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Wheezing in the workplace
Gregory Alford It took almost a year for George Stephens to learn that his asthma was caused by the white haze floating through the bakery where he worked. Stephens knew he was breathing small particles of flour and other dry ingredients, but he had no idea it was making him sick. “I had no clue that things I always thought were safe and inert could cause asthma,” says Stephens, now 33. He worked in a bakery to help make ends meet while attending the University of Oklahoma during the mid-1990s. “I had never even heard of someone going to work and coming home with asthma.” 11 Million at Risk
In December 2003, scientists from the University of Birmingham in
England released the results of a survey, which found that bakers, timber workers, dentists, and waitresses are the workers reporting the highest rates of adult-onset asthma. The survey results also indicate the people most likely to develop occupational asthma are those with a personal or family history of allergies or asthma and frequent exposure to highly sensitizing substances. However, some people, such as Stephens, have no family history of asthma or allergy. ASTHMA MAGAZINE
“I felt fine when I began working at the bakery, but after a couple of months I noticed that I would start to wheeze and have difficulty breathing when I made bread,” says Stephens, who is now a graphic designer in Minneapolis. “The lag time really made it difficult to pinpoint the cause of the problem.” Today, Stephens still needs medication to control his asthma. Occupational asthma is the most common work-related lung disease in
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many industrialized countries. Although estimates vary, it is thought that 15% of adult-onset asthma cases in the United States may be attributable to workplace exposures. The Occupational Safety and Health Administration (OSHA) estimates 11 million workers in the United States are exposed to at least one of the almost 400 substances known to be associated with occupational asthma. (See sidebar for list of common hazardous substances.) Types of Occupational Asthma
Kenneth D. Rosenmann, MD, professor of medicine at Michigan State University, has studied workplace asthma (the term he prefers) for more than 15 years. He says Common Substances Associated With Workplace Asthma
8
Organic dusts
Chemical dusts
Mineral dusts
Flour Cereals Grains Wood Coffee Tea Flax
Vapors Plastics Paints Epoxies Insulation
Platinum Chromium Cotton Nickel sulfate
|
ASTHMA MAGAZINE
occupational asthma generally takes one of 3 forms. • Sensitizing asthma: This is the type with which Stephens was diagnosed. It tends to develop slowly after repeated exposure. This allergy-related asthma is the most commonly diagnosed form of occupational asthma. • Preexisting Occupational Asthma: This type involves a preexisting asthma condition that is significantly aggravated after exposure to an irritating substance in the workplace. • Reactive Airway Dysfunction Syndrome (RADS): This third type of occupational asthma can occur after one or more exposures to high levels of airway irritants. (Common irritants that may cause this are hydrochloric acid, chlorine, acetic acid, and ammonia fumes, according to Dr Rosenmann.) Initial symptoms may include shortness of breath, wheezing, cough, and respiratory distress. Although the initial symptoms usually improve, even a single exposure can result in longterm reactive airway dysfunction. According to Dr Rosenmann, there is a common pattern of occupational asthma. “Symptoms of workplace asthma include wheezing, chest
March/April 2004
tightness, coughing, and shortness of breath. Symptoms usually occur while the worker is exposed to a particular substance at work. In some cases, symptoms may not develop until several hours after work.” He adds that in the early stages of the disease, symptoms usually decrease or disappear during weekends or vacations, only to flair up after returning to work. In later stages of the disease, common substances such as cigarette smoke, dust, or cold air may trigger asthma symptoms. In rare cases, occupational asthma can prove fatal. “I recently became aware of a workplace-related asthma death in Michigan,” says Dr. Rosenmann. “A man in his mid-40s who managed a mom-and-pop auto detailing shop collapsed and died at an urgent care clinic after spraying a chemical bed liner. The man was exposed to isocyanates, which are used to produce polyurethane polymers. Isocyanates are a common cause of workplace asthma and RADS.” Michigan OSHA cited the company for 7 workplace safety violations after the death. In the Michigan case, previous work-related asthma attacks had been treated only with albuterol and a short course of oral corticosteroids, which rankles Dr. Rosenmann. He believes too few physicians aggressively diagnose and adequately treat occupational asthma. People who suspect the workplace is causing or contributing to their asthma should discuss the issue with their doctor. Ask for a referral or switch health care providers if the topic is unfamiliar to your physician, he advises. Diagnosis and Treatment
Allergists, immunologists, pulmonologists, and occupational medicine specialists are generally those with the most experience diagnosing and treating occupational asthma. When occupational asthma is suspected, thorough medical and work histories are taken, and a complete physical examination is performed. The fre-
quency, duration, and severity of symptoms are also noted. Laboratory tests of blood and sputum may help confirm the presence of specific irritants and assist in diagnosing occupational asthma. It takes commitment on the part of both physician and patient to properly diagnose occupational asthma, says Dr. Rosenmann. “It can be difficult to diagnose. I ask patients keep a diary of their peak flow readings, taking one [reading] every 2 hours. It’s also important to have spirometry tests performed on a regular basis. [This is done at your doctor’s office.] Another key is to have spirometry readings done over a period of time, usually 2 weeks, while the patient is away from the workplace,” he says. An important aspect of treatment for occupational asthma is simply to avoid the substance causing the asthma. Employers sometimes provide affected workers with a different job, or allow the person to do their job in a different location within the facility (away from the offending substance) when possible. Other steps employers may take are to improve ventilation, provide personal protective
equipment, or educate staff members. However, when continued exposure at work is unavoidable, even if it is only intermittent, the person may have to leave the job. In addition to avoidance, aggressive drug treatment and regular monitoring are usually recommended. Many people require life-long treatment to control their occupational asthma, even after they are no longer exposed to the harmful substance. Dr. Rosenmann notes that an accurate diagnosis of occupational asthma impacts more than treatment decisions. Severe cases may qualify for workers’ compensation benefits. The number of people filing claims is on the rise. Between 1994 and 1998, the Washington State Workers’ Compensation Fund claims rate for work-related asthma increased by 70%.
routinely wore latex gloves. After several years and thousands of exposures, she developed an allergy to the latex protein. She eventually became so sensitive that she could not touch or be near products that contained latex (which are common in hospitals) without triggering allergy and asthma symptoms. “I loved working at the bedside but couldn’t handle the wheezing and sneezing after a while,” explains Newman. After much deliberation, she went back to college and became a teacher. “My family and I had to make sacrifices. In the end, I realized that life isn’t perfect and being healthy is more important than any job.” For more information about occupations and substances that can cause occupational asthma, visit the Asmapro web site at www.asmanet.com/ asmapro/agents.htm Susan Berg is a freelance writer in Sharon, Mass., who writes about health care and consumer issues. Reprint orders: Elsevier Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314)453-4350. doi: 1016/j.asthmamag.2004.01.003
Career Verses Health
Although Stephens found it fairly easy to leave his job as a baker, some people have much more difficulty when forced to leave an established career due to health concerns. Shelly Newman, 41, of Dallas, Tex., changed careers after being diagnosed with sensitizing occupational asthma in 1999. As a registered nurse who had practiced for more than 10 years, Newman ASTHMA MAGAZINE
to subscribe call 1.800.654.2452
|
9
In December 2003, scientists from the University of Birmingham in
England released the results of a survey, which found that bakers, timber workers, dentists, and waitresses are the workers reporting the highest rates of adult-onset asthma. The survey results also indicate the people most likely to develop occupational asthma are those with a personal or family history of allergies or asthma and frequent exposure to highly sensitizing substances. However, some people, such as Stephens, have no family history of asthma or allergy. ASTHMA MAGAZINE
“I felt fine when I began working at the bakery, but after a couple of months I noticed that I would start to wheeze and have difficulty breathing when I made bread,” says Stephens, who is now a graphic designer in Minneapolis. “The lag time really made it difficult to pinpoint the cause of the problem.” Today, Stephens still needs medication to control his asthma. Occupational asthma is the most common work-related lung disease in
to subscribe call 1.800.654.2452
|
7
many industrialized countries. Although estimates vary, it is thought that 15% of adult-onset asthma cases in the United States may be attributable to workplace exposures. The Occupational Safety and Health Administration (OSHA) estimates 11 million workers in the United States are exposed to at least one of the almost 400 substances known to be associated with occupational asthma. (See sidebar for list of common hazardous substances.) Types of Occupational Asthma
Kenneth D. Rosenmann, MD, professor of medicine at Michigan State University, has studied workplace asthma (the term he prefers) for more than 15 years. He says Common Substances Associated With Workplace Asthma
8
Organic dusts
Chemical dusts
Mineral dusts
Flour Cereals Grains Wood Coffee Tea Flax
Vapors Plastics Paints Epoxies Insulation
Platinum Chromium Cotton Nickel sulfate
|
ASTHMA MAGAZINE
occupational asthma generally takes one of 3 forms. • Sensitizing asthma: This is the type with which Stephens was diagnosed. It tends to develop slowly after repeated exposure. This allergy-related asthma is the most commonly diagnosed form of occupational asthma. • Preexisting Occupational Asthma: This type involves a preexisting asthma condition that is significantly aggravated after exposure to an irritating substance in the workplace. • Reactive Airway Dysfunction Syndrome (RADS): This third type of occupational asthma can occur after one or more exposures to high levels of airway irritants. (Common irritants that may cause this are hydrochloric acid, chlorine, acetic acid, and ammonia fumes, according to Dr Rosenmann.) Initial symptoms may include shortness of breath, wheezing, cough, and respiratory distress. Although the initial symptoms usually improve, even a single exposure can result in longterm reactive airway dysfunction. According to Dr Rosenmann, there is a common pattern of occupational asthma. “Symptoms of workplace asthma include wheezing, chest
March/April 2004
tightness, coughing, and shortness of breath. Symptoms usually occur while the worker is exposed to a particular substance at work. In some cases, symptoms may not develop until several hours after work.” He adds that in the early stages of the disease, symptoms usually decrease or disappear during weekends or vacations, only to flair up after returning to work. In later stages of the disease, common substances such as cigarette smoke, dust, or cold air may trigger asthma symptoms. In rare cases, occupational asthma can prove fatal. “I recently became aware of a workplace-related asthma death in Michigan,” says Dr. Rosenmann. “A man in his mid-40s who managed a mom-and-pop auto detailing shop collapsed and died at an urgent care clinic after spraying a chemical bed liner. The man was exposed to isocyanates, which are used to produce polyurethane polymers. Isocyanates are a common cause of workplace asthma and RADS.” Michigan OSHA cited the company for 7 workplace safety violations after the death. In the Michigan case, previous work-related asthma attacks had been treated only with albuterol and a short course of oral corticosteroids, which rankles Dr. Rosenmann. He believes too few physicians aggressively diagnose and adequately treat occupational asthma. People who suspect the workplace is causing or contributing to their asthma should discuss the issue with their doctor. Ask for a referral or switch health care providers if the topic is unfamiliar to your physician, he advises. Diagnosis and Treatment
Allergists, immunologists, pulmonologists, and occupational medicine specialists are generally those with the most experience diagnosing and treating occupational asthma. When occupational asthma is suspected, thorough medical and work histories are taken, and a complete physical examination is performed. The fre-
quency, duration, and severity of symptoms are also noted. Laboratory tests of blood and sputum may help confirm the presence of specific irritants and assist in diagnosing occupational asthma. It takes commitment on the part of both physician and patient to properly diagnose occupational asthma, says Dr. Rosenmann. “It can be difficult to diagnose. I ask patients keep a diary of their peak flow readings, taking one [reading] every 2 hours. It’s also important to have spirometry tests performed on a regular basis. [This is done at your doctor’s office.] Another key is to have spirometry readings done over a period of time, usually 2 weeks, while the patient is away from the workplace,” he says. An important aspect of treatment for occupational asthma is simply to avoid the substance causing the asthma. Employers sometimes provide affected workers with a different job, or allow the person to do their job in a different location within the facility (away from the offending substance) when possible. Other steps employers may take are to improve ventilation, provide personal protective
equipment, or educate staff members. However, when continued exposure at work is unavoidable, even if it is only intermittent, the person may have to leave the job. In addition to avoidance, aggressive drug treatment and regular monitoring are usually recommended. Many people require life-long treatment to control their occupational asthma, even after they are no longer exposed to the harmful substance. Dr. Rosenmann notes that an accurate diagnosis of occupational asthma impacts more than treatment decisions. Severe cases may qualify for workers’ compensation benefits. The number of people filing claims is on the rise. Between 1994 and 1998, the Washington State Workers’ Compensation Fund claims rate for work-related asthma increased by 70%.
routinely wore latex gloves. After several years and thousands of exposures, she developed an allergy to the latex protein. She eventually became so sensitive that she could not touch or be near products that contained latex (which are common in hospitals) without triggering allergy and asthma symptoms. “I loved working at the bedside but couldn’t handle the wheezing and sneezing after a while,” explains Newman. After much deliberation, she went back to college and became a teacher. “My family and I had to make sacrifices. In the end, I realized that life isn’t perfect and being healthy is more important than any job.” For more information about occupations and substances that can cause occupational asthma, visit the Asmapro web site at www.asmanet.com/ asmapro/agents.htm Susan Berg is a freelance writer in Sharon, Mass., who writes about health care and consumer issues. Reprint orders: Elsevier Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314)453-4350. doi: 1016/j.asthmamag.2004.01.003
Career Verses Health
Although Stephens found it fairly easy to leave his job as a baker, some people have much more difficulty when forced to leave an established career due to health concerns. Shelly Newman, 41, of Dallas, Tex., changed careers after being diagnosed with sensitizing occupational asthma in 1999. As a registered nurse who had practiced for more than 10 years, Newman ASTHMA MAGAZINE
to subscribe call 1.800.654.2452
|
9