U.S. Fire Administration Mission Statement

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2 U.S. Fire Administration Mission Statement As an entity of the Department of Homeland Security s Federal Emergency Management Agency, the mission of the USFA is to reduce life and economic losses due to fire and related emergencies, through leadership, advocacy, coordination and support. We serve the Nation independently, in coordination with other Federal agencies, and in partnership with fire protection and emergency service communities. With a commitment to excellence, we provide public education, training, technology, and data initiatives. This project was developed through a Cooperative Agreement (Developing Materials on the Long-Term Health Effects of Occupational Respiratory Exposures on Fire Fighters' Respiratory Health and the Ability of Exposure Reduction and Post-Exposure Mitigation Strategies to Improve Outcomes - EME-2003-CA-0342) between the Department of Homeland Security, United States Fire Administration and the International Association of Fire Fighters. Copyright 2010 by the International Association of Fire Fighters. This publication is protected by copyright. The IAFF authorizes the reproduction of this document exactly and completely for the purpose of increasing distribution of the materials. None of the materials may be sold for a profit under the provisions of public domain. These materials have been copyrighted under the copyright laws of the United States. Permission to duplicate these materials is conditional upon meeting the above criteria and may be rescinded by the IAFF for failure to comply International Standard Book Number:

3 PREFACE The United States Fire Administration (USFA) is committed to using all means possible for reducing the incidence of occupational diseases, injuries and deaths to fire fighters. One of these means is to partner with fire service organizations who share this same admirable goal. One such organization is the International Association of Fire Fighters (IAFF). As a labor union, the IAFF has been deeply committed to improving the safety of their members and all fire fighters as a whole. This is why the USFA was pleased to work with the IAFF through a cooperative agreement to research and develop materials addressing the long-term effects from occupational respiratory exposures on fire fighter s health and the ability of exposure reduction and post-exposure mitigation strategies to improve health outcomes. The USFA gratefully acknowledges the following leaders of the IAFF for their willingness to partner on this project. General President Harold A. Schaitberger General Secretary-Treasurer Thomas H. Miller Assistant to the General President Occupational Health, Safety & Medicine Richard M. Duffy Director of Occupational Health and Safety James E. Brinkley International Association of Fire Fighters, AFL-CIO, CLC Division of Occupational Health, Safety and Medicine 1750 New York Avenue, NW Washington, DC (202) (202) (FAX) Respiratory Diseases and the Fire Service i

4 The IAFF would also like to thank the following editors and authors for their contributions in addressing fire fighter respiratory diseases and the editors for their tireless efforts in developing and editing this manual so it is consistent, readable and understandable to this Nation s fire service. EDITORS: Richard Duffy, MSc Assistant to the General President Occupational Health, Safety and Medicine International Association of Fire Fighters Washington, DC Andrew Berman, MD Program Director, Combined Training Program in Pulmonary and Critical Care Medicine Associate Professor of Clinical Medicine Albert Einstein College of Medicine Pulmonary Division Montefiore Medical Center Bronx, NY David Prezant, MD Professor of Medicine Albert Einstein College of Medicine Pulmonary Division Montefiore Medical Center Bronx, NY and Chief Medical Officer, Office of Medical Affairs Co-Director of WTC Medical Programs Fire Department City of New York Brooklyn, NY CONTRIBUTING AUTHORS: Amgad Abdu, MD Pulmonary Fellow Albert Einstein College of Medicine Montefiore Medical Center Bronx, NY Thomas K. Aldrich, MD Professor of Medicine Albert Einstein College of Medicine Pulmonary Division Montefiore Medical Center Bronx, NY David W. Appel, MD Associate Professor of Medicine Albert Einstein College of Medicine Director of the Pulmonary Sleep Laboratory Pulmonary Division Montefiore Medical Center Bronx, NY Matthew P. Bars, MS, CTTS Director- FDNY Tobacco Cessation Program Director, IQuit Smoking Centers of Excellence Program Director-Palisades Medical Center Montvale, NJ Andrew Berman, MD Program Director, Combined Training Program in Pulmonary and Critical Care Medicine Associate Professor of Clinical Medicine Albert Einstein College of Medicine Pulmonary Division Montefiore Medical Center Bronx, NY Alpana Chandra, MD Albert Einstein College of Medicine Pulmonary Division Jacobi Medical Center Bronx, NY Naricha Chirakalwasan, MD Pulmonary Fellow Albert Einstein College of Medicine Montefiore Medical Center Bronx, NY Asha Devereaux, MD, MPH President-California Thoracic Society Pulmonary and Critical Care Medicine Coronado, CA ii Respiratory Diseases and the Fire Service

5 Peter V. Dicpinigaitis, MD Professor of Clinical Medicine Albert Einstein College of Medicine and Director Cough Center Pulmonary Division Montefiore Medical Center Bronx, NY Carrie D. Dorsey, MD, MPH Assistant Professor University of Maryland School of Medicine Occupational Health Program Baltimore, MD Richard Duffy, MSc Assistant to the General President Occupational Health, Safety and Medicine International Association of Fire Fighters Washington, DC Felicia F. Dworkin, MD Deputy Director Medical Affairs Bureau of Tuberculosis Control New York City Department of Health and Mental Hygiene New York, NY Adrienne Flowers, MD University of Maryland School of Medicine Occupational Health Program Baltimore, MD James Geiling, MD Associate Professor of Medicine Dartmouth Medical School Hanover, NH and Chief, Medical Service VA Medical Center White River Junction, VT Subha Ghosh, MD Assistant Professor of Radiology Ohio State University Medical Center Department of Radiology Columbus, OH Linda B. Haramati, MD, MS Professor of Clinical Radiology Albert Einstein College of Medicine Director of Cardiothoracic Imaging Department of Radiology Montefiore Medical Center Bronx, NY Chrispin Kambili, MD Assistant Commissioner and Director, Bureau of Tuberculosis Control New York City Department of Health and Mental Hygiene New York, NY Robert Kaner, MD Associate Professor of Clinical Medicine Associate Professor of Genetic Medicine Weill Cornell Medical College Pulmonary Division New York Hospital New York, NY Kerry J. Kelly, MD Chief Medical Officer, Bureau of Health Services and Co-Director of World Trade Center Medical Programs Fire Department City of New York Brooklyn, NY Angeline A. Lazarus, MD Professor of Medicine Uniformed Services University Bethesda, MD Stephen M. Levin, MD Associate Professor of Medicine Department of Community and Preventive Medicine Mount Sinai School of Medicine New York, NY Michelle Macaraig, MPH Assistant Director for Policy and Planning Coordination Bureau of Tuberculosis Control New York City Department of Health and Mental Hygiene New York, NY Melissa A. McDiarmid, MD, MPH Professor of Medicine and Director, University of Maryland Occupational Health Program Baltimore, MD Lawrence C. Mohr, MD Professor of Medicine, Biometry and Epidemiology Director, Environmental Biosciences Program Medical University of South Carolina Charleston, South Carolina Diana Nilsen, MD, RN Director, Medical Affairs Bureau of Tuberculosis Control New York City Department of Health and Mental Hygiene New York, NY David Ost, MD, MPH Associate Professor of Medicine New York University School of Medicine New York, NY Respiratory Diseases and the Fire Service iii

6 David Prezant, MD Professor of Medicine Albert Einstein College of Medicine Pulmonary Division Montefiore Medical Center Bronx, NY and Chief Medical Officer, Office of Medical Affairs Co-Director of World Trade Center Medical Programs Fire Department City of New York Brooklyn, NY Jaswinderpal Sandhu, MD Pulmonary Fellow Albert Einstein College of Medicine Montefiore Medical Center Bronx, NY Michael R. Shohet, MD Associate Clinical Professor Otolaryngology- Head and Neck Surgery Mount Sinai School of Medicine New York, NY Dorsett D Smith, MD Clinical Professor of Medicine Division of Pulmonary Diseases and Critical Care Medicine Department of Medicine University of Washington Medical School Seattle, Washington Leah Spinner, MD Pulmonary Fellow Albert Einstein College of Medicine Montefiore Medical Center Bronx, NY Michael Weiden, MD Associate Professor of Medicine NYU School of Medicine Division of Pulmonary Medicine New York, NY and Medical Officer, Bureau of Health Services World Trade Center Medical Program Fire Department City of New York Brooklyn, NY In concert with the United States Fire Administration, the IAFF sought independent review of this effort to provide us with technical and critical comments so as to ensure a complete and sound final product. The IAFF thanks the following organizations and individuals for their review of this manual. William Troup Fire Program Specialist, Project Manager United States Fire Administration Emmitsburg, MD James Melius, MD, DrPH Chair, Medical Advisory Board International Association of Fire Fighters Administrator, New York State Laborers Health and Safety Trust Fund Albany, NY Lu-Ann Beeckman-Wagner, PhD Health Scientist Division of Respiratory Disease Studies NIOSH Morgantown, WV Robert Castellan, MD, MPH Expert Division of Respiratory Disease Studies NIOSH Morgantown, WV Sandy Bogucki, MD, PhD, FACEP Associate Professor, Emergency Medicine, Yale University Associate EMS Medical Director and Fire Surgeon, Branford Fire Department New Haven, CT Sara A. Pyle, PhD Assistant Professor Preventive Medicine & Family Medicine Kansas City University of Medicine & Biosciences Kansas City, MO Ed Nied Deputy Chief Tucson Fire Department Director, IAFC Health, Safety and Survival Section Tucson, AZ Christopher Coffey, PhD Chief Laboratory Research Branch Division of Respiratory Disease Studies NIOSH Morgantown, WV Paul Enright, MD Expert Consultant to NIOSH Professor University of Arizona Tucson, Arizona Thomas Hales, MD, MPH Senior Medical Epidemiologist Team Co-Leader, NIOSH Fire Fighter Fatality Investigation and Prevention Program NIOSH Cincinnati, OH iv Respiratory Diseases and the Fire Service

7 Paul Henneberger, ScD, MPH Research Epidemiologist Division of Respiratory Disease Studies NIOSH Morgantown, WV Mark Hoover, PhD, CHP, CIH, Research Physical Scientist Division of Respiratory Disease Studies NIOSH Morgantown, WV Rick Hull, PhD Technical Editor National Center for Chronic Disease Prevention and. Health Promotion NIOSH Atlanta, GA Eva Hnizdo, PhD Senior Service Fellow Division of Respiratory Disease Studies NIOSH Morgantown, WV Kay Kreiss, MD Chief Field Studies Branch Division of Respiratory Disease Surveillance NIOSH Morgantown, WV Travis Kubale, PhD Epidemiologist Division of Surveillance, Hazard Evaluations, and Field Studies NIOSH Cincinnati, OH Dori Reissman, MD, MPH Senior Medical Advisor Medical and Clinical Science Director WTC Responder Health Program NIOSH Washington, DC Roger R. Rosa, PhD Senior Scientist Office of the Director NIOSH Washington, DC Philip LoBue, MD Medical Officer National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Centers for Disease Control and Prevention Atlanta, GA Respiratory Diseases and the Fire Service v

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9 TABLE OF CONTENTS Introduction... 1 Fire Fighter Studies... 2 Worker Compensation and Benefits... 3 Implementing Respiratory Disease Programs... 6 Summary...8 The Normal Lung and Risks for Developing Lung Disease Chapter 1-1 Anatomy Lung Components Bronchial Tree Alveoli Parenchyma Cell Morphology and Function Normal Physiology References Chapter 1-2 Occupational Risks of Chest Disease in Fire Fighters Inhalation of Combustion Products Acute Effects Chronic Effects Summary of Studies of Pulmonary Function in Fire Fighters Fire Fighters and Diseases of the Respiratory System Summary of Studies of Respiratory Disease and Mortality in Fire Fighters References Lung Disease Chapter 2-1 Disorders of The Upper Aerodigestive Tract Introduction Anatomy Nose and Sinuses Oral Cavity, Pharynx, and Larynx Disease Rhinitis, Sinusitis, and Rhinosinusitis Pharyngitis, Laryngitis, and Laryngopharyngitis Chapter 2-2 Respiratory Infections Bronchitis and Pneumonia Introduction Airway Infections Acute Bronchitis Chronic Bronchitis Bronchiolitis Bronchiolitis Obliterans With Organizing Pneumonia (BOOP) Bronchiectasis Respiratory Diseases and the Fire Service vii

10 Pneumonias Pneumonia Mortality and Severity Assessment Common Organisms Responsible For Community-Acquired Pneumonias Hospital-Acquired Pneumonia Other Lung Infections Lung Abscess Pleural Effusions and Empyema References Chapter 2-3 Tuberculosis: A Primer For First Responders Introduction Epidemiology of TB Pathogenesis, Transmission, Infection & Proliferation Host Immune Response Progression From Infection to Active Disease Clinical Aspects of TB Disease Evaluation of Persons With Suspected Active TB Disease Diagnostic Microbiology Treatment of Patients With Active TB Disease Drug-Resistant TB Latent TB Infection Diagnostic Tests For TB Infection Tuberculin Skin Test (TST) Blood Tests (e.g. Quantiferon - TB Gold) Populations Who Should Be Tested For LTBI Interpretation of LTBIs: Causes of False Positive and False Negative TST Reactions BCG Vaccinated Individuals Vaccination With Live Attenuated Vaccines Anergy Two-Step Tuberculin Skin Testing Clinical Evaluation For Latent TB Infection Medical History and Physical Examination Chest X-Ray Sputum Examinations Considerations of Pregnant Women LTBI Treatment Regimens Isoniazid Rifampin Rifampin & PZA Combination Contacts to Multidrug Resistant TB (MDRTB) Cases Treatment of Close Contacts With A Prior Positive Test For TB Infection Monitoring Patients During Treatment viii Respiratory Diseases and the Fire Service

11 Summary References Chapter 2-4 Asthma Epidemiology Risk Factors Pathophysiology Clinical Manifestation Diagnosis Differential Diagnosis Classification of Asthma Severity Management of Asthma Medications Quick-Relief Medications Short-Acting Beta-Agonists (SABA) Anticholinergics Long-Term Control Medications Inhaled Corticosteroids (ICS) Long Acting Beta-Agonists (LABA) Leukotriene Receptor Antagonists (LTRA) Mast Cell Stabilizers Methyxanthines Anti IgE Antibody Immunotherapy Stepwise Approach to Therapy The Asthma Control Test Non-Pharmacologic Therapy Asthma Exacerbation References Chapter 2-5 Chronic Obstructive Lung Disease (COPD) Introduction Definition Pathology Natural History Clinical Manifestations Classification and Diagnosis of COPD Burden of COPD Risk Factors Management Summary References Chapter 2-6 Sarcoidosis References Respiratory Diseases and the Fire Service ix

12 Chapter 2-7 Pulmonary Fibrosis and Interstitial Lung Disease Pulmonary Fibrosis Major Categories of Interstitial Lung Disease and Pulmonary Fibrosis Symptoms of Pulmonary Fibrosis Physiologic Consequences of Interstitial Lung Disease and Pulmonary Fibrosis Diagnosis of Pulmonary Fibrosis Made Prognosis Available Treatment Prevention of Pulmonary Fibrosis Increased Risk to Fire Fighters Relationship to World Trade Center Exposure References Chapter 2-8 Pulmonary Vascular Diseases Pulmonary Hypertension (PH) Pathology Epidemiology Etiology Signs and Symptoms Classification Diagnostic Testing Medical Management General Measures Specific Measures Pulmonary Embolism Epidemiology Risk Factors Clinical Presentation Diagnostic Tests Evaluation for DVT D-Dimer Concentration Ventilation-Perfusion (V/Q) Scan Spiral CT or CT Angiogram Pulmonary Angiogram Management General Measures Specific Measures Prognosis Pulmonary Edema Pulmonary Edema Associated with Inhalation of Foreign Material References Chapter 2-9 Fire Fighter Lung Cancer The Fire Fighting Environment x Respiratory Diseases and the Fire Service

13 Lung Cancer Epidemiology Lung Cancer Non Small Cell Lung Cancer (NSCLC) Clinical Presentation and Symptoms of NSCLC Diagnosis Tissue Biopsy Staging of NSCLC Prognosis Treatment of NSCLC Small Cell Lung Cancer Clinical Presentation and Symptoms Diagnosis Staging Prognosis Treatment Screening For Lung Cancer Prevention References Chapter 2-10 Asbestos Related Lung Diseases Introduction What Is Asbestos? The Diseases Caused By Asbestos How Asbestos Causes Disease Health Effects of Exposure to Asbestos Non-Malignant Asbestos Related Diseases Pulmonary Asbestosis Pleural Thickening or Asbestos-Related Pleural Fibrosis Benign Asbestotic Pleural Effusions Treatment of Non-Cancerous Asbestos-Related Disease Asbestos-Related Cancers Lung Cancer Cigarette Smoking and Exposure to Asbestos Treatment of Lung Cancer Malignant Mesothelioma Treatment of Malignant Mesothelioma Preventing Asbestos-Related Disease Among Fire Fighters References Chapter 2-11 Sleep Apnea Syndrome Sleep Sleep Stages Obstructive Sleep Apnea Historical Perspective Epidemiology Risk Factors Pathophysiology Respiratory Diseases and the Fire Service xi

14 Clinical Manifestations Diagnosis Treatment of OSA Central Sleep Apnea Mixed Apnea Upper Airway Resistance Syndrome Narcolepsy References Chapter 2-12 Cough Mechanism of Cough Acute Cough Acute Cough and OTC Cough and Cold Products Subacute Cough Chronic Cough Causes of Chronic Cough Postnasal Drip Syndrome (PNDS) Asthma Non-Asthmatic Eosinophilic Bronchitis (EB) Gastroesophageal Reflux Disease (GERD) Other Specific Issues Relevant to Chronic Cough Cigarette Smoking Gender Medications Taken for Other Reasons World Trade Center Cough References Inhalation Injuries Chapter 3-1 Inhalation Lung Injury from Smoke Particulates, Gases and Chemicals Inhalation Respiratory Illnesses from Aerosolized Particulates Inhalation Respiratory Illnesses from Gases and Vapors Hydrogen Cyanide Carbon Monoxide Exposure to Irritant Vapors and Gases Chlorine Phosgene Diagnosis and Treatment History and Physical Examination Diagnostic Testing Other Pulmonary Functions Chest Imaging Invasive Diagnostic Methods Treatment References xii Respiratory Diseases and the Fire Service

15 Chapter 3-2 Inhalation Lung Injury and Radiation Illness Radiation Doses Acute Radiation Illness Decontamination of Radiological Casualties Internal Radiation Contamination Reference Chapter 3-3 Inhalation Lung Injury Nerve Agents References Chapter 3-4 Disaster Related Infections: Pandemics and Bioterrorism Pandemic Epidemics Post-Disaster Biological Terrorism Agents Smallpox Pathogenesis and Clinical Presentation Laboratory Diagnosis Treatment Infection Control Inhalational Anthrax Pathogenesis and Clinical Presentation Laboratory Diagnosis Treatment Infection Control Tularemia Pathogenesis and Clinical Presentation Laboratory Diagnosis Treatment Infection Control Plague Pathogenesis and Clinical Presentation Laboratory Diagnosis Treatment Infection Control Botulinum Pathogenesis and Clinical Manifestations Treatment Infection Control References Chapter 3-5 World Trade Center Respiratory Diseases Introduction Upper Respiratory Disease Reactive Upper Airways Dysfunction Syndrome (RUDS) and Chronic Rhinosinusitis Lower Respiratory Disease Respiratory Diseases and the Fire Service xiii

16 Reactive (Lower) Airways Dysfunction Syndrome (RADS) and Asthma Gastroesophageal Reflux Disease (GERD) Parenchymal Lung Diseases Pulmonary Malignancies The Impact of Exposure Time On Respiratory Disease Treatment of WTC Upper and Lower Airways Disease Conclusion References Diagnosis and Treatment Chapter 4-1 Pulmonary Function Tests for Diagnostic and Disability Evaluations Introduction Peak Flow/Spirometry/Bronchodilator Responsiveness Peak Flow Meter Spirometry Flow Volume Loop Bronchodilator Responsiveness or Reversibility Test of Lung Volume And Diffusion Capacity Lung Volume Measurements Body Plethysmography Diffusing Capacity Provocative Challenge Testing (Methacholine, Cold Air and Exercise) Exercise Testing Cardiopulmonary Exercise Testing Six-Minute Walk Test Disability Evaluation References Chapter 4-2 Imaging Modalities in Respiratory Diseases Commonly Used Modalities Chest X-Ray (CXR) Science Behind X-Rays Equipment and Procedure Common Uses Benefits of Procedure Risks of Procedure Limitations Abnormal Patterns on CXR Pleural Abnormalities Shadows and Other Markings Computerized Tomography (CT) Scan Equipment and Procedure Common Uses Role of Chest CT in the Diagnosis of Respiratory Diseases xiv Respiratory Diseases and the Fire Service

17 Benefits Risks Limitations Future Advances Role of Special Imaging Modalities: PET & MRI Scans PET Scan MRI Scan Image Guided Tissue Sampling Preparatory Instructions Nature of the Procedure Needles Image Guidance Procedure Benefits Risks Limitations Imaging of Pulmonary Arteries And Veins Pulmonary Angiography Conventional (Catheter) Pulmonary Angiography CT Pulmonary Angiography (CTPA) Benefits Limitations Risks Ventilation Perfusion Scintigraphy (VQ Scanning) Benefits Limitations Risks Role of Ultrasonography in Imaging of Pulmonary Embolism Chapter 4-3 The Solitary Pulmonary Nodule Definition Incidence and Prevalence Malignant Solitary Pulmonary Nodules Benign Solitary Pulmonary Nodules Imaging Techniques Plain Chest Radiography Computed Tomography Positron Emission Tomography (PET) Distinguishing Between Benign And Malignant Nodules Nodule Shape and Calcification Patterns Assessment of Nodule Growth Rate and Frequency of Follow-up Imaging Estimating Probability of Malignancy Biopsy Techniques Bronchoscopy Percutaneous Needle Aspiration Thoracotomy and Thoracoscopy Respiratory Diseases and the Fire Service xv

18 Diagnostic Approach Fire Fighters and Lung Nodules References Chapter 4-4 Where There s Smoke There s Help! Self-Help for Tobacco Dependent Fire Fighters and other First-Responders Tobacco Addiction Measuring Your Tobacco Addiction Let s Get Ready! Reduction to Cessation Treatments (Reduce then Quit) Keep a Cigarette Log No Ashtrays Instead Use a Cigarette Coughee Jar Increase the Inconvenience of Smoking Take Inventory and Do a Balance Sheet Avoid People, Places, Things You Associate with Smoking Alcohol and Tobacco Use Sadness, Depression and Post Traumatic Stress The Money You Save Exercise Start Slow, Start with Your Doctor s Input, but Start! Keep Oral Low-Calorie Substitutes Handy Associate Only with Non-Smokers for a While Medications Are Essential To Increase Your Chances of Success Chantix (Varenicline) or Champix (Outside the USA) Bupropion (Wellbutrin, Zyban) Nicotine Replacement Medications Nicotine Nasal Spray Nicotine Inhaler Nicotine Polacrilex Gum Nicotine Polacrilex Lozenges Nicotine Patches Combination Medications Tobacco Treatment Decision Guidelines U.S. Federal and State Programs IAFF: A Tobacco Free Union A Final Word References Chapter 4-5 Respiratory Failure, Assisted Ventilation, Mechanical Ventilation and Weaning Types of Respiratory Failure Hypoxic Respiratory Failure Hypercapnic Respiratory Failure Clinical Assessment of Respiratory Failure Laboratory Findings Treatment of Respiratory Failure xvi Respiratory Diseases and the Fire Service

19 Mechanical Ventilation Noninvasive vs. Invasive Mechanical Ventilatory Support Types or Modes of Mechanical Ventilation Assist/Control Pressure Support and CPAP (PS/CPAP) Synchronous Intermittent Mandatory Ventilation (SIMV) Specialized Modes Weaning or Removing a Patient from Mechanical Ventilation The Decision to Use Invasive Ventilatory Support and the Importance of Advance Directives in Patients with Chronic Disease Conclusions References Respiratory Diseases and the Fire Service xvii

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21 Introduction By Richard M. Duffy, MSc International Association of Fire Fighters Respiratory diseases remain a significant health issue for fire fighters and emergency responders, as well as civilians. Respiratory disease is the number three killer in North America, exceeded only by heart disease and cancer, and is responsible for one in six deaths. The American Respiratory Association estimates that more than 35 million Americans are living with chronic respiratory diseases such as asthma or chronic obstructive pulmonary diseases (COPD) including emphysema and chronic bronchitis. Fire fighters work hard each and every day, proudly protecting and serving our citizens by answering the call for help -- a call to save lives. That call may be to suppress fire and save lives jeopardized by smoke and flame. It may be a response to a hazardous materials incident, a structural collapse or other special operations event. The response may be for emergency medical assistance and transport to the hospital, with potential exposures to a host of infectious disease. Fire fighters have little idea about the identity of many of the materials they are exposed to or the health hazards of such exposures -- whether they are chemical, biological or particulates. Nevertheless, fire fighters and emergency medical responders continue to respond to the scene and work immediately to save lives and reduce property damage without regard to the potential health hazards that may exist. A fire emergency has no engineering controls or occupational safety and health standards to reduce the effect of irritating, asphyxiating or toxic gases, aerosols, chemicals or particulates. It is an uncontrollable environment that is fought by fire fighters using heavy, bulky and often times inadequate personal protective equipment and clothing. An occupational disease takes years to develop. It is the result of a career of responding to fires and hazardous materials incidents; it is caused by breathing toxic smoke, fumes, biological agents, and particulate matter on the job; and it is the response to continuous medical runs or extricating victims at accidents. Some health effects are immediate while others may take years and even decades to develop and because some respiratory diseases develop over time, it s impossible to say, This specific emergency response caused my disease, yet fire fighters continue to get sick and die from occupationallycaused respiratory diseases. Variability in exposures among fire fighters can be great; however, a number of exposures are commonly found in many fire scenarios. The common combustion products encountered by fire fighters that present respiratory disease hazards include but are not limited to: acrylonitrile, asbestos, arsenic, benzene, benzo(a)pyrene and other polycyclic hydrocarbons (PAHs), cadmium, chlorophenols, chromium, diesel fumes, carbon monoxide, dioxins, ethylene oxide, formaldehyde, orthotoluide, polychlorinated biphenyls and vinyl chloride. Also, findings from fire fighters monitored during the overhaul Introduction 1

22 phase (fire is extinguished, clean-up begins and where respiratory protection is not usually available) of structural fires indicates that short-term exposure levels are exceeded for acrolein, benzene, carbon monoxide, formaldehyde, glutaraldehyde, nitrogen dioxide and sulfur dioxide as well as soots and particulates. They are often exposed in their fire stations to significant levels of diesel particulate from the operation of the diesel fueled fire apparatus. Fire fighters are routinely exposed to respirable particulate matter consisting of liquids, hydrocarbons, soots, diesel fumes, dusts, acids from aerosols, and smoke. Health effects are known to be produced not just by the particulates themselves, but also by certain chemicals adsorbed onto the particulates. Further, the mixture of hazardous chemicals is different at every fire and the synergistic effects of these substances are largely unknown. FIRE FIGHTER STUDIES Although fire fighters have been shown in some studies to suffer chronic respiratory morbidity from their occupational exposures, fire fighters are probably at increased risk for dying from non-malignant respiratory diseases. Such studies that address and link fire fighting with respiratory diseases fall into three main groups laboratory studies, field studies and epidemiological studies. The first, involving animal laboratory experiments, have identified exposure to certain chemicals, biological agents and particulate substances and their contribution to the respiratory disease process. Such studies are invaluable to the understanding of the effect such substances can have on humans and they play a significant role in hazard identification for further risk assessment. The second group, field studies, documents the exposure of fire fighters to these agents through industrial hygiene or biological and physiological monitoring. Industrial hygiene data indicates that the fire environment contains a number of potentially dangerous toxins. Due to the highly unpredictable nature of the fire fighters environment, it is almost impossible to predict with any certainty all of the exposures that could be encountered at any given fire. However, these studies are important since they identify and characterize fire fighter exposures during suppression and overhaul at fires as well as at hazardous materials incidents or other special operations responses. The third group, epidemiologic studies of fire fighters and other occupational groups, is performed to determine if exposures actually result in elevated rates of disease. For example, epidemiological studies have consistently shown excesses of nonmalignant respiratory disease in fire fighters; acute and chronic respiratory function impairment, acute increase in airway reactivity and inflammatory changes in the lower airways of fire fighters. However, there have also been a number of other epidemiologic studies that have not found an increased morbidity or mortality or they provided conflicting information on the health effects of fire fighting on the respiratory system. This is due to a number of factors: Statistical constraints the number of individuals studied may not be sufficient to detect a difference. The studies rely on mortality, measuring only deaths from respiratory disease. Differences in survivorship between an occupational group 2 Introduction

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