Lnv|ronmenta| and Cccupanona|

Lung D|sease (art I)

ClayLon 1. Cowl, Mu, MS, lCC, lACCLM
AssoclaLe rofessor of Medlclne
ulvlslon of ulmonary & Crlucal Care Medlclne
ulvlslon of revenuve, Cccupauonal & Aerospace Medlclne
ulrecLor, Cccupauonal / 1oxlcology Cllnlc
Mayo Cllnlc
8ochesLer, MlnnesoLa uSA

Iacu|ty D|sc|osures
ur. Cowl has no nanclal or oLher conlcLs of lnLeresL
Lo reporL regardlng Lhe Loplcs Lo be presenLed.
Learn|ng Cb[ecnves
Aer Lhls sesslon, learners wlll be able Lo:
8ecognlze Lhe complexlLy of assesslng occupauonal
lung dlsease ln Lerms of addresslng exposure, and ln
handllng admlnlsLrauve aspecLs lnvolved
undersLand essenual concepLs of dlagnoslng and
Lreaung a varleLy of work-relaLed condluons
8e famlllar wlLh baslc concepLs of aluLude
physlology, mounLaln lllness, and dlvlng medlclne/
hyperbarlc oxygen Lherapy
Lnv|ronmenta| and Cccupanona| Lung D|sease
on the A8IM u|monary 8oards (past)
Lnv|ronmenta| and Cccupanona| Lung D|sease
on the A8IM u|monary 8oards (present)
Wh|ch of the fo||ow|ng data sources are most |mportant |n the
assessment of panents w|th suspected occupanona| or
env|ronmenta| |||ness?
A. ueLalled occupauonal & envlronmenLal hlsLory
8. SplromeLry
C. 8adlographlc lmaglng
u. luncuonal/exerclse Lesung
L. MaLerlal SafeLy uaLa SheeLs (MSuS)
Assess|ng Cccupanona| or
Lnv|ronmenta| Lung D|sease
MosL envlronmenLally-lnduced lllness ls recognlzed only
aer a deLalled hlsLory ls obLalned
lLems vlLal for an Cccupauonal PealLh PlsLory lnclude:
1emporal assoclauon wlLh work?
CLher workers aecLed?
Was Lhere a rsL reporL of ln[ury (lncldenL reporL) led?
CurrenL and pasL occupauons?
ersonal proLecuve equlpmenL used?
Any secondary or oLher parL-ume [obs?
Pobbles, mlllLary servlce or oLher exposures?
CurrenL and pasL worklng hours?
Any change ln Lhe process or naLure of Lhe [ob?
Assess|ng Cccupanona| or
Lnv|ronmenta| Lung D|sease
ulagnoslng an occupauonal or envlronmenLal lllness wlll almosL always
lnLroduce admlnlsLrauve lssues
1he admlnlsLrauve aspecLs are Lyplcally forelgn Lo many provlders and
lnvolve recognluon of a varleLy of Lerms and compensauon sysLems:
IMLA (Iam||y Med|ca| Leave Act) - Allows ellglble" employees Lo
Lake o up Lo 12 work weeks ln any 12 monLh perlod for Lhe blrLh
or adopuon of a chlld, Lo care for a famlly member, or lf Lhe
employee Lhemself has serlous healLh condluon.
MSDS (Mater|a| Safety Data Sheets) - A form llsung daLa
regardlng Lhe properues of a parucular subsLance (e.g. melung
polnL, bolllng polnL, ash polnL, LoxlclLy, healLh eecLs, rsL ald,
splll-handllng procedures, eLc.) lnLended Lo provlde workers and
emergency personnel wlLh procedures for handllng or worklng
wlLh LhaL subsLance ln a safe manner.

Assess|ng Cccupanona| or
Lnv|ronmenta| Lung D|sease
Impa|rment versus d|sab|||ty - 1erms lnLroduced by Lhe
WPC ln 1980 and suggesLed lmpalrmenL was an
abnormallLy of a sLrucLure or funcuon (e.g. splromeLrlc
alrow obsLrucuon), and dlsablllLy was Lhe funcuonal
consequence of Lhe lmpalrmenL.
Worker's compensanon - A Lype of no faulL" lnsurance
LhaL provldes compensauon of medlcal care for employees
who are ln[ured ln Lhe course of employmenL, ln exchange
for mandaLory rellnqulshmenL of Lhe employee's rlghL Lo
sue hls or her employer for Lhe LorL of negllgence.
Assess|ng Cccupanona| or
Lnv|ronmenta| Lung D|sease
ADA (Amer|cans W|th D|sab|||nes Act) - Slgned ln 1990 and
prohlblLs employers from dlscrlmlnaung agalnsL qualled
lndlvlduals wlLh dlsablllues ln [ob appllcauon procedures, hlrlng,
rlng, advancemenL, compensauon, [ob Lralnlng, and oLher
Lerms, condluons, and prlvlleges of employmenL. 1he covered
worker ls one wlLh or wlLhouL reasonable accommodauon, who
can perform Lhe essenual funcuons of Lhe [ob ln quesuon.
CSnA (Cccupanona| Safety & nea|th Adm|n|stranon) - ls Lhe
regulaLory agency of Lhe u.S. ueparLmenL of Labor
NICSn (Nanona| Insntute for Cccupanona| Safety and nea|th)
- a branch of Lhe CuC responslble for conducung research and
maklng recommendauons for Lhe prevenuon of work-relaLed
lllnesses and ln[urles
Work |mpa|rment and d|sab|||ty eva|uanon
(e.g. asthma)
ulagnosls of AsLhma
LvaluaLe for oLher causes
Assess 1reaLmenL
Suboptimal
Optimal
- Clve Lemporary raung
- 8ecommend speclc LreaLmenL
or referral Lo speclallsL
- SLaLe when Lo reassess
- Clve long Lerm lmpalrmenL raung
- Lxpress oplnlon wheLher Lhe
calculaLed raung over- or
underesumaLes lmpalrmenL
Assess impact on subjects life
Disability Awards
(nonmedical administrative process)
(Re-evaluate if
clinically changed)
Am Rev Respir Dis 1993;147:1056-61.

ls lL really
asLhma? lf
no, Lhen
CHEST September 2008; Vol. 134(3): Suppl 1S-41S.
Work-re|ated asthma (Dehn|nons)
Work-related asthma
Work-exacerbated asthma Occupational asthma
8tooJ tetm tbot tefets
to ostbmo tbot ls exocetboteJ
ot loJoceJ by lobolouoo
exposotes lo tbe wotkploce.
Astbmo ttlqqeteJ by votloos
wotk-teloteJ foctots lo wotkets
wltb pte-exlsuoq ostbmo
Astbmo ttlqqeteJ Je oovo loJoceJ
by seosluzouoo to o speclfc sobstooce
Work-re|ated asthma ep|dem|o|ogy
Work-related
Asthma

ASTHMA
Prevalence
9-15%
Balmes J. Am J
Respir Crit Care
Med. 2003; 167(5):
787-97.

Work-re|ated asthma
Immunologic-induced asthma
High-Molecular Weight Antigens
Low-Molecular Weight Antigens
Irritant-induced asthma
(RADS)
Inhalation of irritants, gases, fumes
Asthma with latency
Asthma without latency
Work-re|ated asthma preva|ence
May depend on speclc agenL of exposure
Lxamp|e: 1-S of workers exposed to 1DI
20 of workers exposed to ac|d anhydr|des
40 of workers exposed to a||ergens |n our |n
bak|ng |ndustry
1ype, source and concenLrauon of exposure
PosL suscepublllLy facLors (PLA haploLypes and oLher
geneuc polymorphlsms)
Work-re|ated asthma w|th |atency per|od
key: ou may see a panent at any po|nt |n th|s
progress|on.
Malo, Chan-Yeung. J Allergy Clin Immunol 2001; 108:317.
Agents
assoc|ated w|th
caus|ng
Cccupanona|
Asthma
Rabatin and Cowl. Mayo
Clinic Proc 2001; 76(6):
633-40.
There are more than
400 known causes of
work-related asthma.
http://www.occupationalasthma.com/
Click Causes tab
Categor|es of Sens|nzer-|nduced
Asthma (w|th |atency per|od)
n|gh Mo|ecu|ar We|ght
Anngens (>S,000 Da|tons)
More common
lanL, anlmal proLelns
lg-L medlaLed allerglc
response
Skln prlck Lesung or
8AS1 Lesung avallable
for many subsLances
lmmedlaLe asLhmauc
response mosL common
ALopy a rlsk facLor
Model of exLrlnslc"
asLhma
Low Mo|ecu|ar We|ght
Anngens (<S,000 Da|tons)
Less common
lndusLrlal chemlcals,
meLals (e.g. plaunum,
nlckel, 1MA)
non-lgL medlaLed
no speclc LesLs avallable
uelayed asLhmauc
responses are more
frequenL
ALopy noL a rlsk facLor
8lnd Lo nauve proLeln
carrler and LMW molecule
acLs as a hapLen
Ior the 8oards:
n|gh Mo|ecu|ar We|ght
Anngens
I|our and gra|n dust
a||ergens |n bakers
An|ma| prote|n anngens |n
|aboratory workers (mur|ne
ur|ne)
Natura| rubber |atex
prote|ns |n hea|th care
workers w|th g|oves
Low Mo|ecu|ar We|ght
Anngens
Meta| sa|ts (n|cke|,
chrom|um, p|annum)
Isocyanates (1DI, nDI)
Can cause severe sens|nv|ty
w|thout hx of atopy
||cacnc ac|d |n Western ked
cedar dust
Ac|d anhydr|des |n epoxy mfg
(e.g. tr|me|||nc anhydr|de)
Co|ophony |n so|derers
Wh|ch of the fo||ow|ng panents |s most ||ke|y to be
d|agnosed w|th kADS (reacnve a|rway dysfuncnon
syndrome)?
A. 22-year-old forkll operaLor wlLh aLoplc asLhma who
experlences cough and chesL paln whlle aL work
8. 32-year-old research Lechnlclan who 6 monLhs prlor
Look a posluon ln a lab analyzlng mouse excremenL and
now wheezes aL nlghL
C. 44-year-old palnLer who develops dyspnea and cough
elghL hours aer applylng a new Lwo-coaL palnL Lo a
seml-Lraller
u. 62-year-old laborer on a couon farm who has wheezlng
and chesL ughLness on Mondays LhaL lmproves
LhroughouL Lhe week
Reactive Airways
Dysfunction
Syndrome (RADS)
keacnve A|rways Dysfuncnon
Syndrome (kADS)
4n osthmo-/ike i//ness thot occurs oer o sinq/e exposure
to hiqh /eve/s of o respirotory irritont {vopor, fume, smoke)
frequent/y occurrinq oer o workp/oce occident or spi//.
5ymptoms deve/op within hours of exposure ond ore
ossocioted with methocho/ine cho//enqe responsiveness.
5ymptoms ond oirwoy responsiveness oen persist /onqer
thon one yeor ond moy be permonent.
"Low-uose k4u5" hos been described:
4n osthmo-/ike i//ness occurrinq over months or yeors to o /ow- or
moderote-/eve/ exposure to known respirotory irritonts .
Brooks SM, Lockey J. Am Rev Respir Dis 1981;123:A11.
atho|ogy of Work-re|ated Asthma
kesemb|es typ|ca| asthma
8ronchlal wall Lhlckenlng, eoslnophlllc lnlLraLes, alrway
edema, smooLh muscle hyperLrophy, lncreased alrway
secreuons and lnammauon.
In kADS
Slmllar Lo Lyplcal asLhma wlLh lncreased amounLs of
subeplLhellal brosls, and less 1-cell mucosal lnlLrauon.
Brooks SM, Lockey J. Am Rev Respir Dis 1981;123:A11.
Work-re|ated asthma d|agnos|s
An early recognluon of W8A wlLh removal from Lhe
causauve agenL lmproves probablllLy of recovery
SuspecL work as a cause of asLhma and obLaln deLalled
hlsLory
Larly, laLe and dual response pauerns may be noLed
A laLenL perlod ls Lyplcally requlred for alrway sensluzauon
SympLoms may progress LhroughouL Lhe workweek
Sequenual cllnlcal decllne may occur week by week resulung
ln perslsLenL alrway hyperresponslveness
lmmunologlc response develops ln a small percenLage of
Lhose exposed (oLherwlse conslder lrrlLanL-lnduced asLhma
lf muluple workers aecLed)
Work-re|ated asthma d|agnos|s
(cont.)
Conrm Lhe presence of asLhma
lf sensluzers suspecLed, obLaln lmmunologlc resulLs (e.g. skln
prlck, 8AS1, eLc.) - buL remember LhaL Lhese only documenL
exposure & noL a causal relauonshlp
Conslder Ll monlLorlng and non-spec lnhalauon challenge
llke meLhachollne (lf non-spec challenge ls negauve wlLhln 2
wks of lasL exposure, CA can be ruled ouL)
Speclc lnhalauon challenge
lew locauons avallable
Can be rlsky ln Lhose wlLh dramauc responses
Can be very eecuve ln ldenufylng a speclc causal agenL ln a complex
envlronmenL
SlLe vlslL
lrom: World Allergy Crganlzauon
Work-re|ated asthma d|agnos|s
(cont.)
unforLunaLely, ln Lhe real world" pauenLs oen have
le work and recovered, and secondary galn lssues
occaslonally arlse (e.g. reLrospecuve sympLomaLology")
Conslder oLher posslblllues lf Lhe dlagnosuc workup ls
negauve for asLhma:
Pypervenulauon syndrome
vocal cord dysfuncuon
Cardlac-relaLed abnormallues
osL-nasal drlp wlLh cough
Medlcauon-lnduced cough
Chronlc bronchlus
Work-re|ated asthma management
1herapy parallels sLandard asLhma LreaLmenL wlLh an
emphasls on envlronmenLal conLrols (e.g. removal
from proposed lnclung exposure)
lor workers exposed Lo sensluzers or poorly
conLrolled levels of lrrlLanLs, prlmary prevenuon
Lhrough conLrol of exposures uslng:
Lllmlnauon
SubsuLuuon
rocess modlcauon
8esplraLor use
Lnglneerlng conLrols
1CkIC INnALA1ICNS
A tra|n dera||s |n your commun|ty at 2 am resu|nng |n a ma[or
rupture of an unknown gas, and you are paged to ass|st w|th
severa| v|cnms who have been transported for eva|uanon to
the Lk. What |nformanon wou|d be most usefu| to you |n
car|ng for these panents?
A. number of Lank cars deralled
8. Color of Lhe smoke and gas plumes
C. WaLer solublllLy of Lhe gas
u. WheLher or noL Lhe gas lgnlLed or lf Lhere was an
exploslon
L. ConcenLrauon of Lhe gas aL slLe of derallmenL



What 1h|ngs Do I Need to Cons|der |n Assess|ng the
anent?
hyslcal roperues of Cas
AcuLe Cllnlc llndlngs as an AssessmenL of ln[ury SeverlLy
Common 1ypes of 1ox|c Inha|anons
Ammonla
Chlorlne uerlvauves
Sulfur dloxlde
nlLrogen oxldes
hosgene
Czone
Cadmlum
Mercury
Zlnc chlorlde
Mace & 1ear Cas
Cas
lormless sLaLe of mauer ln whlch
molecules move freely
Aerosol
SLable suspenslon of llquld dropleLs or
solld parucles ln a gaseous medlum
vapor
Caseous form of subsLance LhaL ls
normally a llquld or solld LhaL can be
changed back by lncreaslng amblenL
pressure or decreaslng LemperaLure
lume
Aerosol of solld parucles arlslng from a
chemlcal reacuon or condensauon of
vapors, usually aer combusuon of
molLen maLerlal


Smoke
volauzauon of gaseous and paruculaLe
producLs of combusuon

Water So|ub|||ty and Mechan|sm of In[ury of Gaseous
kesp|ratory Irr|tants
Irritant Gas Water solubility Mechanism of Injury
Ammonia High Alkali burns
Chlorine Intermediate Acid burns; reactive
oxygen species; reactive
nitrogen species
Hydrogen chloride High Acid burns
Oxides of nitrogen Low Acid burns; reactive
oxygen species; reactive
nitrogen species
Ozone Low Reactive oxygen species;
reactive nitrogen species
Phosgene Low Acid burns; reactive
oxygen species; protein
acetylation
Sulfur dioxide High Acid burns; reactive
oxygen species
lrom SchwarLz uA: ln 8osensLock L (ed) Cccup Medlclne, 1987, pp 297-318.
Water So|ub|||ty and S|te of In|na| Impact of
1ox|c Irr|tants
lrom 8alklssoon 8: ln Cccupauonal upper Alrway ulsease. Clln ChesL Med 2002, 23:717-723.
Water Solubility Initial Level of
Impact
Inhalant
High Nose
Pharynx
Larynx
Ammonia
Chlorine
Sulfur dioxide
Medium Trachea
Bronchi
Ozone
Low Bronchioles
Alveoli
Nitrogen dioxide
Phosgene
hys|ca| ropernes of 1ox|c Irr|tants
Slze of parucles
WaLer solublllLy
ConcenLrauon of subsLance ln amblenL alr
uenslLy of subsLance
uurauon of exposure
resence or absence of venulauon
PosL facLors
Age, smoklng sLaLus, co-morbldlues
8esplraLory proLecuon
Spec|hc Compounds
Ammon|a
WaLer-soluble and nlLrogen conLalnlng
8anks among Lhe mosL commonly spllled hazardous
subsLances
Pousehold cleaner, chemlcal coolanL, ferullzer, xauve ln
phoLocoplers, used ln smelllng salLs
ulssolved lnLo waLer for LransporLauon and vaporlzes
upon exposure Lo alr
MeLhampheLamlne lab exposures
Spec|hc Compounds
Ammonla
"ked, Wh|te, and 8|ue rocess" of methamphetam|ne producnon

8ed phosphorus, pseudoephedrlne or ephedrlne (whlLe), and blue lodlne (whlch ls
Lechnlcally a purple color ln elemenLal form), from whlch hydrolodlc acld ls
formed.
uangerous process for amaLeur chemlsLs, because phosphlne gas, a slde-producL
from ln slLu hydrolodlc acld producuon, ls exLremely Loxlc Lo lnhale.
8lrch reducuon (also called Lhe "nazl meLhod"), ln whlch meLalllc llLhlum,
commonly exLracLed from non-rechargeable llLhlum, ls subsuLuLed for dlmculL-Lo-
nd meLalllc sodlum.
Powever, Lhe 8lrch reducuon ls dangerous because Lhe alkall meLal and llquld
anhydrous ammonla are boLh exLremely reacuve, and Lhe LemperaLure of llquld
ammonla makes lL suscepuble Lo exploslve bolllng when reacLanLs are added.
Spec|hc Compounds
Ammon|a
AecLs proxlmal alrways
lorms CP+ and ussue llquefacuon
ulls formerly lnLracellular waLer ouL of ussue, perpeLuaung
Lhe reacuon
8urns resulL from boLh pP and exoLhermlc reacuons
ulrecLly causuc Lo alrway aL levels of >1000 ppm
21 of a cohorL of ammonla-exposed pauenLs dled wlLhln 60
days from Lhelr ln[urles

Ammon|a
1reaLmenL
8emoval from source of lrrlLanL
Secure Lhe alrway (alrway managemenL musL be aggresslve)
Coplous lrrlgauon over all surfaces (especlally eyes) wlLh
waLer
Supporuve care
CorucosLerold and anublouc use noL shown Lo be beneclal ln
any peer-revlewed Lrlal
Spec|hc Compounds
Ch|or|ne, Ch|oram|nes, and nydroch|or|c Ac|d
PlsLorlcally, mosL ln[urles were seen ln WWl
Severe cases now mosLly lndusLrlal - ln paper manufacLure, cloLh
manufacLurlng, anusepucs
Common household cleanlng producL reacuon beLween hypochlorlLe
bleach and ammonla or phosphorlc acld or PCl
Common ln or around swlmmlng pools (calclum hypochlorlLe and
chlorlnaLed lsocyanurluc aclds) used for waLer purlcauon
ulrecL Loxlc eecLs on alrway due Lo reacuon producLs of PCl and
hypochlorous acld (PCCl)
May lrrlLaLe Lrlgemlnal nerve endlngs and Lrlgger bronchospasm
May form reacuve chemlcal specles wlLhln cell aer lonlzauon
1reaLmenL: Supporuve care, posslbly sodlum blcarbonaLe nebullzauon

Spec|hc Compounds
N|trogen Cx|des
Common alr polluLanLs released from combusuon englnes
and clgareue smoke, cases of hockey arena lssues
8esponslble for Sllo-llller's ulsease", an lnhalauon of nC
2

from decomposlng nlLrogenous blomaLerlal
Pydrolyzed by waLer Lo form nlLrlc and nlLrous acld
ls a llquld aL normal room LemperaLure and reddlsh-brown
gas aL LemperaLures greaLer Lhan 70 degrees l smelllng llke
clover"
1he calm before Lhe sLorm" lncludes mlld cough, faugue
and mlld nausea - lnLense pulmonary edema and an A8uS-
llke reacuon Lhen may ensue wlLh 8C laLer

1reaLmenL: vlgllanL monlLorlng and supporuve care
Spec|hc Compounds
hosgene (carbony| ch|or|de or CCC|
2
)
Was WWl gas agenL, currenLly used ln Lhe producuon of pesucldes,
polyureLhane, 1ul, and dyes
May be produced accldenLally because of heaL decomposluon of solvenLs, dry
cleanlng ulds, or weldlng o-gasslng
Low waLer solublllLy so peneLraLes deep lnLo alveolar spaces
Colorless, lacks a sLrong odor
non-lrrlLaung Lo Lhe upper alrway mucosa
Can see eplLhellal necrosls ln dlsLal alrways (reacLs wlLh waLer Lo make PCl
and CC2, and rapldly aceLylaLes ussue proLelns
auenLs may experlence chesL ughLness, wheezlng or cough and some have
no sympLoms, laLenL perlod 30 mlnuLes Lo 8 hours laLer may lnvolve worse
sympLoms and pulmonary edema
1reaLmenL: 8emoval from source and supporuve care (dlrecLed aL pulmonary edema)

Spec|hc Compounds
Czone
Colorless, odorless gas
Low waLer solublllLy
Maln oxldanL polluLanL ln smog
AcuLe exposures relaLed Lo cerLaln dlslnfecLanLs, fabrlc bleachlng, plasucs
manufacLure
ls exLremely reacuve and forms reacuve nlLrogen specles LhaL Lyplcally
aecL Lhe membrane llplds

1reaLmenL: 8emoval from source and supporuve care (dlrecLed aL pulmonary
edema)

Spec|hc Compounds
Cadm|um
Plghly corroslon-reslsLanL meLal
used mosLly ln nlckel-cadmlum bauerles, buL also ln a wlde range of lndusLrlal
sources
lnhlblLs Lhe synLhesls of alpha-1-anuLrypsln, causlng hlgher prevalence of
emphysema ln Lhese pauenLs
When maLerlals wlLh cadmlum are heaLed, cadmlum vapors and cadmlum
oxlde fumes released
auenLs have mlld fever, malalse, and myalglas followed occaslonally by
resplraLory fallure
Can use urlne Lo deLecL
Serum and urlne Cadmlum levels are elevaLed from clgareue smoklng
1reaLmenL: 8emoval from source and supporuve care (dlrecLed aL pulmonary edema)

Spec|hc Compounds
Su|fur d|ox|de (SC
2
)
Peavy, colorless, and hlghly waLer-soluble
ungenL odor of burnL maLches
MosL dangerous emlsslon from volcanos (Cameroon, 1986)
8emalns low Lo ground
8eacLs Lo form sulfurlc acld and muluple by-producLs can be reacuve
oxygen specles
May cause boLh upper and lower alrway lrrlLauon
1reaLmenL: 8emoval from source and supporuve care lncludlng humldled
supplemenLal oxygen and bronchodllaLors

Spec|hc Compounds
Mercury
Low solublllLy ln dlsulled waLer buL solublllLy lncreases wlLh conLacL wlLh
plasma or whole blood
Mercury gas ls very volaule
lound ln denLal amalgams, cemenL producuon, fossll fuel combusuon,
mercury spllls (schools, eLc)
Can experlence meLalllc LasLe ln mouLh and resplraLory sympLoms are
oen laLe onseL (mosL lssues are neurologlcally relaLed)
Crganlc versus lnorganlc Pg and homeopaLhlc scams (chelauons)

1reaLmenL: 8emoval from source and supporuve care (rarely, chelauon)
Spec|hc Compounds
2|nc ch|or|de (hex|te or 2nC|
2
)
1he cornersLone lngredlenL of smoke bombs and smoke generaLors
8esulLs from lnhalauon aer zlnc oxlde reacLs wlLh hexachloroeLhane
ZnCl2 ls an ulLrane parucle, whlch can peneLraLe lnLo Lhe lower
resplraLory LracL
lorms Lracheobronchlus and pneumonlus
Conslder zlnc urlne level
+/- use of n-aceLyl cysLelne (may faclllLaLe zlnc clearance)



Spec|hc Compounds
Mace and 1ear Gas
An acuLe resplraLory lrrlLanL used for crowd conLrol and securlLy
auenLs develop very acuLe lnLense mucosal membrane reacuons
Cne case of hypersensluvlLy has been reporLed resulung ln deaLh
1reaLmenL ls supporuve



Stay tuned for Lnv|ronmenta| &
Cccupanona| (art 2) !