Prevention of Sensitizer-Induced Occupational Asthma

Primary, secondary, and tertiary preventive measures may reduce the incidence and severity of sensitizer-induced asthma.

Prevention of Sensitizer-Induced Occupational Asthma

Primary prevention

• Avoid introducing predicted new sensitizing agents into the workplace (efficacy as primary prevention currently theoretical).
• Avoid use of known sensitizing agents if safer alternatives are available.
• Modify the physical or chemical form of known sensitizers to reduce risk of exposure (e.g., less volatile preparations, polymerized products, and latex gloves with a low-protein and low-powder content).
• Reduce exposure to work sensitizers by means of occupational hygiene measures (e.g., use of robotics, containment, ventilation, and respirators).
• Educate workers in the use of safe practices at work.
• Monitor and control levels of exposure to workplace sensitizers.

Secondary prevention (early detection)

• Institute medical-surveillance programs for workers at risk, consisting of preplacement and periodic respiratory questionnaires, with spirometry and immunologic tests as indicated.
• Ensure that health care providers have adequate knowledge of occupational asthma and consider it early in the evaluation of all adults with asthma symptoms, leading to early diagnosis and management of occupational asthma.
• Educate workers about the risks of occupational asthma through workplace programs, information provided by health care providers, and public-education programs (e.g., from news media, lung associations, and Web-based programs).

Tertiary prevention (appropriate treatment)

• Evaluate symptomatic workers early and obtain an accurate diagnosis.
• Remove workers from further exposure to the implicated agent after a confirmed diagnosis, when possible.
• Control other triggers and use pharmacologic measures if necessary.
• Assist the patient with a workers’ compensation claim when applicable, to limit the socioeconomic effects of the diagnosis.
• Monitor the patient’s asthma in future work locations to ensure safe placement.

References:

1. Tarlo SM, Lemiere C. Occupational asthma. N Engl J Med. 2014 Feb 13;370(7):640-9.[Medline]
2. Heederik D, Henneberger PK, Redlich CA; ERS Task Force on the Management of Work-related Asthma. Primary prevention: exposure reduction, skin exposure and respiratory protection. Eur Respir Rev. 2012 Jun 1;21(124):112-24.[Medline]

Sedation Scales for Patients in the ICU

Of the sedation scales described, the Riker Sedation–Agitation Scale and the Richmond Agitation–Sedation Scale are the most commonly reported, but in head-to-head comparison, neither is demonstrably superior Sedation Scales for Patients in the intensive care unit (ICU).

Sedation Scales for Patients in the ICU

Riker Sedation–Agitation Scale (SAS)
Scoring	Scale	Description
score of 7	Dangerous agitation	Pulling at endotracheal tube, trying to remove catheters, climbing over bed rail, striking at staff, thrashing from side to side
score of 6	Very agitated	Requiring restraint and frequent verbal reminding of limits, biting endotracheal tube
score of 5	Agitated	Anxious or physically agitated, calming at verbal instruction
score of 4	Calm and cooperative	Calm, easily rousable, follows commands
score of 3	Sedated	Difficult to arouse but awakens to verbal stimuli or gentle shaking; follows simple commands but drifts off again
score of 2	Very sedated	Arouses to physical stimuli but does not communicate or follow commands, may move spontaneously
score of 1	Cannot be aroused	Minimal or no response to noxious stimuli, does not communicate or follow commands
Richmond Agitation–Sedation Scale (RASS)
Scoring	Scale	Description
score of 4	Combative	Overtly combative, violent, immediate danger to staff
score of 3	Very agitated	Pulls or removes tubes or catheters; aggressive
score of 2	Agitated	Frequent nonpurposeful movement, fights ventilator
score of 1	Restless	Anxious but movements not aggressive or vigorous
score of 0	Alert and calm	Alert and calm
score of -1	Drowsy	Not fully alert but has sustained awakening (eye opening or eye contact) to voice (>/=10 sec)
score of -2	Light sedation	Briefly awakens with eye contact to voice (<10 sec)
score of -3	Moderate sedation	Movement or eye opening to voice but no eye contact
score of -4	Deep sedation	No response to voice but movement or eye opening to physical stimulation
score of -5	Cannot be aroused	No response to voice or physical stimulation

References:

1. Reade MC, Finfer S. Sedation and delirium in the intensive care unit. N Engl J Med. 2014 Jan 30;370(5):444-54. [Medline]
2. Brummel NE, Girard TD. Preventing delirium in the intensive care unit. Crit Care Clin. 2013 Jan;29(1):51-65. [Medline]
3. Riker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med. 1999 Jul;27(7):1325-9. [Medline]
4. Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O'Neal PV, Keane KA, Tesoro EP, Elswick RK. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002 Nov 15;166(10):1338-44. [Medline]

Diagnostic Criteria for Temporomandibular Disorders (2014)

Overview The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD), by Schiffman et al, are available in the Journal of Oral & Facial Pain and Headache, 2014.  The DC/TMD is intended for use in both clinical settings and applied research settings.  Schiffman et al describe the rationale and methodology underlying the changes from the RDC/TMD to the DC/TMD.  The extensive development process can be explored in greater detail. Further research examining core properties is expected, and forthcoming additional DC/TMD research tools are intended to augment the DC/TMD for such research.  All tools required for clinical implementation are available on this page.  The DC/TMD tools are living documents, and revisions are managed by the Consortium Network; the most current version will always be available here.  Translations Early translated versions (Dutch, Spanish, and Swedish) of the DC/TMD were developed in order to test the adequacy of the English source documents and some of these versions have also been used in examiner training, calibration, and reliability field trials; these versions will soon be available for download.  Consortium members have begun work on a total of 27 translations: Arabic, Chinese (short form), Danish, Estonian, Farsi, Finnish, French, German, Greek, Hebrew, Hindi, Indonesian, Italian, Japanese, Korean, Malay, Nepali, Norwegian, Polish, Portuguese (Brazil), Portuguese (Portugal), Thai, Turkish, and Urdu. Please contact the team leaders on this list for more information about a translation, and please contact us if your language of interest is not yet included and you would like to request permission to do a translation. Please see theTranslation Guidelines page for further information regarding translation procedures for the Consortium.   Examiner Training, Calibration, and Reliability Assessment An annotated video of the DC/TMD clinical examination has been completed and is currently under peer review at Med Portal.  A link will be posted here for accessing the video once it is published.  Self-study guidelines as well as description of supervised skill development are described in further detail. Additional information will be provided at a later time regarding scheduled workshops for examiner training. Documents for Downloading The URL links in the references of the DC/TMD publication access resource documents on this website.  If the "Modified Date" in the list to the right is prior to January 29, 2014, the document version is current as of the DC/TMD publication.  Document filenames contain dates representing the relative version of the document; however, those filename dates may not correspond to the "Modified Date" shown tin the file listing.  The inconsistency emerges due to separate production cycles, in the final month, for the manuscript and for the support documents.  All documents contain a date within, usually in the footer; the internal date corresponds to the Modified Date in the listing.  The DC/TMD reference URLs will always link to the documents current at the time of publication.  Any Modified Date in the file listing after January 29, 2014 represents an updated version since the DC/TMD was published, and this page will always contain the most current version.  Suggestions for improving this arrangement are welcomed. Complete DC/TMD Instrument Set Document Link Modified Date DC/TMD: Complete PDF Open 1/29/2014 Individual Instruments, Forms, Protocol Document Link Modified Date TMD Pain Screener Open 10/11/2013 DC/TMD Symptom Questionnaire Open 5/12/2013 Demographics Open 5/12/2013 Examination form: International Open 5/1/2/2013 Examination form: North America Open 5/1/2/2013 Examiner Protocol Open 1/24/2014 DC/TMD Decision Trees Open 1/24/2014 DC/TMD DIagnostic Criteria Open 1/24/2014 Pain drawing Open 5/12/2013 Graded Chronic Pain Scale (v2) Open 5/12/2013 JFLS-8 Open 5/12/2013 JFLS-20 Open 5/12/2013 PHQ-4 Open 5/12/2013 PHQ-9 Open 5/12/2013 GAD-7 Open 5/12/2013 PHQ-15 Open 5/12/2013 Oral Behaviors Checklist Open 5/12/2013

Criteria for the Diagnosis of Asthma

Asthma is a chronic inflammatory disease of the airways that is characterized by variable narrowing of the airways and symptoms of intermittent dyspnea, wheezing, and nighttime or early-morning coughing.

Criteria for the Diagnosis of Asthma

Presence of episodic symptoms of airflow obstruction or airway hyperresponsiveness
Objective assessment consisting of one of the following

Airflow obstruction that is at least partially reversible with the use of an inhaled short-acting beta 2-agonist, as shown by one of three variables

An increase in FEV1 of >/=12% from baseline
An increase in predicted FEV1 of >/=10 percentage points from baseline
An increase in PEF of >/=20% (or 60 liters/min) from baseline

Diurnal variation in PEF (measured twice daily) of more than 10%

* FEV1 denotes forced expiratory volume in 1 second, and PEF peak expiratory flow.

References:

1. Bel EH. Clinical Practice. Mild asthma. N Engl J Med. 2013 Aug 8;369(6):549-57.[Medline]
2. Mintz M. Asthma update: part I. Diagnosis, monitoring, and prevention of disease progression. Am Fam Physician. 2004;70:893-898. [Medline]