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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In a great many jobs&#44; workers inhale aerosol substances that can cause asthma&#44; aggravate pre-existing asthma&#44; or cause symptoms that mimic asthma&#46; Both occupational asthma and work-aggravated asthma are common entities&#46; Ten percent of adult asthma cases are thought to be job-related&#44; and more than 25&#37; of asthma patients of working age can suffer exacerbations related to their working conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In occupational asthma&#44; the best therapy is to avoid the causal agent<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a>&#59; this involves leaving the job and obtaining a certificate of incapacity due to an occupational disease&#44; which would entitle the patient to receive disability benefit&#46; Being classed as &#8220;unfit for work&#8221; is not always advantageous&#44; and depending on the age&#44; profession and social and economic circumstances of the worker it can even be detrimental to a greater or lesser extent&#46; However&#44; in the case of work-aggravated asthma due to non-specific stimuli&#44; controlling factors such as cold&#44; irritants&#44; exercise&#44; stress and treatment non-compliance&#44; and facilitating adherence and optimizing therapy can often suffice to allow a return to work&#46; Other processes that mimic asthma&#44; such as reactive airway dysfunction syndrome&#44; irritable larynx syndrome and COPD&#44; however&#44; must be ruled out&#46; Therefore&#44; when a worker reports asthma symptoms linked to occupational exposure&#44; it is essential&#44; from a therapeutic&#44; occupational and economic perspective&#44; to determine which process is involved&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> Occupational asthma must be diagnosed as soon as possible on the basis of objective tests that can ensure the highest degree of certainty&#59; this&#44; however&#44; is far from simple&#46; Scientific societies and groups of experts have devised algorithms that can be used with available tools to facilitate what is essentially a complex diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">4&#44;5</span></a> Today&#39;s recommendations are reliable and can help clinicians take the right decisions&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">According to the widely accepted definition&#44; occupational asthma is &#8220;a disease characterized by variable airflow limitation and&#47;or airway hyperresponsiveness due to causes and conditions attributable to a particular occupational environment and not to stimuli encountered outside the workplace&#8221;&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> and the first step is to confirm the presence of the disease&#46; Diagnostic criteria for asthma&#44; which mainly consist of confirming reversible obstruction&#44; bronchial hyper-responsiveness and characteristic inflammation&#44; are clearly defined in universally accepted guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> An important factor to bear in mind in occupational asthma is that prolonged separation from the causal agent can mitigate these manifestations&#59; therefore&#44; it is best for the patient to continue working while the physician immediately starts diagnostic studies&#46; Only once asthma has been objectively confirmed should the next step be taken&#44; namely&#44; establishing the causal relationship with a specific agent present in the workplace&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In most cases of occupational asthma&#44; the pathogenic mechanism is an allergic response to high or low molecular weight antigens&#44; either through the interaction with specific IgE antibodies or by other immune mechanisms&#46; Irritant-induced asthma is not caused by an allergic response&#44; and as such is beyond the scope of this article&#46; A great many asthma allergen triggers have been described&#44; with latency periods from first exposure ranging from weeks to years&#46; In all cases of adult-onset and poorly controlled asthma it is essential to obtain a detailed occupational history of the patient&#46; Symptom onset can vary&#44; depending on the length of exposure and the trigger allergen&#46; Rhinitis often precedes asthma symptoms&#44; although this has been shown to have a low positive predictive value and should never suffice for a diagnosis of occupational asthma&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Positive skin prick tests indicate sensitization and help identify the likely trigger&#46; However&#44; such tests have poor sensitivity and specificity&#44; and it is important to bear in mind that they cannot identify the target organ of the allergic response&#44; and therefore cannot diagnose asthma when used alone&#46; Once the disease has been diagnosed&#44; the causal relationship must be identified&#44; starting with an observation of changes in clinical signs&#44; lung function &#40;serial peak flow measurements and hyperresponsiveness to methacholine&#41; and markers of inflammation &#40;eosinophil count and measurement of exhaled nitric oxide&#41; in response to exposure and separation from the workplace trigger in alternating periods of at least 2 weeks&#46; Evaluating the results of these studies as a whole will increase their diagnostic yield&#44; and although they have their limitations&#44; they are often sufficient to give a high degree of certainty&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The specific bronchial challenge test is the gold standard for identifying the allergy trigger&#59; however&#44; it is rarely used and poorly implemented&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> In some hospitals&#44; it is a first-line procedure&#44; although in most it is used when alternative methods have failed to provide conclusive evidence&#46; Other indications include identification of new triggers not previously described&#44; cases where re-exposure to the workplace is impossible&#44; and as a gold standard test in research&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Diagnosis of irritant-induced asthma depends on evidence of asthma together with a history of exposure and clinical signs&#44; none of which are wholly conclusive&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">All the aforementioned studies will only yield reliable results when performed following strict quality and safety standards&#44; but they are time-consuming&#44; and not all hospitals have the required resources&#46; Moreover&#44; it is important to gain the trust of the worker and help them understand the need for patience and cooperation in reaching a firm diagnosis that will always be to their advantage&#46; The cost of obtaining an accurate diagnosis is no higher than the cost of poorly controlled disease&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">A brief look at current recommendations reveals areas of improvement&#44; and it is clear that diagnosis is a process that involves the general practitioner&#44; occupational physician&#44; pulmonologist and allergist&#44; and often requires specialized units&#46; Professionals in the field of occupational medicine and primary care should bear in mind that&#58; &#40;1&#41; Occupational asthma should be suspected in all workers presenting with initial symptoms of asthma or with poorly controlled disease&#44; &#40;2&#41; A comprehensive occupational history is crucial when dealing with workers with respiratory symptoms&#44; &#40;3&#41; Not all asthma related with a patient&#39;s job is necessarily occupational asthma&#44; &#40;4&#41; Occupational asthma cannot be ruled out on the basis that the job is not considered high-risk&#44; and &#40;5&#41; Both causal and aggravating factors can be present&#44; and non-specific causal factors such as fungi and plants can be found in the workplace&#46; In addition to these factors&#44; pulmonologists must ensure they reach an objective diagnosis of asthma&#44; and when they lack the resources needed to establish a causal relationship&#44; they must refer the patient to specialized units to complete the diagnostic process and confirm their suspicions&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The epidemiological significance of occupational asthma is beyond dispute&#46; In recent years&#44; a number of tools have been developed to help physicians overcome diagnostic uncertainty&#46; Despite this&#44; the data show that occupational asthma is under-diagnosed&#44; and it is up to healthcare professionals to make good use of existing recommendations to improve their diagnostic skills and improve their understanding of this disease&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest&#46;</p></span></span>"
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Editorial
Following Recommendations: A Challenge in Occupational Asthma
Seguir las recomendaciones, un desafío en el asma ocupacional
Cristina Martínez
Corresponding author
cmartinez@hca.es

Corresponding author.
, Rosirys Guzmán, Ramón Fernández
Área del Pulmón, Instituto Nacional de Silicosis-Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In a great many jobs&#44; workers inhale aerosol substances that can cause asthma&#44; aggravate pre-existing asthma&#44; or cause symptoms that mimic asthma&#46; Both occupational asthma and work-aggravated asthma are common entities&#46; Ten percent of adult asthma cases are thought to be job-related&#44; and more than 25&#37; of asthma patients of working age can suffer exacerbations related to their working conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In occupational asthma&#44; the best therapy is to avoid the causal agent<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a>&#59; this involves leaving the job and obtaining a certificate of incapacity due to an occupational disease&#44; which would entitle the patient to receive disability benefit&#46; Being classed as &#8220;unfit for work&#8221; is not always advantageous&#44; and depending on the age&#44; profession and social and economic circumstances of the worker it can even be detrimental to a greater or lesser extent&#46; However&#44; in the case of work-aggravated asthma due to non-specific stimuli&#44; controlling factors such as cold&#44; irritants&#44; exercise&#44; stress and treatment non-compliance&#44; and facilitating adherence and optimizing therapy can often suffice to allow a return to work&#46; Other processes that mimic asthma&#44; such as reactive airway dysfunction syndrome&#44; irritable larynx syndrome and COPD&#44; however&#44; must be ruled out&#46; Therefore&#44; when a worker reports asthma symptoms linked to occupational exposure&#44; it is essential&#44; from a therapeutic&#44; occupational and economic perspective&#44; to determine which process is involved&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> Occupational asthma must be diagnosed as soon as possible on the basis of objective tests that can ensure the highest degree of certainty&#59; this&#44; however&#44; is far from simple&#46; Scientific societies and groups of experts have devised algorithms that can be used with available tools to facilitate what is essentially a complex diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">4&#44;5</span></a> Today&#39;s recommendations are reliable and can help clinicians take the right decisions&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">According to the widely accepted definition&#44; occupational asthma is &#8220;a disease characterized by variable airflow limitation and&#47;or airway hyperresponsiveness due to causes and conditions attributable to a particular occupational environment and not to stimuli encountered outside the workplace&#8221;&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> and the first step is to confirm the presence of the disease&#46; Diagnostic criteria for asthma&#44; which mainly consist of confirming reversible obstruction&#44; bronchial hyper-responsiveness and characteristic inflammation&#44; are clearly defined in universally accepted guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> An important factor to bear in mind in occupational asthma is that prolonged separation from the causal agent can mitigate these manifestations&#59; therefore&#44; it is best for the patient to continue working while the physician immediately starts diagnostic studies&#46; Only once asthma has been objectively confirmed should the next step be taken&#44; namely&#44; establishing the causal relationship with a specific agent present in the workplace&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In most cases of occupational asthma&#44; the pathogenic mechanism is an allergic response to high or low molecular weight antigens&#44; either through the interaction with specific IgE antibodies or by other immune mechanisms&#46; Irritant-induced asthma is not caused by an allergic response&#44; and as such is beyond the scope of this article&#46; A great many asthma allergen triggers have been described&#44; with latency periods from first exposure ranging from weeks to years&#46; In all cases of adult-onset and poorly controlled asthma it is essential to obtain a detailed occupational history of the patient&#46; Symptom onset can vary&#44; depending on the length of exposure and the trigger allergen&#46; Rhinitis often precedes asthma symptoms&#44; although this has been shown to have a low positive predictive value and should never suffice for a diagnosis of occupational asthma&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Positive skin prick tests indicate sensitization and help identify the likely trigger&#46; However&#44; such tests have poor sensitivity and specificity&#44; and it is important to bear in mind that they cannot identify the target organ of the allergic response&#44; and therefore cannot diagnose asthma when used alone&#46; Once the disease has been diagnosed&#44; the causal relationship must be identified&#44; starting with an observation of changes in clinical signs&#44; lung function &#40;serial peak flow measurements and hyperresponsiveness to methacholine&#41; and markers of inflammation &#40;eosinophil count and measurement of exhaled nitric oxide&#41; in response to exposure and separation from the workplace trigger in alternating periods of at least 2 weeks&#46; Evaluating the results of these studies as a whole will increase their diagnostic yield&#44; and although they have their limitations&#44; they are often sufficient to give a high degree of certainty&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The specific bronchial challenge test is the gold standard for identifying the allergy trigger&#59; however&#44; it is rarely used and poorly implemented&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> In some hospitals&#44; it is a first-line procedure&#44; although in most it is used when alternative methods have failed to provide conclusive evidence&#46; Other indications include identification of new triggers not previously described&#44; cases where re-exposure to the workplace is impossible&#44; and as a gold standard test in research&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Diagnosis of irritant-induced asthma depends on evidence of asthma together with a history of exposure and clinical signs&#44; none of which are wholly conclusive&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">All the aforementioned studies will only yield reliable results when performed following strict quality and safety standards&#44; but they are time-consuming&#44; and not all hospitals have the required resources&#46; Moreover&#44; it is important to gain the trust of the worker and help them understand the need for patience and cooperation in reaching a firm diagnosis that will always be to their advantage&#46; The cost of obtaining an accurate diagnosis is no higher than the cost of poorly controlled disease&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">A brief look at current recommendations reveals areas of improvement&#44; and it is clear that diagnosis is a process that involves the general practitioner&#44; occupational physician&#44; pulmonologist and allergist&#44; and often requires specialized units&#46; Professionals in the field of occupational medicine and primary care should bear in mind that&#58; &#40;1&#41; Occupational asthma should be suspected in all workers presenting with initial symptoms of asthma or with poorly controlled disease&#44; &#40;2&#41; A comprehensive occupational history is crucial when dealing with workers with respiratory symptoms&#44; &#40;3&#41; Not all asthma related with a patient&#39;s job is necessarily occupational asthma&#44; &#40;4&#41; Occupational asthma cannot be ruled out on the basis that the job is not considered high-risk&#44; and &#40;5&#41; Both causal and aggravating factors can be present&#44; and non-specific causal factors such as fungi and plants can be found in the workplace&#46; In addition to these factors&#44; pulmonologists must ensure they reach an objective diagnosis of asthma&#44; and when they lack the resources needed to establish a causal relationship&#44; they must refer the patient to specialized units to complete the diagnostic process and confirm their suspicions&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The epidemiological significance of occupational asthma is beyond dispute&#46; In recent years&#44; a number of tools have been developed to help physicians overcome diagnostic uncertainty&#46; Despite this&#44; the data show that occupational asthma is under-diagnosed&#44; and it is up to healthcare professionals to make good use of existing recommendations to improve their diagnostic skills and improve their understanding of this disease&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest&#46;</p></span></span>"
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