Abstract

This guideline describes the workplace-related inhalation test, in German named “Arbeitsplatz-bezogener Inhalationtest (AIT)” for the identification of allergic or immunological asthma and hypersensitivity pneumonitis (also called exogenous allergic alveolitis) in patients with symptoms such as cough, wheezing or shortness of breath in the workplace, including delayed reactions. The AIT or workplace-related inhalation test is an elaborate specific test in which the sick person is exposed in a controlled manner under laboratory conditions to an agent present in his or her workplace. Common synonyms for the workplace-related inhalation test or, in international usage, “specific inhalation challenge” (SIC) include “specific bronchial provocation testing” and “occupational-type challenge testing” [41].

Woitowitz (Germany 1970) [45] and Pepys (UK 1975) [24] are considered early developers of the AIT and SIC, respectively. The SIC is now well established in occupational health diagnostics; its implementation has been refined. It is an important component in the diagnosis of workplace-related asthma; it can also be used in the diagnosis of hypersensitivity pneumonitis when the diagnosis cannot be confirmed otherwise. The SIC remains the best method for identifying and documenting the allergological relevance of new working materials to the upper and lower respiratory tract.

The concept of SIC on which the guideline is based allows the use of native agents as well as allergen solutions to detect or exclude characteristic reactions in the area of the deeper airways and the upper respiratory tract, i.e. the nasal mucosa.

The aim and purpose of this guideline is to describe the SIC based on the current state of knowledge in occupational medicine and pneumology. It is intended to provide guidance for the diagnosis of workplace-related respiratory diseases. The SIC allows the verification of the probable causal relationship between workplace-related inhalation exposure and a respiratory or lung disease. It is therefore an important component for answering the question of whether, from a preventive point of view, it is medically justifiable for the sick person to continue to be exposed at the workplace. In addition to a review of the scientific literature, this guideline also contains practical advice on the implementation of SIC.

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2. Methodology of guideline development
The guideline on SIC was compiled according to the guidelines for the development of medical guidelines of the Association of the Scientific Medical Societies in Germany (AWMF, www. awmf.org). According to the three-stage concept of the AWMF, the present guideline corresponds to the S2k evidence grading. The following professional societies were involved in the development of the guideline:

German Society for Occupational and Environmental Medicine e. V. (DGAUM, notifying professional society)
German Society for Pneumology and Respiratory Medicine e. V. (DGP)
German Society for Allergology and Clinical Immunology e. V. (DGAKI)
as well as the German Respiratory League e. V. (GRL) as further professional representation. The individual mandated representatives of the professional societies are named under the authorship on the first page.

The recommendations formulated in the course of guideline development are based on two sources. First, the assessment of existing guidelines, in particular the comprehensive recommendations on the implementation of SIC published in 2014 by a task force of the European Respiratory Society (ERS) [41] and the German guideline from 2010 [3]. Second, an updated systematic literature search conducted for the period January 2013 – June 2018 using the bibliographic search terms published by the ERS Task Force [41, Appendix A] and updated until August 2020.

In addition to the evaluation of existing guidelines and the scientific literature, the clinical experience of the group members and theoretical considerations have also been incorporated into the recommendations. The consensus-building process took place through two face-to-face meetings of the group members on October 6, 2017 (Wiesbaden) and March 8, 2018 (Munich), repeated voting via video conferences and e-mails, and a final written circulation procedure (Delphi procedure) in accordance with the recommendations of the AWMF.

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