Respiratory Diseases and the Fire Service

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David Prezant, MD Professor of Medicine Albert Einstein College of Medicine Pulmonary Division Montefiore Medical Center Bronx, NY and Chief Medical Officer, Office of Medical Affairs Co-Director of World Trade Center Medical Programs Fire Department City of New York Brooklyn, NY Jaswinderpal Sandhu, MD Pulmonary Fellow Albert Einstein College of Medicine Montefiore Medical Center Bronx, NY Michael R. Shohet, MD Associate Clinical Professor Otolaryngology- Head and Neck Surgery Mount Sinai School of Medicine New York, NY Dorsett D Smith, MD Clinical Professor of Medicine Division of Pulmonary Diseases and Critical Care Medicine Department of Medicine University of Washington Medical School Seattle, Washington Leah Spinner, MD Pulmonary Fellow Albert Einstein College of Medicine Montefiore Medical Center Bronx, NY Michael Weiden, MD Associate Professor of Medicine NYU School of Medicine Division of Pulmonary Medicine New York, NY and Medical Officer, Bureau of Health Services World Trade Center Medical Program Fire Department City of New York Brooklyn, NY In concert with the United States Fire Administration, the IAFF sought independent review of this effort to provide us with technical and critical comments so as to ensure a complete and sound final product. The IAFF thanks the following organizations and individuals for their review of this manual. William Troup Fire Program Specialist, Project Manager United States Fire Administration Emmitsburg, MD James Melius, MD, DrPH Chair, Medical Advisory Board International Association of Fire Fighters Administrator, New York State Laborers’ Health and Safety Trust Fund Albany, NY Lu-Ann Beeckman-Wagner, PhD Health Scientist Division of Respiratory Disease Studies NIOSH Morgantown, WV Robert Castellan, MD, MPH Expert Division of Respiratory Disease Studies NIOSH Morgantown, WV Sandy Bogucki, MD, PhD, FACEP Associate Professor, Emergency Medicine, Yale University Associate EMS Medical Director and Fire Surgeon, Branford Fire Department New Haven, CT Sara A. Pyle, PhD Assistant Professor Preventive Medicine & Family Medicine Kansas City University of Medicine & Biosciences Kansas City, MO Ed Nied Deputy Chief Tucson Fire Department Director, IAFC Health, Safety and Survival Section Tucson, AZ Christopher Coffey, PhD Chief Laboratory Research Branch Division of Respiratory Disease Studies NIOSH Morgantown, WV Paul Enright, MD Expert Consultant to NIOSH Professor University of Arizona Tucson, Arizona Thomas Hales, MD, MPH Senior Medical Epidemiologist Team Co-Leader, NIOSH Fire Fighter Fatality Investigation and Prevention Program NIOSH Cincinnati, OH iv Respiratory Diseases and the Fire Service
Paul Henneberger, ScD, MPH Research Epidemiologist Division of Respiratory Disease Studies NIOSH Morgantown, WV Mark Hoover, PhD, CHP, CIH, Research Physical Scientist Division of Respiratory Disease Studies NIOSH Morgantown, WV Rick Hull, PhD Technical Editor National Center for Chronic Disease Prevention and. Health Promotion NIOSH Atlanta, GA Eva Hnizdo, PhD Senior Service Fellow Division of Respiratory Disease Studies NIOSH Morgantown, WV Kay Kreiss, MD Chief Field Studies Branch Division of Respiratory Disease Surveillance NIOSH Morgantown, WV Travis Kubale, PhD Epidemiologist Division of Surveillance, Hazard Evaluations, and Field Studies NIOSH Cincinnati, OH Dori Reissman, MD, MPH Senior Medical Advisor Medical and Clinical Science Director WTC Responder Health Program NIOSH Washington, DC Roger R. Rosa, PhD Senior Scientist Office of the Director NIOSH Washington, DC Philip LoBue, MD Medical Officer National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Centers for Disease Control and Prevention Atlanta, GA Respiratory Diseases and the Fire Service v
Page 2 and 3: U.S. Fire Administration Mission St
Page 4 and 5: The IAFF would also like to thank t
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Page 10 and 11: Pneumonias.........................
Page 12 and 13: Chapter 2-7 • Pulmonary Fibrosis
Page 14 and 15: Clinical Manifestations............
Page 16 and 17: Reactive (Lower) Airways Dysfunctio
Page 18 and 19: Diagnostic Approach................
Page 22 and 23: phase (fire is extinguished, clean-
Page 24 and 25: In recognition of the causal relati
Page 26 and 27: and adjudicatory purposes and are n
Page 28 and 29: escue workers responded on the morn
Page 32 and 33: The wall of the alveoli is primaril
Page 34 and 35: Figure 1.1.1 Figure 1-1.1 Lung Volu
Page 38 and 39: helium, nitrogen and nitrogen oxide
Page 40 and 41: years. At the initial evaluation th
Page 42 and 43: and indirect (mannitol) airway chal
Page 44 and 45: Tornling et al 1994: Observed less
Page 46 and 47: 27. Feuer E, Rosenman K. Mortality
Page 48 and 49: Oral Cavity, Pharynx, and Larynx Fo
Page 50 and 51: where the offending agents can be d
Page 52 and 53: The typical evaluation of chronic l
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fall and early spring. Bacteria are
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mucus plugging can lead to progress
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In adults, this is often aspirated
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Antibiotic treatment is sometimes g
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Pneumonia can also occur as patchy
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inhalation of an infected aerosol g
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ill or “toxic". The chest radiogr
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Currently, effective treatment is w
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20. Kaplan V, Angus DC, Griffin MF,
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A Person with Active TB Disease Has
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Figure 2-3.2: TB is spread from per
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Clinical Aspects of TB Disease Prog
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Drug-Resistant TB Drug-resistant TB
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Patients who have a positive TST re
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ecommended that close contacts with
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Individuals with immunosuppressive
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Vaccination with Live Attenuated Va
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than 18 years should be counseled a
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Treatment for Latent TB Infection D
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Directly Observed Therapy (DOT) for
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Monthly liver function tests (LFTs)
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19. Nolan CM, Goldberg SV, Buskin S
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to such allergens as house dust mit
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CLINICAL MANIFESTATION Patients usu
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who has persistent asthma. Patients
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Long-Term Control Medications Inhal
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Table 2-4.2: Stepwise approach to t
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Treatment should be started as soon
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21. Nathan RA, Sorkness CA, Kosinsk
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Pathology COPD affects the three ma
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CLASSIFICATION AND DIAGNOSIS OF COP
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different survey methods and variab
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A few other risk factors deserve me
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Suggested Questions for Follow-Up V
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counseling, social support and medi
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SUMMARY In summary, COPD is a progr
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or fungal), autoimmune diseases or
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Figure 2-6.2: Chest radiograph of S
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Other skin findings may occur and w
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prior to the start of our prospecti
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WTC and therefore had follow-up for
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18. Baughman RP, Teirstein AS, Juds
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products like cotton. The key chara
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signs are specific for interstitial
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Certain features of the high-resolu
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lung diseases without a known cause
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An APR or PAPR will not protect aga
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heart. Pulmonary hypertension is th
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suppressant drug, amironex fumarate
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MEDICAL MANAGEMENT General Measures
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Clinical Risk Factors Clinical symp
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with renal failure. In many patient
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Pulmonary Edema Associated with Inh
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Tobacco Use in the US, 1900-2000 50
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Environmental Causes of Lung Cancer
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Figure 2-9.3 depicts the frequency
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are allowing even small lung nodule
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Figure 2-9.6: Chest X-ray and CT Sc
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Figure 2-9.8: Chest CT Scan Showing
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Certain types of SCLC can secrete b
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Physicians Guidelines for the Diagn
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17. Alberg AJ and Samet JM. Epidemi
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use. Cases of mesothelioma, a type
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The mechanism by which asbestos cau
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There are a number of medical condi
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diagnosis is made by excluding othe
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The role of lung scarring in the de
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screening through the use of the IA
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Normal nocturnal sleep is divided i
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However, during sleep there is gene
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from sleep, eye movements, breathin
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Figure 2-11.3: Effects of nasal CPA
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People with OSAS undergoing surgery
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with or without cataplexy. The cond
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26. Appel D, Schmidt-Nowarra WW, Po
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ACUTE COUGH As mentioned above, a c
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cough occurred in adults and adoles
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Gastroesophageal Reflux Disease (GE
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WORLD TRADE CENTER COUGH Immediatel
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materials may produce smoke that is
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The effects of frequent smoke expos
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the most intense exposure to air po
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seizures, coma and death 64 . Addit
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highly water-soluble and, thus, wil
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Diagnostic Testing Initial pulmonar
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symptoms in an inhalation lung inju
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17. Musk AW, Peters JM, Wegman DW.
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42. Herbert R, Moline J, Skloot G,
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71. Kales S, Christiani D. Acute ch
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DECONTAMINATION OF RADIOLOGICAL CAS
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Procedure for Determining Approxima
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Following a three Gy exposure, lymp
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decontamination of the patient and
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treated as per standard burn protoc
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time course for this phenomenon, re
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groups have been identified to be a
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fever accompanied by mouth sores an
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and Aspergillus species which are u
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enal failure. Encephalitis and bact
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progress to severe, fulminant illne
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may be present. A systemic disease
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one percent are primary pneumonic p
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gentamicin is recommended. In a mas
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9. Kilbourne E. Influenza. 1st ed.
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44. Marik PE, Bowles SA. Medical as
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74. Advisory Committee on Immunizat
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the Mt. St. Helens eruption in 1980
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UPPER RESPIRATORY DISEASE Reactive
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Pulmonary function declines or abno
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Currently, for asthma in general an
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Thirteen were identified during the
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(FDNY, NY/NJ consortium coordinated
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For example at the WTC site, FDNY h
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21. Jalloul AS and Banks DE. The he
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49. Banauch GI, Hall C, Weiden M, e
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PEAK FLOW/SPIROMETRY/BRONCHODILATOR
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Spirometry results can usually diff
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of these conditions on spirometry i
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At beginning of gas dilution test A
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calculate a single-breath estimate
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is often referred to as cardiopulmo
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Classification of Respiratory Impai
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taken with the plate pressed agains
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• Granulomas: Small nodules, ofte
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clarity can be obtained in a shorte
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CT findings may be non-specific and
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Sarcoidosis is a common chronic gra
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Risks Risks from the procedure incl
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while certain slow growing tumors (
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the insertion of needle after preli
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CT Pulmonary Angiography (CTPA) CTP
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Risks • Although the total amount
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INCIDENCE AND PREVALENCE The freque
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Hamartomas are the most common beni
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Figure 4-3.1: Spiculated lesion on
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Assessment of Nodule Growth Rate an
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Estimating Probability of Malignanc
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advanced emphysema); those with bul
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c. If old chest images are availabl
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4. Henschke CI, Yankelevitz DF, Nai
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While most people are aware that sm
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Modified Fagerström Test for Smoke
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nicotine gum, inhalers, or nicotine
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Common Reasons Fire Fighters Expres
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and while anyone can temporarily ex
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heart and lungs, increasing the ris
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your doctor, healthcare professiona
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protection from tobacco cravings, w
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cessation. The entire program is ac
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drive, the neural control of breath
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Figure 4-5.2: The balance between i
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TREATMENT OF RESPIRATORY FAILURE Tr
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Mechanical Ventilatory Support Fact
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WEANING OR REMOVING A PATIENT FROM
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7. Esteban A, Frutos F, Tobin MJ, A
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International Association of Fire F
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Respiratory Diseases and the Fire Service

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