RU2742342C1 - Method for selecting probationers of chemical production in group of high risk of developing conditioned cardiorespiratory pathology - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to preventive and rehabilitation medicine, occupational health, and can be used for selection of trained chemical workers in a group of high risk of developing conditioned cardiorespiratory pathology. Medical examination of chemical industry workers with experience of more than 10 years is carried out by determining diagnostic laboratory and functional indicators. Laboratory factors are hemoglobin (Hb), erythrocytes, lipid hydroperoxides (LHP), malonic dialdehyde (MDA), antioxidant activity of plasma (AAP), erythropoietin, nitrogen oxide, vascular endothelium growth factor (VEGF), homocysteine and highly sensitive C-reactive protein (hs-CRP). Functional parameters are the signs of the left and right ventricles increase by the electrocardiography method by the electric heart axis position setting, the ST segment position relative to the isoline in V₆ and the T wave in V1; type of ventricular complex; through the size of the voltage of the tooth R', height R in lead V₆, tooth P on electrocardiogram (ECG). Fixed exhalation volume in 1 s (FEV1₁), forced vital capacity of lungs (FVC); ratio of FEV₁/FVC and average volume rate of forced exhalation (COC25-75) by spirography. Performing the functional test using a bronchodilator with the "incremental exhalation rate per second" gain estimate, and establish an annual decline in FEV₁ compared with the previous year and the rate of decrease in endothelial reaction for the year. Results of obtained values are compared with physiological norm. Those workers who have the following deviations in terms of physiological norm, namely: exceeding the upper limit of the standard by more than 10 % of the level of Hb, erythrocytes, LHP, MDA, VEGF, homocysteine and hs-CRP, exceeding the upper limit of the norm by more than 20 % of the AAP level, reducing the level of erythropoietin and nitrogen oxide from the lower limit by more than 10 %, with simultaneous electrocardiography by electric heart deviation to right to 100 degrees; steeply descending depression of ST segment in V₆; negative T wave in standard leads; negative tooth T in V₁; ventricle-type complex of rSR' type; voltage of R' wave more than 7 mm, high R wave in V₆ lead, voltage P increase greater than 2 mm on ECG electrocardiogram; with FEV₁ spiography setting less than 80 % of the norm; ratio of FEV₁/FVC equal to 65 %–70 %; COC25-75 - 70 %–75 %; when performing a functional test using a bronchodilator, an increase in the "FEV score per second" value by 8–12 % of the expected value; annual reduction of FEV₁ 35–50 ml a year, rate of reducing endothelial functional activity per year by more than 0.3 %, referred to a group of workers with a high risk of developing conditioned cardiorespiratory pathology.

EFFECT: method enables to develop criteria for selection of trained chemical workers in a high-risk group of developing conditioned cardiorespiratory pathology by determining a set of laboratory and physiological indicators and comparing the values with standard values.

1 cl, 1 tbl, 2 ex, 2 dwg

Description

The invention relates to the field of preventive and rehabilitative medicine, occupational hygiene, in particular to methods for predicting premorbid conditions in trained workers of chemical industries (for example, metallurgical), preceding the development of production-related cardiorespiratory pathology through diseases of the cardiovascular and respiratory system. The objective of the invention is to expand the range of medical control over the functional state of trained workers in chemical industries, in order to increase the effectiveness of measures aimed at preserving the health of workers of pre-retirement age of chemical industries, threatened by the development of diseases of the respiratory system and the circulatory system caused by exposure to harmful production factors.

According to multicenter studies, the main reason for the decrease in labor productivity among workers of pre-retirement age is the low adaptive potential of life support systems and the development of chronic diseases, primarily the circulatory and respiratory systems.

The results of clinical observations indicate that almost half of the workers (47.1%) of the chemical industry (the chemical industry is a complex of enterprises using all kinds of technological processes based on the chemical transformation of raw materials (hydrocarbon, mineral, etc.) into intermediary materials and elements of consumption) at the age of 50 and older, the adaptive reserves of the body and indicators of endurance are reduced by more than 30-40%, respectively; the heart rate (HR) during the work shift reaches 100-120 beats. per minute, and systolic blood pressure (SBP) - 160 mm Hg. According to the results of periodic medical examinations (PMO) and an examination of professional suitability, 1/3 of the trained workers are registered with 3 or more chronic diseases, among which the priority places are occupied by diseases of the respiratory system (AR) and diseases of the circulatory system (BSC). Moreover, AML and BSK are medical contraindications for performing certain types of work at chemical enterprises, in addition, they are the most common cause of temporary disability for workers of pre-retirement age and increase the risk of death in the workplace.

Based on the foregoing, the development of criteria for the selection of trainees in the high-risk group for the development of work-related cardiorespiratory pathology is urgent.

The term "cardiorespiratory pathology" is understood as a combination of pathology of the lower respiratory tract and the circulatory system, which have common pathogenetic links (comorbidity of chronic obstructive pulmonary disease (COPD) and hypertension (HD) [TN Vasilkova, YA Rybina - 2013]).

It should be noted that at present, scales have been developed for assessing the risk of developing cardiovascular diseases (CVD) and their complications (SCORE, FRS), which make it possible to determine the possibility of developing cardiovascular events within 10 years, questionnaires aimed at identifying respiratory symptoms for early diagnosis of COPD (CAT, questionnaire for patients with respiratory diseases, St. George's Hospital, etc.). However, there is evidence that in 74.5% of cases myocardial infarction develops in people with a low (less than 10% on the FRS scale) risk, and COPD makes a significant contribution to the increase in the number of cases of disability and premature mortality, while, as a rule, develops after 40 years and slowly progresses unnoticed by the worker, which makes early diagnosis difficult. Consequently, the identification of the unfavorable impact of production factors on the risk of development in workers of professionally conditioned combined pathology of the circulatory and respiratory systems is relevant for determining the prediction of the risk of developing production-related cardiorespiratory pathology and labor prognosis. Therefore, the search for new markers of the formation of cardiorespiratory pathology and new diagnostic approaches remains relevant.

From the prior art (RF patent No. 2487663) there is a known method for assessing the degree of metabolic and cardiorespiratory adaptation of cardiac surgery patients. For this, during the operation and intensive therapy, a gas mixture is successively inhaled with 51% (FiO ₂ = 0.51) and 21% (FiO ₂ = 0.21) oxygen content. Then, oxygen consumption and carbon dioxide evolution are determined at each stage, and the power of the anaerobic threshold in FiO ₂ in the gas mixture is calculated, corresponding to the moment when the anaerobic threshold is reached. When the power of the anaerobic threshold is more than> 0.14, the degree of metabolic and cardiorespiratory adaptation of the patient is considered low. When the value of the indicator is <0.1, the degree of metabolic and cardiorespiratory adaptation of the patient is considered high. When the value of the indicator is 0.1-0.14, the degree of metabolic and cardiorespiratory adaptation of the patient is considered average. The method allows to reduce the likelihood of developing hypoxic complications in critically ill patients by determining the degree of metabolic and cardiorespiratory adaptation during surgery and intensive care, including in the monitoring mode.

However, this method cannot be applied to trained workers in chemical production.

A number of technical solutions are known from the prior art related to the determination of deviations in the health of workers in chemical production, for example:

- A method for selecting trainees who are in contact with metallic mercury vapors into the risk group for the development of chronic mercury intoxication (RF patent No. 2460458) (the method consists in conducting neuropsychological testing with the determination of indicators of analytical and synthetic thinking, indicators of the counting system: triple counting, simple counting operations; indicators of conceptual thinking by selecting opposites in a passive and active plan; visual and long-term memory; dynamic and spatial praxis; indicators of visual gnosis: recognition of crossed out images, recognition of superimposed images, digital gnosis. Then the discriminant function F is calculated, compared the result obtained with a constant and when F is greater than the constant of trained workers is attributed to the risk group, when F is less than or equal to the constant - to the group without signs of the effect of mercury on the body).

- A method for predicting the risk of developing occupational bronchial asthma (RF patent No. 2583948) (the method consists in determining the presence of relatives with an allergic reaction, a history of rhinitis, urticaria or other allergic reaction, household, food and drug allergic reactions, occupational hazards, at the same time, the concentration of total IgE in the blood serum is additionally determined, the "symptoms of elimination", "exposure test", "the effect of re-exposure" are determined as occupational hazards, each sign is evaluated in points. Further, the points are summed up and if their sum is less than 15, a low degree of occupational risk is predicted bronchial asthma, 16-30 points - medium risk, 31 points and more - high risk).

- A method for predicting the left ventricular myocardial mass index in chemical workers depending on systolic blood pressure and low-density lipoprotein concentration (RF patent No. 2704788) (in the examined workers, such predictors of myocardial remodeling as age, systolic blood pressure, waist circumference and concentration are determined low density lipoproteins in venous blood serum The obtained anamnestic data and examination results are substituted into the developed mathematical model: LVMI = 1.134 × SBP + 0.207 × Age - 0.272 × RT + 2.256 × LDL - 23.631; where: LVMI - left ventricular myocardial mass index, g / m ² ; SBP - systolic blood pressure, mm Hg; Age - employee's age, years; OT - waist circumference, cm; LDL - concentration of low density lipoproteins in blood serum, mmol / L. According to domestic and foreign recommendations for the treatment of arterial hypertension for the upper limit of the norm of the index m Asses of the myocardium of the left ventricle are taken 110 g / m ² for women and 134 g / m ² for the male population. With diagnosed arterial hypertension, this parameter is reduced in men to 125 g / m ² . If LVMI exceeds the specified maximum allowable values, then left ventricular myocardial hypertrophy is diagnosed).

- A method for predicting a high risk of developing industrial and occupational diseases in workers of a chemical complex employed in hazardous working conditions (RF patent No. 2545911) (the method includes determining the general antioxidant status in blood serum, while additionally determining the quantitative content of peroxidation products in blood serum lipids and with a simultaneous increase in the quantitative content of peroxides in lipids of more than 4.31 μmol / l and a decrease in the total antioxidant status of less than 1.3 mmol / l predict a high risk of developing work-related and occupational diseases).

However, all these methods do not carry informational value in terms of establishing criteria for assigning trainees to a group of high risk for the development of work-related cardiorespiratory pathology.

At the same time, the prior art did not reveal the known methods of selecting trainee workers in the chemical industry in the group of high risk of developing production-related cardiorespiratory pathology, therefore, it is not possible to choose the closest analogue to the claimed invention.

The technical result achieved by the proposed invention is to provide the possibility of developing criteria for the selection of trainee workers in chemical production in a group of high risk of developing production-related cardiorespiratory pathology.

The set technical result is achieved by the proposed method of selecting trainee workers in chemical production in the group of high risk of developing production-related cardiorespiratory pathology, characterized by the fact that they conduct a medical examination of workers in chemical production with more than 10 years of experience by determining diagnostic laboratory and functional indicators, while as laboratory indicators determine the levels of hemoglobin (Hb), erythrocytes, lipid hydroperoxide (HPL), malondialdehyde (MDA), plasma antioxidant activity (AOA), erythropoietin, nitric oxide, vascular endothelial growth factor (VEGF), homocysteine and highly sensitive C-reactive protein (hs -CRB); and as functional indicators, signs of an increase in the left and right ventricles of the heart are determined by the method of electrocardiography by establishing the position of the electrical axis of the heart, the position of the ST segment relative to the isoline in V ₆ and the T wave in V1; type of ventricular complex; through the size of the voltage of the R wave, the height of the R wave in lead V _{6 of the} P wave on the electrocardiogram (ECG); fixed expiratory volume in 1 sec. (FEV ₁ ), forced vital capacity (FVC); the ratio of FEV ₁ / FVC and the average forced expiratory flow rate (SOS25-75) by spirography; carrying out a functional test using a bronchodilator with an assessment of the increase in the indicator "assessment of forced expiration in a second", and establish the annual decrease in FEV ₁ in comparison with the results of the previous year and the rate of decrease in the endothelial response for the year, compare the results of the obtained indicators with the physiological norm, and those workers, in which the following deviations in indicators from the physiological norm were revealed, namely: an excess of the level of Hb, erythrocytes, GPL, MDA, VEGF, homocysteine and hs-CRP from the upper limit of the norm by more than 10%, excess from the upper limit of the norm by more than 20 % of the level of AOA, a decrease from the lower limit of the norm by more than 10% in the level of erythropoietin and nitric oxide, while the deviation of the electrical axis of the heart to the right is established by electrocardiography up to 100 degrees; oblique depression of the ST segment in V ₆ ; negative T wave in standard leads; negative T wave in V ₁ ; a rSR 'ventricular complex; the voltage of the R wave is more than 7 mm, the high R wave in lead V ₆ , the increase in the voltage of P is more than 2 mm on the ECG electrocardiogram; when the FEV ₁ method is established by spirography less than 80% of the norm; the ratio of FEV ₁ / FVC equal to 65% -70%; indicator SOS25-75 - 70% -75%; when carrying out a functional test using a bronchodilator, an increase in the "FEV assessment per second" indicator by 8-12% of the due; the annual decrease in FEV ₁ 35-50 ml per year, the rate of decrease in the functional activity of the endothelium per year by more than 0.3%, are attributed to the group of workers with a high risk of developing production-related cardiorespiratory pathology.

The specified technical result is achieved due to the following.

Based on the totality of production factors, the working conditions of workers in the main professions of chemical enterprises are assessed as harmful (degree 3.3-3.4) and are considered as the main reason for the development of professional and production-related AML and BSK. The a priori occupational risk in workers of the main professions of chemical enterprises is assessed as high (intolerable), which requires urgent measures to be taken to reduce it and prevent the development of occupational and occupationally conditioned respiratory pathology and associated occupationally conditioned cardiovascular diseases.

In workers of the main professions of chemical production aged 45 years and older in conditions of constant employment in their specialty for at least 10 years, the combined impact of labor process factors increases the probability of developing non-carcinogenic health disorders by 15-20% annually in relation to persons not associated with exposure to these production factors ...

In Fig. 1 shows the result of modeling the integral health risk of workers without the impact of production factors and under the influence of production factors.

In Fig. 2 shows the result of modeling the change in the integral health risk of workers under the influence of production factors in various pathologies.

It should be noted that the physical activity of a person decreases with age due to a decrease in the physiological reserve of life support systems. In this case, physiological aging will act as a risk factor for COPD and BSC. With age, the functional activity of human organs and systems begins to gradually decrease. This is due to the fact that the number of functional units of organs and the mitotic activity of the renewing organs decrease: the number of alveoli in the lungs, vascular glomeruli in various organs, the intensity of cell division, and other renewing tissues also decrease during the aging process.

Usually, age-related changes in the respiratory system are accompanied by a decrease in muscle tone, which contributes to atrophy of the muscles that are directly involved in the implementation of the respiratory act, proliferation of fibrous tissue and fat deposits between muscle fibers, which determines the general nature of changes in the structure and function of the chest.

Age-related changes in the circulatory system significantly limit the adaptive capabilities of the body, create preconditions for the development of atherosclerosis, hypertension, coronary heart disease and brain disease. The systolic blood pressure and pulse pressure increase, the venous bed expands, the tone, the elasticity of the venous wall decreases - the determining factors for lowering the venous blood pressure. A decrease in muscle tone and a decrease in the suction action of the chest reduces the return of blood to the heart. Weakening of sympathetic extracardiac influences contributes to a decrease in heart rate. With age, the repolarization process also changes, the QRS complex widens; despite the development of age-related pulmonary emphysema, the electrical axis of the heart is deflected to the left, which indicates predominant changes in the left ventricular myocardium.

That is why special attention should be paid to the health of trainees, in whom the above factors are aggravated due to the additional influence of harmful production factors such as noise, exposure to toxicants, vibration, etc.

Arterial hypertension (AH) and chronic obstructive pulmonary disease (COPD) have common occupational and non-occupational risk factors that determine the development and progression of each of the diseases: lifestyle (smoking, low physical activity, acute and chronic stress), general biological processes (physiological aging) , the presence of somatic pathology (overweight, metabolic syndrome), production factors and working conditions.

Chronic exposure of the bronchial endothelium to chemical aerosols and dust forms an imbalance in the activity of pro- and antioxidant systems, which is accompanied by uncontrolled lipid peroxidation and accumulation of lipid peroxidation products, which have a cytotoxic and pro-inflammatory effect with the development of chronic bronchitis and COPD. Hypoxia due to chronic bronchitis / COPD disrupts the functioning of endothelium-dependent vasodilating mechanisms, which contributes to an increase in blood pressure (BP). The pathogenesis of the development of pulmogenic hypertension is due to the morphological restructuring of the lung tissue and bronchial tree, subsequent disturbances in pulmonary gas exchange and hemodynamics of the pulmonary circulation, the formation of hypoxia, hypercapnia and metabolic disturbances of vasoactive substances (catecholamines, serotonin, histamine, kinins, angiotensin II). A decrease in the oxygen content in blood and tissues stimulates the chemoreceptors of arterial and venous vessels, enhances afferent excitatory effects on autonomic neurons, and enhances efferent sympathetic vasoconstrictor activity in the periphery. With the aggravation of bronchial obstruction and the progression of hypertension, the central β-adrenergic and dopaminergic activity increases. An increase in the activity of the sympathoadrenal system (SAS) contributes to the disruption of the functional state of the hypothalamic-pituitary system and an increase in the modulating effect of adrenocorticotropic hormone on the mineralocorticoid function of the adrenal glands, which leads to an increase in aldosterone secretion. The activation of the renin-angiotensin-aldosterone system (RAAS) occurs both during the direct development of hemic hypoxia in the kidney tissue, and indirectly - through the activation of the SAS. Chronic combined exposure to such production factors characteristic of chemical industries as the presence of aerogenic chemical toxicants, industrial noise, vibration, the severity and intensity of the labor process, increase by 25-30% the incidence of hypercholesterolemia and arterial hypertension in workers, which is due to the activation of the sympathetic autonomic division. nervous system and hypothalamic-pituitary-adrenal mechanisms of release of corticotropin-releasing factor, adrenocorticotropic hormone and glucocorticoids.

It was found that predictors of occupational and work-related cardiorespiratory pathology in chemical workers are: the combined development of chronic diseases of the upper respiratory tract and astheno-neurotic / astheno-vegetative syndromes with an annual decrease in the forced expiratory volume in the first second (FEV ₁ ) (up to 35 ml annually) and endothelium reactions in the endothelium-dependent vasodilation sample (by 0.3% or more annually); the presence of radiological signs of moderate peribronchial fibrosis with a progressive course; a slight expansion of the right borders of the heart against the background of an increase in the antioxidant activity of plasma (AOA), erythropoietin, nitric oxide, vascular endothelial growth factor (VEGF), homocysteine, and highly sensitive C-reactive protein (hs-CRP) by more than 10% of the upper limit of the norm.

Due to the fact that the diagnostics of workers is carried out by determining the totality of objective (and not subjective) indicators, the most reliable and accurate assessment of the employee's assignment to the group of high risk of developing production-related cardiorespiratory pathology is provided.

Due to the fact that during the implementation of the proposed method, the following comparison of the indicated laboratory and physiological parameters with the standard values is carried out, the most accurate assessment of the establishment of the probability of health disorders of trainees in terms of cardiorespiratory pathology, which will be of a production-related nature, is provided.

Based on the foregoing, we can conclude that the delivered technical result is ensured by the combination of operations of the proposed method, their sequence and modes of its implementation.

When implementing the proposed method, the following operations are carried out in the following sequence:

1. At the initial stage, a selection is made for the subsequent medical examination of workers in chemical production, with work experience of 10 years or more and with an age of 45 years and older.

2. Conduct a clinical examination of workers to identify the following parameters: changes in the shape of the chest (not changed, or emphysematous), reduced excursion of the lower edge, increased resistance of the chest, percussion sound (dullness of percussion sound, percussion sound with a box shade); breathing characteristic (weakening of vesicular breathing), the presence of wheezing (wheezing outside of exacerbation is not heard); borders of the heart (a slight increase in the borders to the right and left), apical impulse (high), accentuation of tones (accentuation of tones is preserved or accent of II tone on a. Puim), heart murmurs (not heard), heart rate (HR) - brady- or tachycardia, blood pressure (BP) - above 130/80 mm. Hg

3. Conduct the subsequent determination of functional indicators: the position of the electrical axis of the heart, ST segment, R wave, T wave, P wave, ventricular complex on the ECG; FEV ₁ , FVC, FEV1 / FVC ratio, residual lung volume, forced expiratory flow rate (SOS25-75) according to spirography results; when carrying out a functional test using a bronchodilator, an increase in the indicator "forced expiration in a second"; the annual decrease in FEV ₁ in comparison with the results of the previous year and the rate of decrease in the functional activity of the endothelium in the endothelium-dependent vasodilation of the brachial artery in dynamics (given that chemical workers undergo a mandatory medical examination once a year, the endothelial response is measured annually).

4. The following laboratory parameters are determined in a blood sample: hemoglobin (Hb), erythrocytes, lipid hydroperoxide (HPL), malondialdehyde (MDA), plasma antioxidant activity (AOA), erythropoietin, nitric oxide, vascular endothelial growth factor (VEGF) , homocysteine, and highly sensitive C-reactive protein (hs-CRP).

5. Carry out the subsequent comparison of all the specified laboratory and functional parameters with the physiological norm (Functional diagnostics: national guidelines / edited by NF Beresten, VA Sandrikov, SI Fedorova. - M .: GEOTAR-Media, 2019. - 784 p: ill. - (Series "National guidelines"). - ISBN 978-5-9704-4242-5. Clinical laboratory diagnostics: a guide. In 2 volumes / Edited by V.V. Dolgov. 2012. - 928 p. (Series "National Guides") - ISBN 978-5-9704-2129-1).

6. The examined workers are referred to the group of high risk of development of work-related cardiorespiratory pathology, if they have the following deviations from the physiological norm:

- excess from the upper limit of the norm by more than 10% in the levels of Hb, erythrocytes, GPL, MDA, VEGF, homocysteine and hs-CRP,

- excess of the AOA level from the upper limit of the norm by more than 20%,

- a decrease from the lower limit of the norm by more than 10% in the level of erythropoietin and nitric oxide,

- while establishing by electrocardiography the deviation of the electrical axis of the heart to the right up to 100 degrees; oblique depression of the ST segment in V ₆ ; negative T wave in standard leads; negative T wave in V1; rSR 'ventricular complex; the voltage of the R wave is more than 7 mm, the high R wave in lead V ₆ , the P wave is more than 2 mm on the electrocardiogram (ECG);

when the FEV ₁ method is established by spirography less than 80% of the norm; the ratio of FEV ₁ / FVC equal to 65% -70%; indicator SOS25-75 - 70% -75%; when carrying out a functional test using a bronchodilator, an increase in the "FEV assessment per second" indicator by 8-12% of the due; annual decrease in FEV ₁ 35-50 ml per year, the rate of decrease in the functional activity of the endothelium per year by more than 0.3%.

When implementing the proposed method, laboratory diagnostics was performed according to standard methods using automatic hematological AcT5diff AL (Beckman Coulter Inc., USA, France), biochemical Keylab "(BPC + Biosed, Italy) analyzers.

Ultrasound assessment of the state of the vascular endothelium was carried out according to the modified method of Celermajer D.S. et al. (1992) on a Viamo SSA-640A portable ultrasound scanner (Toshiba medical, Japan) using a 7 MHz linear probe. The diameter of the brachial artery and the maximum blood flow velocity were measured in a longitudinal section 2-5 cm above the elbow bend at rest 30 s prior to compression induced by a sphygmomanometer cuff applied above the visualization of the brachial artery and inflated to a pressure of 50 mm Hg. Art. exceeding systolic. The compression duration was 5 minutes. The diameter of the brachial artery and the maximum blood flow velocity were determined at 60 seconds after air was removed from the cuff. Changes in vessel diameter were assessed as a percentage of the initial value. For a normal reaction of the brachial artery, its expansion by 10 percent or more from the initial level was taken. A smaller increase or vasoconstriction was interpreted as impaired endothelial function.

ECG recording was performed on a Shiller AT-102plus apparatus according to the standard technique (Schiller AG, Switzerland, serial number 025.13126).

Respiratory function (RPF) analysis was performed on a Schiller SP-1 spirometer using an SP-20 sensor (Schiller AG, Switzerland, serial number 542.10636) using ITS standards to calculate the proper values.

To prove the legitimacy of the estimated probabilistic indicators (deviations of functional and laboratory indicators) used in the proposed method, the methods of nonparametric statistics, logistic regression models were used. The estimation of the parameters of the models was carried out using software products associated with MS-Office applications. The assessment of the reliability and adequacy of the obtained models was carried out according to the Fisher criterion, the coefficient of determination [S. Glantz, 1998].

To assess the relationship of working conditions with the health status of workers, epidemiological research methods were used, including the calculation of the odds ratio (OR), the relative risk (RR) and the etiological response rate due to exposure to the occupational risk factor (EF), which make it possible to study the causal relationships between exposure unfavorable factors of the production process and the frequency of occurrence of certain types of responses from the health of workers. To assess the reliability of the data obtained, a 95% confidence interval (CI) was used. The presence of a connection is considered reliably established if the lower limit of the confidence interval is greater than one (R 2.2.1766-03 "Guidelines for assessing occupational health risks of workers, organizational and methodological foundations. Principles and criteria for assessment").

An example of a specific implementation.

To prove the possibility of implementing the method for determining the diagnostic significance of the laboratory and functional criteria indicated in the proposed method, workers of the chemical industry were examined, namely, workers of a metallurgical enterprise:

- observation group: 225 employees of a metallurgical enterprise, average age 49.7 ± 4.7 years, average experience - 25.4 ± 5.3 years (smelter of non-ferrous metals, metal casting, electrolysis worker, chlorinator);

- comparison group: 97 representatives of the administrative apparatus of the enterprise; average age 47.4 ± 5.5 years (p> 0.05), average length of service 22.8 ± 6.3 years (p> 0.05).

All examined men.

The working conditions of these workers were assessed based on the results of a special assessment of working conditions (SOUT) and in accordance with the “Guidelines for the hygienic assessment of factors of the working environment and the labor process. Criteria and classification of working conditions. R 2.2.2006-05 ".

The general assessment of the working conditions of the employees of the observation group corresponds to class 3.2-3.3. The main industrial hazards: dust of the respirable fraction and chemical substances, the composition of which was determined by the nature of the materials and the characteristics of the technological process. In the air of the working area (WZ), the proportion of suspended particles (dust) with sizes up to 2.5 microns inclusive was up to 10%, and for particles less than 10 microns, inclusive, from 28 to 47%. The noise exceeded the maximum permissible level (MPL) from 1 to 7 dBA, the total vibration exceeded the MPL from 1.5 to 1.7 times, the microclimate parameters determined the heating microclimate in the warm season and cooling in the cold one. The heat load of the environment exceeded the standard level from 3.4 to 10 ° C.

The category of a priori occupational risk among employees of the observation group corresponds to high (intolerable).

For workers in the comparison group, working conditions correspond to working conditions class 2 (permissible).

The examination included a clinical examination, determination of the functional parameters of the circulatory and respiratory systems by electrocardiography (ECG) and spirography (SPG); assessment of the functional activity of the vascular endothelium in the sample of postocclusive endothelium-dependent vasodilation of the brachial artery; and laboratory blood parameters (the content of hemoglobin and erythrocytes in the blood, lipid hydroperoxide, malondialdehyde, antioxidant activity of plasma, erythropoietin, nitric oxide, vascular endothelial growth factor, homocysteine and C-reactive protein).

The average group values of clinical, laboratory and functional indicators characterizing the mechanism of development of cardiorespiratory pathology in the observation group workers significantly exceed those of the comparison group (Table 1).

These tests proved the choice of reliably significant probabilistic indicators, through which it is possible to assess the likelihood of health disorders associated with the development of an occupationally conditioned cardiorespiratory pathology in trained workers of chemical industries exposed to the combined effects of a complex of harmful production factors: dust of a respirable fraction and chemicals; noise, vibration and microclimate, i.e. working in harmful working conditions. Below is the rationale for why trainee workers in chemical industries may experience production-related cardiorespiratory pathology.

To prove the negative impact of the combined impact of production factors (dust of the respirable fraction and chemicals; noise, vibration and microclimate) on the workers of the observation group, the levels of laboratory and functional indicators of the surveyed contingent of the comparison group were used as criteria for assessing deviations in laboratory parameters.

Industrial dust has an additive effect on the development of respiratory symptoms and causes inflammatory reactions at the level of the endothelium of the respiratory tract, resulting in the activation of the inflammatory response and the formation of cytokines. Production associated with inhalation toxins, dust, chemical vapors increases the risk and can cause obstructive pulmonary disease. Fine dust contributes to the penetration of chemicals into the lower respiratory tract, causing an inflammatory reaction. The combined inhalation effect of fine dust and chemicals mutually reinforce the damaging effect on the mucous membrane of the respiratory tract. Industrial dust generated during various technological processes causes mechanical damage to the mucous membrane of the respiratory tract, initiating an infiltrative-proliferative inflammatory process, as a result of which the sensitivity of tissues to the effects of chemicals increases. Additional exposure to chemicals with a pronounced irritant effect (chlorine and its compounds, etc.), enhances the alterative-exudative phase of inflammation. Small particles (such as PM _2.5 ) are able to penetrate into the lower parts of the lungs and alveoli, and trigger a number of mechanisms underlying long-term effects: effects on the autonomic nervous system (decrease in heart rate variability), conduction and repolarization processes, as well as systemic inflammatory reactions, which include endothelial dysfunction, oxidative stress. Chronic exposure to chemical aerosols and dust on the bronchial endothelium forms an imbalance in the activity of pro- and antioxidant systems, which is accompanied by uncontrolled lipid peroxidation and accumulation of lipid peroxidation products, which have a cytotoxic and pro-inflammatory effect with the development of chronic bronchitis and chronic obstructive pulmonary disease (COPD). Hypoxia due to chronic bronchitis / COPD disrupts the functioning of endothelium-dependent vasodilating mechanisms, which contributes to an increase in blood pressure (BP). Currently, three main mechanisms of the effect of airborne particles on the cardiovascular system have been identified: the classic way is the release into the systemic circulation of pro-inflammatory mediators produced in the lungs (IL-6, TNF-α, substance P, neurokinin A); an alternative path is the direct penetration of particles from the lungs into the systemic circulation; and the central pathway whereby particulate matter stimulates alveolar receptors to affect the autonomic nervous system. The development of pulmonary hypertension triggers a cascade of structural and functional changes in the myocardium and vessels of the systemic circulation, which underlies the development of systemic hypertension. The mechanism of the prohypertensive action of dust particles is associated with the development of a reflex imbalance of the autonomic nervous system in combination with endothelial dysfunction against the background of oxidative stress.

Industrial noise contributes to an increase in systolic and / or diastolic blood pressure, dyslipidemia, activation of lipid peroxidation and the formation of reactive oxygen species, systemic inflammatory reactions, impaired endothelial functional activity. The prohypertensive effect of noise is in direct proportion to the intensity, frequency and duration of its exposure and is characterized by the development of neurocirculatory syndrome, which occurs with hypertensive reactions and a tendency to transition to hypertension. Noise activates stress reactions with an increase in the tone of the sympathetic nervous system, an increase in the level of corticosteroids, catecholamines and angiotensin II in the blood against the background of a decrease in the activity of endothelial NO synthetase, which together determines the development of endothelial dysfunction.

Vibration at work is a proven prohypertensive factor and is characterized by the development of neurocirculatory syndrome, which occurs with hypertensive reactions. Vibration causes a violation of vegetative-vascular regulation on the segmental and suprasegmental, including the limbic-reticular complex, the hypothalamus. Activation of the sympathetic division of the autonomic nervous system (ANS) occurs, which leads to vagospasm, against the background of depression of the parasympathetic division of the ANS. As a result, damage to the endothelium of small vessels is released endoteliina and thromboxane A _2, which cause vasoconstriction without regulatory influence of the autonomic nervous system (ANS).

It should also be borne in mind that functionality decreases with age. This is due to the fact that the number of functional units of organs and the mitotic activity of the renewing organs decrease: the number of alveoli in the lungs, vascular glomeruli in various organs, the intensity of cell division of other renewing tissues also decrease during the aging process.

The unfavorable microclimate of industrial premises leads to a decrease in the adaptive capabilities of the organism; intensive biological aging of workers occurs. There is a decrease in sympathetic vasoconstrictive tone. A significant tension in hemodynamics is manifested in the form of persistent neurocirculatory dystonia of the hypertensive type, myocardiopathies, increased heart rate and, accordingly, an increase in the minute volume of blood circulation. Chronic heat exposure is accompanied by an increase in the functional activity of the adrenal cortex. Chronic heat exposure causes hypercoagulation of the blood, the amount of products of thermal denaturation of blood proteins and tissues, as well as under-oxidized products of disturbed tissue metabolism, increases in the blood.

Reduced air temperatures as a result of activation of the sympathetic division of the autonomic nervous system (ANS) increases the minute volume of respiration, increases pulmonary ventilation; the number of platelets and erythrocytes in the blood, cholesterol content, blood viscosity increases; glycogenolysis increases; increased secretion of adrenaline. Cooling the mucous membrane of the respiratory tract helps to reduce the resistance of the respiratory tract, inducing inflammatory responses. The tension of the center of thermoregulation is manifested by the activation of the sympathetic division of the ANS, angiospasms. A decrease in temperature causes an increase in the concentration of tropic hormones of the hypothalamus, thyroid hormones (thyroxine, etc.) and adrenal glands (adrenaline, etc.), which increase oxidative processes, activate enzymes that catalyze glycogenolysis in skeletal muscles and liver, as well as lipolysis in adipose tissue.

Age-related changes in the respiratory system are accompanied by a decrease in muscle tone, which contributes to atrophy of the muscles that are directly involved in the implementation of the respiratory act, the proliferation of fibrous tissue and fat deposits between muscle fibers), which determines the general nature of changes in the structure and function of the chest. With forced inhalation and exhalation, the difference in the perimeters of the chest, the mobility of the lower edges of the lungs and the excursion of the diaphragm decrease. With age, the lungs themselves change: they decrease in size, mass and become inactive. A decrease in the elasticity of elastic fibers and their atrophy lead to irreversible stretching and loss of the structure of the alveoli, the disappearance of the interalveolar septa, and the expansion of the alveolar passages. Emphysematous age-related changes develop, accompanied by a decrease in the gas exchange surface of the lungs. The vital capacity of the lungs decreases, a number of its components decrease: tidal volume, reserve volume of inhalation and exhalation. At the same time, the volume of residual air and especially its share in the total lung capacity increases. The decrease in respiratory efficiency with age is due to an increase in lung ventilation and a decrease in oxidative metabolism and hypoxia as a result of molecular, structural and functional changes. Age-related changes in the circulatory system significantly limit the adaptive capabilities of the body, create preconditions for the development of atherosclerosis, hypertension, coronary heart disease and brain disease. The systolic blood pressure and pulse pressure increase, the venous bed expands, the tone, the elasticity of the venous wall decreases - the determining factors for lowering the venous blood pressure. A decrease in muscle tone and a decrease in the suction action of the chest reduces the return of blood to the heart. Weakening of sympathetic extracardiac influences contributes to a decrease in heart rate. With age, the repolarization process also changes, the QRS complex widens; despite the development of age-related pulmonary emphysema, the electrical axis of the heart is deflected to the left, which indicates predominant changes in the left ventricular myocardium; the electric systole of the heart is lengthened; the spread of excitation in the atria slows down (expansion, flattening, deformation of the P wave); atrioventricular conduction and the spread of excitation through the ventricular myocardium are somewhat slowed down; there is a decrease in cardiac output; the functional reserve of cardiac output decreases. In the process of biological oxidation, semi-reduced forms of oxygen are also formed, which are highly reactive. All reactive oxygen species: O ₂ , OH⋅ and H ₂ O _2, when interacting with cell structures, damage them due to lipid peroxidation, inactivation of proteins or damage to nucleic acids.

Comparative analysis of changes in the indices of impaired regulation of vascular tone showed the damaging effect of a complex of production factors on the epithelium of the respiratory tract and vascular endothelium, which is confirmed by the identified abnormalities as a result of ECG, SPG and ultrasound examination (US) of the brachial artery: Р-pulmonale and signs of left ventricular hypertrophy (LVH ); annual decrease in FEV ₁ by 35-50 ml per year, FEV ₁ / FVC <70%, increase in residual lung volume, decrease in COC25-75 <20%; when carrying out a functional test using a bronchodilator, an increase in the indicator "forced expiration per second" by more than 12%; the rate of decrease in endothelial response is 0.3% per year.

These changes indicate a high risk of developing cardiorespiratory pathology.

The investigated laboratory parameters showed statistically significant changes between the groups, which reflect a number of subclinical features of the functioning of the circulatory and respiratory system in workers of chemical production.

Thus, the above data show that the clinical, laboratory and functional indicators indicated in the claimed method in the observation group, the level of which significantly differs from the level in the comparison group and the direction of their deviation from the physiological norm, is biologically plausible, therefore they can serve as criteria for assessment of the risk of developing cardiorespiratory pathology in chemical workers.

Below are examples of a specific implementation of the proposed method for workers of mines with varying degrees of risk of the likelihood of health problems associated with the development of production-related arterial hypertension.

Example 1. Employee A (age 46 years, work experience in metallurgical production 11 years 8 months) complains when questioned about increased fatigue, decreased exercise tolerance, shortness of breath during exercise, episodic increase in blood pressure after exercise up to 140/90 mm Hg, rare cough with a small amount of mucous sputum.

According to the examination results: satisfactory condition, excess body weight (BMI 29.1 kg / m ² ), physiological skin, normal humidity. Persistent red dermographism. The rib cage is of the correct shape, a slight increase in the lower borders; the excursion of the lower edge is moderately reduced, the resistance of the chest is moderately increased. With percussion, the dullness of the percussion sound is determined; auscultatory - vesicular breathing, evenly weakened, wheezing is not heard; respiratory rate 15 / min. The borders of the heart are shifted to the right by 0.5 cm; the apical impulse is high. With auscultation, the accentuation of the tones is preserved, the noises are not heard. HELL 145/85 mm Hg, pulse 58 beats. in min. Based on the results of a functional examination:

• ECG - Heart rate: sinus with a heart rate of 56. Deviation of the electrical axis to the right (α + 95 °). P wave in II and III assignments pointed, 2.2 mm; RV ₆ 37 mm; SV ₃ + RaVL = 2.9 mV; QRS expansion (95 ms) (signs of P-pulmonale and left ventricular (LV) hypertrophy)

• with LNG - Forced vital capacity (FVC) 79%, forced expiratory volume for 1 sec (FEV ₁ ) 56%, OF _B1 / FVC 70%, average volumetric velocity at the level of 25-75% (SOS 25-75) 71 % (Violation of ventilation capacity by obstructive type, slight decrease). Decrease of OB in ₁ during the year 37 ml.

• Sample of postocclusive reactive hyperemia on the brachial artery - initial data: artery diameter, D ₀ : 0.44 cm, peak systolic blood flow velocity, Vmax ₀ : 81 cm / s, Parameters after reocclusion: artery diameter: D ₁ : 0.47 cm , peak systolic blood flow velocity, Vmax ₁ : 92 cm / s. Change in the diameter of the brachial artery 0.03 cm, the relative increase in the diameter of the artery: 6.82%, the shear stress on the endothelium, the initial: T ₀ : 36.82, the shear stress on the endothelium after the test: T ₁ : 39.15 sensitivity of the brachial artery to stress shear, K: 1.08. The thickness of the intima-media complex (CMM) = 0.7 mm. Signs of endothelial dysfunction

Assessment of the functional state of the brachial artery endothelium in dynamics - the rate of decrease in the endothelial response per year is 0.4%.

According to laboratory data, it is observed:

• The content of erythrocytes 6.4 * 10 ^{12 /} cubic dm (exceeding the upper limit of the norm (UHN) by 10.1%).

• The level of Hb is 194 g / dm 3 (excess of VGN by 11.2%).

• The MDA level is 2.9 μmol / cc / l. (excess of VGN by 11.2%)

• VEGF level 799.40 pg / ml (excess of VGN by 14.2%)

• The level of hs-CRP 13.2 (excess of VGN by 10.8%)

• GPL level 412.4 μmol / cubic dm (excess of VGN by 14.7%)

• Homocysteine level 17.23 μmol / cubic dm (excess of VGN by 14.8%)

• AOA level 47.2% (exceeding VGN by 22%)

• The level of nitric oxide 61.3 μmol / cubic dm (decrease in the lower limit of the norm (LHN) by 12.8%)

• The level of erythropoietin 7.2 mIU / cubic mm (decrease in NGN by 11.2%).

For this trainee worker, the likelihood of developing a work-related cardiorespiratory pathology is assessed as high and he can be attributed to a high-risk group.

Example 2. In employee B (age 48 years, work experience in metallurgical production 15 years 2 months) when questioning complaints about increased fatigue, decreased exercise tolerance, shortness of breath during and after work, episodic increase in blood pressure to 150/90 mm Hg Art., more often after exercise, cough during exercise with mucous sputum.

According to the examination results: satisfactory condition, obesity of I degree (BMI 32.3 kg / m ² ), pale skin, moist, moderately pronounced cyanosis of the lips. Mixed dermographism. The chest is emphysematous; excursion of the lower edge is reduced, chest resistance is increased. With percussion, a percussion sound with a box shade is determined; auscultation - vesicular breathing, evenly weakened, carried out in all departments, wheezing is not heard; respiratory rate 14 / min. The borders of the heart are shifted to the right by 1 cm; the apical impulse is high. On auscultation - the accent of the II tone in the II intercostal space on the left (on a. Pulm), noises are not heard. BP 145/90 mm Hg, pulse 60 beats. in min.

Based on the results of a functional examination:

• ECG - Heart rate: sinus with heart rate 56. Deviation of the electrical axis to the right (α + 90 °). The P wave in lead II is pointed, 2.1 mm; RV ₆ 35 mm; SV ₃ + RaVL = 2.7 mV; QRS expansion (98 ms) (signs of P-pulmonale and LV hypertrophy)

• with LNG-Forced vital capacity (FVC) 61%, forced expiratory volume for 1 sec (OF _B1 ) 70%, OF _B1 / FVC 65%, average space velocity at the level of 25-75% (SOS 25-75) 75 % (Violation of ventilation capacity by restrictive type, moderate decrease). Decrease of OB _B1 during the year 48 ml.

• Sample of postocclusive reactive hyperemia on the brachial artery - initial parameters: artery diameter, D ₀ : 0.32 cm, peak systolic blood flow velocity, Vmax ₀ : 26.92 cm / s. Parameters after reocclusion: artery diameter, D ₁ : 0.35 cm, peak systolic blood flow velocity, Vmax ₁ : 100.38 cm / s. Change in brachial artery diameter: 0.03 cm, relative increase in artery diameter: 9.38%, initial shear stress on the endothelium: T ₀ : 16.825, shear stress on the endothelium after the test: T ₁ : 57.36 sensitivity of the brachial artery to shear stress , K: 0.0389. CMM thickness: 1.1mm. Signs of endothelial dysfunction. Evaluation of the functional state of the brachial artery endothelium in dynamics - the rate of decrease in the endothelial response of 0.36%.

According to laboratory data, it is observed:

• Content of erythrocytes 6.6 * 10 ^{12 /} cubic dm (excess of VGN by 14.2%).

• The Hb level is 196 g / dm3 (excess of VGN by 12.8%).

• MDA level is 2.7 μmol / cc / l. (excess of VGN by 10.5%)

• VEGF level 803.60 pg / ml (excess of VGN by 14.8%)

• The level of hs-CRP 13.4 (excess of VGN by 11.2%)

• GPL level 416.2 μmol / cubic dm (excess of VGN by 15.6%)

• Homocysteine level 17.17 μmol / cubic dm (excess of VGN by 14.5%)

• AOA level 45.8% (excess of VGN by 20.5%)

• Nitric oxide level 61.3 μmol / cubic dm (decrease in NGN by 12.8%)

• Erythropoietin level 7.04 mIU / cubic mm (decrease in NGN by 12%)

For this trainee worker, the likelihood of developing a work-related cardiorespiratory pathology is also regarded as high and he can be attributed to a high-risk group.

The data obtained during the implementation of the proposed method are necessary to solve expert questions about the possibility of minimizing the risk of developing cardiorespiratory pathology in trained workers of chemical industries to keep their jobs in the profession.

The choice of numerical parameters of probabilistic indicators for a group of trained workers of high risk of development was due to the fact that deviations of functional and laboratory indicators are persistent pathological in nature even in the absence of complaints and a clinical picture, are characterized by asthenovegetative syndrome and are the initial signs of cardiorespiratory pathology.

When assessing the proposed method of the risk of development of production-related cardiorespiratory pathology in workers of chemical production, the following was taken into account:

structural changes in the heart in cardiorespiratory pathology have common links of pathogenesis: the development of endothelial dysfunction and inflammation:

- Endothelium dependent vasodilation characterizes the processes of endothelial dysfunction, which is one of the main pathogenetic mechanisms of the development of both AH and COPD;

- remodeling of the heart is a compensatory reaction, however, the depletion of functional reserves leads to maladaptive consequences: asymptomatic enlargement of the left ventricle and overload of the right heart. These changes may be associated with production factors that do not directly affect the structure of the heart and its functioning, for example, heat radiation, physical and emotional overload, but can cause serious hemodynamic disturbances, increasing the risk of sudden death;

- dysfunctions of external respiration, characterized by a decrease in lung volumes (restrictive disorders), in chemical production workers are early signs of respiratory damage, often even with preserved LNG values. Hyperventilation may initially be of a compensatory nature (overcompensation) associated with the excitation of the respiratory center (exposure to high temperatures, chemicals);

- the main functions of VEGF (a signaling protein produced by cells to stimulate vasculogenesis) - the creation of new blood vessels; Can be caused in cells that are not getting enough oxygen

- insufficient oxygen also stimulates erythropoiesis;

- nitric oxide (II) is critical for the regulation of normal vascular tone, as a mediator of vasodilation (vasodilation). The production of nitric oxide (II) is enhanced under the influence of various factors, such as hypoxia, tissue damage (in particular, damage to the vascular endothelium), etc. Through a series of intermediate stages, this leads to a change in the activity of contractile proteins of smooth muscle cells. The end result is smooth muscle cell relaxation, vasodilation and increased blood flow. Nitric oxide (II) also affects the myocardium. Low concentrations of nitric oxide increase the contractile function of the myocardium, heart rate and cardiac output, stroke and cardiac output, which compensates for the hypotension caused by it as a result of vasodilation, and in combination with the vasodilation and bronchodilation caused by nitric oxide, it allows to eliminate hypoxia, improve oxygen delivery to tissues ... Higher concentrations of nitric oxide, on the other hand, restrict the work of the heart, lowering its contractile function, heart rate and strength, and decreasing myocardial oxygen consumption simultaneously with an increase in coronary blood flow. These properties are the basis for the use of organic nitrates in ischemic heart disease and heart failure. Under physiological conditions, nitric oxide (II) is one of the important regulators of myocardial contractile function and myocardial oxygen consumption;

- in the process of vital activity in the human body free radicals are formed. These are very active scraps of molecules that enter into chemical reactions with cell membranes and DNA; the formation of a large number of free radicals is the initial stage of cardiorespiratory pathology - free radicals can damage the endothelium of arteries, accelerate physiological aging. The body has an antioxidant defense system. Disruption of antioxidant protection is characterized by the development of free radical damage to various components of the cell and tissues;

- C-reactive protein (CRP) is the main protein in blood plasma that reflects inflammatory processes in the body. An increase in this protein is also seen with low background inflammation in the body, which may portend an increased risk of cardiovascular disease; C-reactive protein is produced in response to inflammation and damage to body tissues, for example in arteries and / or lungs, and the risks of cardiorespiratory pathology in workers without clinical symptoms can be predicted;

- homocysteine is the most important sulfur-containing amino acid that is found in the cells of the body. This component is involved in general metabolism, ensures normal blood flow and the functioning of the cardiovascular system. The level of homocysteine determines the risks of developing diseases of the circulatory system;

Thus, the proposed method has the following advantages over known methods:

- allows to determine for workers of chemical industries in a complex of production factors (combined exposure to industrial noise and vibration above the MPL and the concentration of dust and chemicals above the MPC, microclimate parameters) the professional conditionality of prenosological indicators characterizing the mechanism of development of cardiorespiratory pathology;

- to identify workers with a high health risk, due to the likelihood of developing cardiorespiratory pathology, for carrying out medical and preventive measures to minimize the risk and maintain professional ability to work.

Claims (1)

A method for selecting trainee workers in chemical production in a group of high risk of developing industrial-related cardiorespiratory pathology, characterized by the fact that they conduct a medical examination of workers in chemical production with more than 10 years of experience by determining diagnostic laboratory and functional parameters, while hemoglobin levels (Hb ), erythrocytes, lipid hydroperoxide (HPL), malondialdehyde (MDA), plasma antioxidant activity (AOA), erythropoietin, nitric oxide, vascular endothelial growth factor (VEGF), homocysteine and highly sensitive C-reactive protein (hs-CRP); and as functional indicators, signs of an increase in the left and right ventricles of the heart are determined by the method of electrocardiography by establishing the position of the electrical axis of the heart, the position of the ST segment relative to the isoline in V ₆ and the T wave in V1; type of ventricular complex; through the size of the R wave voltage, the height of the R wave in lead V ₆ , the P wave on the electrocardiogram (ECG); fixed expiratory volume in 1 sec. (FEV1 ₁ ), forced vital capacity (FVC); the ratio of FEV ₁ / FVC and the average forced expiratory flow rate (SOS25-75) by spirography; carrying out a functional test using a bronchodilator with an assessment of the increase in the indicator "assessment of forced expiration in a second", and establish the annual decrease in FEV ₁ in comparison with the results of the previous year and the rate of decrease in the endothelial response for the year, compare the results of the obtained indicators with the physiological norm, and those workers, in which the following deviations in indicators from the physiological norm were revealed, namely: an excess of the level of Hb, erythrocytes, GPL, MDA, VEGF, homocysteine and hs-CRP from the upper limit of the norm by more than 10%, excess from the upper limit of the norm by more than 20 % of the level of AOA, a decrease from the lower limit of the norm by more than 10% in the level of erythropoietin and nitric oxide, while the deviation of the electrical axis of the heart to the right is established by electrocardiography up to 100 degrees; oblique depression of the ST segment in V ₆ ; negative T wave in standard leads; negative T wave in V ₁ ; a rSR 'ventricular complex; the voltage of the R wave is more than 7 mm, the high R wave in lead V ₆ , the increase in the voltage of P is more than 2 mm on the ECG electrocardiogram; when the FEV ₁ method is established by spirography less than 80% of the norm; the ratio of FEV ₁ / FVC equal to 65% -70%; indicator SOS25-75 - 70% -75%; when carrying out a functional test using a bronchodilator, an increase in the "FEV assessment per second" indicator by 8-12% of the due; the annual decrease in FEV ₁ 35-50 ml per year, the rate of decrease in the functional activity of the endothelium per year by more than 0.3%, are attributed to the group of workers with a high risk of developing production-related cardiorespiratory pathology.

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