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IntroductionThe aim of this study was to describe the demographic, clinical, exposure history and investigatory Results of hypersensitivity pneumonitis (HP) cases diagnosed by an expert regional NHS interstitial lung disease (ILD) board, to determine the extent and distribution of occupational aetiology.MethodsAll HP cases identified from a database over a 13 year period were included. The demographic, clinical, exposure history and investigatory Results were reviewed from clinical notes. Cases were categorised in to three groups: occupational, non-occupational and no known cause. Hypothesis testing at the 95% confidence level was used to identify significant differences between the 3 groups.ResultsA total of 127 cases (13 occupational; 34 non-occupational; 80 no known cause) of HP were identified. Men were more likely to experience occupational HP (p=0.029) compared to the other groups. Occupational HP cases were younger (p=0.002), more likely to experience weight loss (p=0.004), to have systemic symptoms (p=0.007) and a recurrence of symptoms (p<0.001). Occupational HP were due to metal working fluids (MWF), birds, mould/fungi, Farmer’s lung, and cleaning and treatment sprays. Non-occupational HP were due to birds, mould/fungi in the home and medication. Percentage lymphocyte count in broncho-alveolar lavage (BAL) was significantly raised in occupational HP (p=0.001). Where no causative agent was identified, there was a greater absence of exposure history (13.2%–32.5%).ConclusionOccupations where there is exposure to birds or those working in trades where industrial processes and the use of chemical compounds predominate, are at risk of occupational HP. Birds remain an important cause of non-occupational HP. Clinical features such as weight loss, systemic symptoms and recurrent symptoms should raise a suspicion of an occupational cause of HP. BAL remains an important investigatory tool in HP, especially in occupational HP. An exposure history, especially an occupational history, is mandatory when assessing suspected cases of HP.

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Omalizumab is effective treatment for patients with severe asthma. It is reserved for patients with truly severe disease as it is expensive and associated with significant treatment burden. Identifying this small number of patients in problematic severe asthma (PSA) group is challenging. We evaluated the impact of multidisciplinary severe asthma (SA) protocol on identifying those with severe disease and on potential use of omalizumab. After initial clinic visit, 19 patients aged between 6-15yrs with PSA underwent specialist nurse led SA protocol which included: assessment of clinical status, lung function, atopy, inhaler technique, asthma control test (ACT), quality of life (QoL); home visit for further assessment of environment, adherence and psychosocial comorbidities; school contact to address impact on education. Before SA protocol, 17/19 patients met criteria for use of omalizumab. After SA protocol, only 6(35%)were eligible as modifiable factors were identified in 11(65%). They included poor adherence, ongoing allergen exposure and psychological issues. 5/6 patients received omalizumab and 4(80%) improved. Of other 11 patients, clinical status improved in 6 (55%), unchanged but stable in 4(36%), worsened in 1(9%) after assessment. SA protocol identified modifiable factors in significant proportion of PSA children limiting omalizumab use to those with truly severe disease. Home visit assessment is essential to identify these factors which would otherwise be unrecognised. We hypothesise that proper recognition and management of these factors might not only ensure appropriate use of omalizumab but also improve its effectiveness.