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Slide 1 :Institute and Outpatient Clinic for Occupational and Environmental Medicine • Ziemssenstrasse 1 • 80336 Munich • Germany http://arbmed.klinikum.uni-muenchen.de Dennis Nowak, Rudolf Jörres Non invasive methods used to assess occupational exposures Institute and Outpatient Clnic for Occupational and Environmental Medicine Ludwig-Maximilians-Universität München Germany


Slide 2 :BHR / lung function Markers in serum / urine Noninvasive monitoring of airway inflammation Sputum induced spontaneous Exhaled air Nitric oxide Carbon monoxide Breath condensate Electronic nose Temperature


Slide 3 :Induced sputum


Slide 4 :Induced sputum – Cell differentials Homogeneous distribution on cytospin slide


Slide 5 :Eosinophil numbers not affected Holz et al. CEA 2001 Freezing of sputum samples for intermediate storage


Slide 6 :CD3 CD4 CD8 T4/T8 native sample (% cells) frozen samples (% cells) Jaksztat et al. ERJ 2004 Freezing of sputum samples – Flow cytometry


Slide 7 :% Eosinophils valid (cytospin) CD4/CD8 ratio valid (flow cytometry) 15 % DMSO -20°C (normal freezing compartment) Freezing of sputum samples for intermediate storageis a valid procedure Holz et al. CEA 2001 Jaksztat et al. ERJ 2004


Slide 8 :Sputum cells indicate inflammatory response after allergen challenge Gauvreau et al. AJRCCM 1999


Slide 9 :(%) Gauvreau et al. JACI 1999 Reproducibility of sputum analysis after allergen challenge 0 20 40 60 80 100 20 40 60 80 100 first challenge (%) 7 h after challenge second challenge 0 20 40 60 80 100 20 40 60 80 100 first challenge 24 h after challenge Sputum eosinophils


Slide 10 :History Clinical investigation X-ray picture Spirometry Methacholine challenge no clear diagnosis Sputum induction Jayaram et al. ERJ 2000 Algorithm for diagnosis in patients with chronic cough


Slide 11 :Eosinophilia Eosinophilic bronchitiswithout asthma Occupational cause Neutrophilia + elevated total cell number Infectious bronchitis(bakterial/viral/atypic) Bronchiectases Cystic fibrosis Normal or Neutrophilia + normal total cell number Gastrooesophagealreflux Habitual cough Algorithm for diagnosis in patients with chronic cough Jayaram et al. ERJ 2000 Induced sputum


Slide 12 :Maestrelli et al. CEA 1994 Lemiere et al. ERJ 1999 Sputum eosinophils and Occupational Asthma (isocyanate)


Slide 13 :Lemiere et al. CEA 2004 Sputum neutrophils/IL-8 and Occupational Asthma (isocyanate) 8 patients with OA (7 patients with corticosteroids)


Slide 14 :Girard et al. AJRCCM 2004 49 patients with suspected OA 2 weeks at work (Peak flow) 2 weeks not at work (Peak flow) specific challenge (SIC) 26 negative 23 positive induced sputum „at work“ induced sputum „off work“ Flow sheet for the diagnosis of Occupational Asthma


Slide 15 :Diagnosis of Occupational Asthma - Results Girard et al. AJRCCM 2004


Slide 16 :Sensitivity Specificity of diagnosis (after specific challenge) only peak flow peak flow/sputum Diagnosis of Occupational Asthma - Judgement by experts % Girard et al. AJRCCM 2004


Slide 17 :Sputum neutrophils after Diesel exhaust exposure FA Diesel exhaust (PM10: 300µg/m3) 0 20 40 60 80 100 Healthy Nordenhall et al. ATS 2000 ** 6 h after exposure 0 5 10 15 20 Healthy ** 6 h after exposure Neutrophils IL-6 (pg/mL) (%) n = 7 n = 7


Slide 18 :10 months after September 11th, 2001 Comparison of 39 NY-FF, 12 TA-FF, 8 control subjects (hospital workers) Fireman et al. Environ Health Persp 2004 WTC dust-exposed firefighters


Slide 19 :WTC dust-exposed firefighters Irregular particle formin WTC dust-exposure Fireman et al.Environ Health Persp 2004


Slide 20 :Fireman, Environ Health Persp 2004 WTC dust-exposed firefighters


Slide 21 :Induced sputum evaluation in microwave popcorn production workers Exposure to popcorn flavoring agents (mainly Deacetyl = 2,3-butanedione) Apkinar-Elci et al. Chest 2005


Slide 22 :Sputum induced cellularity in a group of traffic policemen Dragonieri et al. 2006 Sputum neutrophils p<0.01


Slide 23 :Occupational eosinophilic bronchitis without asthma due to chloramine (CLT) exposure Sputum analysis Krakowiak et al. 2005 Time course of FEV1


Slide 24 :Leukotrienes and isocyanate-induced asthma: a pilot study using induced sputum Lemiere et al. CEA 2004 Cysteinyl leukotriene (LTC4, LTD4) receptor expression BLT1 (mediating LTB4 response) receptor expression Receptor expression on sputum neutrophils


Slide 25 :Exhaled nitric oxide (eNO)


Slide 26 :Vasodilation Host defence Neuronal transmission Inflammatory responses Nitric oxide - physiological functions


Slide 27 :Epithelial & endothelial cells Granulocytes Macrophages Cellular origin of eNO


Slide 28 :Sievers NOA 280 EcoMedics CLD88 Aerocrine NIOX Exhaled nitric oxide (eNO) - Commercially available analyzers


Slide 29 :NIOXMINO™ Portable eNO device


Slide 30 :Possible sources Nasal sinuses/nose extreme concentrations (>1 ppm)  exclude by measurement procedure (positive pressure) Airways (bronchi) bronchoscopically detectable derived from flow dependence of concentration Alveoli high affinity of hemoglobin to NO  alveolar NO low, difficult to measure Exhaled nitric oxide (eNO)


Slide 31 :Measurement of exhaled nitric oxide (eNO)-Procedure Deep inspiration (NO-free air) 3 measurements, values immediately available Slow expiration against reistance; control flow rate by optical display or special resistance Expiration, attach to mouthpiece Analyzer measures NO on-line by chemiluminescence. Guidelines AJRCCM 2005


Reproducibility of eNO measurements is high :Reproducibility of eNO measurements is high Louw et al. DGP 2002 2 measurements within about 2 weeks


Slide 33 :Factors influencing eNO Smoking Spirometry Coffein Diet rich in nitrates


Slide 34 :Jatakanon et al. Thorax 1998 eNO vs. BHR in asthma


Slide 35 :Baur et al. ERJ 2005 Specific rise of eNO levels in patients sensitized to latex 22 h after challenge independent of asthma/rhinitis sensitized nonsmokers sensitized smokers


Slide 36 :Rise of eNO level after challengein patients with west red cedar asthma Obata et al. ERJ 1999 eNO associated with sputum eosinophils


Slide 37 :Effect of repeated peak ozone exposure on eNO as marker of inflammation/asthma Number of ozone peaks per year Pulpmill workers Olin et al. ERJ 2004


Slide 38 :Effect of an educational intervention in farmers with occupational asthma on the level of exhaled NO


Slide 39 :All subjects Subjects with FeNO>35 ppb n.s. n.s. p=0.009 p=0.006 Dressel et al. ERS 2006 Effect of an educational intervention in farmers with occupational asthma on the level of exhaled NO


Slide 40 :Many compounds have been detected Exhaled breath condensate (EBC)


Slide 41 :Exhaled breath condensate (EBC) Collecting devices, two-way valve and cooler


Slide 42 :End of expiration Inspiration Generation of small droplets from the walls of alveoli and small airways during the breathing cycle Hypothesis of aerosol generation in the lung Mechanism different from coughing!


Examples of compounds measured inexhaled air or breath condensate :NO CO Pentane, ethane ... Nitrite (NO2-), nitrate (NO3-) Nitrotyrosine Hydrogen peroxide (H2O2 ) NH3/NH4+ Leukotrienes (LTB4, cysteinyl-LT) 8-Isoprostans Macromolecules (albumin, ECP...) pH, conductivity ..... ..... ... .. . Examples of compounds measured inexhaled air or breath condensate


Exhaled gases / breath condensate (EBC) vs diagnosis :NO  Asthma,  K.-S. (nasal) CO  Asthma Pentane  Asthma,  ARDS NO2-, NO3-  Asthma,  CF Nitrotyrosine  Asthma,  CF H2O2  Asthma,  COPD,  CF,  Bronchiectases,  ARDS Leukotrienes  Asthma 8-Isoprostane  Asthma,  COPD,  CF,  Sarcoidosis,  ARDS,  OSA NH3/NH4+  Asthma,  URTI pH  Asthma,  COPD,  URTI,  Bronchiectases Specificity / Sensitivity not clarified Exhaled gases / breath condensate (EBC) vs diagnosis


Slide 45 :6 h >4 weeks Holz et al. ATS 1999 H2O2 in breath condensate time between measurements Only short-time reproducibility


Slide 46 :Analysis of exhaled air – Further methods Carbon monoxide (CO) potential marker of oxidative stress Electronic nose alteration of hydrocarbon pattern in tumour patients Temperature profile of exhaled air bronchial blood flow


Slide 47 :Currently no clear-cut datain Occupational Medicine Exhaled breath condensate (EBC)


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