Cleaning (Acute Inhalational Injury RADS)

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Cleaning (Acute Inhalational Injury
RADS)
Prof. Metin Gorguner Atatürk University Medical
Faculty Department of Pulmonary
Diseases gorguner_at_atauni.edu.tr
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Terminology

• Cleaning
• Cleaning Worker
• Cleanliness
• Clean

T.L.F. Dictionary
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Cleaning Industry
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Cleaning Agents and Other Household Products
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Inhaled Toxic Substances

• Gas
• Aerosol
• Stable suspended solid or liquid particles with
  in gas environment
• Vapor
• Gas condition of solid or liquid substances in
  normal
• Fume
• Solid particles aerosol lt 0,1 ?m
• Duman
• Volatile gas or particles formed by burning

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Inhalation of Toxic Substance
inhalation of toxic substance
pathologic changes developing with in seconds
chronic pulmonary disease
systemic disease
sudden respiratory distress
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Factors Affecting Toxicity

• Particles diameter
• Solubility in water
• Consantration
• Exposure time
• Ventilation
• Personal characteristics
• Age, cigarette, comorbid disease, prevention,
  genetic predisposition

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Most Important Factors
solubility in water
particles diameter
region of damage heavy of damage
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Characteristics of Solubilitiy in Water
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High Solubility in Water
sudden onset of symptoms
environment away from or exposition source of
deactivation
excitement of irritant receptors
bronchospasm
prevention of distal transition of toxic
substance
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Low Solubility in Water
no irritation
not removed from the environment no bronchospasm
prolonged exposure time
increased exposure amount
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Particles Diameter
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Localization Damages

• Upper airways
• Acute
• Chronic?
• Conducting airways
• Acute
• Chronic (RADS, Vocal cord dysfunction)
• Distal airways - parenchymal
• Acute
• Chronic (BO, BOOP)

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Upper Airways

• Sudden and short-term toxic effect
• Typical symptoms
• Burning in throat
• Sticky mucus
• Cough and sneeze
• Extrapulmonary symptoms
• Burning eyes
• Headache and dizziness

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Upper Airways

• 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

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Conducting Airways

• 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

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Conducting Airways

• Chronic damage
• Vocal Cord Dysfunction
• Reaktif Airway Dysfunction Syndrome (RADS)

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Distal Airways - 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

Slight dyspnea Cough
ARDS
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Distal Airways - Parenchymal

• Chronic damage
• BO (Bronchiolitis obliterans)
• BOOP (Bronchiolitis obliterans organized
  pneumonia)

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Mesleksel Hastalik
1. SKIN
Variant
2. RESPIRATORY SYSTEM

• Industrial bronchitis
• Asthma-like syndrome

1. Airway disease
AHR
2. Parenchymal disease
Persistent

• Work related asthma

3. Pleural disease
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Work Related Asthma
WORK RELATED ASTHMA
Work Exacerbated Asthma
Occupational Asthma
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Occupational Asthma
High Molecular Weight
Immunological (IgE)
Low Molecular Weight
Non-immunological
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Non-immunological

• Irritants Irritant induced asthma
• Multiple exposure
• Single exposure (RADS)
• Organic dusts and microbial agents
  Asthma-like syndrome

Mapp CE, et al. Occupational Asthma AJRCCM 2005
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Work Related Asthma
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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
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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
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• 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
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• 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
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Reactive Airways Dysfuntion Syndrome

• 10 clinical case
• Önceden solunum sistemi semptomu olmayan
• Yüksek düzeyde kimyasal iritana maruziyet sonrasi
  dakikalar-saatler içerisinde solunumsal
  semptomlar
• Persistan astim (gt1yil) öksürük, vizing, dispne,
  FEV1de ?, havayolu asiri duyarliligi
• Biyopside nonspesifik havayolu inflamasyonu
• Re-maruziyet yok

Brooks SM, et al. Reactive airways dysfunction
syndrome (RADS). Chest 1985
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Reactive Airways Dysfuntion Syndrome

• Acute inhalational damage
• after
• new onset
• asthma

Brooks SM, et al. Reactive airways dysfunction
syndrome (RADS). Chest 1985
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RADS-Pathophysiology
Epithelial Damage
Inflammation
AHR
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Inflammation Remodelling
Acut Period
Chronic Period
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RADS Criteria for Diagnosis

1. Absence of preceeding respiratory complaints
2. The oncet of symptoms occured after a single
   spesific exposure
3. The exposure was to a gas, smoke, fume which was
   present in very high concentrations
4. The onset of symptoms occurred within 24 hours
5. Symptoms persisted for at least 3 months
6. Symptoms simulated asthma (cough, wheezing,
   dyspnea)
7. Pulmonary function tests may show airflow
   obstruction
8. Positive Methacholine/histamine challenge testing
9. Other types of pulmonary diseases were ruled out

Brooks SM, et al. Reactive airways dysfunction
syndrome (RADS). Chest 1985 Nemery B, Leuven
2009
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Substances that can make RADS
Acetic acid Diesel fuel Spray paint
Sulfuric acid Diethilaminethanol Sulfur dioxide
Chloridric acid Epichlorohydrine Gas (chlorine, mustard, phosgene)
Heated acid Ethylene oxide Fire smoke
Ammonia Isocyanates Grouting
Laundry bleach Metal cleaners Formalin
Chlorine Oxyde Spray Cleaner
Chloropicrine Heated paint Hydrazine
Cleaning supplies Phthalic anhydride
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• 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
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Bleach Hydrochloric Acid Mixture
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Gorguner M, et al. Inhal Toxicol 2004
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Gorguner M, et al. Inhal Toxicol 2004
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• A lower age, higher initial PEFR, higher initial
  paO2,
• Exposure in the kitchen or bathroom,
• Exposure after waiting 1015 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
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Treatment

• Prevention is more important
• Treated like asthma when sypmtoms develop
• Steroid therapy in early stage can prevent RADS
  do ?
• Nebulized Sodium-Bicarbonate treatment

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Nebulize Sodyum Bikarbonat
Kandis H, et al. Inhalation Toxicology 2006
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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)

Kandis H, et al. Inhalation Toxicology 2006
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(No Transcript)
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• In NSB group
• NSB group had significantly higher FEV1 values
  (plt0,05)
• Significantly more improvement in QoL
  questionnaire scores occurred in the NSB group
  (plt0,01)

Kandis H, et al. Inhalation Toxicology 2006
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Thank you for your attention