RECURRENCE PREVENTION IN ASTHMA PATIENTS:

THE EFFECT OF DUST IN THE HOME AND WORKPLACE ON ASTHMA

Harianto P*, Werdhani RA**, Head of puskesmas ?? ***

*Fifth Grade Medical Student at Medical Faculty at University of Indonesia 2010/2011,
**Community Medicine Department of Medical Faculty at University of Indonesia
***Head of puskesmas..??

Abstract
Background: Asthma is a multifactorial and chronic disease that requires control or
prevention of asthma relapse. Several trigger factors such as dust, cold air and upper
respiratory tract infections are common factors that cause asthma relapse. It is important for
patients, familiy and medical personnel, in this case the physician, to identify what are the
specific trigger that causes asthma patients relapse and do preventive measures to avoid
exposure to trigger factors that have been identified. It is expected that the frequency of
asthma relapses can be minimal or controlled, the quality of life of patients to be optimal and
cost of medical facility visit to hospitals or physician become efficient and effective through
the avoidance of dust exposure.
Goals: To identify problems that exist in managing patients and conduct comprehensive
treatment of patient, occupation, and family.
Methods: Holistic diagnosis wasis established by anamnesis, physical examination, home
visit and investigation. Family function was also assessed to determine whether or not
coaching familyfamily provision was needed. After that, the comprehensive management of
patients was wtaken to resolve the problem. Patients was obtained from Puskesmas
Kelurahan Pasar Minggu 2, Jakarta, where the author conducted fieldwork.
Results: Problems of patients and families have been identified and comprehensive
treatments have been done such as…???. The result is that patients understand the treatment
of disease, prevention of asthma relapse so that the frequency of recurrence is minimal,
achieved optimal lung function as possible and good quality of life, and families participated
in this effort.
Conclusion: Prevention of asthma relapse can be achieved by educating patients and families
to avoid trigger factors such as cold air, dusty and less ventilation environment and maintain
health in order to avoid frequent respiratory tract infection disease.
Key Words: Dust, upper respiratory tract infection (URTI), asthma recurrence

BACKGROUND remain normal or near normal.1

Management of asthma required special
attention by both the patient and caregiver or
physician in preventing recurrence of asthma
relapse.
The main target of asthma treatment is to
minimize the chronic symptoms that interfere
normal activity, prevent the recurrence of
acute attacks, reducing the frequency of
patient visits to the emergency department or
hospital and to maintain lung function to
There are several risk factors of somebody for
developing asthma. They are endogenous,
environment, and trigger factors. Endogenous
factors are genetic or heredity, history of
atopy, sex and hyperresponsiveness of
airways. Environmental factors include indoor
or outdoor allergens, air pollutans in the
workplace or roadway, tobacco smoke and
respiratory infections. Meanwhile, the factors
that can trigger asthma attacks is allergens,
upper respiratory tract infections caused by
viruses, exercise and hyperventilation, cold
air, sulfur dioxide, drugs such as beta blockers
and aspirin, stress, irritants like air freshener or
vapor wall paint, etc.2
The following case report discusses the
concerned patients with intermittent asthma
which is frequently relapsed due to upper
respiratory tract infection accompanied by a
history of allergy to dust and cold air. The patient
hasve high risk of exposure from the dust because
of lack of his home sanitation and ventilation??.
There wereare also risk of exposure of dust and
air pollutant at the roadway when patient go to
workplace or at the warehouse where he works.
Prevention of asthma patients can be done
through the efforts of maintaining cleanliness
of the neighborhood from dust, cold air,
maintaining optimal ventilation and lighting.
That included in holistic treatment of this
patient besides the pharmacological treatment.
The data was taken as primary data obtained from
anamnesis, physical examination, and
investigation, when patients visited Puskesmas
Kelurahan Pasar Minggu 2 and when author visits
to the patient’s house.
CASE ILLUSTRATION
Mr. A, 21 years old patient, single, came into
Puskesmas Kelurahan Pasar Minggu 2 seeking
for treatment because of shortness of breathing
that which was triggered by cough and flu
since 3 days before coming admission to the
health center.
The patient had suffered from asthma since his
childhood (6 yerars old). Patients was treated
at the primary care health center when hiss
asthma relapsed. During all this time, patients
hasd not hadve not to routineely consume
medication or inhaled medication to control
his asthma. Shortness of breathing relapsed if
the patient hadget common cold or upper
respiratory tract infection first. Shortness of
breathing also relapsed if the patient was in the
cold or dusty area. Shortness of breathing
relapsed approximately once every 2 months.
History of shortness of breathing at night is
less than one1 time a month. If shortness of
breathing relapsed, patients trying to consume
STOP COLD® tablet but was not cured. In
this situation patient seek treatment at the
health center.
One year before admission to the health
center, patient hashad hads a history of one
acute severe asthma attack so that the patient
must came to the hospital and get inhalation
therapy. Since 3 days before coming to the
health center patients stricken with a common
cold and sputum productive cough. Patients
also complained about shortness of breathing.
Past illness history such as hypertension,
diabetes, tuberculosis, jaundice, or history of
being treated in hospital was denied by the
patient.
Patients have a family history of asthma
(patient’s mother). History of other diseases in
the family was denied.
Patients has smoking habbit history. He
smoked 2 rods per day (but rare) since the age
of 18 years. But the patient had have stopped
smoking since one year ago. Patients rarely
exercise because he spend a lot of time on his
workplace (10 hours in a day) and take a rest
after work at home.
Patients hasve been working for 8 months at a
printing company, PT. Airlangga, in the
Quality Control Subdivision. Patients go to
work using motorcycle. There wasis a risk of
exposure to dust and air pollution at the
roadway to his workplace. Patients hasave
started to wear masker while riding the
motorcycle.
Patient’ss duty wasis to assessing the quality
of the books printed. The workplace wasis in
aa warehouse and opened wide enough so that
air is well ventilated. According to the patient,
the warehouse wasis at risk of the dust and air
pollutant due to smoke generated by the book
transporter vehicle. Patients did not wear
masker while working.
Patient's family is a diverse family forms.
Patients wasis living with father, mother, the
sister and her husband and also a nephew from
his sister's. Patient’s mother is the closest
family member to the patient. Based on the
observation of the home, the condition of
environment wasis lack of ventilation and
lighting, high level of humidity and there
wereare some dusty place such as stack of
books, dirty floor, bed mattresses made of
cotton and the corners of furniture (cabinets,
chairs, tables and beds) in his family’s home.
On physical examination, obtained blood
pressure wasis 120/80 mmHg, pulse 80 x /
min, body temperature 37 ° C, and respiration
24 x / min, hyperremic conca, hyperemic
pharynx, and wheezing in both lung. Patients
was diagnosed with intermittent asthma and
acute rhinopharyngitis.
Treatment given to the patients include
pharmacological and nonpharmacological While based on Lagorio et al study it is
therapy. Nonpharmacological therapy were concluded that among the asthmatics, NO was 2

education to avoid exposure to dust or cold air, associated with a decrease in FEV1.6
immediately seek treatment if getting common
colds or URTI, improve ventilation and Thus the effort to keep the house clean from
lighting in the house and cleanliness of dust. dust, especially dust mites and also to avoid air
Pharmacological therapy waswere salbutamol pollutant exposure on the roadway or
2x20 mg, 2x30 mg Ambroxol, and workplace like NO2 are expected to prevent
Dexamethason 2x15 mg. the recurrence and increasing severity of
asthma in this patients.
Intervention from occupational point of
view??? The objectives to prevent asthma relapse and
worsening lung function by avoidance from
Family Provision Results dust exposure can be done by using adequate
Family was educated to maintain cleanliness masker.8
of floor, wall, household’s furniture, use
sponge mattress on the bed, and maintain the Discussion on occupational point of view??
adequate ventilation and lighting of the house. Potential hazard and protective personal
Evaluation of family provision results had device such as masker (which one is the
been done on second visit, two weeks after recommended one??)
first visit. The results wasis that the family had
done the advice to maintain cleanliness of CONCLUSION
home environtment. But there is still lack of Dust mites is the most common trigger that
ventilation and lighting of the house because contribute to decrease lunc function and to
of the lack of window space (<20% of total increase severity of asthma. Efforts to
space area). So that the family was adviced to maintain the cleanliness of the neighborhood
make more window. And family promised to and workplace from dust mites or to avoid the
make more window soon after. exposure by using adequate masker are
expected to have a high success rate in
DISCUSSION preventing asthma relapse.
Patients experiencing an asthma relapse at
least once every 2 months in the past year. The
most common cause of asthma recurrence in
patients is the upper respiratory tract infection.
In addition, the dusty environtment and cold
air can also trigger patient’s asthma relapse.
Therefore the environmental condition of
house should be the concern because it is one
of place where patients spend most of his time
daily. And the cleanliness of the house to dust,
good ventilation and adequate lighting is an
important factor which should be noted by the
patient for the risk of upper respiratory tract
infection and recurrence of asthma.

Therefore, the authors are interested to trace

the evidence based data about the effect of the
dust on recurrence of asthma relapse.

Based on the critical appraisal results obtained

by the authors, it is concluded that dust mites
is the most common trigger that contribute to
decrease lung function and to increase severity
of asthma.3,4,5,7
REFFERENCE

1. Mcphee SJ, Papadagakis MA, et al.

Current Medical Diagnosis & Treatment
2010. New YorkThe McGraw-Hill
Companies. 2009.
2. Schwartzstein RM. Asthma. In: Fauci,
AS et al (eds). Harrison’s Principles of
Internal Medicine. 17th ed. McGraw-
Hills Companies, Inc. 2009.
3. Valero A, Pereira C, Laureiro C, et al.
Interrelationship Between Skin
Sensitization, Rhinitis, and Asthma in
Patients With Allergic Rhinitis: A Study
of Spain and Portugal, J Investig Allergol
Clin Immunol 2009; Vol. 19(3): 167-172.
4. Boneberger A, Radon K, Baer J, et al.
Asthma in Changing Environments. BMC
Pulmonary Medicine 2010, 10:43.
5. Trupin L, Balmes JR, Chen H, et al. An
integrated model of environmental factors
in adult asthma lung function and disease
severity: a cross-sectional study.
Environmental Health 2010, 9:24
6. Lagorio S, Forastiere F, Pistelli R, et al.
Air pollution and lung function among
susceptible adult subjects: a panel study.
Environmental Health: A Global Access
Science Source 2006, 5:11
7. Wieringa MH, Weyler JJ, Nelen VJ, et al.
Higher asthma occurrence in an urban than
a suburban area: role of house dust mite
skin allergy. Eur Respir J 1997; 10:
1460–1466
8. Takemura Y, Kishimoto T, Takigawa T, et
al. Eff ects of Mask Fitness and Worker
Education on the Prevention of Occupational
Dust Exposure. Acta Med. Okayama,
2008.Vol. 62, No. 2, pp. 75 ﾝ 82.
Conceptual Framework EXTERNAL FACTORS
Scheme  Poor sanitation of home environtment
because of dusty environtment, lack of
ventilation and lighting
 Working environment ???
INTERNAL FACTORS
 Positive family history of asthma
(patient’s mother)
 Allergic history of dust and cold air
 Reccurence history of URTI (once in 2
months)
 Smoking habbit (stopped 1 year ago)

SUPPORTING
FACTOR
 High motivation to
perform the
prevention of asthma
relapse
 Patients is already
using masker when
he ride motorcycle
 Patient is routinely
visit primary health
care if his asthma
relapsed
PATIENT PROBLEM
 Asthma Intermittent
 Acute Rhinopharyngitis
 Reccurence of Asthma Relapse
INTEGRATED
(every 2 month)
CARE
 High sense of care
by patient’s mother
 Puskesmas
TREATMENT Kelurahan Pasar
Non Pharmacologic: Minggu 2
 Avoid of dust or air pollutant  Private Doctor
exposure Clinic near to
 Using adequat masker patient’s house
 Maintain the cleanliness of
home environment
 Make more window
Pharmacologic
 Salbutamol 3x20 mg
FOLLOW
Ambroxol
UP3x 30 mg
 Coughing, sneezing, dyspneu
and wheezing complaint had
been decreased and almost
normalized
 Patient is following the
doctor’s advice
 Sanitation of home
environment (of dust),
adequate ventilation and
lighting
Patient’s Family Genogram
 Mr. A Mrs. Z
60 yo 50 yo

Mrs. N Mr. A 21 yo
30 yo

Child I
3,5 yo

Legend

: Male : Patient

: Female : Living in one roof

Evidence Based Case Report

THE EFFECT OF DUST IN THE HOME AND WORKPLACE ON ASTHMA

Harianto P*, Werdhani RA**

*Fifth Grade Medical Student at Medical Faculty at University of Indonesia 2010/2011,
**Community Medicine Department of Medical Faculty at University of Indonesia

Case Illustration
Mr. A, 21 years old patient, suffer from acute exacerbations of asthma intermittaant and acute
rhinopharyngitis acute. Patients often experience cough and common cold at least once every 2
months. And when attacked by common cold and cough, patient’s asthma always relapse. Patients
have a history of allergy to dust both within his home or outside the home (working place) and cold
weather. Based on the observation of patients house, there wereare lack of ventilation and lighting,
humid and there wereare some dusty place such as stacks of books, dirty floor, bed mattresses made
of cotton and the corners of furniture (cabinets, chairs, tables and beds). Besides the home
environment, there wereare also higher risk of dust or air pollutant exposure for patient at the roadway
to workplace. Not only that, patient workplace is also at the risk of dust or air pollutant produced by
book transporter vehicles. All condition mentioned above can lead patient to get higher risk of
exposure from the dust, allergens, irritants and also air pollutant. So the risk of asthma relapse and
upper respiratory tract infections in patients was also higher. Therefore, the authors interested to
perform data retrieval of evidence based about the effects of environmental factors, especially the dust
factor, to asthma patient.

Clinical Question
How the effect of dustmites in homes and workplaces as well as air pollutants on the roadway to
asthma patient condition?
P = asthma patient
I = dust or air pollutant exposure
C = no exposure
O = patient condition

Critical Appraisal
Searching was made on www.pubmed.gov website. Keywords used by this search are Asthma AND
Dust AND Young Adult. The search results was 14 journals. But there were only 5 journals that met
the relevance and criteria of clinical question.
1. Valero A, Pereira C, Laureiro C, et al. Interrelationship Between Skin Sensitization, Rhinitis, and
Asthma in Patients With Allergic Rhinitis: A Study of Spain and Portugal, J Investig Allergol Clin
Immunol 2009; Vol. 19(3): 167-172.
2. Boneberger A, Radon K, Baer J, et al. Asthma in Changing Environments. BMC Pulmonary Medicine
2010, 10:43.
3. Trupin L, Balmes JR, Chen H, et al. An integrated model of environmental factors in adult asthma lung
function and disease severity: a cross-sectional study. Environmental Health 2010, 9:24
4. Lagorio S, Forastiere F, Pistelli R, et al. Air pollution and lung function among susceptible adult
subjects: a panel study. Environmental Health: A Global Access Science Source 2006, 5:11
5. Wieringa MH, Weyler JJ, Nelen VJ, et al. Higher asthma occurrence in an urban than a suburban
area: role of house dust mite skin allergy. Eur Respir J 1997; 10: 1460–1466
Critical Appraisal Study 1 Study 2 Study 3
Parameters
Validity
Where there clearly defined Yes Yes Yes
groups of patients, similar in all
important ways other than
exposure?
Were exposures and clinical Yes Yes Yes
outcomes measured in the same
ways in both groups? Was the
assessment of outcomes either
objective or blinded to
exposure?
Was the follow-up of the study No Yes No
sufficiently long and complete?
Do the results of the etiology Yes Yes Yes
study satisfy some of the tests
for causation?
Importance
What is the magnitude of the The most prevalent Some 78% of the Dust, indoor air quality,
aeroallergens detected cases, and about half of antigen-specific
association between the
were house dust the controls (47%) IgE antibodies, and lung
exposure and outcome? mites from the showed at function (percent
Dermatophagoides least one atopic predicted FEV1) were
species (63%) and grass sensitization in the skin assessed through home
(53%). prick test. visits.

What is the precision of the
estimate of the association
between the exposure and
the outcome?
Applicability
Is our patient so different
from those included in the
study that its results cannot
apply?
What is our patient’s risk of
harm from exposure?
What are our patient’s
preferences, concerns and
expectations from this
exposure?
Critical Appraisal
Parameters
There was a signifi cant 12-month prevalence of Mean FEV1 was 85.0 ±
correlation rhinitis (82% vs. 51%) 18.6%; mean asthma
(r=0.88, P<.001) between and wheeze (68% vs. severity score was 6.9 ±
the number of 16%) were statistically 5.6. Of 29 variables
sensitizations and the significantly screened,
sensitization index. (p-value: <.0001) higher
Patients with among cases.
concomitant asthma had
a signifi cantly
higher number of
aeroallergens and
sensitization intensity
than those without
asthma (P<.001).
No No No
Exposure in home, Exposure in home, Exposure in home,
road and workplace. road and workplace. road and workplace.
The asthma reccurence The asthma reccurence The asthma reccurence
will be minimized by will be minimized by will be minimized by
avoid the dust avoid the dust avoid the dust
exposure exposure exposure
Study 4 Study 5
 Validity
Where there clearly defined
groups of patients, similar in all
important ways other than
exposure?
Were exposures and clinical
outcomes measured in the same
ways in both groups? Was the
assessment of outcomes either
objective or blinded to
exposure?
Was the follow-up of the study
sufficiently long and complete?
Do the results of the etiology
study satisfy some of the tests
for causation?
Importance
What is the magnitude of the
association between the
exposure and outcome?
What is the precision of the
estimate of the association
between the exposure and
the outcome?
Applicability
Is our patient so different
from those included in the
study that its results cannot
apply?
What is our patient’s risk of
harm from exposure?
What are our patient’s
preferences, concerns and
expectations from this
exposure?
Results
Yes
Yes
No
Yes
Among the asthmatics,
NO2 was associated with a
decrease in FEV1.
The respiratory function
of the relatively young and
mild asthmatics included
in this study seems
to worsen when ambient
levels of NO2 increase.
No
Exposure in home,
road and workplace.
The asthma reccurence
will be minimized by
avoid the dust
exposure
Yes
Yes
No
Yes
The risk for prior asthma
diagnosis was found to
be twice as high in
subjects living in the city
of Antwerp (OR 2.10;
95% CI 1.03–4.30).
(Urban > Rural)
In urban Antwerp,
more subjects had skin
reactions to the
allergens tested. These
patients were most
striking for HDM
allergy, which was also
the most
prevalent allergy.
No
Exposure in home,
road and workplace.
The asthma reccurence
will be minimized by
avoid the dust
exposure
Study 1 shows that the most prevalent aeroallergens detected were house dust mites from the
Dermatophagoides species (63%) and grass (53%). There was a signifi cant correlation (r=0.88,
P<.001) between the number of sensitizations and the sensitization index. Patients with concomitant
asthma had a signifi cantly higher number of aeroallergens and sensitization intensity than those
without asthma (P<.001).

Study 2 shows that some 78% of the cases, and about half of the controls (47%) showed at least one
positive atopic sensitization in the skin prick test. 12-month prevalence of rhinitis (82% vs. 51%) and
wheeze (68% vs. 16%) were statistically significantly (p-value: <.0001) higher among cases.

Study 3 shows that mean FEV1 was 85.0 ± 18.6%; mean asthma severity score was 6.9 ± 5.6. of 29
variables screened (dust, indoor air quality, antigen-specific IgE antibodies, and lung function
(percent predicted FEV1) were assessed through home visits).

Study 4 shows that among the asthmatics, NO2 was associated with a decrease in FEV 1. The
respiratory function of the relatively young and mild asthmatics included in this study seems to
worsen when ambient levels of NO2 increase.

Study 5 shows that the risk for prior asthma diagnosis was found to be twice as high in subjects living
in the urban area than in the rural area. (OR 2.10; 95% CI 1.03–4.30). In urban area, more subjects
had skin reactions to the allergens tested. These patients were most striking for house dust mites
allergy, which was also the most prevalent allergy.

Conclusion

Dust mites is the most common trigger that contribute to decrease lungc function and to increase
severity of asthma. Efforts to maintain the cleanliness of the neighborhood and workplace from dust
mites and also to avoid the exposure by using adequate masker are expected to have a high success
rate in preventing asthma relapse.