1. Occupational Lung Diseases Year II 2010

2. The Top 8 Occupational Diseases • Asbestosis • Asbestos induced pleural disease • Noise induced hearing loss • Upper respiratory infection • Solvent intoxication • Occupational asthma • Carpal tunnel syndrome

3. Respiratory History – Step 1 • Chief complaint: ? Temporal relation to job • Social History: • Tobacco exposure • All jobs and duration of each • Fumes, dusts, chemicals, irradiation

4. Step 2: Explore the Work • Description of actual job duties • Potential for exposure • Products manufactured • Similar illness in other workers

5. Step 3: Home/environment • Nearby industries • Work clothes contaminated • Any illness in neighbors • Pollution, ozone • Household chemicals • Hobbies

6. Step 4: Explore the Work Place • Handling of substances • Usual operations • Clean up practices • Protective equipment • Ventilation system • Hire an occupational site investigator?

7. Step 5: Follow the Patient • H and P a must • Pulmonary function tests • CXRs • ??CT • ?? Disease markers • ?? Pathology

8. “5 things” • Dust Macules • Fibrotic Lung Diseases • Immunologic Lung Diseases • Obstructive Lung Diseases • Toxic Lung Injury

9. DUST MACULES

10. Dust Macules • deposited and retained in lung • little or no host reaction • scattered opacities on CXR • No physiologic abnormalities

11. Origins: Mining and Refining • Aluminum • Antimony, Barium, Chromium ore • Coal Dust (black) • Iron (red) • Tin (gray) • Titanium (white)

12. Clinical actions • Once it is determined that the patient has dust macules by CXR, perform PFT. • In the absence of other abnormalities or exposures, you can reassure the patient there will be no progressive disease.

13. Fibrotic Lung Disease Hint: Concentrate on these!

14. Fibrotic Lung Diseases • Silica • Coal workers • Asbestos • A word on cobalt

15. Silicosis • Pneumoconiosis due to crystalline silica • Alpha quartz most commonly- dnt have 2 know • Tridymite, cristobilite: More fibrogenic • Increasing exposure: more disease • World wide the most common pneumoconiosis (not for USA) • Ubiquitous (major part of earth’s crust)

16. Occupational sources: Hard rock mining, construction, road work, tunneling, sandblasting, foundry work (unmolding), granite/stone work, silica flour production/use, ceramics, glass manufacturing, work with dental prostheses,

17. Dental Technicians • First case reports 1986, 1989 • Grinding, cutting, polishing prep • Prosthetic material may contain: • Silica, silicon carbide • Asbestos • Vitallium • Acrylic resins

18. Clinical Features • Silico-proteinosis • Simple silicosis • Complicated Silicosis • (Progressive Massive Fibrosis)

19. Acute silicosis • AKA silico-proteinosis • rare, progressive, fatal • massive exposure • ground glass upper lobes

20. Chronic (Simple) Silicosis • silcotic nodules (<1 cm) • upper zones predominate • more changes with more exposure • eggshell calcification of hilar nodes • minimal PFT changes • Few symptoms

21. Radiographs • Simple silicosis: upper zone nodules < 1 cm in size, uniform • Lymph node enlargement • 10% have “eggshell” calcifications

25. Complicated Silicosis Simple nodules coalesce • disabling and life threatening • Can progress after exposure ends • Obstructive and restrictive PFTs • + ANA and + RF common • Caplan’s Syndrome (RA) - more benign

26. Radiographs • Complicated silicosis, PMF: • Coalescence of nodules • Nodules > 1 cm (2 cm) • Basilar (traction) emphysema • Pleural adhesions • Compression of vena cava, esophagus • PTX often fatal

28. Clinical • Occupational history and CXR key • Simple: few symptoms • PMF: dyspnea, cough, hypoxemia, etc. • PFT: restrictive, obstructive or mixed; DLCO variably affected. • Biopsy usually not needed • If wt loss, think TB

30. Progressive Massive Fibrosis • Massive nodule coalescence • Retraction bullae at lung bases • Involvement of great vessels (veins) • Can be fatal

32. Silicotuberculosis • Silica poisons macrophages • 4-6 fold increased risk of TB • Both affect upper lobes • High TB relapse rate • All silicosis: annual PPD • NB: no increase in lung CA

33. Management • Supportive care • Annual PPD, rx at 10 mm • Evaluate for autoimmune diseases • Watch for hypoxemia • Note: at present no evidence for increased risk of lung CA

34. Other silicates assoc w/Lung Dz • Talc (often contaminated w/asbestos • Kaolin (“china clay”, aluminum silicate) • Fuller’s Earth • Bentonite (another Al silicate)

35. Coal Workers’ Pneumoconiosis “Inhalation, deposition of coal dust and the tissue’s reaction to its presence.”

36. Coal Workers’ Pneumoconiosis • Accumulation of coal dust in the lungs • + tissue’s reaction to its presence • Legal diagnosis: • 10 years underground exposure • Nodules on CXR • Clinically, controversy on physiologic significance

37. CWP Myths • All due to silicosis: FALSE • All due to smoking: FALSE • Related to coal + infection: probably false • Something autoimmune: maybe

38. Coal and Mining Methods and Dz • Forms of coal • Anthracite: oldest, hardest, highest amt disease • Bituminous • Peat: newest, softest, least disease • Depth of Mine • Worst: deep shaft mine • Intermediate: shelf mining, digging • Least: open strip mines

39. At Risk • Miners: related to type of coal, depth of mine and duration of exposure • PA, anthracite, underground: 46% • Strip miners: 4-5% • Non-miners: those involved in crushing, sizing, washing, blending, loading ships, barges, RR cars.

40. CXR in CWP • Simple: small opacities, UL predominate • Complicated: increasing size of opacities, may aggregate, may  PMF • CXR related to total dust exposure

41. Simple CWP • Cough, blackish sputum • CXR: fine nodules • Pulmonary function tests: • Normal (like dust macules) • Often see obstructive disease due to smoking

43. Complicated CWP • Similar to complicated silicosis • Can lead to progressive massive fibrosis • Mechanism??: • Silica + coal dust exposure • Massive dust exposure • Infection + coal dust exposure

44. Asbestos • Mining • Manufacture and shipping • Insulation • Demolition

45. “Classic” occupations • (1940s) Naval veterans, shipyards • (1950s) Brake linings, construction • (1970s) Naval veterans • Pipe fitters, boiler workers, plumbers, demolition, reconstruction

46. Asbestos- Pleural Disease • Pleural plaques • Thickened pleura (uncommon) • Exudative pleural effusion (bloody)

48. Asbestosis • Fibrotic lung disease secondary to inhalation and lung reaction • Generally prominent in lung bases • Restrictive process: dry cough, crackles, exertional dyspnea, low lung volumes • Can result in clubbing, respiratory failure