Wo R K - R E L a T E D a S T H M a : a C a S E - B a S E D a P P Ro a C H to Management by Karin A. Pacheco,

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Wo r k - R e l a t e d A s t h m a : A C a s e - B a s e d A p p ro a c h to Management Karin A. Pacheco,
KEYWORDS  Occupational asthma  Work-exacerbated asthma  Work-aggravated asthma  Work-related asthma  Management MD, MSPH
a

, Susan M. Tarlo,

MB BS, FRCP(C)

b,

*

The pharmacologic treatment of work-related asthma is the same as for nonoccupational asthma, following the National Heart, Lung, and Blood Institute (NHLBI)1 or Global Initiative on Asthma (GINA) guidelines.2 However, additional concerns related to managing workplace exposures, job and task modifications, and medicolegal aspects make work-related asthma more complicated to manage.3 This article focuses mainly on those issues that are more specific to work-related asthma, to provide insight and direction as to how to manage these additional, more problematic aspects. Finally, it discusses levels and methods of prevention as the best management for occupationally induced or exacerbated asthma. Each category of workrelated asthma—occupational asthma (OA) and work-exacerbated asthma (WEA)—begins with a case vignette illustrating management issues specific to that type of asthma. HIGH-MOLECULAR-WEIGHT SENSITIZER-INDUCED ASTHMA Case Example

A 30-year-old woman without a past history of asthma or allergies worked as a dental assistant for the past 10 years. Three years ago she developed red, raised, itchy welts

Disclosures: Dr Susan Tarlo has received peer-reviewed research grant funding from the Ontario Workplace Safety and Insurance Board and from WorkSafeBC and the Workers’ Compensation Board of Newfoundland and Labrador for studies on work-related asthma. Disclosure: Dr Karin Pacheco has received research funding from the National Institute of Allergy and Infectious Diseases, National Institutes of Health for studies on occupational asthma. a Department of Medicine, National Jewish Health, Colorado School of Public Health, University of Colorado, CO, USA b Department of Medicine, University of Toronto, and Dalla Lana School of Public Health, Toronto Western Hospital, EW7-449, 399 Bathurst Street, Toronto, Ontario, M5T 2S8, Canada * Corresponding author. E-mail address: susan.tarlo@utoronto.ca Immunol Allergy Clin N Am 31 (2011) 729–746 doi:10.1016/j.iac.2011.07.006 immunology.theclinics.com

0889-8561/11/$ – see front matter Crown Copyright Ó 2011 Published by Elsevier Inc. All rights reserved.

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on her arms, anterior chest, and neck that usually appeared at work but were absent on vacations. They typically occurred 2 to 3 times a week, lasting 30 to 60 minutes, and resolved when she took oral antihistamines. Over the past year, she developed episodic cough, shortness of breath, and chest tightness, sometimes at work and sometimes in the evening after work. Her hives have not resolved after switching to nitrile gloves, and coworkers also only use nitrile gloves. The patient’s job entails a variety of different tasks and some exposures to potentially sensitizing materials. She makes impressions for bleach trays using an alginate impression material (cell-wall constituents of brown algae). She performs in-office bleaching using concentrated hydrogen peroxide, and also applies a phosphoric acid etching solution to each tooth before applying a resin base for a crown. She applies restorative composites of dimethacrylates and bisphenol A, and much of her time is spent cementing crowns in place using a two-part paste of ethyl and dimethacrylates, bisphenol A, and benzoyl peroxide. She also assists with minor oral surgery and applies mercury and nickel amalgams. In addition to these jobs, she cleans work surfaces using wipes containing quaternary ammonium compounds, and sterilizes dental equipment that she soaks in a proteinase subtilisin solution before sorting them into packets that are autoclaved in a heat sterilizer. Her evaluation is significant for a methacholine challenge consistent with mild asthma, and...
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