355-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 07/04/2022] [Indexed: 12/04/2022] Open
Abstract
Fractional exhaled nitric oxide (FeNO) is a non-invasive biomarker of respiratory tract inflammation, originally designated to identify eosinophilic airway inflammation and to predict steroid response. The main field of application of this biomarker is asthma, but FeNO has also been used for other allergic and non-allergic pulmonary disorders such as chronic obstructive pulmonary disease, hypersensitivity pneumonitis and interstitial lung disease. A substantial part of respiratory diseases are related to work, and FeNO, a safe and easy measure to conduct, is a potential valid examination in an occupational setting. This systematic review assesses the value of measuring FeNO related to three types of airborne exposures: allergens, irritants, and respiratory particles inhaled during occupational activities. The review covers results from longitudinal and observational clinical studies, and highlights the added value of this biomarker in monitoring effects of exposure and in the diagnostic criteria of occupational diseases. This review also covers the possible significance of FeNO as an indicator of the efficacy of interventions to prevent work-related respiratory diseases. Initially, 246 articles were identified in PUBMED and SCOPUS. Duplicates and articles which covered results from the general population, symptoms (not disease) related to work, non-occupational diseases, and case reports were excluded. Finally, 39 articles contributed to this review, which led to the following conclusions: a) For occupational asthma there is no consensus on the significant value of FeNO for diagnosis, or on the magnitude of change needed after specific inhalation test or occupational exposure at the workplace. There is some consensus for the optimal time to measure FeNO after exposure, mainly after 24 h, and FeNO proved to be more sensitive than spirometry in measuring the result of an intervention. b) For other occupational obstructive respiratory diseases, current data suggests performing the measurement after the work shift. c) For interstitial lung disease, the evaluation of the alveolar component of NO is probably the most suitable.
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Affiliation(s)
| | - Anne Kristin M Fell
- Occupational and Environmental Medicine, Telemark Hospital, Skien, Norway.,Department of Global Health and Community Medicine, Institute of Health and Community, University of Oslo, Oslo, Norway
| | - Claudia Mariana Handra
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Colentina Clinical Hospital, Clinic for Occupational Medicine, Bucharest, Romania
| | - Mathias Holm
- Occupational and Environmental Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Francesca Larese Filon
- Unit of Occupational Medicine, Department of Medical Sciences, University of Trieste, Trieste, Italy
| | - Dragan Mijakovski
- Institute of Occupational Health of RN Macedonia, Skopje, North Macedonia.,Faculty of Medicine, Ss. Cyril and Methodius, University in Skopje, Skopje, North Macedonia
| | - Jordan Minov
- Institute of Occupational Health of RN Macedonia, Skopje, North Macedonia.,Faculty of Medicine, Ss. Cyril and Methodius, University in Skopje, Skopje, North Macedonia
| | - Andreea Mutu
- Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Central Military University Emergency Hospital "Carol Davila", Bucharest, Romania
| | | | - Zara Ann Stokholm
- Department of Occupational Medicine, Danish Ramazzini Centre, Aarhus University Hospital, Aarhus, Denmark
| | - Sasho Stoleski
- Institute of Occupational Health of RN Macedonia, Skopje, North Macedonia.,Faculty of Medicine, Ss. Cyril and Methodius, University in Skopje, Skopje, North Macedonia
| | - Vivi Schlünssen
- Department of Public Health, Environment, Occupation and Health, Danish Ramazzini Centre, Aarhus University, Aarhus, Denmark
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Walters GI, Huntley CC. Updated review of reported cases of reactive airways dysfunction syndrome. Occup Med (Lond) 2021; 70:490-495. [PMID: 33063819 DOI: 10.1093/occmed/kqaa133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND A previous systematic review of the diagnosis of reactive airways dysfunction syndrome (RADS), undertaken from 1985 to 2004, found a lack of standardization of case reporting, thus misattribution of symptoms can occur. AIMS We aimed to update the systematic review, update the list of reported causes and see whether a more structured approach to reporting has been adopted. METHODS We undertook a systematic literature review, using the databases EMBASE and Ovid MEDLINE, with search terms 'reactive airways dysfunction syndrome' or 'asthma AND acute irritant', and reported according to PRISMA guidelines. We included papers and abstracts published from January 2005 to September 2019, and articles were grouped by the presence or absence of diagnostic features: 'definite' RADS (met Brooks' criteria) or 'possible' RADS (Brooks' criteria not met or insufficient data). We collected demographic and diagnostic data for cases, where given. RESULTS Eleven papers and six conference abstracts met the inclusion criteria, 13 of which were case series or reports, and comprised 752 cases in total; seven articles met Brooks' criteria for RADS diagnosis. A variety of agents were implicated, with chlorine or chlorine-releasing molecules most frequently reported. CONCLUSIONS A lack of standardized reporting of RADS remains. The majority of published articles and conference abstracts either do not meet, or contain insufficient data to judge against, Brooks' criteria, particularly in relation to onset of symptoms and bronchial hyper-reactivity or variability of airflow obstruction. Some novel agents are described, in keeping with recognized structural taxonomies.
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Affiliation(s)
- G I Walters
- Birmingham Regional NHS Occupational Lung Disease Service, Birmingham Chest Clinic, Birmingham, UK.,Occupational and Environmental Medicine, Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - C C Huntley
- Birmingham Regional NHS Occupational Lung Disease Service, Birmingham Chest Clinic, Birmingham, UK
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Burge PS, Moore VC, Robertson AS, Walters GI. Do laboratory challenge tests for occupational asthma represent what happens in the workplace? Eur Respir J 2018; 51:13993003.00059-2018. [PMID: 29748310 DOI: 10.1183/13993003.00059-2018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 05/02/2018] [Indexed: 11/05/2022]
Abstract
Specific inhalation challenge (SIC) is the diagnostic reference standard for occupational asthma; however, a positive test cannot be considered truly significant unless it can be reproduced by usual work exposures. We have compared the timing and responses during SIC in hospital to Oasys analysis of serial peak expiratory flow (PEF) during usual work exposures.All workers with a positive SIC to occupational agents between 2006 and 2015 were asked to measure PEF every 2 h from waking to sleeping for 4 weeks during usual occupational exposures. Responses were compared between the laboratory challenge and the real-world exposures at work.All 53 workers with positive SIC were included. 49 out of 53 had records suitable for Oasys analysis, 14 required more than one attempt and all confirmed occupational work-related changes in PEF. Immediate SIC reactors and deterioration within the first 2 h of starting work were significantly correlated with early recovery, and late SIC reactors and a delayed start to workplace deterioration were significantly correlated with delayed recovery. Dual SIC reactions had features of immediate or late SIC reactions at work rather than dual reactions.The concordance of timings of reactions during SIC and at work provides further validation for the clinical significance of each test.
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Affiliation(s)
- P Sherwood Burge
- Occupational Lung Disease Unit, Birmingham Heartlands Hospital, Birmingham, UK
| | - Vicky C Moore
- Occupational Lung Disease Unit, Birmingham Heartlands Hospital, Birmingham, UK
| | | | - Gareth I Walters
- Occupational Lung Disease Unit, Birmingham Heartlands Hospital, Birmingham, UK
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Coman I, Lemière C. Fractional Exhaled Nitric Oxide (FeNO) in the Screening and Diagnosis Work-Up of Occupational Asthma. CURRENT TREATMENT OPTIONS IN ALLERGY 2017. [DOI: 10.1007/s40521-017-0122-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Abstract
OBJECTIVE Summarize developed evidence-based diagnostic and treatment guidelines for work-related asthma (WRA). METHODS Comprehensive literature reviews conducted with article critiquing and grading. Guidelines developed by a multidisciplinary expert panel and peer-reviewed. RESULTS Evidence supports spirometric testing as an essential early test. Serial peak expiratory flow rates measurement is moderately recommended for employees diagnosed with asthma to establish work-relatedness. Bronchial provocation testing is moderately recommended. IgE and skin prick testing for specific high-molecular weight (HMW) antigens are highly recommended. IgG testing for HMW antigens, IgE testing for low-molecular weight antigens, and nitric oxide testing for diagnosis are not recommended. Removal from exposure is associated with the highest probability of improvement, but may not lead to complete recovery. CONCLUSION Quality evidence supports these clinical practice recommendations. The guidelines may be useful to providers who diagnose and/or treat WRA.
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Turner AM, Tamasi L, Schleich F, Hoxha M, Horvath I, Louis R, Barnes N. Clinically relevant subgroups in COPD and asthma. Eur Respir Rev 2016; 24:283-98. [PMID: 26028640 DOI: 10.1183/16000617.00009014] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
As knowledge of airways disease has grown, it has become apparent that neither chronic obstructive pulmonary disease (COPD) nor asthma is a simple, easily defined disease. In the past, treatment options for both diseases were limited; thus, there was less need to define subgroups. As treatment options have grown, so has our need to predict who will respond to new drugs. To date, identifying subgroups has been largely reported by detailed clinical characterisation or differences in pathobiology. These subgroups are commonly called "phenotypes"; however, the problem of defining what constitutes a phenotype, whether this should include comorbid diseases and how to handle changes over time has led to the term being used loosely. In this review, we describe subgroups of COPD and asthma patients whose clinical characteristics we believe have therapeutic or major prognostic implications specific to the lung, and whether these subgroups are constant over time. Finally, we will discuss whether the subgroups we describe are common to both asthma and COPD, and give some examples of how treatment might be tailored in patients where the subgroup is clear, but the label of asthma or COPD is not.
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Affiliation(s)
- Alice M Turner
- Clinical and Experimental Medicine, University of Birmingham, Queen Elizabeth Hospital Birmingham, Birmingham, UK Dept of Respiratory Medicine, Birmingham Heartlands Hospital, Birmingham, UK
| | - Lilla Tamasi
- Dept of Pulmonology, Semmelweis University, Budapest, Hungary
| | | | - Mehmet Hoxha
- Service of Allergology and Clinical Immunology, UHC "Mother Teresa", Tirana, Albania
| | - Ildiko Horvath
- Dept of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Renaud Louis
- Respiratory Medicine, CHU Sart-Tilman B35, Liege, Belgium
| | - Neil Barnes
- GlaxoSmithKline, Stockley Park West, Uxbridge, UK
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Walters GI, Moore VC, McGrath EE, Burge S. Fractional exhaled nitric oxide in the interpretation of specific inhalational challenge tests for occupational asthma. Lung 2014; 192:119-24. [PMID: 24232978 DOI: 10.1007/s00408-013-9531-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2013] [Accepted: 10/22/2013] [Indexed: 11/28/2022]
Abstract
PURPOSE Fractional exhaled nitric oxide (FENO) measurements are recommended for the assessment of eosinophilic airway inflammation in asthma. Clinically relevant increases in FENO have been reported 24 h after positive specific inhalational challenge (SIC) tests in occupational asthma. We aimed to determine whether positive SICs could be discriminated from control tests, on the basis of change in FENO. METHODS We reviewed all positive SICs to a variety of agents performed at our institution 2008-2012 and gathered data on age, sex, asthmatic response (immediate/dual/late), smoking status, inhaled corticosteroid usage, and FENO pre- and 24-h postcontrol and positive SIC from each worker. Changes in FENO after positive SICs were compared with control SICs from each worker, by using paired Student's t tests. RESULTS In 16 workers, negative control challenges were associated with mean changes in FENO of 9 % (95 % CI -1.14 to 19.01) or 1.1 ppb (95 % CI -3.59 to 5.84); 2 of 16 (13 %) workers tested showed increases in FENO that were clinically relevant based on recent guidelines. Subsequent positive SICs were associated with mean changes in FENO of 7 % (95 % CI −15.73 to 29.6) or 2.1 ppb (95 % CI -6.07 to 10.19), which were not significantly different to controls; only 2 of 16 (13 %) workers had FENO changes that were clinically relevant. CONCLUSIONS FENO changes above the upper confidence limits of ≥20 % or ≥6 ppb may be considered to be outside the range of normality. However, the majority of workers who had clearly positive SICs to common low molecular weight agents also had no statistically or clinically relevant increase in FENO. Therefore, change in FENO does not predict a positive SIC in this group.
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Abstract
The study of occupational asthma (OA) provides insights into asthma in general, as the cause is known. The relationships between the cause and response can be measured and modifying factors can be identified and their influence quantified. Developing OA has much more serious consequences for the patient than new onset asthma unrelated to work exposures, as the patient's livelihood is nearly always affected. Many healthcare professionals are more ready to accept and act on asthmatic symptoms when they are unrelated to work than when work may be the cause; antagonism can also occur in the workplace. This article reviews some of the areas where development and controversy enrich the study of OA. It makes no attempt to be comprehensive.
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Affiliation(s)
- Sherwood Burge
- Occupational Lung Disease Unit, Birmingham Heartlands Hospital, Birmingham, B9 5SS, UK.
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Induced Sputum, Exhaled Nitric Oxide, and Particles in Exhaled Air in Assessing Airways Inflammation in Occupational Exposures. Clin Chest Med 2012; 33:771-82. [DOI: 10.1016/j.ccm.2012.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Walters GI, Moore VC, Robertson AS, Burge CBSG, Vellore AD, Burge PS. An outbreak of occupational asthma due to chromium and cobalt. Occup Med (Lond) 2012; 62:533-40. [PMID: 22826555 DOI: 10.1093/occmed/kqs111] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Five metal turners employed by an aerospace manufacturer presented to the Birmingham Chest Clinic occupational lung disease unit. Four cases of occupational asthma (OA) due to chromium salt (3) and cobalt (1) were diagnosed by serial peak-expiratory flow measurements and specific inhalation challenge testing. AIMS To measure the extent of the outbreak and to provide epidemiological data to ascertain the aetiology. METHODS Participants answered a detailed, self-administered questionnaire, designed to detect occupational lung disease. Urine chromium and cobalt excretion, spirometry and exhaled nitric oxide measurements were taken. Those with possible, probable or definite non-OA or OA, after questionnaire, were invited to undertake two-hourly peak flow measurements and received specialist follow-up. RESULTS A total of 62 workers (95% of workforce) participated. Sixty-one per cent of employees were working in higher metalworking fluid (MWF) exposure areas. Ninety per cent of workers had urinary chromium excretion indicating occupational exposure. Sixty-six per cent of workers reported active respiratory symptoms, although there were no significant differences between exposure groups. Two further workers with probable OA were identified and had significantly higher urinary chromium and cobalt concentration than asymptomatic controls. Eighteen cases of occupational rhinitis (OR) were identified, with significantly raised urinary chromium concentration compared with asymptomatic controls. CONCLUSIONS Chromium salt and cobalt can be responsible for OA and OR in workers exposed to MWF aerosols. Onset of symptoms in those with positive specific challenges followed change in MWF brand. Workers with OA had increased urinary concentrations of chromium and cobalt, and those with OR had increased urinary concentrations of chromium.
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Affiliation(s)
- G I Walters
- Occupational Lung Disease Unit, Birmingham Heartlands Hospital Bordesley Green East, Birmingham B9 5SS, UK.
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