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Specific inhalation challenge in the diagnosis of occupational asthma: consensus statement

Olivier Vandenplas, Hille Suojalehto, Tor B. Aasen, Xaver Baur, P. Sherwood Burge, Frederic de Blay, David Fishwick, Jennifer Hoyle, Piero Maestrelli, Xavier Muñoz, Gianna Moscato, Joaquin Sastre, Torben Sigsgaard, Katri Suuronen, Jolanta Walusiak-Skorupa, Paul Cullinan
European Respiratory Journal 2014 43: 1573-1587; DOI: 10.1183/09031936.00180313
Olivier Vandenplas
1Dept of Chest Medicine, Mont-Godinne Hospital, Université Catholique de Louvain, Yvoir, Belgium
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Hille Suojalehto
2Occupational Medicine Team, Finnish Institute of Occupational Health, Helsinki, Finland
17H. Suojalehto and P. Cullinan are Task Force co-chairs
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  • For correspondence: hille.suojalehto@ttl.fi
Tor B. Aasen
3Dept of Occupational Medicine, Haukeland University Hospital, Bergen, Norway
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Xaver Baur
4Institute for Occupational Medicine, Charité University, Berlin, Germany
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P. Sherwood Burge
5Dept of Respiratory Medicine, Heart of England NHS Foundation Trust, Birmingham
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Frederic de Blay
6Division of Asthma and Allergy, Dept of Chest Diseases, University Hospital of Strasbourg, Fédération de Médecine translationnelle, Strasbourg University, Strasbourg, France
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David Fishwick
7Dept of Respiratory Medicine, Royal Hallamshire Hospital, Sheffield
8Dept of Respiratory Medicine, North Manchester General Hospital, Manchester
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Jennifer Hoyle
8Dept of Respiratory Medicine, North Manchester General Hospital, Manchester
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Piero Maestrelli
9Dept of Cardiologic, Thoracic and Vascular Sciences, University of Padova, Padova
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Xavier Muñoz
10Pulmonology Dept, Hospital Vall d'Hebron, Barcelona
11CIBER de Enfermedades Respiratorias (CIBERES), Madrid
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Gianna Moscato
12Dept of Public Health, Experimental and Forensic Medicine of the University of Pavia, Pavia, Italy
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Joaquin Sastre
11CIBER de Enfermedades Respiratorias (CIBERES), Madrid
13Allergy Dept, Fundacion Jimenez Diaz-Capio, Madrid, Spain
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Torben Sigsgaard
14Dept of Public Health, Section of Environment, Occupation and Health, Aarhus University, Aarhus, Denmark
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Katri Suuronen
2Occupational Medicine Team, Finnish Institute of Occupational Health, Helsinki, Finland
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Jolanta Walusiak-Skorupa
15Dept of Occupational Diseases, Nofer Institute of Occupational Medicine, Łodz, Poland
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Paul Cullinan
16Dept of Occupational and Environmental Medicine, Imperial College, National Heart and Lung Institute, London, UK
17H. Suojalehto and P. Cullinan are Task Force co-chairs
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  • Figure 1–
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    Figure 1–

    The place of specific inhalation challenge (SIC) in the diagnosis of occupational asthma. In some centres it is the first-choice technique, in others it is used selectively in the context of other diagnostic approaches (white boxes). PEF: peak expiratory flow; FEV1: forced expiratory volume in 1 s; NSBHR: nonspecific bronchial hyperresponsiveness.

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    Figure 2–

    Schematic flowchart for performing specific inhalation challenge with an occupational agent. The timing of some measurements varies between centres. FEV1: forced expiratory volume in 1 s; NSBHR: nonspecific bronchial hyperresponsiveness; FeNO: exhaled nitric oxide fraction. #: proceed to additional active challenge(s) when the changes in FEV1 on day 2 are equivocal or negative and challenge with a higher dose is considered appropriate, or when there is a significant increase in sputum eosinophils or in FeNO post-day 2 challenge. ¶: NSBHR can be measured in the morning before the control and active challenge exposures provided that no inhaled bronchodilator is administered.

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  • Table 1– Key messages for performing and interpreting specific inhalation challenge (SIC) with occupational agents
    General safety requirements, contraindications and precautions should be strictly applied in order to minimise the risk of severe adverse events
    The duration or concentration of exposure to occupational agents should only be gradually increased under close monitoring of functional parameters
    A control challenge test with a 6–8 h period of spirometric monitoring on a separate day is required for the interpretation of the SIC results
    Changes in FEV1 should be the primary physiological outcome measure, but other functional indices (i.e. airway resistance/conductance) may be useful in subjects who are not able to complete reproducible expiratory manoeuvres
    NSBHR should be measured at least before the SIC and at the end of a negative SIC procedure. A significant increase in post-challenge NSBHR provides further evidence for a positive response when changes in FEV1 are indeterminate and indicates that additional challenges are necessary before excluding a diagnosis of occupational asthma
    Sputum eosinophils and FeNO may help interpret equivocal tests and indicate the need for longer SIC exposures to reduce the risk of false-negative results
    • FEV1: forced expiratory volume in 1 s; NSBHR: nonspecific bronchial hyperresponsiveness; FeNO: exhaled nitric oxide fraction.

Additional Files

  • Figures
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  • Supplementary material

    Please note: supplementary material is not edited by the Editorial Office, and is uploaded as it has been supplied by the author.

    Files in this Data Supplement:

    • Appendix A - Bibliographic search strategy
    • Appendix B - Workplace challenges
    • Final handbook - HANDBOOK OF PROCEDURES FOR SPECIFIC INHALATION CHALLENGE TESTING IN THE DIAGNOSIS OF OCCUPATIONAL ASTHMA
  • Disclosures

    Files in this Data Supplement:

    • F. de Blay
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Specific inhalation challenge in the diagnosis of occupational asthma: consensus statement
Olivier Vandenplas, Hille Suojalehto, Tor B. Aasen, Xaver Baur, P. Sherwood Burge, Frederic de Blay, David Fishwick, Jennifer Hoyle, Piero Maestrelli, Xavier Muñoz, Gianna Moscato, Joaquin Sastre, Torben Sigsgaard, Katri Suuronen, Jolanta Walusiak-Skorupa, Paul Cullinan, the ERS Task Force on Specific Inhalation Challenges with Occupational Agents
European Respiratory Journal Jun 2014, 43 (6) 1573-1587; DOI: 10.1183/09031936.00180313

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Specific inhalation challenge in the diagnosis of occupational asthma: consensus statement
Olivier Vandenplas, Hille Suojalehto, Tor B. Aasen, Xaver Baur, P. Sherwood Burge, Frederic de Blay, David Fishwick, Jennifer Hoyle, Piero Maestrelli, Xavier Muñoz, Gianna Moscato, Joaquin Sastre, Torben Sigsgaard, Katri Suuronen, Jolanta Walusiak-Skorupa, Paul Cullinan, the ERS Task Force on Specific Inhalation Challenges with Occupational Agents
European Respiratory Journal Jun 2014, 43 (6) 1573-1587; DOI: 10.1183/09031936.00180313
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  • Article
    • Abstract
    • Abstract
    • Introduction
    • Task Force methodology
    • Rationale and indications for performing specific inhalation challenges
    • Methodology of specific inhalation challenges
    • Assessment of bronchial response
    • Interpretation of specific inhalation challenge results
    • Limitations of specific inhalation challenges
    • Research needs
    • Conclusion
    • Footnotes
    • References
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More in this TOC Section

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  • Imaging of pulmonary hypertension: Fleischner Society position paper
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