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Cleaning ( Acute Inhalational Injury RADS ). Prof. Metin Gorguner Atatürk University Medical Faculty Department of Pulmonary Diseases gorguner@atauni.edu.tr. Terminology *. Cleaning Cleaning Worker Cleanliness Clean. * T.L.F. Dictionary. Cleaning Industry.
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Cleaning(AcuteInhalationalInjury RADS) Prof. Metin Gorguner Atatürk University Medical Faculty Department of Pulmonary Diseases gorguner@atauni.edu.tr
Terminology* • Cleaning • Cleaning Worker • Cleanliness • Clean * T.L.F. Dictionary
InhaledToxicSubstances • Gas • Aerosol • Stablesuspendedsolidorliquidparticleswith in gasenvironment • Vapor • Gascondition of solidorliquidsubstances in normal • Fume • Solidparticlesaerosol < 0,1 m • Duman • Volatilegasorparticlesformedbyburning
Inhalation of ToxicSubstance inhalation of toxicsubstance pathologicchangesdevelopingwith in seconds systemicdisease chronicpulmonarydisease suddenrespiratorydistress
FactorsAffectingToxicity • Particles diameter • Solubility in water • Consantration • Exposure time • Ventilation • Personal characteristics • Age, cigarette, comorbid disease, prevention, genetic predisposition
MostImportantFactors solubility in water particlesdiameter region of damage – heavy of damage
HighSolubility in Water suddenonset of symptoms environmentawayfromorexpositionsource of deactivation excitement of irritantreceptors bronchospasm prevention of distaltransition of toxicsubstance
LowSolubility in Water no irritation not removedfromtheenvironment no bronchospasm prolongedexposure time increasedexposureamount
Localization – Damages • Upper airways • Acute • Chronic • Conducting airways • Acute • Chronic (RADS, Vocal cord dysfunction) • Distal airways - parenchymal • Acute • Chronic (BO, BOOP)
UpperAirways • Sudden and short-term toxic effect • Typical symptoms • Burning in throat • Sticky mucus • Cough and sneeze • Extrapulmonary symptoms • Burning eyes • Headache and dizziness
UpperAirways • Most important risk: airway obstruction • Reflex laryngospasm or bronchospasm • Mucosal edema • Increased secretion • Epithelial damage • If hoarseness or stridor; • Careful observation in terms of respiratory insufficiency • Non-sequelaous improvement in general
ConductingAirways • Acute Damage • Epithelial damage like upper airways • Life-threatening edema, inflammation, bronchospasm • Wheezing, reduction in air flow with PEF-meter or spirometer, abnormal chest X-ray, dyspnea, chest tightness
ConductingAirways • Chronic damage • Vocal Cord Dysfunction • Reaktif Airway Dysfunction Syndrome (RADS)
DistalAirways - Parenchymal • Acute damage • Cellular toxicity increased alveolo-capillary membran permeability ARDS • Typically; a latent period after the first exposition • Minimum 24 hours of observation period should be done in terms of respiratory distress Slightdyspnea Cough ARDS
DistalAirways - Parenchymal • Chronicdamage • BO (Bronchiolitisobliterans) • BOOP (Bronchiolitisobliteransorganizedpneumonia)
Mesleksel Hastalık 1. SKIN Variant 2. RESPIRATORY SYSTEM • Industrialbronchitis • Asthma-likesyndrome 1. Airwaydisease AHR 2. Parenchymaldisease Persistent • Workrelatedasthma 3. Pleuraldisease
WorkRelatedAsthma WORK RELATED ASTHMA WorkExacerbatedAsthma OccupationalAsthma
OccupationalAsthma HighMolecularWeight Immunological (IgE) LowMolecularWeight Non-immunological
Non-immunological • İrritants “İrritant induced asthma” • Multiple exposure • Single exposure (RADS) • Organic dusts and microbial agents “Asthma-like syndrome” Mapp CE, et al. Occupational Asthma AJRCCM 2005
Population Attributable Risk Population attributable risk (PAR) for asthma due to occupational exposures: median 15 % (21 studies: 4% to 58%) Balmes J, et al.AJRCCM 2003
Asthma and Cleaning Agents In female cleaners Use of bleach Reported inhalation incident Use of cleaning sprays High risk of asthma Karjalainen et al. ERJ 2002, Medina-Ramon et al. OEM 2005, Zock et al. AJRCCM 2007
43 female cleaners with recent history of asthma and/or chronic bronchitis • 2-week diary (symptoms, PEF 3/d, exposures) • Upper respiratory symptoms: • no association with exposure • Lower respiratory symptoms: associations with; • exposure to bleach (O.R. 2.5) • degreasing sprays (O.R. 2.6) • air refreshing sprays (O.R. 6.5) Medina-Ramon et al. OEM 2005
USA (CA, MA, MI, NJ), 1993 – 1995 SENSOR (Sentinel Event Notification System for Occupational Risks)program Work related RADS (123 cases) 18 (15 %) of the RADS cases Most common class of agents was cleaning materials Henneberger PK, et al.J Occup Environ Med 2003
Reactive Airways Dysfuntion Syndrome • 10 clinical case; • Önceden solunum sistemi semptomu olmayan • Yüksek düzeyde kimyasal iritana maruziyet sonrası dakikalar-saatler içerisinde solunumsal semptomlar • Persistan astım (>1yıl): öksürük, vizing, dispne, FEV1’de , havayolu aşırı duyarlılığı • Biyopside nonspesifik havayolu inflamasyonu • Re-maruziyet yok Brooks SM, et al. Reactive airways dysfunction syndrome (RADS). Chest 1985
Reactive Airways Dysfuntion Syndrome • Acute inhalational damage • after • new onset • asthma Brooks SM, et al. Reactive airways dysfunction syndrome (RADS). Chest 1985
RADS-Pathophysiology EpithelialDamage Inflammation AHR
Inflammation – Remodelling AcutPeriod ChronicPeriod
RADS – Criteria for Diagnosis Brooks SM, et al. Reactive airways dysfunction syndrome (RADS). Chest 1985 Nemery B,Leuven – 2009 Absence of preceedingrespiratorycomplaints Theoncet of symptomsoccuredaftera singlespesificexposure Theexposurewasto a gas, smoke, fumewhichwaspresentin veryhighconcentrations Theonset of symptomsoccurredwithin 24 hours Symptomspersistedforat least 3 months Symptomssimulatedasthma (cough, wheezing, dyspnea) Pulmonaryfunctiontestsmayshowairflowobstruction PositiveMethacholine/histaminechallengetesting Othertypes of pulmonarydiseaseswereruledout
Inhalation accidents and RADS occuring; • Workplace • Petrochemistry, fire-fighting, industrial cleaning • Home • Indoor cleaning* • Daily life • Transportation accidents • Fire & Explosion * Akkoçlu, A., et al.The effect of hydrochloric acid and hypochlorite as the cause of RADS Dokuz Eylul Univ. Med. J. 1990
A lower age, higher initial PEFR, higher initial paO2, • Exposure in the kitchen or bathroom, • Exposure after waiting 10–15 min after mixing the solutions • Shorter duration of the acute exposure • Less long-term use of the mixture were associated with a better response to therapy • Smoking status was not related to differing responses to treatment Gorguner M, et al. Inhal Toxicol 2004
Treatment • Prevention is more important • Treated like asthma when sypmtoms develop • Steroid therapy in early stage can prevent RADS do ? • Nebulized Sodium-Bicarbonate treatment
Nebulize Sodyum – Bikarbonat Kandiş H, et al. Inhalation Toxicology 2006
Sodium – Bicarbonate Treatment • 44 patients • Patients were divided into two groups • Bronchdilator + steroid given to all • In addition; nebulized 4,2 % sodium bicarbonate solution given to one group (NSB), and placebo to other group (NP) Kandiş H, et al. Inhalation Toxicology 2006
In NSB group; • NSB group had significantly higher FEV1 values (p<0,05) • Significantly more improvement in QoL questionnaire scores occurred in the NSB group (p<0,01) Kandiş H, et al. Inhalation Toxicology 2006