Upper Respiratory Tract disorder in occupational setting - PowerPoint PPT Presentation

Loading...

PPT – Upper Respiratory Tract disorder in occupational setting PowerPoint presentation | free to download - id: 6ad336-OWI1M



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Upper Respiratory Tract disorder in occupational setting

Description:

Upper Respiratory Tract disorder in occupational setting Causes of Rhinitis Allergy NARES syndrome Occupational Hormonal Drug induced Anatomic defects Irritants ... – PowerPoint PPT presentation

Number of Views:15
Avg rating:3.0/5.0
Date added: 9 September 2019
Slides: 78
Provided by: mehdi
Learn more at: http://www.ssu.ac.ir
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Upper Respiratory Tract disorder in occupational setting


1
Upper Respiratory Tract disorder in occupational
setting
2
Causes of Rhinitis
  • Irritants
  • Adverse food reaction
  • Emotional
  • Atrophic
  • Ciliary dyskinesia
  • Immunodeficiency diseases
  • Allergy
  • NARES syndrome
  • Occupational
  • Hormonal
  • Drug induced
  • Anatomic defects

3
Evaluation of Rhinitis
  • History and physical
  • Sinus transillumination
  • Direct visualization with nasal specula
  • Rhinoscopy
  • Nasal smear
  • Allergy screening tests (skin tests or RAST)
  • Imaging for persistent disease

4
What Do You Need to Know in Addition to Symptoms?
  • Age at onset
  • Are sx acute, chronic, recurrent, seasonal or
    perennial?
  • What causes the symptoms?
  • What is the response to antihistamines?
  • Does patient have any pets Any associated
    illnesses (asthma, skin rash, otitis media)?
  • Is there a family history of allergy?

5
Allergic Patients Generally Have
  • Early onset of symptoms (70 lt age 20)
  • Family history of allergy
  • Seasonal symptoms
  • Symptoms with animal exposure
  • Symptoms worse outdoors
  • Symptoms worse near fresh-cut grass
  • Symptoms better in air conditioning
  • Tobacco and chemicals are not primary excitants
  • Previous immunotherapy was helpful

6
Nonallergic Patients Generally Have
  • Later onset of symptoms (70 gt age of 20)
  • No family history of allergy
  • Tobacco smoke and chemicals primary excitants
  • Weather changes provoke symptoms
  • No seasonal aspect to symptoms
  • No symptoms with exposure to dust
  • No symptoms with exposure to animals

7
Symptoms of Allergic Rhinitis
  • Sneezing
  • Nasal congestion
  • Watery nasal discharge
  • Itchy watery eyes
  • Postnasal drip
  • Itching

8
Physical Changes of Allergic Rhinitis
  • Pale blue, edematous turbinates
  • Clear, watery nasal discharge
  • Crease from nasal salute
  • Lymphoid hyperplasia
  • Watery, itchy eyes

9
(No Transcript)
10
Allergic Rhinitis and Concomitant Disease
  • Management of allergic rhinitis may decrease
    exacerbations of sinusitis, asthma and otitis
    media
  • Early immunotherapy for allergic rhinitis has
    been shown to decrease the development of asthma

11
Physical Examination
  • Eyes conjunctivitis, dark circles, Dennies
    lines
  • Ears OM, TM mobility, serous otitis
  • Mouth mouth breathing
  • Lungs wheezing

12
Nasal Smear
  • Clear nose of secretions
  • Gently scrape sample from mucosa of inferior or
    middle turbinate with plastic ear spatula or
    cotton swab
  • Wrights or Hansels stain
  • Eosinophilia
  • Allergy (present in 90 of allergic patients)
  • NARES syndrome
  • Aspirin sensitivity
  • Neutrophilia
  • Infection

13
Sinus X-rays and CT Scans
  • Sinus x-rays
  • Not needed for diagnosis of acute rhinosinusitis
  • Waters view for the maxillary sinuses
  • Towns view for ethmoid and frontal sinuses
  • Lateral view for the sphenoid
  • Limited coronal CT scan
  • Osteomeatal complex
  • All sinuses visualized
  • CT scan gives much better imaging for minimal
    increased cost

14
Rhinoscopy
  • Nasal polyps
  • Septal deviation
  • Concha bullosa
  • Eustachian tube dysfunction
  • Causes of hoarseness
  • Adenoid tissue
  • Tumors

15
Treatment of Allergic Rhinitis
  • Avoidance of identified allergens
  • Nasal steroids
  • Antihistamine nasal spray
  • Antihistamines (sedating and nonsedating)
  • Decongestants
  • Nasal sprays (limited 2-3 days)
  • Oral preferred (limited by side effects)
  • Nasal irrigation
  • Leukotrienes

16
General Treatment Modalities
  • Vigorous exercise
  • Posture
  • Avoidance procedures
  • Saline irrigation

17
Nasal Irrigation
  • Commercial buffered sprays
  • Bulb syringe
  • 1/4 tsp of salt to 7 ounces water
  • Waterpik with lavage tip
  • 1 tsp salt to reservoir
  • Disposable enema bucket
  • 2 tsp salt, 1 tsp soda per quart of water

18
Treatment of Mild Allergic Rhinitis Step 1
  • Occasional exposure/symptoms
  • Environmental control
  • Saline irrigation
  • Monotherapy
  • Nasal steroid or
  • Nonsedating antihistamine or
  • Astelazine nasal spray

19
Treatment of Moderate Allergic Rhinitis Step 2
  • May Last for Months to One Year
  • Environmental control
  • Normal saline irrigation
  • Combination therapy
  • Nasal steroid and
  • Nonsedating antihistamine with or without
    decongestant or
  • Astelazine
  • Immunotherapy

20
Treatment of Severe Allergic Rhinitis step 3
  • Chronic, persistent associated with Sinusitis,
    Otitis media , asthma
  • Environmental control
  • Normal saline irrigation
  • NSA/- decongestant
  • High-dose nasal steroid
  • Afrin 3 days or fewer
  • Oral steroid
  • Immunotherapy

21
Environmental Control/Avoidance
  • Dust mites
  • Controls plastic covers, frequent vacuuming of
    carpet
  • Avoid overstuffed chairs, curtains, stuffed
    animals, dust-collecting boxes under bed
  • Cockroaches
  • Poisoning

22
Environmental Control
  • Air conditioning
  • Frequent dusting, cleaning surfaces
  • Air filters
  • Hepa filtration
  • Vacuum cleaners
  • Dry versus water filtration
  • Ionizers
  • Wood burning stoves

23
Pharmacotherapy
  • Allergic rhinitis
  • Antihistamines
  • OTC
  • Nonsedating
  • Nasal steroids
  • Nasal cromolyn
  • Astelazine nasal spray
  • Decongestants
  • Nonallergic rhinitis
  • Antihistamines
  • Drying effect
  • Decongestants
  • Astelazine
  • Ipatropium
  • Nasal steroids
  • NARES syndrome

24
Nasal Steroids
  • Flonase
  • Beconase
  • Nasonex
  • Nasacort
  • Rhinocort
  • Vancenase
  • Tri-Nasal

25
Nonsteroid Nasal Sprays
  • Astelazine
  • Atrovent
  • Nasalcrom
  • Saline

26
Nonallergic Rhinitis
  • As important as allergic rhinitis
  • Present in 57 of patients with rhinitis

27
Nonallergic/Vasomotor Rhinitis
  • Perennial or episodic symptoms
  • Chronic, nonpruritic rhinorrhea/congestion
  • Negative nasal eosinophils
  • Negative allergy screening
  • Nonallergic excitants
  • Viruses
  • Chemicals, tobacco smoke, potpourri
  • Nonallergic foods
  • Weather changes

28
Symptoms of Nonallergic Rhinitis
  • Nasal congestion is prominent
  • Sneezing and nasal itching uncommon
  • Concomitant asthma is less likely
  • Eye symptoms are fewer
  • Postnasal drip
  • Fatigue
  • Loss of sense of smell and taste

29
Tests Helpful in Diagnosing Nonallergic Rhinitis
  • Nasal smear will be void of eosinophils
  • Eosinophils present in 90 of allergic rhinitis
  • Neutrophils suggest bacterial infection
  • Skin prick tests or in-vitro testing negative
  • Negative allergy testing is the best predictor of
    the nonallergic state

30
Treatment of Nonallergic Rhinitis
  • Astelazine nasal spray
  • Steroid nasal spray
  • Nasal irrigation
  • Avoidance
  • Effectiveness of antihistamines questionable

31
Rhinitis Case Study
  • 23-year-old has had nasal congestion for the past
    23 months. Started as a cold, but symptoms never
    cleared. Allergies several times a year as a
    child but outgrew them. Never tested. No family
    hx of allergy. Cant sleep without his
    medication.
  • Is he allergic?
  • What is your next question?

32
Rhinitis Case Study
  • What medication are you using?
  • Answer Afrin, I cant breath or sleep without
    it.

33
Rhinitis Medicamentosa
  • Rebound congestion from overuse of topical
    decongestants oxymetazolone, phenylephrine,
    cocaine
  • Erythematous mucosa, congestion, punctate
    bleeding
  • Interstitial edema and vasoconstriction
  • Withdrawal of medication, topical steroids, oral
    steroids

34
Treatment of Rhinitis Medicamentosa
  • Initiate topical steroid bilaterally, discontinue
    decongestant in one nostril, then the second
    nostril one week later
  • One-week dose of tapering steroids
  • Evaluate for the underlying cause of the rhinitis

35
Hormonal Causes of Rhinitis
  • Pregnancy
  • Second month to term
  • Puberty
  • Oral contraceptives
  • Hypothyroid state

36
Rhinitis of Pregnancy
  • Mild symptoms may have been present before
    (pregnancy aggravated symptoms)
  • Increase in circulating blood volume
  • Progesterone induced smooth muscle relaxation
  • Hormonal effect on nasal mucosa

37
Treatment of Rhinitis in Pregnancy
  • Caution with medication usage
  • Nasal saline sprays, steam inhalation
  • Avoidance of known triggers
  • Topical medical therapy rather than systemic when
    possible
  • Oral pseudoephedrine
  • Chlorpheniramine

38
Rhinitis Case Study
  • 28-year-old with a two-year history of profuse
    rhinorrhea. No history of rhinitis or asthma as
    child. Occasional sneezing, little congestion.
  • Clear nasal discharge on exam, pharynx, tympanic
    membrane, lungs all normal.
  • Skin test is negative with good positive control.
  • What in-office test will make the diagnosis
    clear?
  • Nasal smear
  • revealed marked eosinophilia
  • Diagnosis NARES syndrome nonallergic rhinitis
    with eosinophilia

39
NARES Syndrome
  • Perennial symptoms
  • Sneezing
  • Rhinorrhea
  • Pruritis
  • Occasional loss of smell
  • Nasal smear positive for eosinophils
  • Allergy screen is negative

40
Nasal Mastocytosis is Rare
  • Basophilic metachromic nasal disease
  • Histologic diagnosis
  • Mast cell infiltration of the mucosa
  • No eosinophils

41
Atrophic Rhinitis (Ozena)
  • Found in patients who have had radical nasal
    tissue removal for congestion
  • Removal of inferior and or middle turbinates
  • Empty nose syndrome
  • Excessive drying, crusting and infection
  • Atrophic changes in the elderly
  • Klebsiella colonization

42
Treatment of Atrophic Rhinitis
  • Nasal irrigation 3-4 times per day for 2-3
    months, then 1-2 times per day indefinitely

43
Rhinitis Case Study
  • 45-year-old female with no history of previous
    symptoms of rhinosinusitis presents with
    headaches, daily nasal congestion and fatigue for
    3-4 months. No hx of viral URI. No family hx of
    allergy. No changes in cosmetics, no additions
    to house, no new clothes. No pets. No food
    reactions known.
  • What other element of a thorough history might
    give you a clue as to diagnosis?

44
Rhinitis Case Study
  • Where do you work?
  • How long have you worked there?
  • Do your symptoms coincide with changing jobs?
  • Are you more symptomatic at work than at home?
  • Do your symptoms clear on the weekend or on
    vacation?

45
Occupational Rhinitis
  • Patients experience symptoms in workplace
  • Symptoms improve on weekends/vacation
  • May be allergic or nonallergic
  • May coexist with occupational asthma
  • Treatment is avoidance
  • Move to another area in the workplace
  • Move to another job

46
Causes of Occupational Rhinitis
  • Sick building syndrome
  • Department of Ecology and Environmental
    Protection
  • Gasses from office machines
  • Inks, paper
  • Perfumes
  • Paints, carpet, carpet glue
  • Laboratory animals

47
Common Workplaces for Occupational Rhinitis
  • Beauty salons
  • Clothing stores
  • Supermarkets
  • Auto body spraying
  • Service stations
  • Woodworking
  • Pesticide industry
  • Plastic manufacturing
  • Tanneries
  • Paper industry
  • Gardening products
  • Insecticides
  • Food industry
  • Laboratory animals
  • Office machinery
  • Paints, chemicals

48
Common Chemical Exposures Causing Rhinitis
  • Gasoline/diesel fuels
  • Chlorine
  • Perfumes
  • Cleaning agents
  • Room deodorizers
  • Hair dyes
  • Permanent solutions
  • Paints
  • Auto body paints
  • Herbicides
  • Potpourri
  • Burning candles
  • Petroleum products
  • Formaldehyde
  • New clothing odor
  • Hair spray
  • Toluene
  • Ammonia
  • Acids

49
Mechanical Causes of Rhinitis
  • Meningocoele
  • Adenoid hypertrophy
  • Variants of the osteomeatal complex
  • Concha bullosa
  • Deviated nasal septum
  • Nasal polyps
  • Foreign body
  • Tumors of the nose
  • Congenital atresia

50
Gustatory Rhinitis
  • Rhinorrhea and/or nasal congestion related to
    eating
  • Treatment is identification and elimination
  • Common causes of gustatory rhinitis
  • Cheeses
  • Spicy foods
  • Wines

51
Food Reactions
  • Diagnosed by skin prick tests, RAST or
    elimination diet
  • Skin prick tests, in-vitro testing will only
    diagnose IgE-related foods
  • Elimination diet will diagnose all types adverse
    food reactions

52
Vasculitides, Autoimmune and Granulomatous Causes
  • Churg-Strauss Syndrome vasculitis
  • Systemic lupus erythematosis
  • Relapsing polychondritis
  • Sjogrens syndrome
  • Sarcoidosis
  • Wegeners granulomatosis

53
Nasal Polyps
  • Grape-like clusters
  • Maxillary sinus
  • Inflammatory process
  • One third associated with asthma
  • Asthma-aspirin-polyp triad
  • High rate of recurrence

54
Treatment of Nasal Polyps
  • Allergy control
  • Intranasal steroids
  • Systemic steroids
  • Avoidance of ASA, NSAIDs
  • Polypectomy
  • Ethmoidectomy

55
Importance of Allergy Testing
  • Distinguishes between allergic, nonallergic and
    mixed rhinitis
  • Aids in selecting specific pharmacotherapy
  • Identifies specific allergens to be avoided
    and/or treated by immunotherapy when indicated

56
Indications for Allergy Testing
  • Identification of allergens
  • Chronic or recurrent symptoms
  • Symptoms not controlled by avoidance and
    medication
  • Medication not tolerated
  • Decrease cost of medication

57
Contraindications for Allergy Skin Testing
  • Uncontrolled asthma or recent asthma attack
  • PEFR must be above 70 personal best effort
  • Cardiac problems
  • History of hymenoptera sensitivity
  • History of anaphylaxis of any kind
  • Shellfish
  • Medications

58
Refer to an Allergist
  • Hymenoptera sensitivities
  • Antibiotic desensitization
  • Anesthetic testing
  • Patients with history of anaphylaxis
  • Medication
  • Shellfish
  • Peanut or other food reactions

59
Instruments Used in Allergy Testing
  • Invivo tests
  • Individual skin prick tests
  • DuoTip
  • Morrow Brown needle
  • GreerPick
  • Multiple antigen applicators
  • MultiTest
  • Quintest
  • Invitro tests
  • Modified in-vitro testing
  • CAP system

60
Skin Testing Disadvantages
  • Affected by medications
  • Antihistamines
  • Steroids
  • Patient discomfort
  • Rare possibility of anaphylaxis
  • Dermagraphism
  • Chronic skin disorders
  • Very young and atrophic skin

61
Puncture/Prick Testing
Figure 1
  • Disease-free site
  • Swipe with alcohol
  • Apply drop of antigen (110 or 120 conc.)
  • Prick skin at 45 to 60 degree angle, or puncture
    at 90 degrees
  • Gently lift device, no bleeding should occur
  • Read positive control in 10 minutes
  • Read allergens in 15-20 minutes

Example of a skin prick/puncture epicutaneous
test
62
Multiple Antigen Testing
  • Alcohol wipe and dry area to be used
  • Remove device from package
  • Place in loading dock
  • Apply to forearm
  • Read positive control in 10 minutes
  • Record allergen response in 15-20 minutes

63
Multiple Antigen Testing contd
Figure 2
Figure 3
Example of multiple-puncture device in its
loading dock
Example of multiple-puncture device allowing
simultaneous placement of six allergens plus a
positive and negative control
64
Multiple Antigen Testing contd
Figure 4
Figure 5
Example of positive and negative skin responses
to allergens applied with a multiple-puncture
device note the positive and negative control
sites
Example of application of a multiple-puncture
device to the forearm
65
Skin Testing Precautions
  • Physician always present
  • Emergency equipment available and current
  • Adrenalin and albuterol in testing room
  • Determine patients most recent use of
    antihistamines, steroids, H2 blockers
  • Is patient on a beta blocker?
  • Switch medications or in vitro testing

66
Grading of MultiTest
  • 0 No reaction-1-3 mm wheal
  • 1 Erythema with 3mm wheal
  • 2 Erythema with 5 mm wheal
  • 3 Erythema with 7-10 mm wheal
  • 4 Erythema with gt10 mm wheal
  • 5 Erythema with gt10 mm wheal and pseudopods

67
Reading and Recording Results
  • Best done by physician scoring and nurse
    recording
  • If reaction is borderline, read as the higher
    class
  • Example
  • Difficulty determining if result is 3 or 4
    record as 4

68
Positive and Negative Controls
  • Imperative to use to validate skin response
  • Positive negative control dermagraphism
  • Negative positive control medication reaction
    or hypoactive skin

69
Indications for In-Vitro Testing
  • Dermatographism
  • Eczema
  • Very young skin
  • Atrophic skin
  • Long-acting antihistamines
  • Beta blockers, ACE inhibitors, MAOs
  • Patients with poorly controlled asthma (70)
  • History of anaphylaxis

70
RAST Procedure
  • Allergen coupled to paper disc
  • Add patients serum
  • Antigen-antibody complex formed
  • Radioactive anti IgE added
  • Anti IgE-antibody-allergen complex formed
  • Gamma counter scoring

71
RAST Scoring
  • Class 0 200-500 No allergy
  • Class 0/1 500-750 Questionable allergy
  • Class 1 750-1,600 Mild allergy
  • Class 2 1,600-3,600 Moderate allergy
  • Class 3 3,600-8,000 More allergic
  • Class 4 8,000-18,000 More allergic
  • Class 5 Over 18,000 Most allergic

72
Advantages of In-Vitro
  • Patient safety, no anaphylaxis
  • Cost-effective screening
  • Not affected by medication
  • No irritating skin reactions
  • Sets safe starting doses for immunotherapy

73
Disadvantages of In-Vitro
  • Patient does not experience the reaction
  • Less sensitive than skin tests (?)
  • Cost per test may be higher
  • RAST requires 3-14 days to get results

74
RAST Scoring as a Guide to Immunotherapy
  • The higher the RAST class the more dilute the
    starting dose of immunotherapy
  • The lower the RAST class the higher the starting
    dose of immunotherapy

75
Prescribing Immunotherapy Based on RAST Results
  • Blood sample is drawn anytime
  • Serum is removed
  • Sent to lab and processed
  • Results correlated with history
  • Prescription for immunotherapy written
  • Lab makes up immunotherapy sets

76
Indications for Immunotherapy
  • Inadequate control with avoidance and
    pharmacotherapy
  • Pharmacotherapy for more than 3-4 months per year
  • Intolerable side effects of medication
  • Progressive severity of disease
  • Desire for long-lasting control without Rx

77
Evidence-Based Recommendations
  • Practice Recommendation Treat patients diagnosed
    as having allergic seasonal rhinitis with
    prophylactic medications (antihistamines and/or
    intranasal corticosteroids).
  • Practice Recommendation Prescribe intranasal
    corticosteroids to control allergic rhinitis
    symptoms.
  • Practice Recommendation Educate patients with
    allergic rhinitis about avoidance activities.
  • Practice Recommendation Reserve immunotherapy
    for patients with allergic rhinitis for whom
    optimal avoidance measures and medication therapy
    are insufficient to control symptoms.
About PowerShow.com