RESUMO
This document replaces the DGP recommendations published in 1998 and 2013. Based on recent studies and a consensus conference, the indications, choice and performance of the adequate exercise testing method and its necessary technical and staffing setting are discussed. Detailed recommendations are provided: for blood gas analysis and right heart catheterization during exercise, walk tests, spiroergometry, and stress echocardiography. The correct use of different exercise tests is discussed for specific situations in respiratory medicine: exercise induced asthma, obesity, monitoring of rehabilitation or therapeutical interventions, preoperative risk stratification, and evaluation in occupational medicine.
Assuntos
Teste de Esforço/normas , Guias de Prática Clínica como Assunto , Pneumologia/normas , Testes de Função Respiratória/normas , Espirometria/normas , Alemanha , Humanos , Medicina do TrabalhoRESUMO
In Germany, bakers with occupational asthma willing to stay in their job are included in an interdisciplinary program of the Social Accident Insurance for Foodstuff and Catering Industry (BGN). The primary aim is to reduce flour dust exposure, and to provide adequate medical treatment. Our aim was to evaluate the program's effect on the disease's course using routinely collected data. Forty three bakers with allergic occupational asthma and with the available baseline level of IgE (f4, f5) were investigated. Changes in IgE related to wheat and rye flour exposure were measured by ImmunoCAP test during follow-up visits. A questionnaire on work-related allergic complaints (WRAC), the Asthma Control Test (ACT), a 10-point scale of asthma severity grade, and quality of life instruments (EQ-5D-5L, Mini-AQLQ) were administered. We found an improvement of asthma severity in 88.4 % of the bakers. WRAC were reported by 65 %; 77 % had good asthma control (ACT ≥ 20); and 81 % had regular asthma medication. A relevant reduction of ≥2 CAP-classes for both allergens was seen in 12 % of the subjects. Health-related and asthma-specific quality of life was high. We conclude that satisfactory asthma control is probably the result of adequate medical management. In a subgroup of bakers with decreased specific IgE, it may also be attributed to reduced allergen exposure.
Assuntos
Alérgenos/efeitos adversos , Asma Ocupacional/etiologia , Hipersensibilidade/etiologia , Imunoglobulina E/imunologia , Exposição Ocupacional/efeitos adversos , Qualidade de Vida , Índice de Gravidade de Doença , Asma Ocupacional/patologia , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
Pulmonary fibrosis leads to a decrease of oxygen diffusion, in particular during exercise. Bronchial obstruction also could decrease the partial pressure of oxygen (P(a)O(2)). In this study we investigated the validity of blood gas content, especially P(a)O(2) and P(a)O(2) affected by hyperventilation (P(a)O(2corr)) and alveolo-arterial oxygen gradient (P(A-a)O(2)) in comparison with the CO diffusion capacity (DLCO) in different lung diseases. A total of 250 subjects were studied (52.3 ± 12.5 year; F/M 40/210), among which there were 162 subjects with different lung disorders and 88 healthy controls. Pearson's correlation coefficients (r) of DLCO with P(a)O(2), P(a)O(2corr), and PA-aO(2) were analyzed in each group. The results show that the diagnostic power of P(A-a)O(2) against P(a)O(2corr) was equivalent, especially during exercise (r = -0.89 and -0.92, respectively). DLCO showed only weak correlations with P(a)O(2corr) and P(A-a)O(2) (r = 0.17 and -0.19, respectively). In conclusion, DLCO shows a better match with blood gas content during exercise than at rest during which it is routinely tested. Thus, the exercise test is advisable. The P(A-a)O(2) takes into account the level of ventilation, which makes it correlate better with DLCO rather than with blood gas content. The most significant problems in clinical evaluation of blood gas parameters during exercise are the insufficiently defined limits of normal-to-pathological range.
Assuntos
Pulmão/efeitos dos fármacos , Capacidade de Difusão Pulmonar/efeitos dos fármacos , Estudos de Coortes , Exercício Físico , Feminino , Humanos , Pneumopatias/metabolismo , Pneumopatias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Doenças Profissionais/fisiopatologia , Consumo de Oxigênio/efeitos dos fármacos , Troca Gasosa Pulmonar , Testes de Função Respiratória , DescansoRESUMO
Standard exercise testing (ET) comprises progressive exercise provocation with cardiovascular monitoring. Exercise tolerance is estimated by workload. Cardiopulmonary exercise testing (CPX) is a non-invasive measurement of ventilatory gas exchange which provides more accurate quantifications of cardiorespiratory fitness (CRF). Workload is usually increased stepwise in ET and continuously (ramp) in CPX. Our aim was to examine the comparability of the results. Thirty two healthy volunteers (17 females/15 males, age 26.8±6.1 years, BMI 24.5±3.0) underwent exercise testing on a bicycle ergometer up to maximum physical exhaustion; under ramp protocol (CPX) and 2-7 days later with a stepwise increase of workload (ET). We compared the physical work capacity under both methods at maximum workload, at heart rate of 150 and 170 beats/min (PWC150 and PWC170), and the exercise duration. We found that there were no statistically significant differences in the maximum heart rate (CPX: 177.1±11.7/min vs. ET: 178.5±11.2/min) or maximal workload (CPX: 219.8±50.6 vs. ET: 209.4±42.5). PWC150 and PWC150/kg were higher with CPX than those with ET (156.6±51 vs. 146.4±42.3, p<0.001 and 2.1±0.5 vs. 1.9±0.4, respectively, p<0.001). Exercise duration was almost equal (12.1 vs. 11.3 min). We conclude that overall physical performance was higher with CPX. Since the results are similar, we recommend the CPX: wattage and other parameters in performance assessment are to be determined directly, interpolations are obsolete.
Assuntos
Limiar Anaeróbio/fisiologia , Teste de Esforço/métodos , Teste de Esforço/normas , Tolerância ao Exercício/fisiologia , Exercício Físico/fisiologia , Adulto , Feminino , Humanos , Masculino , Consumo de Oxigênio/fisiologia , Resistência Física/fisiologia , Aptidão Física/fisiologia , Fatores Sexuais , Suporte de Carga/fisiologia , Adulto JovemRESUMO
Malignant mesothelioma of the pleura represents a signal tumour for (occupational) exposure to asbestos. Almost 20 years after the ban of asbestos in Germany, incident cases are still occurring due to the long latency period between the initial exposure to asbestos and the onset of the tumour. Of particular interest is the development of mesothelioma epidemiology. In Germany, it is extensively discussed whether the incidence of malignant pleura mesothelioma continues to rise, has already reached a plateau or is expected to decline in the next few years. The development is predominantly caused by the total asbestos use, its application and the gradual substitution of asbestos. The prevention of asbestos-related diseases due to former exposures, but also due to existing asbestos contaminations and their restoration is still a hot topic in occupational medicine. It is thus of major importance to ensure an adequate occupational safety and to care for asbestos-exposed workers - even after cessation of their exposure - with effective and efficient measures of early detection. New technologies, such as nanotechnology with carbon nanotubes, represent new potential health hazards.
Assuntos
Asbestose/mortalidade , Monitoramento Ambiental/estatística & dados numéricos , Mesotelioma/mortalidade , Exposição Ocupacional/prevenção & controle , Exposição Ocupacional/estatística & dados numéricos , Neoplasias Pleurais/mortalidade , Asbestose/prevenção & controle , Causalidade , Comorbidade , Diagnóstico Precoce , Monitoramento Ambiental/métodos , Alemanha/epidemiologia , Humanos , Incidência , Mesotelioma/prevenção & controle , Neoplasias Pleurais/prevenção & controle , Fatores de Risco , Análise de Sobrevida , Taxa de SobrevidaRESUMO
This document replaces the DGP recommendations published in 1998. Based on recent studies and a consensus conference, the indications, choice and performance of the adequate exercise testing method in its necessary technical and staffing setting are discussed. Detailed recommendations are provided: for arterial blood gas analysis and right heart catherterization during exercise, 6-minute walk test, spiroergometry, and stress echocardiography. The correct use of different exercise tests is discussed for specific situations in respiratory medicine: exercise induced asthma, monitoring of physical training or therapeutical interventions, preoperative risk stratification, and evaluation in occupational medicine.
Assuntos
Teste de Esforço/normas , Testes de Função Cardíaca/normas , Guias de Prática Clínica como Assunto , Pneumologia/normas , Testes de Função Respiratória/normas , Espirometria/normas , AlemanhaRESUMO
Medical expert opinion by occupational physicians and pneumologists has two main objectives: making a diagnosis with probability bordering on certainty and clarifying a causal relationship to a present or former occupational exposure to irritant toxic, allergenic or fibrosing dusts, gases, welding fumes or mineral fibres. Especially for conditions that are associated with exertional dyspnea, the diagnosis at rest using spirometry, body plethysmography, pulmonary function test, blood gas analysis, electrocardiogram and echocardiography is of limited use. This paper identifies the indications for cardiopulmonary exercise testing (CPET) in occupational medicine, explains the related measurements and their differential diagnostic value with special consideration of the flow-volume curve under exercise as well as the alveolar-arterial oxygen gradient. Diagnostic statements on the relevance of oxygen uptake measured at continuous and peak load compared to the wattage ascertained on the bicycle ergometer are presented. Characteristic CPET findings are explained in terms of their differential diagnostic significance. Furthermore, the importance of CPET for the assessment of occupational disease-related functional loss (clinical proportions in the reduction of working capacity) is shown.
Assuntos
Doenças Cardiovasculares/diagnóstico , Pneumopatias/diagnóstico , Doenças Profissionais/diagnóstico , Medicina do Trabalho/tendências , Aptidão Física , Alemanha , HumanosAssuntos
Asma/diagnóstico , Poeira , Farinha/efeitos adversos , Doenças Profissionais/diagnóstico , Doenças Profissionais/etiologia , Hipersensibilidade Respiratória/diagnóstico , Hipersensibilidade Respiratória/etiologia , Poluentes Ocupacionais do Ar , Obstrução das Vias Respiratórias/diagnóstico , Obstrução das Vias Respiratórias/etiologia , Obstrução das Vias Respiratórias/prevenção & controle , Obstrução das Vias Respiratórias/terapia , Asma/prevenção & controle , Asma/terapia , Hiper-Reatividade Brônquica , Diagnóstico Precoce , Alemanha , Humanos , Testes Intradérmicos , Masculino , Doenças Profissionais/prevenção & controle , Doenças Profissionais/terapia , Exposição Ocupacional/efeitos adversos , Exposição Ocupacional/prevenção & controle , Hipersensibilidade Respiratória/prevenção & controle , Hipersensibilidade Respiratória/terapia , Fatores de RiscoRESUMO
Our aim was to determine by means of five exhaled flow rates differential parameters of FeNO and the relations between them in smokers and non-smokers. 34 smokers (without respiratory symptoms and medication) were examined. Compared to 43 healthy non-smokers, FeNO was significantly lower. The analysis of the differential NO parameters by means of the two-compartment model of NO production revealed a significant decrease in the bronchial NO concentration, but no significant changes of NO in alveolar fraction by smokers. The relations between differential parameters in non-smokers confirm the theoretical expectations of the two-compartment model. Conversely, smokers exhibit an abnormal remarkable correlation, namely, a high correlation between the reduced C(aw) und FeNO at all five flow rates. It may be assumed that the alveolar NO fraction in smokers is to some extent of bronchial origin. Such a preposition is in line with significantly decreases of FEV(1), FEF(50) and FEF(75) in smokers, which are associated with turbulences, flow inhomogeneity and a varied delay of expiration time from the peripheral airways. We hypothesize that the decreased NO concentration in the bronchial wall of smokers plays a pathophysiological role in the genesis of small airways disease.
Assuntos
Brônquios/metabolismo , Modelos Biológicos , Óxido Nítrico/metabolismo , Alvéolos Pulmonares/metabolismo , Fumar/metabolismo , Adolescente , Adulto , Idoso , Simulação por Computador , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
The increasing transport of goods worldwide is mainly carried in standard containers. These containers are frequently fumigated in order to protect freight from pests and to follow regulations of importing countries. Fumigants as well as toxic industrial chemicals can adsorb to goods and be emitted from them over various periods of time. This review is based on a literature search, analyses of air samples from a randomized selection of import containers at the port of Hamburg and clinical investigations of intoxicated subject. These data indicate that about 70% of imported containers exceed national or international threshold levels, about one sixth exceeding occupational exposure limits of fumigants and/or toxic industrial chemical, 0.5% had concentrations immediately dangerous to life or health. Intoxications by inhalation mainly occur in workers in the logistics area. No information exists on possible fumigation in small and medium-sized companies where the container units are unloaded. Neurological and respiratory ailments dominated in patients from our outpatient clinic and those reported in the literature: symptoms were often misdiagnosed. Our results confirm findings of other investigators that subjects who unload containers or have otherwise intensive contact with imported goods are frequently exposed to toxic or very toxic volatile chemicals. It can be assumed that there are many unrecognized cases and also health risks to the ultimate consumers of transported goods. History taking targeted on potential exposure is of great diagnostic importance in elucidating typical temporal relationship between exposure by inhalation and symptoms such as headache, skin irritation, cough, dyspnea, diarrhoea and neurological deficits. Detailed investigations by medical specialists is necessary to confirm suspected diagnoses. This should be combined with immediate special analyses of air samples and laboratory tests (biological monitoring).
Assuntos
Fumigação/efeitos adversos , Praguicidas/análise , Embalagem de Produtos/normas , Doenças Respiratórias/induzido quimicamente , Meios de Transporte/normas , Ar/análise , Ar/normas , Monitoramento Ambiental , Contaminação de Equipamentos/prevenção & controle , Alemanha , Humanos , Cooperação Internacional , Pacientes Ambulatoriais , Meios de Transporte/métodosRESUMO
The actual literature as well as two case reports described in detail show that grain dust induces asthmatic reactions and ODTS which are obviously not of allergic origin. For diagnosis occupational-type exposure tests are decisive whereas allergological testing usually is not. Endotoxins which are present in the grain dust samples in high concentrations have to be regarded as the major causative components. To avoid irreversible lung function impairment a comprehensive early diagnosis is necessary. Generally, a remarkable reduction of exposure to dust with high levels of airborne endotoxin in agriculture has to be achieved since in many workplaces corresponding exposures are still rather high.