title: Bronchial asthma and COPD due to irritants in the workplace - an evidence-based approach.
abstract: BACKGROUND
  Respiratory irritants represent a major cause of occupational obstructive airway diseases. We provide an overview of the evidence related to irritative agents causing occupational asthma or occupational COPD.
  
  
  METHODS
  We searched MEDLINE via PubMed. Reference lists of relevant reviews were also screened. The SIGN grading system was used to rate the quality of each study. The modified RCGP three-star system was used to grade the body of evidence for each irritant agent regarding its causative role in either occupational asthma or occupational COPD.
  
  
  RESULTS
  A total of 474 relevant papers were identified, covering 188 individual agents, professions or work-sites. The focus of most of the studies and the predominant diagnosis was occupational asthma, whereas occupational COPD arose only incidentally.The highest level assigned using the SIGN grading was 2+ (well-conducted systematic review, cohort or case-control study with a low risk of confounding or bias). According to the modified RCGP three-star grading, the strongest evidence of association with an individual agent, profession or work-site ("**") was found for 17 agents or work-sites, including benzene-1,2,4-tricarboxylicacid-1,2-anhydride, chlorine, platinum salt, isocyanates, cement dust, grain dust, animal farming, environmental tobacco smoke, welding fumes or construction work. Phthalic anhydride, glutaraldehyde, sulphur dioxide, cotton dust, cleaning agents, potrooms, farming (various), foundries were found to be moderately associated with occupational asthma or occupational COPD ("*[+]").
  
  
  CONCLUSIONS
  This study let us assume that irritant-induced occupational asthma and especially occupational COPD are considerably underreported. Defining the evidence of the many additional occupational irritants for causing airway disorders will be the subject of continued studies with implications for diagnostics and preventive measures.
authors.affiliation: Institute for Occupational and Maritime Medicine, University Medical Center Hamburg-Eppendorf, Seewartenstr, 10, 20459, Hamburg, Germany. baur@uke.uni-hamburg.de.
authors.forename: Xaver
authors.initials: X
authors.lastname: Baur
authors.forename: Prudence
authors.initials: P
authors.lastname: Bakehe
authors.forename: Henning
authors.initials: H
authors.lastname: Vellguth