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Occupational Medicine Advance Access published online on February 27, 2008
Occupational Medicine, doi:10.1093/occmed/kqn013
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© The Author 2008. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Which agents cause reactive airways dysfunction syndrome (RADS)? A systematic review

M. S. Shakeri1, F. D. Dick2 and J. G. Ayres2

1 Department of Occupational Heath, Province Health Centre, Mazandaran University of Medical Science, Sari, Iran
2 Department of Environmental & Occupational Medicine, Institute of Applied Health Sciences, School of Medicine, University of Aberdeen, Aberdeen, UK

Correspondence to: Jon Ayres, Department of Environmental & Occupational Medicine, Liberty Safe Work Research Centre, Institute of Applied Health Sciences, School of Medicine, University of Aberdeen, Foresterhill Road, Aberdeen AB25 2ZP, UK. Tel: +44 1224 558188; fax: +44 1224 551826; e-mail: j.g.ayres{at}abdn.ac.uk


   Abstract
Top
 Abstract
Background
 Methods
 Results
 Discussion
 Conflicts of interest
 References
 
Aim: To identify those agents reported as being associated with reactive airways dysfunction syndrome (RADS).

Methods: A systematic review was undertaken. Abstracts were screened and those selected reviewed against pre-determined diagnostic criteria for RADS.

Results: Significant information gaps were identified for all measures of interest. In some articles, even the causative agent was not reported. The most commonly reported agents were chlorine (nine subjects), toluene di-isocyanate (TDI) (n = 6) and oxides of nitrogen (n = 5). Most exposures occurred in the workplace (n = 51) and affected men (60%). Dyspnoea (71%) and cough (65%) were the commonest symptoms. Median symptom duration was 13 months (interquartile range = 6.5–43.5) for RADS.

Conclusions: Although the most commonly reported agent associated with RADS was chlorine, the main finding of a general lack of adequate information on exposure, investigation and outcome suggests that to better explore RADS a more structured approach to gathering information is required. A minimum data set for reporting RADS cases is proposed.

Keywords      Asthma; irritant-induced asthma; reactive airways dysfunction


   Background
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 Abstract
 Background
Methods
 Results
 Discussion
 Conflicts of interest
 References
 
Twenty years ago, Brooks coined the term ‘reactive airway dysfunction syndrome’ (RADS) [1] which he defined as symptoms simulating asthma within 24 h of a single, massive, chemical exposure. The United Kingdom surveillance of work-related and occupational respiratory disease (SWORD) survey found that the prevalence of asthma in those who had had an acute irritant exposure varied, apparently affected by the intensity and length of acute exposure, the duration of follow-up and the suspected agent [2]. As the agent involved in RADS may affect prognosis, the authors aimed to assess the range of agents implicated in RADS.


   Methods
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 Methods
Results
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A systematic review of RADS using Brooks' criteria (see Figure 1) was undertaken. Studies were included if subjects suffered from RADS as defined by Brooks. Reactive airways dysfunction was defined (see Figure 1) as requiring a documented absence of preceding respiratory complaint with symptom onset occurring after a single specific exposure incident to a gas, smoke, fume or vapour present in very high concentrations which had irritant qualities to its nature. Further, Brooks required that the onset of symptoms occurred within 24 h after the exposure and persisted for at least 3 months, that symptoms simulated asthma (cough, wheezing, chest tightness and dyspnoea) and that while pulmonary function tests might show airflow obstruction, methacholine challenge testing was positive and other types of pulmonary disease were ruled out. Studies were excluded if they contained no cases meeting Brooks' RADS criteria or were duplicate publications or follow-up studies.


Figure 1
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  		Figure 1. Flow chart showing on the left the suggested minimum data set for reporting any case of reactive airways dysfunction and on the right Brook's diagnostic criteria referred to in this review.

 
Studies were identified by searching MEDLINE, EMBASE and CINAHL from 1985 to 2005 (limited to English language and further limited to human research for EMBASE and MEDLINE) supplemented by review of references of recent review articles and original reports. The search was complemented by hand-searching conference abstracts published in the American Review of Respiratory and Critical Care Medicine, European Respiratory Journal and Thorax from 1985 onwards. Keyword search terms included reactive airways dysfunction syndrome, irritant-induced asthma, toxic gas inhalation, non-immunologic asthma or irritant gas.

Two people (M.S.S. and F.D.D.) reviewed all titles and abstracts to exclude studies that failed to meet inclusion criteria. Full texts selected were reviewed to exclude studies where the patient did not have RADS. Disagreements on three cases were resolved by discussion. A single reviewer (M.S.S.) extracted data on the causative agent or agents, exposure level, duration of overexposure, location of accident, number of cases, symptom onset, symptoms, symptom duration, the provocation concentration causing a 20% fall (PC20) in forced expiratory volume in 1 s after inhalation of methacholine or histamine, forced expiratory volume in 1 s (FEV1%), FEV1/forced vital capacity ratio (FVC), variation of PEF, treatment onset, treatment type, treatment response, atopy and, where undertaken, biopsy results. After data extraction, results were entered on separate tables for each category of data (e.g. PC20, FEV1%) extracted.


   Results
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 Abstract
 Background
 Methods
 Results
Discussion
 Conflicts of interest
 References
 
Eighty-four articles and abstracts were found but 25 of the articles identified either contained no cases meeting RADS criteria or were duplicate publications or follow-up studies and so were excluded. Among the 633 cases described in the 59 articles selected, 63 cases met Brooks' criteria and 570 had insufficient data for allocation to RADS. Of the 63 RADS cases, 38 (60%) were male, 12 (19%) female and in 13 (21%) gender was not reported. The mean age in this group was 37.8 (SD 11.6) years but age was not reported for seven people.

The most common agents in patients who met Brooks' criteria were chlorine (nine subjects), TDI (six subjects), oxides of nitrogen (five subjects), acetic acid (four subjects), sulphur dioxide (four subjects) and paint (four subjects) [1].

The most frequent location of exposure episode in those with RADS (n = 63) was the workplace (n = 51) with others occurring in the environment (eight subjects), home (three subjects) and not reported (one subject). The proportion of non-atopic patients was higher than atopic patients but for 41% of RADS group atopic status was not reported.

The onset of symptoms in Brooks' group occurred immediately (within 1 h) in 29 patients and within 24 h in 34 patients. In one article that reported 20 cases [3], the onset of symptoms in 17 cases occurred within 24 h and in three cases within 1 week. It is unclear in which of those cases symptoms began within 1 week. As it was not possible to categorize these 20 patients, they were excluded.

Dyspnoea, cough and wheeze were the most common symptoms. Seventy-one per cent of RADS subjects had dyspnoea (n = 45), 65% cough (n = 41), 43% wheeze (n = 31), 43% chest tightness (n = 27), 29% upper respiratory irritation (n = 18), 25% eye irritation (n = 16), 16% mucus production (n = 10) and 6% cyanosis (n = 4). In the RADS group, symptom duration was recorded in all cases. The median and interquartile range (IQR) for symptom duration in patients who met Brooks' criteria was 13 (6.5–43.5) months.

Of 63 patients who met Brooks' criteria, 19 (30%) were smokers with a median (IQR) consumption of 11 (7–18)) pack-years, 7 patients (11%) were ex-smokers with a median (IQR) consumption 5 (5–10.8) pack-years and 21 (33%) patients were non-smokers. In 16 subjects with RADS (25%), no information was given about smoking.

Information regarding FEV1% was available for 49 of the 63 (78%) subjects with RADS. Among these 49 subjects, 16 subjects (33%) had an FEV1% <80%, the median (IQR) for FEV1% being 63% (55.5–75). FEV1/FVC ratios were available for 44 of the 63 patients (70%) meeting Brooks' criteria and in 23 of these 44 cases (52%), the ratio was <80%. The median FEV1/FVC ratio was 69% (64.3–71.8).


   Discussion
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 Abstract
 Background
 Methods
 Results
 Discussion
Conflicts of interest
 References
 
The most commonly reported agents in the literature associated with a diagnosis of RADS were chlorine, TDI and oxides of nitrogen. The agents most frequently implicated in RADS were as anticipated although this list is likely to be incomplete as many cases of RADS may go unreported. It is possible that a degree of publication bias exists as once an agent has been first reported thereafter single case studies are less likely to be published and so the relative contribution of some agents to the overall burden of RADS may be underestimated. As these reports are essentially descriptive papers such suspected publication bias cannot be formally tested. However, the main finding was the remarkable inconsistency in the information provided, which in many cases did not permit a diagnosis of RADS despite being reported as such. In >40% of all cases, data were missing. In five articles, the causative agents were not stated.

Information on outcomes in relation to exposures needs to be collected formally and in a structured way if better advice and understanding of these conditions is to be gained. It is proposed that the data listed in Figure 1 constitute a minimum data set for reporting of RADS cases in the medical literature. A web-based reporting system with a database that could be updated online to permit the reporting and follow-up of cases would be of benefit and would deal to some extent with the issue of publication bias.

In summary, a systematic review of agents reported as being associated with RADS has been undertaken. The key finding is a lack of complete reporting of relevant information which limits generalization from, or summary of, these reports. As a consequence, a minimum data set for reporting RADS in the literature is proposed.


   Conflicts of interest
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 Abstract
 Background
 Methods
 Results
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 Conflicts of interest
References
 
None declared.


Appendix 1: Papers included in systematic review and agents implicated in RADS

First author Year RADS exposures (No.)a Cases not meeting Brooks' criteria (No.)a
Brooks [1] 1985 Uranium hexafluoride, floor sealant, spray paint (3), 35% hydrazine, heated acid, fumigating fog, metal coat remover, fire/smoke
Boulet [21] 1988 Sulphuric acid, bleaching agent, perchloroethylene, TDI
Tarlo [5] 1989 Acids, chlorine, sulphuric acid, sulphur dioxideb, burnt paint fume, spray paint without isocyanates, chlorine, TDI, diphenyl methane diisocyanate
Gilbert [28] 1989 Dust or mold in silo (fungus)
Luo [12] 1990 TDI (2)
Promisloff [20] 1990 Sodium hydroxide, silicon tetrachloride, trichlorosilane b(2) Sodium hydroxide, silicon tetrachloride, trichlorosilane b
Demeter [29] 1990 Sulphuric acid, unknown Lithium bromide, hydrogen chloride, cleaning solvent, zinc chloride (11)
George [30] 1990 Smoke (7)
Saric [31] 1991 Respiratory irritant such as hydrogen fluoride (30)
Kern [32] 1991 Acetic acid (4) Acetic acid
Angelillo [17] 1992 Chlorine (3)
Hu [33] 1992 o-chlorobenzylidene malononitrile
Blanc [34] 1993 Sodium azide (2), epoxy resin, household cleaner containing morpholine
Palczynski [35] 1994 TDIs
Chan-Yeung [36] 1994 Sulphur dioxide, hydrogen sulphide, acetic acid, hydrogen peroxide, chlorine, chlorine dioxide, hydrogen sulphide, methyl mercaptan, sulphur dioxide, hydrogen peroxide b(2)
Gautrin [37] 1994 Chlorine (12), nitrogen dioxide (3)
Palczynski [38] 1994 Freons and phosgeneb
Deschamps [39] 1994 Sodium hypochlorite and hydrochloric acid (chlorine)b
Tarlo [40] 1995 Isocyanates (8), acid (3), acrylate (2), solvents, fume (2)
Sallie [41] 1995 Chlorine (9), sulphur dioxide (4), oxides of nitrogen (3), phosphine (2), ammonia (2), hydrogen sulphide, hydrogen chloride gas, sodium hydroxide, sulphuric acid, chloracetyl chloride, sodium fumes, hypochlorite, carboxylic acid, cleaning agents (3), combustion products (3), isocyanate (3), epoxy resin, glutaraldehyde, azodicarbonamide, aromatic amine, enzymes, trichloroethylene (3), methylene chloride, paint, pesticide, lubrication oil, unknown chemical
Stanbury [42] 1996 Pentamidine
Piirila [15] 1996 Sulphur dioxide (4) Sulphur dioxide
Cormier [43] 1996 Hydrogen sulfide
Weiss [18] 1996 Sodium azide and hydrozoic acidb (2)
Schonhofer [19] 1996 Chlorine (3)
Lemiere [44] 1996 Isocyanates mixed with organic solvent
Yelon [45] 1996 Formic acid
Lemiere [46] 1997 Chlorine
Burns [47] 1997 Bromine and hydrobromic acid (2)
Provencher [48] 1997 Chlorine, isocyanates and acid were the most often reported causal agent
Danielsen [49] 1998 Hydrogen peroxide (3)
Forrester [16] 1997 Refractory ceramic fibre, phosphoric acidb
Leroyer [50] 1998 Diphenylmethane diisocyanate
Conrad [51] 1998 Dinitrogen tetroxide (5)
Wheeler [52] 1998 General fume (4), solvent/hydrocarbon (2), corrosive agents (3), formaldehyde (3), irritant gas (2), other (4)
Chatkin [6] 1999 TDI (4), isocyanate, chlorine, spray paint Methyl mercaptan, solvent, glueb, solvent, acrylateb, TDI, isocyanate
Woolf [53] 1999 Bromine
de la Hoz [13] 1999 Bromotrifluoromethane, hydrogen fluoride, hydrogen bromide, carbonyl fluoride, carbonyl bromideb
Langley [54] 1999 Welding fume
Hill [55] 2000 o-chlorobenzylidene malononitrile (CS)
Meyer [56] 2001 Hydrogen fluoride, nitric acidb, aldehydes, acetic acidb
Dube [57] 2002 Fume from an iron smelting process
Kopferschmitt-Kubler [58] 2002 Acid (4), chlorine (3), isocyanate (3)
Perfetti [59] 2003 Diphenylmethane diisocyanate
McLaughlin [60] 2003 Chlorine (2), rubber fume, sewerage gas, ammonia, propionic acid, NH4 and sorbic acidb, ethanol, isopropanol, gingerineb
Piirila [22] 2003 Thermal decomposition products of CFC(2)
Henneberger [61] Some selected agents 2003 Nickel, Petroleum fraction (2), smoke (3), diisocyanates (2), soldering fume, caustic acids, dry wall powder, solvents (5), glues, 2-butoxyethanol, styrene-maleic anhydride resin, isopropanol, herbicides, sulfur dioxide, Petroleum distillate, Copier toner, Safrotin, Chemicals (NOS) (4), Ethyl acrylate, Sewer cleaner chemicals, paint fumes, diesel fuel, sodium hydroxide, chlorine, diazonin, gasoline, diesel fuel, ethylene glycolb, ammonia, acids, bases, oxidizer (NOS)b, muriatic acid, ethanolamines, indoor air pollutant
Franzblau [14] 2003 Hydrofluoric acid
Rosenman [62] 2003 Cleaning agent (42)
Banauch [63] 2003 World trade centre fume (20)
Matrat [11] 2004 Bromochlorodifluoromethane Bromochlorodifluoromethane (2)
Gorguner [64] 2004 Sodium hypochlorite and hydrochloric acid (chlorine) (55)b

a n =1 except where otherwise indicated.

b Indicates exposure to multiple agents.


   References
Top
 Abstract
 Background
 Methods
 Results
 Discussion
 Conflicts of interest
 References
 

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