Second Nature--I Feel Short of Breath!

I Feel Short of Breath!

University of Massachusetts Medical School
Worcester, Massachusetts
Instructor(s): Rest, Kathleen
Subject area: Health / Medicine
Department: Family and Community Medicine
Level: Graduate
Duration of exercise: 2 hours
Learning objective: Develop Individual Skills, Provide Information
Teaching style: Active Learning, In-class Activity

Please note that the copyright for this course project is retained by the instructor.

This case was used in the Physician, Patient and Society Course at the University of Massachusetts Medical School.

GOALS

By the end of the session, students should be able to:
1. Understand and appreciate the influence of the workplace, home and community environments on the patient and community health.
2. Elicit an appropriately detailed occupational and environmental history from a patient.
3. Develop a problem list that includes occupational and environmental risk factors.
4. Discuss the mechanisms by which occupational and environmental exposures and other factors influence the development and severity of asthma.
5. Identify informational, clinical, and community resources available to assist with environmental and occupational health problems.

PATIENTS

Standardized patients

READINGS

Goldman R and Peters J. "The occupational and environmental health history." JAMA 246(24):2831-2836, 1981.

Balmes JR. "Asthma" IN: Occupational and Environmental Respiratory Disease. P Harber, M Schenker, J Balmes, eds St. Louis: Mosby, 1996.

Newman-Taylor A. "Environmental determinants of asthma." Lancet. 345:296299, 1995.

METHODS

Small group session

A. Discuss

Readings: How will you: ask about co-existing illnesses? Occupational Issues?? Home? Environmental Issues?

B. Interview the patient

Ask for a volunteer and have that student take the history.

At the end of the history, stop and ask the group If they can identify the factors that may have some bearing on the case. If necessary, remind them that they should inquire about the patient's general health habits, and home, workplace,, and community environments,} all of which will contribute something to the patient's symptoms.

Resume the interview and let the group ask additional questions.

Thank the patient and allow him/her to leave.

C. Have the group construct a problem list that identifies medical problems and factors/ hazards in the patient's home, workplace, and community environments that may be contributing to his/her respiratory problems.

Home environment factors (forced hot air heating, air quality, renovations); work factors being a painter, use of latex paint and a power-belt sander to sand walls, dust exposure); possible COPD, respiratory infection.

D. Ask the group to discuss the basic mechanisms for asthma.

Triggers: Irritation, Infection, allergy
Triggers: Increased secretions and smooth muscle contraction, inflammation.

E. Have the group discuss what they would do for this patient diagnostically? Therapeutically?

What would you recommend for this patient diagnostically? Chest X-ray (if not done in the ER ); PFTs/peak flow; possible methacholine challenge?

What would you recommend for the patient therapeutically? Additional or stronger medicines? Change job or apartment? What things could be changed at work to improve symptoms? How would you evaluate the work to see whether it is safe? (Physician or patient might contact the company or union safety representative, OSHA, an occupational medicine physician or other health and safety experts. Would a respirator be helpful? What might be some of the problems in asking this worker to use a respirator? (You don't know which one is the right one to use; you don't know if it will; do: any good without a good fit-test; you don't know whether it can be comfortably worn in this particular work situation, and you don't know whether the employer will provide the necessary facilities to clean and maintain it, etc.) Treatment of other illnesses.

F. Have the group discuss whether the occupational and environmental risk factors they identified pose a potential problem for the patient's family [in this case the patient's fiancée], co workers, or neighbors in the community.

CASE

A 35-45 year-old patient who complains of difficulty breathing during an office visit with a primary care physician practicing in New York City.

Patients must be able to respond to questions about their home environment, their job activities and exposures, and their community environment. This information will be provided.

The patient should volunteer only the first paragraph of the chief complaint/ history of present illness below, and provide additional information only if asked by the students. If the students don't ask you about your job or home environments, you can say something to get them going.

Patient's History

Chief Complaint and History of Present Illness

You are seeing the physician today because of difficulty breathing. Your symptoms include wheezing (you and your fiancée can both hear it), chest tightness, coughing, and production of yellow phlegm. These symptoms happen pretty much on a daily basis, but over the past week, they seem worse than usual. Last week, it got so bad that you went to the emergency room one night. The physicians there gave you some new medications and said you should follow-up with a physician as soon as possible. That's why you are here today. The new medicine seems to have helped a little, but you still have to use the inhaler a lot at night and you are getting concerned about it. "This just isn't right."

If asked, you had fever and chills last week but not now. Over the past few months, you can have aggravation of your symptoms at any time of day, but it seems to be much more frequent in the evenings. Symptoms last for several hours, and gradually resolve, though sometimes they keep you up most of the night and you are still a little short of breath in the morning. Your symptoms seem to have gotten worse since you moved to New York City (NYC) three months ago. Normally, you can walk up the 4 flights of stairs to your apartment briskly, but when it's bothering you a lot, you have to stop several times to catch your breath, and this has been much worse over the past week.

Past Medical History

You have a history of mild asthma which began In childhood. It was always mild. As a kid, you used an inhaler only occasionally and took Theophylline until you graduated from high school. The doctor told you that you were allergic to several types of pollen, as it always seemed worse in the fall. After that, you managed the symptoms pretty well, using the inhaler only occasionally. You have never been hospitalized for asthma, and you have not seen a physician for a long time. You don't have a local doctor in NYC and have not had any lung testing for several years.

In the past, a couple things would "set you off." These included: bad cold with a cough, exercise in cold weather, and very heavy dusts. Now, however, the symptoms occur a lot; they are much worse than before, even without cold air. No other pertinent medical history - no history of hives, heart trouble, food allergies, or increased symptoms around dogs, cats, hair spray, soaps or detergents. Emotional upsets don't seem to trigger your asthma.

Medications

Proventil inhaler -- 2 puffs 2x/day, as needed (to open airways)
Beclovent -- 2 puffs 2x/day, as needed (to decrease inflammation)
Theodur -- 2 tablets 2x/ day (to open airways)
Bactrim -- DS 1 tablet 2x/day (to treat possible respiratory infection)

The last three medications were prescribed last week by the doctor in the emergency room.

Social History

You were born and raised in Brewster, NY -- a semi-rural community about 50 miles from NYC. You have 2 brothers and 1 sister, none of whom have asthma. They still live around Brewster. Your parents are alive and well, also with no history of respiratory disease. You are an ex-smoker (you started at age 11 and smoked 2 ppd. until you quit completely about 3 years ago). You drink only very occasionally, and use no drugs.

You moved to NYC because your fiancée works there and because you thought job opportunities would be better. Your fiancée smokes occasionally, but never inside your apartment.

Environmental History

You moved to NYC and into a newly renovated apartment with your fiancee about 3 months ago. It is a 2-bedroom, loft apartment with new hardwood floors throughout and a new kitchen with a gas stove. There is no air conditioning; it has forced hot air heating. You have no pets (except for tropical fish). Except for a new couch, the furniture is old -- some belonging to you and some to your fiancée. The hardwood floors appear to be finished with a polyurethane resin, a very hard and shiny finish. When you first moved in, there was a 'new construction' smell of new wood and paint, but this has gone away since then.

If asked, you can tell the students you notice that the air quality is much worse in NYC than it was in Brewster. The outside air sometimes feels heavy and smoggy -- there is lots of traffic and car exhaust in the neighborhood. You worry about air pollution, especially on some recent days when the air seems to be particularly bad, and the weather report included a bad air warning. You seem to wheeze more when you go out for a brisk walk even if for just a few miles, on these days.

There are also a couple of small factories in the neighborhood, but you do not know what they do.

Occupational History

Since graduating from high school, you have been a painter. You have worked for many different employers/contractors over the years. You are a member of the Painters Union. This means that you report to the Union Hall to get jobs.

You paint indoors, mostly in residential settings, (although once in a while you might be involved in painting commercial offices). You use mostly latex paint, and occasionally enamel or oil-based paints. You don't know what's in the paint, but you don't think it's dangerous. Sometimes the paints have a strong odor, almost always these are oil-based. Depending on the job, you use a roller, a brush, or a spray gun. You have done this same job for years, and you like it. Because you are in the union, you get good wages and good benefits. |

If asked about protective gear, you usually wear safety goggles when painting with a sprayer or when using a power sander. You rarely use gloves, except when using a lot of oil-based paints. The paint brush and equipment are usually cleaned with hot water and soap, although the oil-based paints require cleanup with paint thinner. You recall having been given a respirator on a job several years ago, when finishing a floor with a special coating, but have not used one since.

You did this type of work in Brewster, and you are doing it now in NYC. The only difference is that, since moving to NYC, you now don't have the help you used to have in the preparation of paint surfaces. In the past, other workers would sand, scrape, and prepare the surfaces for painting before you got there. Now, on many jobs, you have to sand walls and wood trim yourself (baseboards, door and window frames, etc.) You do this with a power beltsander. You don't really mind doing this, but you are kind of peeved that it happens because employers are trying to cut down on the number of union workers on a job.

If they ask, you can tell the students that the sanding generates a lot of dust (combination of paint dust, wood dust, plaster or wallboard dust). You do not wear a mask or respirator. Ventilation is poor; there are usually just a few open windows and no exhaust fans.

If asked about any unusual activities at work, say that there are none other than the ones that you have described.

If asked about the time-course of symptoms, reiterate that they seem to be worse since moving to NYC. They have been particularly bad over the past week or so. If asked about whether symptoms appear to be worse after doing specific activities at work, indicate that sometimes the worst evenings seem to follow days when you have done a lot of sanding. In fact, that was what you were doing at work on the day that you went to the emergency room. Symptoms usually begin in the afternoon or evenings, and persist for a few hours. You have not noticed that painting aggravates your symptoms, even when using a variety of different paints. You are generally better on weekends and noticed that you had no symptoms when you visited your sister in Brewster for 3 days last month.

If asked about co-workers, they also cough a lot during the sanding jobs. In fact, one has been bringing in his own dust mask to wear when these jobs are being done.

If asked about symptoms in relation to turning on the heat in the apartment, you can say that they first day you ran the heat, you did wheeze more, but it only bothered you on that day.

For Preceptor: Points For Discussion

The physical examination may be normal at the time of the visit, if the patient doesn't have a current exacerbation. However, smoking may lead to COPD and decreased breath sounds, and a URI may cause thick secretions and rhonchi. To document an exposure-related effect, you might have to examine the patient before and after the exposure, perhaps with lung function testing. If there's greater than 10 - 15% drop in the amount of air that the patient can expel in 1 second (FEV1), then it is likely that something has aggravated the patient's asthma.

An easier way to evaluate exposure-related changes is to give the patient a peak flow meter, and test before work, after work, and again several hours later. Of course, this would be hard to evaluate until the acute URI is treated.

What role do you think non-workplace, environmental factors might have here (obviously, this patient has exacerbations that are triggered by ambient air pollution, probably during inversions. Other environmental factors might include gas stove, new construction materials in the apartment that off-gas formaldehyde, toluene di-isocyanate from polyurethane floor coatings, and even second-hand cigarette smoke, as well as pollution from local factories).

Conclusion (Answers to the conclusion questions are below. )

What occupational and environmental agents are known to cause or exacerbate asthma?

What advice would you give this patient to help control his/her respiratory symptoms?

How can physicians begin to recognize the contribution of occupational and environmental factors to their patient's health (and disease)?

Where can physicians get additional information about or assistance with an occupational or environmental health problem?

How do other medical issues complicate the diagnosis and treatment here?

Conclusion: Answers

What occupational and environmental agents are known to cause or exacerbate asthma?

See Balmes and Newman-Taylor Readings -- and Tables 11-3, 23-2.

What advice would you give this patient to help control his/her respiratory symptoms?

For symptoms that appear to be aggravated by work (this seems to be the primary source of her symptoms), ask employer for respiratory protection. If she works as a private contractor, she may have to invest in her own respiratory protection. It will be important for her to get the right type of respirator. It should be properly fitted, and it will need to be cleaned regularly and well-maintained. To decrease her exposure to dusts at work, there may be a way to capture the dust generated by the power-sander, such as an attached vacuum system. She might be able to trade off jobs with others so that she doesn't have to do as much sanding.

At home, she has a gas stove, which perhaps could be better ventilated. She should definitely check the filter in her heating system and consider safe humidification because low humidity may be a factor in her illness. For symptoms related to jogging or exercising at home, she may want to try using an inhaler.
How can physicians begin to recognize the contribution of occupational and environmental factors to their patients' health (and disease)?

First, by recognizing that many conditions are caused or exacerbated by occupational and environmental factors. This requires a thorough history, including timecourse of illness, similar symptoms/problems in others with similar exposures, and coincidence of symptom onset with changes in the work, home, school, or community environments. Other questions should address potential exposures at home (hobbies, home construction), at work, and where patients live. It's most important to ask patients whether they think any occupational or environmental conditions or exposures exacerbate their illness and to describe how this occurs. Establishing a diagnosis of work- or environmentally related illness may require expert consultation, specific laboratory tests, more detailed information on exposures and effects in others similarly exposed, and follow-up after removal from exposure. With environmentally-related illness, the physician can be most effective by focusing on prevention-related activities, as these usually lead to resolution of the illness in the patient, as well as prevention of illness in others who are or who may be similarly exposed.

Where can physicians get additional information about or assistance with an occupational or environmental health problem?

Occupational/Environmental Medicine Specialists
At UMass, contact Dr. Glenn Pransky at 856-6164; to locate an . Occupational/environmental medicine specialist in a particular area, contact the Association of Occupational and Environmental Clinics (202/347-4976) and the membership directory of the American College of Occupational and Environmental Medicine.
State Health Departments
Federal Agencies, such as Environmental Protection Agency and the
National Institute for Occupational Safety and Health
Poison Control Centers
Textbooks and Electronic Databases (Toxnet, Medline)

Table 11-3 Agents that cause occupational asthma
.

Agent	Industries and Occupations	Skin Test	Specific IgE antibodies
Vegetable Dusts and Woods	.	+	-
Grain	Grain handlers	+	+
Flour (Wheat/Rye)	Millers, bakers	+	+
Coffee beans	Planters, processors	.	+
Castor beans	Oil producers	.	+
Tea dust	Tea workers	+	.
Tobacco	Tobacco workers	+	+
Western Red cedar California Redwood Oak Mahogany	Sawmillers, carpenters, cabinetmakers, other woodworkers, construction workers	+ - -	+ -
Colophony (pine resin)	Electronics workers	.	+
Gum acacia	Printers	+	.
Animals, birds, shellfish	.	.	.
Rats Mice Guinea Pigs Rabbits	Animal handlers, laboratory workers, veterinarians	+ + + +	. +
Pigeons	Pigeon breeders	+	.
Chickens	Poultry workers	+	+
Turkeys	Poultry workers	+	+
Crabs	Crab processors	+	.
Prawns	Prawn processors	+	+
Oysters	Oyster farmers	+	+
Enzymes	.	.	.
Subtilisins	Detergent manufacture	+	+
Papain	Meat packaging	+	+
Trypsin	Pharmaceutical workers	+	+
Pepsin	Pharmaceutical workers	+	+
Metals	.	.	.
Platinum and salts	Platinum refining and plating	+	.
Chromium salts	Tanning of leather	+	+
Nickel	Metal plating	+	+
Cobalt	Manufacture of hard metals	+	.
Vanadium	Manufacture of hard metals	.	.
Miscellaneous chemicals	.	.	.
Toluene diisocyanate (TDI)	Manufacture of polyurethane foam, painters, plastics manufacture	+	+
Diphenylmethane diisocyanate (MDI)	Core makers in foundries, painters	-	+
Phthallic anhydride	Epoxy resins, plastics	+	+
Trimellitic anhydride	Epoxy resins, plastics	+	+
Formaldehyde	Hospital workers, laboratory technicians, chemical workers	-	-
Azodicarbonamide	Plastics and rubber workers	-	.
Ethanolamines	Solderers, spray painters, metal machining	-	.

Key: + = positive skin test or specific IgE has been reported in affected workers, but not necessarily in ail of those affected; - = no reports of a positive skin test or specific IgE antibodies among those who were tested, although for many of these agents only small numbers of affected individuals have been examined + = conflicting data: some researchers have found a positive skin test or specific IgE, but other investigation ton did not.

Source Data derived from M Chan-Yeung and sS. Lam, Occupational asthma (state of art) Am. Rev. Respir. Dis. 133:686, 1986.

Table 23-2. Examples of agents that may cause environmental asthma

Agent	Exposures
Animal
Small animals rats, mice, guinea pigs	Pet owning
Domestic animals	Domestic animal owning
Wool	Wool working
Birds (feathers, serum droppings)	Bird breeding
Sea squirt fluid	Oyster and pearl gathering
Culture oysters (marine organisms)	Oyster shucking
Glue (fish origin)	Bookbinding
Hog trypsin, pancreadc extract, amylase	Cystic fibrosis (both children and parents)
Bacillus subtilis, esperase	Detergent enzymes
Human hair products	Hairdressing
Beetles (coleoptera)	Insect collecting
Locusts	Insect Collecting
Moths, butterflies	Butterfly collecting
Stick insects	Insect collecting
Cockroaches	Homes, insect collecting
Crickets	Outdoor work
Housefly maggots	Angling
River flies sewerworm flies, sewage flies	Outdoor work
Ivory dust	Ivory carving
Vegetable
Wood dusts of various types	Woodworking, carpentry
Latex	Use of latex gloves, condoms; spina bifida
Papain	Food technologists
Diastase	Food handling
Karaya gum	Food processing
Gum arabic, acacia, tragacandh	Printing
Altensana, Aspergillus, spores of Cladosporium	Indoor air pollution
Verticillium, paccilomyses, Merulius lacrymans	Domestic work
Pink rot fungus	Celery picking
Mushroom molds	Mushroom picking
Potatoes	Homemakers
Alkaline hydrolysis derivative of gluten	Biscuit making
Chemical
Trimellitic anhydride	Epoxy resins
Ammonium thioglycate	Hairdressing cosmetics
Dioazonium salt	Photocopying
Colophony	Soldering
Persulfate salts, extract of henna	Hairdressing
Reactive dyes	Texile dying
Paraphenylene diamine	Fur dying
Psyllium	Mixing laxative powders
Amprolium hydrochlolide	Poultry feed mixing
Pesticides, insecticides	Application, fumigation
Sulphone chloramides	Home brewing
Hexamethaline diisocyanate	Auto body spray-painting
Toluene diisocyanate	Polyurethane

From: Abrons HL et al. "Disorders of the Upper and Lower Respiratory Tract." In: Environmental Medicine, S. Brooks, et al. eds. St. Louis, Mosby-Year Book, Inc, 1995s

This document was last modified on 06/14/2000 03:08:03 PM

This resource was acquired by CEEM (Consortium for Environmental Education in Medicine), a program of Second Nature, under the auspices of a NIEHS grant to gather and disseminate environmental health educational resources over the internet in order to help medical and allied health sciences faculty identify, locate and use resources for incorporating environment and health perspectives into their curricula. CEEM has authorized the use of these materials on this website for archival purposes. Please note that the copyright for this material is retained by the instructor and/or contributing institution.