Occupational & Environmental Lung Diseases | Jindal Chest Clinic

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Occupational Environmental Lung Diseases
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Harmful Effects of Inhaled Particles

• Determinant Factors
• Biological factors e.g. allergens, pollens
• Chemical factors e.g. gases, quartz
• Physical factors asbestos fibers
• Total Mass of inhaled dust is important
• Spectrum of Environmental Problems
• General Non-specific, skin, eye systemic
• Specific (Occupational) Inorganic organic
  dusts
• 
  Gaseous pollutants

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Respiratory Diseases

• General respiratory symptoms Cough
• Infections Tuberculosis
• Asthma Environmental factors, Occupational
  asthma
• Chronic Obstructive Pulmonary Disease (COPD)
• Pneumoconioses Silicosis
• Lung cancer
• Interstitial Lung Disease
• Nonspecific respiratory symptoms

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Systemic Problems

• Cardiac
• Hypertension Atherosclerosis
• Ischaemic heart disease heart attacks
• Cardiomyopathies
• Cerebrovascular
• Atherosclerosis cerebral, cerebrovasc
  (Strokes)
• Cerebellar, cerebral and spinal
  syndromes, Musculoskeletal
• Neuro-psychiatric Depression and other
  emotional disturbances
• Gastro-intestinal (mostly water-borne)
• Parasitic infestations and other
  Infections
• Diarrhoeas, Dysenteries, Hepatitis,
  Dyspepsia ulcers
• Cancers

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Clinical Aetiological Classification

• Inhalable dust diseases
• Deposition Solid , inorganic dusts
• Hypersensitivity Organic dusts
• Hypersensitivity
  pneumonias
• Occupational asthma
• Gases and fumes
• Miscellaneous Infections, allergies

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Inorganic Dust Exposures (Occupational)

• Silicosis
• Anthracosis- Coal workers pneumoconioses
• Asbestosis
• Deposition of tin, mica

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Silicosis

• Most prevalent chronic occupational lung disease
• Irreversible and chronic fibrotic disease caused
  by inhalation, retention and pulmonary reaction
  to large amounts of silica dust (SiO2)
• Mining, stone cutting, ceramic, pottery, agate,
  brick making, slate pencil, etc. are a few of the
  many industries which are particularly at risk

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Clinical Course 3 forms

• Chronic/Classic Silicosis
• Accelerated Silicosis
• Acute Silicosis

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Chronic Silicosis

• Develops following low-to-moderate level exposure
  to silica dust for gt20 yrs
• 1st ? Silica laden macrophages accumulate
• Later ? Silicotic nodules form as a result of
  host response to the foreign body
• Nodules mainly seen in upper lobes
• Calcified LN maybe seen
• Nodules enlarge and coalesce (gt2cm) ? PMF or
  complicated silicosis
• Increased susceptibility to TB and cavitation

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• Accelerated Silicosis
• Heavy silica exposure in lt5-10 yrs
• Progresses faster than chronic silicosis
• Sometimes associated with CTD
• Acute silicosis
• V.High concentration of silica exposure over
  weeks to months eg. Sandblasters, rock
  drilling, etc
• B/l alveolar opacities without silicotic nodules
• Intense inflammatory reaction due to freshly
  fractured silica particles
• Hypertrophic Type II pneumocytes ? produce excess
  surfactant ? Resembles PAP

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Complications

• Tuberculosis
• Cor pulmonale
• Spontaneous pneumothorax
• Broncholithiasis
• Tracheobronchial obstruction
• Lung cancer
• Hypoxemic ventilatory failure

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Silico-tuberculosis

• The association of Silicosis and TB has been
  suspected several hundred years
• Exposure to silica causes a renewed
  multiplication of bacilli in the healing TB
  lesions
• Increased risk of PTB in silicosis
• Exposure of silica has an unfavourable influence
  on the course of induced TB

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Interaction of silicosis with TB

• There is more fibrosis produced by combination
• Synergistic effect of silicosis and TB
  proliferative fibrous reaction ? Rapid fibrosis
• TB may complicate simple silicosis as well as
  advanced disease
• It may develop PMF with cavitation
• Poor response to ATT ?Longer duration needed

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Treatment of Silicosis

• No specific therapy for silicosis
• Prevent further exposure to silica dust
• Strongly advise patients to quit smoking
• Immunize against influenza, pneumococci
• Experimental approaches tried without success are
  - whole-lung lavage, aluminum inhalation, and
  corticosteroids
• Screen for TB with sputum AFB x 2
• Complications should be treated appropriately

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Prevention

• Dust suppression,
• Process isolation,
• Ventilation,
• Use of nonsilicacontaining abrasives.
• Respiratory masks
• Surveillance of exposed workers with respiratory
  questionnaires, spirometry, and chest x-rays is
  recommended

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Diseases associated with exposure to Silica dust

• Occupational asthma
• Chronic obstructive pulmonary disease
• Emphysema
• Chronic bronchitis
• Mineral dust induced small airway disease
• Lung cancer
• Mycobacterial infection
• MTB
• NTM
• Immune Related Disease
• PSS, RA, CRD, SLE

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Coal Workers Pneumoconiosis

• Coal dust consists of carbon (60-80), apart from
  50 different elements and oxides including
  Silica
• Higher the quality of coal higher the silica
  content in the dust
• 2 forms simple CWP and PMF
• Three Criteria needed for diagnosis of CWP
• CXR consistent with CWP
• A work history sufficient in exposure and latency
  to cause CWP
• Absence of other illnesses which mimic CWP

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Simple CWP

• Small rounded opacities from pinhead sized to 1
  cm
• 1st upper zones ? then all over lung fields
• Slowly progressive illness over decades
• Chest radiograph correlates with amount of coal
  dust inhaled
• Pathology Coal macule is characteristic lesion
• Consists of coal dust, reticulin fibres and coal
  laden macrophages
• Later enlarges and forms coal nodule
• Surrounded by focal area of emphysema
• Silicotic nodules may coexist

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PMF Progressive Massive Fibrosis

• When one or more nodules attain a size of gt2cm
• MC in posterior segments of upper lobes or
  superior segments of lower lobes
• Assymetrical
• Development influenced by
• Combined inhalation of silica
• NTM infection
• Immunologic response

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Other diseases caused by coal

• COPD
• Industrial bronchitis
• Caplans syndrome
• Complications
• Cor pulmonale
• Pneumothorax
• Hypoxemic Respiratory failure
• Silicotuberculosis more common when exposed to
  high levels of silica in coal dust

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Asbestosis

• Asbestosis highly dangerous, but extremely useful
  industrial material.
• Used in cement, building material, plastic,
  insulation, fire proofing, ship building, Railway
  workshops, cement friction product manufacture
• Environmental pollution is known.

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Asbestosis

• Exposure to asbestos causes asbestosis, lung
  cancer, mesothelioma of pleura and peritoneum ,
  Interstitial lung fibrosis
• Asbestos fibres are fire-resistant,
  indestructible. An inhaled fibre may lie dormant
  for several years to cause lung damage

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OTHER DEPOSITION DISEASES

• Other silicate materials Talc, Kaolin, Mica,
  Cement
• Erionite (Fibrous aluminium silicate)
• Man made vitreous fibres e.g.
• Glass wool, rock wool, ceramic fibres
• Siderosis, Stannosis, Baritosis,
• Tungston, Carbon, Antimony
• Produce X-ray abnormalities, but no functional
  change
• Minimal inflammatory response

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ORGANIC DUST DISEASES

• Occupational Asthma
• Hypersensitivity Pneumonias (HP)
• Farmers Lung Agricultural exposures, fungi.
• Byssinosis Cotton, Textile, Jute Industry
• Monday morning illness, Acute Mill Fever,
• weavers cough. 7-9 in Textile workers
• Prevention dust levels lt 0.5 mg/m3
• Drugs and chemicals

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Hypersensitivity Pneumonias

• Type 3 immunological response to sensitizing
  antigens (Cf. type 1 for asthma)
• Presentation delayed 4-6 hrs or more after
  exposure
• Symptoms Cough, fever, breathlessness, malaise
  etc
• Types Farmers lung, Byssinosis, Baggasosis
• Psittacosis, Pigeon breeder lung,
  Grain lung,
• Air-conditioner lung, compost
  lung etc
• Diagnosis History of exposure-symptom
  relationship
• CXR Non-specific. Eosinophilia,
  Antibodies
• Tmt Removal of offending antigens
• Symptomatic and anti-inflammatory
  treatment

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Byssinosis

• Byssinosis is an occupational lung disease caused
  by exposure to cotton, flax and hemp dust.
• Presents with asthma-like symptoms
• Maximum number of workers with byssinosis are
  reported in the cotton textile industry as it is
  one of the largest industries in the world.
• The  workers engaged  in the initial processes of
  textile manufacturing (blow, card, frame and ring
  frame) are exposed to cotton dust and develop the
  disease after some years of exposure. 

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Other environmental exposures

• Gases Fumes
• Accidental leakage
• Bhopal tragedy (MIC)
• Occupational.
• Mechanisms
• Asphyxiation CO2,
• Nitrogen, Methane
• Irritation NH3, Chlorine,
• SO2,O3, Phosgene

• Infections
• Respiratory tract
• Infections Pneumonias
• Tuberculosis
• HIV
• Anthrax
• Parasitic
• Viral

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Effects attributed to long term exposure

• Mortality due to cardiovascular and respiratory
  disease
• Chronic respiratory disease incidence and
  prevalence (asthma, COPD, chronic pathological
  changes)
• Chronic changes in physiologic functions
• Lung cancer
• Chronic cardiovascular disease
• Intrauterine growth restriction (low birth weight
  at term, intrauterine growth retardation, small
  for gestational age

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Other Indoor pollution

• Aero-allergens
• Sources- Dampness, Pets
• Poor ventilation
• Thermophilic actinomycetes
• Fungi, Aspergillosis, Bacteria
• Other sensitizing antigens
• Humidity Low relative humidity
• Dryness of eyes respiratory tract
• Electromagnetic hypersensitivity
• Deleterious effects in patients with asthma,
  diabetes, multiple sclerosis,fatigue,
  fibromyalgia

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Exposure Antigens Diseases
Mouldy hay6 Thermophilic actinomycetes Farmers lung
Mouldy bagasse7 Thermophilic actinomycetes Bagassosis
Mouldy compost and mushroom8 Thermophilic actinomycetes Mushroom workers disease
Contaminated barley9 Aspergillus clavatus Malt workers lung
Compost10 Aspergillus spp. Compost lung
Esparto grass11 Aspergillus spp. Esparto dust lung
Soy sauce brewing12 Aspergillus spp. Soy sauce lung
Contaminated humidifiers, air Thermophilic actinomycetes Ventilator lung
conditioners, heating systems13    
Domestic birds14 Bird proteins Bird fanciers lung
Pigeon droppings15 Serum, feathers, droppings Pigeon breeders disease
Parakeets16 Serum, feathers, droppings Budgerigar fanciers lung
Silkworm larvae17 Silkworm larvae proteins Sericulturists lung
Grains18 Grain weevil Grain lung
Isocyanates19 Altered proteins Hypersensitivity pneumonitis
Wood cutting20 Plant protein Woodmans disease
Contaminated metal working fluid21 Pseudomonas spp Machine operators lung
Detergent enzymes22 Bacillus subtilis Detergent workers disease
    (washing powder lung)
Contaminated basement23 Cladosporium spp, Penicillium spp Basement lung
Contaminated hot tub water24 Mycobacterium avium complex Hot-tub lung
House dust25 Trichosporum asahii Japanese summer house hypersensitivity
    pneumonitis
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Occupational Asthma

• Animal proteins
• Plant proteins
• Legumes and seeds
• Wood dusts
• Antibiotics and other drugs manufacturing
• Metal salts- platinum, cobalt, nickel, chromium
• Diisocyanates
• Dyes and chemicals

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Diagnosis Treatment

• Exposure-symptom relationship
• Radiological investigations
• Immunological investigations Skin test, antibody
  demonstration
• Occasionally, histopathology
• Management Largely symptomatic
• Reduction/ removal of exposure
• Management of complications

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