vor 5 Jahren

2011 (pdf, 4 MB) - Universitätsklinikum Hamburg-Eppendorf

2011 (pdf, 4 MB) - Universitätsklinikum Hamburg-Eppendorf

Management of Work

Management of Work related Asthma The new guidelines for „Management of Work-related Asthma” Overview X. Baur, T. Sigsgaard, T. B. Aasen, P. S. Burge, D. Heederik, P. Henneberger , P. Maestrelli, J. Rooyackers, V. Schlünssen, O. Vandenplas, D. Wilken on behalf of the ERS Task Force on the Management of Work-related Asthma. Eur Respir J 2012;39 529-545 Work-related asthma, which includes occupational asthma and work-aggravated asthma, has become one of the most prevalent occupational lung diseases.These guidelines aim to upgrade occupational health standards, contribute importantly to transnational legal harmonisation and reduce the high socio-economic burden due to this disorder. A systematic literature search related to five key questions was performed (diagnostics, risk factors, outcome of management options, medical screening and surveillance, controlling exposure for primary prevention). Each of the 1329 retrieved papers was reviewed by two experts followed by SIGN grading and formulation of statements graded according to the RCGP three star system. Finally, on basis of the evidence-based statements recommendations were made, which comprise the following major evidence-based strategic points: • A comprehensive diagnostic approach considering the individual specific aspects is recommended. • Early recognition and diagnosis is necessary for timely preventive and appropriate preventive measures. • A stratified medical screening strategy and surveillance programme should be applied to atrisk workers. • Whenever possible, removing exposure to the causative agent should be achieved, it leads to the best health outcome. If not possible, reduction is the second best option, whereas respirators are of limited value. • Exposure elimination should be the preferred primary prevention approach Editorial Xaver Baur, ZfAM, Torben Sigsgaard, Aarhus University, Institute of Environmental and Occupational Medicine, School of Public Health, Denmark Eur Respir J 2012;39 518-519 Work-related asthma, which includes occupational asthma as well as work-aggravated asthma, has become one of the most prevalent occupational lung diseases. In spite of increasing knowledge on causes and underlying pathophysiological mechanisms this preventable disorder continues to account for at least 15 % of all asthma cases in the adult population and is responsible for a significant socio-economic burden [1-2]. Using national data sets of 1999 from the United States of America Leigh et al. [3-4] estimated the annual direct and indirect costs of occupational asthma and occupational COPD to be 1.5, and 2.2 billion USD, respectively, mostly born by affected workers, their families and the taxpayer. In 2009 the financial burden for work-related asthma and for COPD (the latter only refers to hard coal miners) of the German statutory accident injurance institutions amounted 1o1,4, and 60.4 million Euro, respectively [5]. The total costs across Europe are not known in detail, but should be more than 1.2 billion EURO per year. 131

Management of Work related Asthma A panel of international experts was convened to develop an overview chapter [1] and five adjacent chapters [6-10] of the ERS guidelines “Management of Work-related Asthma”. They are based on systematic reviews for five key questions and 30 ancillary questions on occupational asthma as well as work-aggravated asthma. The guidelines cover prevention and include issues on diagnostics, personal and occupational risk factors, medical screening and surveillance, and finally interventions to prevent the disease and improve prognosis. They intend to inform and help occupational health professionals as well as employers who are responsible for creating healthy workplaces according to national and European regulations. The Task Force makes far-reaching recommendations based on evidence statements derived from the key and ancillary questions. 42 evidence-based statements were formulated. From these statements recommendations for management options, especially in prevention, were formulated. Primary prevention is the first choice. It means substituting asthma-inducing agents by harmless substances or reduction of exposures to levels not causing work-related asthma. Examples for reducing exposure include engineering controls such as local exhaust ventilation systems or process redesign such as encapsulation of powdered allergenic enzymes.Further major recommendations include intensifying secondary preventive measures with screening and surveillance of exposed workers (those with high risk exposures or increased individual susceptibility) enabling early diagnosis and removal from harmful exposure which is associated with a better prognosis. Those failing surveillance need comprehensive assessment to confirm or exclude work-related asthma. Workers education needs improvement to improve the workers ability to work safely avoid acute exposures and avoid smoking as a co-factor in lung function deterioration. Respiratory protective equipment is the last resort for prevention and is ineffective for long term control in affected workers. These guidelines have some in common with previously published guidelines and statements, i. e. by the British, Spanish and North American publications [11-19]. However, there are also several differences. For example, for the first time, sufficient information was retrieved to allow these guidelines to recommend medical surveillance programmes for all workers with increased risk of work-related asthma. ACCP supports serial methacholine challenges for diagnosis whereas the present guidelines favor a computerized interpretation system for records of serial peak expiratory flow or spirometry readings. Similar to the ACCP document allergological testing with occupational allergens is emphasized if IgE-mediated occupational asthma is assumed. Further, gaps in current knowledge of causes and mechanisms were identified and respective future research requirements outlined. The essential message of these guidelines is that present knowledge on causes and mechanisms can lead to substantial improvements in the management of work-related asthma. Work-related asthma is obviously significantly under-recognized in most statistics on occupational diseases. The same is true for occupational COPD which shows some overlap with work-related asthma, but has been scarcely covered in population studies so far. Occupational causes of airway disorders should always be considered if a worker develops workplace-related respiratory symptoms and / or an obstructive ventilatory pattern during occupational exposure to airborne allergens or irritants. These frequent disorders have huge socio-economic and psychosocial implications [13]. They also raise ethical issues relating to the costs of preventing reduced quality of life [20] in affected workers (as measured by DALYs and QALYs). Proper management of work-related asthma is not expensive, whereas not managing work-related asthma is very costly and associated with financial as well as psychosocial disadvantages of affected workers, respective the society. Compensation of work-related asthma is a critical issue which varies widely between European countries mostly being inadequate and needing considerable improvement [10]. 132

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