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Cleaning ( Acute Inhalational Injury RADS )

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 ( Acute Inhalational Injury RADS )

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  1. Cleaning(AcuteInhalationalInjury RADS) Prof. Metin Gorguner Atatürk University Medical Faculty Department of Pulmonary Diseases gorguner@atauni.edu.tr

  2. Terminology* • Cleaning • Cleaning Worker • Cleanliness • Clean * T.L.F. Dictionary

  3. CleaningIndustry

  4. Cleaning Agents and Other Household Products

  5. InhaledToxicSubstances • Gas • Aerosol • Stablesuspendedsolidorliquidparticleswith in gasenvironment • Vapor • Gascondition of solidorliquidsubstances in normal • Fume • Solidparticlesaerosol < 0,1 m • Duman • Volatilegasorparticlesformedbyburning

  6. Inhalation of ToxicSubstance inhalation of toxicsubstance pathologicchangesdevelopingwith in seconds systemicdisease chronicpulmonarydisease suddenrespiratorydistress

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

  8. MostImportantFactors solubility in water particlesdiameter region of damage – heavy of damage

  9. Characteristics of Solubilitiy in Water

  10. HighSolubility in Water suddenonset of symptoms environmentawayfromorexpositionsource of deactivation excitement of irritantreceptors bronchospasm prevention of distaltransition of toxicsubstance

  11. LowSolubility in Water no irritation not removedfromtheenvironment no bronchospasm prolongedexposure time increasedexposureamount

  12. ParticlesDiameter

  13. Localization – Damages • Upper airways • Acute • Chronic • Conducting airways • Acute • Chronic (RADS, Vocal cord dysfunction) • Distal airways - parenchymal • Acute • Chronic (BO, BOOP)

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

  15. 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

  16. 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

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

  18. 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

  19. DistalAirways - Parenchymal • Chronicdamage • BO (Bronchiolitisobliterans) • BOOP (Bronchiolitisobliteransorganizedpneumonia)

  20. Mesleksel Hastalık 1. SKIN Variant 2. RESPIRATORY SYSTEM • Industrialbronchitis • Asthma-likesyndrome 1. Airwaydisease AHR 2. Parenchymaldisease Persistent • Workrelatedasthma 3. Pleuraldisease

  21. WorkRelatedAsthma WORK RELATED ASTHMA WorkExacerbatedAsthma OccupationalAsthma

  22. OccupationalAsthma HighMolecularWeight Immunological (IgE) LowMolecularWeight Non-immunological

  23. 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

  24. WorkRelatedAsthma

  25. 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

  26. 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

  27. 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

  28. 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

  29. 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

  30. Reactive Airways Dysfuntion Syndrome • Acute inhalational damage • after • new onset • asthma Brooks SM, et al. Reactive airways dysfunction syndrome (RADS). Chest 1985

  31. RADS-Pathophysiology EpithelialDamage Inflammation AHR

  32. Inflammation – Remodelling AcutPeriod ChronicPeriod

  33. 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

  34. Substancesthat can make RADS

  35. 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

  36. Bleach – Hydrochloric Acid Mixture

  37. Gorguner M, et al. Inhal Toxicol 2004

  38. Gorguner M, et al. Inhal Toxicol 2004

  39. 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

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

  41. Nebulize Sodyum – Bikarbonat Kandiş H, et al. Inhalation Toxicology 2006

  42. 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

  43. 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

  44. Thank you for your attention…

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