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Occupational Asthma
Is your client's asthma misdiagnosed?

By Nachman Brautbar, M.D.

According to the Occupational Safety and Health Administration, Youth Department of Labor, an estimated 11 million workers in a wide range of industries and occupations are potentially exposed to at least one of the deleterious agents known to be associated with the development of occupational asthma. Occupational factors have been associated with up to 15% of the disabling asthma cases in the United States, including 558,000 workers exposed to grain dust, 1.4 million healthcare workers potentially exposed to latex products, and others (Occupational Safety and Health Administration 05/17/00).

Asthma can typically be characterized by intermittent breathing difficulties; however, in many of the workers, asthma is not recognized due to its very atypical presentation, such as an unexplained cough, unexplained chest tightness, and unexplained shortness of breath. According to the Occupational Safety and Health Administration, Youth Department of Labor, asthma is a frequently serious and sometime fatal condition.

Workers may be unaware of the possible relationship between their symptoms and their work. Commonly workers do not associate their symptoms of cough, chest tightness, irritation of the skin, or shortness of breath with their industrial exposures. Commonly According to the various agencies specializing in asthma, employers often have inadequate surveillance procedures to measure the frequency of occupational asthma.

Workers are exposed to a wide variety of airborne contaminants on the job, such as dust, welding fumes, gases, sandblasting dust, solvent vapors and mists. Inhaling dirty workroom air can irritate the respiratory system and cause sneezing, cough, chest tightness or difficulty in breathing. Prolonged exposure over months or years can lead to chronic long-term lung disease with a chronic disability such as chronic bronchitis, asthma, pulmonary fibrosis, and emphysema.

How Long Does Asthma Take to Develop?
There is no fixed period of time in which asthma can develop. Asthma is a disease which may develop from a few hours, days, weeks to many years after initial exposure (the argument that the patient cannot have contracted the asthma at work, because he was diagnosed as having asthma only "5 years after his exposures took place" is refuted scientifically). Studies carried out on platinum refinery workers show that in most cases asthma develops in 6-12 months, but may occur within 10 days or be delayed as long as 25 years. (For reference Canadian Center for Occupational Health & Safety 05/17/00. As a matter of fact, the most common form of occupational asthma is occupational asthma with latency. The latency period may vary from weeks to years. (For reference Western Australian Asthma Organization 05/17/00).

When Should You Suspect Occupational Asthma?
1. Cough or wheeze that improves on weekends or on holidays.
2. A high risk occupation, especially if there are other symptoms such as skin rashes, nose irritation, eye irritation or eczema.
3. Other unexplained exacerbations of preexisting well-controlled asthma.
4. Newly diagnosed asthma in an adult (adult onset asthma).

What Occupations are Associated With an
Increased Risk for Asthma?

Occupation

Agent

Baker
Millers

Wheat

Chemist
Coffee Bean Baggers and Handlers
Gardeners
Oil Industry Workers
Farmers

Castor Beans

Farmers
Grain Handlers

Grain Dust

Cigarette Factory Workers

Tobacco Dust

Drug manufacturers
Mold Makers In Sweet Factories
Printers

Gum Acacia

Gum Manufacturers
Sweet Makers

Gum Tragacanth

Strawberry Grower

Strawberry Pollen

Tea Sifters and Packers

Tea Dust

Tobacco Farmers

Tobacco Leaf

Woolen industry Workers

Wool

Laboratory Workers

Locusts
Cockroaches
Grain Weevils
Rats
Mice
Guinea Pigs
Rabbits

Aircraft Fitters

Triethyltetramine

Chemical Plant Worker

Chlorine

Electronic Workers

Colophony

Foundry mold makers

Furan Based Resin Binder Systems

Hair dressers

Persulfate Salts

Laboratory workers
nurses

Formalin / Formaldehyde

Meat wrappers

Polyvinyl Chloride Vapors

Paint Manufacturers

Phthalic Anhydride

Paint sprayers

Dimethylethanolamine

Photographic workers

Ethylenediamine

Solderers

Polyether Alcohol

Boat Builders
Foam Manufacturers
Office Workers
Plastic Factory Workers
Refrigerator Manufacturers
Printers
Laminators

Toluene Diisocyanate

Car Sprayers

Diisocyanate

Cement Workers

Potassium Dichromate

Chrome Platers
Chrome Polishers

Sodium Bichromate
Chromic Acid

Nickel Platers

Nickel Sulfate

Platinum Chemists

Chloroplantinic Acid

Rubber Workers

Naphthalene Diisocyanate

Welders

Stainless Steel Fumes

Pharmacists

Gentian Powder

Pharmaceutical Workers

Methyldopa
Salbutamol
Dichloramine
Piperazine Dihydrochloride

Carpenters
Wood Workers

Western Red Cedar
Cedar of Lebanon
California Redwood
African Zebra Wood

Saw Mill Workers
Pattern Workers

Mansonia
Oak
Mahogany

Health Care Workers

Latex
Glutaraldehyde

Painters
Mechanics
Automotive Welders

Solvents

(This list is by no means inclusive, but only partial)

When Should You Suspect an
Occupational Lung Disease Such as Asthma?

First of all, the worker in an industry which is considered a high risk such as health care workers, car painters, painters, wood workers, gardeners, pesticide/insecticide sprayers, and mechanic workers. The symptomatology of discrete and otherwise medically unexplained atypical cough, chest tightness, skin irritation, eye irritation which appears as a result of a work environment which was not there before, and have a temporal relationship to the work environment exposure.

Presentation of a Case And Analysis
J. W., 42 years, worked for Aeronautic Supplier in the paint spraying facility. He experienced an industrial orthopaedic injury, and was referred to the company doctor. He received physical therapy, was unhappy with the treatment, and elected his own primary treating physician of choice. The primary treating physician of choice was diligent enough to take a good occupational history, and was intrigued by the patient's cough and chest tightness. The diligent doctor referred the patient to my office for a consultation. After a detailed exposure history, non-industrial factors, absence of history of preexisting asthma, absence of heavy smoking, and some typical diagnostic studies which were positive, such as the Methacholine stimulation test, the diagnosis of industrial asthma was made. Essentially what happened here was, the company physician failed to take an adequate appropriate occupational history. The company failed to screen the workers on an annual basis, and specifically this worker who worked there for 10 years, in a high risk occupation known to be associated with an increased risk of occupational lung disease, specifically asthma, and the intake person in the attorneys' office concentrated on the industrial orthopaedic injuries, (since the attorney's office is not in the medical business, and is not trained to take an occupational history). It was this patient's luck to be sent to a good primary treating physician who picked up some unusual symptomatology of the chest, and quickly referred the patient to our offices. Removal of the patient from his work environment and appropriate treatment alleviated the symptoms, established a diagnosis, and required vocational rehabilitation, and a disability which included no exposure to concentration of fumes and dust particles, and in light of very abnormal oxygen saturation, and oxygen exchange on metabolic exercise test, a work restriction of no heavy work.

Take Home Message
Make sure to have the details, correct history, make sure that the primary treating physician understands occupational medicine, and will take an accurate and detailed occupational history, and will be alert to symptoms which may not be typical of asthma, but which highly supports the diagnosis of asthma. The final diagnosis should be made based on objective studies to include, when indicated, methacholine stimulation test, and for disability rating, when indicated, metabolic exercise test with oxygen exchange measurements. (See also AMA 5th Guides, American Thoracic Society)


Dr. Brautbar is a board-certified internist and nephrologist, and certified in forensic medicine. If you are interested in retaining Dr. Brautbar for forensic and expert witness testimony services, please submit the Contact Form.


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