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Harrison'sPrinciplesofInternalMedicine,18e>

Chapter256.Occupationaland
EnvironmentalLungDisease
JohnR.BalmesFrankE.Speizer

OccupationalandEnvironmentalLungDisease:Introduction
Occupationalandenvironmentallungdiseasesaredifficulttodistinguishfromthoseofnonenvironmentalorigin.
Virtuallyallmajorcategoriesofpulmonarydiseasecanbecausedbyenvironmentalagents,andenvironmentally
relateddiseaseusuallypresentsclinicallyinamannerindistinguishablefromthatofdiseasenotcausedbysuch
agents.Inaddition,theetiologyofmanydiseasesmaybemultifactorialoccupationalandenvironmentalfactors
mayinteractwithotherfactors(suchassmokingandgeneticrisk).Itisoftenonlyafteracarefulexposurehistory
istakenthattheunderlyingworkplaceorgeneralenvironmentalexposureisuncovered.
Whyisknowledgeofoccupationalorenvironmentaletiologysoimportant?Patientmanagementandprognosis
areaffectedsignificantlybysuchknowledge.Forexample,patientswithoccupationalasthmaorhypersensitivity
pneumonitisoftencannotbemanagedadequatelywithoutcessationofexposuretotheoffendingagent.
Establishmentofcausemayhavesignificantlegalandfinancialimplicationsforapatientwhonolongercanwork
inhisorherusualjob.Otherexposedpeoplemaybeidentifiedashavingthediseaseorpreventedfromgettingit.
Inaddition,newassociationsbetweenexposureanddiseasemaybeidentified(e.g.,nylonflockworker'slung
diseaseanddiacetylinducedbronchiolitisobliterans).
Althoughtheexactproportionoflungdiseaseduetooccupationalandenvironmentalfactorsisunknown,alarge
numberofindividualsareatrisk.Forexample,1520%oftheburdenofadultasthmaandchronicobstructive
pulmonarydisease(COPD)hasbeenestimatedtobeduetooccupationalfactors.

HistoryandPhysicalExamination
Thepatient'shistoryisofparamountimportanceinassessinganypotentialoccupationalorenvironmental
exposure.Inquiryintospecificworkpracticesshouldincludequestionsaboutthespecificcontaminantsinvolved,
thepresenceofvisibledusts,chemicalodors,thesizeandventilationofworkspaces,theuseofrespiratory
protectiveequipment,andwhethercoworkershavesimilarcomplaints.Thetemporalassociationofexposureat
workandsymptomsmayprovidecluestooccupationrelateddisease.Inaddition,thepatientmustbequestioned
aboutalternativesourcesofexposuretopotentiallytoxicagents,includinghobbies,homecharacteristics,
exposuretosecondhandsmoke,andproximitytotrafficorindustrialfacilities.Shorttermandlongterm
exposurestopotentialtoxicagentsinthedistantpastalsomustbeconsidered.
WorkersintheUnitedStateshavetherighttoknowaboutpotentialhazardsintheirworkplacesunderfederal
OccupationalSafetyandHealthAdministration(OSHA)regulations.Employersmustprovidespecificinformation
aboutpotentialhazardousagentsinproductsbeingusedthroughMaterialSafetyDataSheetsaswellastraining
inpersonalprotectiveequipmentandenvironmentalcontrolprocedures.Reminderspostedintheworkplacemay
warnworkersabouthazardoussubstances.However,theintroductionofnewprocessesand/ornewchemical
compoundsmaychangeexposuresignificantly,andoftenonlytheemployeeontheproductionlineisawareof
thechange.Forthephysiciancaringforapatientwithasuspectedworkrelatedillness,avisittotheworksitecan
beveryinstructive.Alternatively,anaffectedworkercanrequestaninspectionbyOSHA.

Thephysicalexaminationofpatientswithenvironmentallyrelatedlungdiseasesmayhelpdeterminethenature
andseverityofthepulmonaryconditionbutusuallydoesnotcontributeinformationthatpointstoaspecific
etiology.

PulmonaryFunctionTestsandChestImaging
Exposurestoinorganicandorganicdustscancauseinterstitiallungdiseasethatpresentswitharestrictive
patternandadecreaseddiffusingcapacity(Chap.252).Similarly,exposurestoanumberoforganicdustsor
chemicalagentsmayresultinoccupationalasthmaorCOPDthatischaracterizedbyairwayobstruction.
Measurementofchangeinforcedexpiratoryvolume(FEV1)beforeandafteraworkingshiftcanbeusedto
detectanacutebronchoconstrictiveresponse.Forexample,anacutedecrementofFEV1overthefirstworkshift
oftheweekisacharacteristicfeatureofcottontextileworkerswithbyssinosis(anobstructiveairwaydisorderwith
featuresofbothasthmaandchronicbronchitis).
Thechestradiographisusefulindetectingandmonitoringthepulmonaryresponsetomineraldusts,certain
metals,andorganicdustscapableofinducinghypersensitivitypneumonitis.TheInternationalLabour
Organisation(ILO)InternationalClassificationofRadiographsofPneumoconiosesclassifieschestradiographsby
thenatureandsizeofopacitiesseenandtheextentofinvolvementoftheparenchyma.Ingeneral,smallrounded
opacitiesareseeninsilicosisorcoalworker'spneumoconiosisandsmalllinearopacitiesareseeninasbestosis.
Theprofusionofsuchopacitiesisratedbyusinga12pointscheme.Althoughusefulforepidemiologicstudies
andscreeninglargenumbersofworkers,theILOsystemcanbeproblematicwhenappliedtoanindividual
worker'schestradiograph.Withdustscausingroundedopacities,thedegreeofinvolvementonthechest
radiographmaybeextensive,whereaspulmonaryfunctionmaybeonlyminimallyimpaired.Incontrast,in
pneumoconiosiscausinglinear,irregularopacitieslikethoseseeninasbestosis,theradiographmayleadto
underestimationoftheseverityoftheimpairmentuntilrelativelylateinthedisease.Forpatientswithahistoryof
asbestosexposure,conventionalcomputedtomography(CT)ismoresensitiveforthedetectionofpleural
thickeningandhighresolutionCT(HRCT)improvesthedetectionofasbestosis.
Otherproceduresthatmaybeofuseinidentifyingtheroleofenvironmentalexposuresincausinglungdisease
includeevaluationofheavymetalconcentrationsinurine(cadmiuminbatteryplantworkers),skinpricktestingor
specificIgEantibodytitersforevidenceofimmediatehypersensitivitytoagentscapableofinducingoccupational
asthma(flourantigensinbakers),specificIgGprecipitatingantibodytitersforagentscapableofcausing
hypersensitivitypneumonitis(pigeonantigeninbirdhandlers),andassaysforspecificcellmediatedimmune
responses(berylliumlymphocyteproliferationtestinginnuclearworkersortuberculinskintestinginhealthcare
workers).Sometimesabronchoscopytoobtaintransbronchialbiopsiesoflungtissuemayberequiredfor
histologicdiagnosis(chronicberylliumdisease).Rarely,videoassistedthoracoscopicsurgerytoobtainalarger
sampleoflungtissuemayberequiredtodeterminethespecificdiagnosisofenvironmentallyinducedlung
disease(hypersensitivitypneumonitisorgiantcellinterstitialpneumonitisduetocobaltexposure).

ExposureAssessment
Ifreliableenvironmentalsamplingdataareavailable,thatinformationshouldbeusedinassessingapatient's
exposure.Sincemanyofthechronicdiseasesresultfromexposureovermanyyears,currentenvironmental
measurementsshouldbecombinedwithworkhistoriestoarriveatestimatesofpastexposure.
Insituationsinwhichindividualexposuretospecificagentseitherinaworksettingorviaambientairpollutants
hasbeendetermined,thechemicalandphysicalcharacteristicsofthoseagentsaffectboththeinhaleddose
andthesiteofdepositionintherespiratorytract.Watersolublegasessuchasammoniaandsulfurdioxideare
absorbedintheliningfluidoftheupperandproximalairwaysandthustendtoproduceirritativeand

bronchoconstrictiveresponses.Incontrast,nitrogendioxideandphosgene,whicharelesssoluble,maypenetrate
tothebronchiolesandalveoliinsufficientquantitiestoproduceacutechemicalpneumonitisthatcanbelife
threatening.
Particlesizeofaircontaminantsmustalsobeconsidered.Becauseoftheirsettlingvelocitiesinair,particles>10
15mindiameterdonotpenetratebeyondthenoseandthroat.Particles<10minsizearedepositedbelowthe
larynx.Theseparticlesaredividedintothreesizefractionsonthebasisoftheirsizecharacteristicsandsources.
Particles~2.510m(coarsemodefraction)containcrustalelementssuchassilica,aluminum,andiron.These
particlesmostlydepositrelativelyhighinthetracheobronchialtree.Althoughthetotalmassofanambientsample
isdominatedbytheselargerrespirableparticles,thenumberofparticles,andthereforethesurfaceareaonwhich
potentialtoxicagentscandepositandbecarriedtothelowerairways,isdominatedbyparticles<2.5m(fine
modefraction).Thesefineparticlesarecreatedprimarilybytheburningoffossilfuelsorhightemperature
industrialprocessesresultingincondensationproductsfromgases,fumes,orvapors.Thesmallestparticles,
those<0.1minsize,representtheultrafinefractionandmakeupthelargestnumberofparticlestheytendto
remainintheairstreamanddepositinthelungonlyonarandombasisastheycomeintocontactwiththealveolar
walls.Iftheydodeposit,however,particlesofthissizerangemaypenetrateintothecirculationandbecarriedto
extrapulmonarysites.Newtechnologiescreateparticlesofthissize("nanoparticles")foruseinmanycommercial
applications.Besidesthesizecharacteristicsofparticlesandthesolubilityofgases,theactualchemical
composition,mechanicalproperties,andimmunogenicityorinfectivityofinhaledmaterialdetermineinlargepart
thenatureofthediseasesfoundamongexposedpersons.

OccupationalExposuresandPulmonaryDisease
Table2561providesbroadcategoriesofexposureintheworkplaceanddiseasesassociatedwithchronic
exposureinthoseindustries.
Table2561CategoriesofOccupationalExposureandAssociatedRespiratoryConditions

NatureofRespiratory
Responses

Comment

Asbestos:mining,processing,
construction,shiprepair

Fibrosis(asbestosis),
pleuraldisease,cancer,
mesothelioma

Virtuallyallnewmining
andconstructionwith
asbestosdonein
developingcountries

Silica:mining,stonecutting,
sandblasting,quarrying

Fibrosis(silicosis),
progressivemassive
fibrosis(PMF),cancer,
tuberculosis,chronic
obstructivepulmonary
disease(COPD)

Improvedprotectionin
UnitedStates,persistent
riskindeveloping
countries

Coaldust:mining

Fibrosis(coalworker's
pneumoconiosis),PMF,
COPD

Riskpersistsincertain
areasofUnitedStates,
increasingincountries
wherenewminesopen

OccupationalExposures
InorganicDusts

Acutepneumonitis(rare),

Beryllium:processingalloysforhigh
techindustries

chronicgranulomatous
disease,lungcancer
(highlysuspect)

Riskinhightech
industriespersists

Othermetals:aluminum,chromium,
cobalt,nickel,titanium,tungsten
carbide,or"hardmetal"(contains
cobalt)

Widevarietyof
conditionsfromacute
pneumonitistolung
cancerandasthma

Newdiseasesappearwith
newprocessdevelopment

Cottondust:milling,processing

Byssinosis(anasthma
likesyndrome),chronic
bronchitis,COPD

Increasingriskin
developingcountrieswith
dropinUnitedStatesas
jobsshiftoverseas

Graindust:elevatoragents,dock
workers,milling,bakers

Asthma,chronic
bronchitis,COPD

Riskshiftingmoreto
migrantlaborpool

Otheragriculturaldusts:fungalspores,
vegetableproducts,insectfragments,
animaldander,birdandrodentfeces,
endotoxins,microorganisms,pollens

Hypersensitivity
pneumonitis(farmer's
lung),asthma,chronic
bronchitis

Importantinmigrantlabor
poolbutalsoresulting
frominhomeexposures

Toxicchemicals:widevarietyof
industries,seeTable2562

Asthma,chronic
bronchitis,COPD,
hypersensitivity
pneumonitis,
pneumoconiosis,and
cancer

Reducedriskwith
recognizedhazards
increasingriskfor
developingcountries
wherecontrolledlabor
practicesareless
stringent

Otherrespiratoryenvironmentalagents:
uraniumandradondaughters,
secondhandtobaccosmoke,polycyclic
hydrocarbons,biomasssmoke,diesel
exhaust,weldingfumes,woodfinishing

Occupationalexposures
estimatedtocontributeto
upto10%ofalllung
cancerschronic
bronchitis,COPD,and
fibrosis

Inhomeexposures
importantindeveloping
countriesbiomasssmoke
isamajorriskfactorfor
COPDamongwomen

OrganicDusts

AsbestosRelatedDiseases
Asbestosisagenerictermforseveraldifferentmineralsilicates,includingchrysolite,amosite,anthophyllite,and
crocidolite.Inadditiontoworkersinvolvedintheproductionofasbestosproducts(mining,milling,and
manufacturing),manyworkersintheshipbuildingandconstructiontrades,includingpipefittersandboilermakers,
wereoccupationallyexposedbecauseasbestoswaswidelyusedduringthetwentiethcenturyforitsthermaland
electricalinsulationproperties.Asbestosalsowasusedinthemanufactureoffireresistanttextiles,incementand
floortiles,andinfrictionmaterialssuchasbrakeandclutchlinings.
Exposuretoasbestosisnotlimitedtopersonswhodirectlyhandlethematerial.Casesofasbestosrelated
diseaseshavebeenencounteredinindividualswithonlybystanderexposure,suchaspaintersandelectricians
whoworkedalongsideinsulationworkersinashipyard.Communityexposureresultedfromtheuseofasbestos

containingmineandmilltailingsaslandfill,roadsurface,andplaygroundmaterial(e.g.,Libby,MT,thesiteofa
vermiculitemineinwhichtheorewascontaminatedwithasbestos).Finally,exposurecanoccurfromthe
disturbanceofnaturallyoccurringasbestos(e.g.,fromincreasingresidentialdevelopmentinthefoothillsofthe
SierraMountainsinCalifornia).
Asbestoshaslargelybeenreplacedinthedevelopedworldwithsyntheticmineralfiberssuchasfiberglassand
refractoryceramicfibers,butitcontinuestobeusedincreasinglyinthedevelopingworld.DespitecurrentOSHA
regulationsmandatingadequatetrainingforanyworkerpotentiallyexposedtoasbestos,exposurecontinues
amonginadequatelytrainedandprotecteddemolitionworkers.Themajorhealtheffectsfromexposureto
asbestosarepleuralandpulmonaryfibrosis,cancersoftherespiratorytract,andpleuralandperitoneal
mesothelioma.
Asbestosisisadiffuseinterstitialfibrosingdiseaseofthelungthatisdirectlyrelatedtotheintensityandduration
ofexposure.Thediseaseresemblesotherformsofdiffuseinterstitialfibrosis(Chap.261).Usually,moderateto
severeexposurehastakenplaceforatleast10yearsbeforethediseasebecomesmanifest,anditmayoccur
afterexposuretoanyoftheasbestiformfibertypes.Themechanismsbywhichasbestosfibersinducelung
fibrosisarenotcompletelyunderstoodbutareknowntoinvolveoxidativeinjuryduetothegenerationofreactive
oxygenspeciesbythetransitionmetalsonthesurfaceofthefibersaswellasfromcellsengagedinphagocytosis.
Thechestradiographcanbeusedtodetectthepulmonarymanifestationsofasbestosexposure.Pastexposure
isspecificallyindicatedbypleuralplaques,whicharecharacterizedbyeitherthickeningorcalcificationalongthe
parietalpleura,particularlyalongthelowerlungfields,thediaphragm,andthecardiacborder.Withoutadditional
manifestations,pleuralplaquesimplyonlyexposure,notpulmonaryimpairment.Benignpleuraleffusionsalso
mayoccur.Thefluidistypicallyaserousorbloodyexudate.Theeffusionmaybeslowlyprogressiveormay
resolvespontaneously.Irregularorlinearopacities,evidenceofasbestosisthatusuallyarefirstnotedinthelower
lungfieldsandspreadingintothemiddleandupperlungfields,occurasthediseaseprogresses.Anindistinct
heartborderora"groundglass"appearanceinthelungfieldsisseeninsomecases.Incasesinwhichthexray
changesarelessobvious,HRCTmayshowdistinctchangesofsubpleuralcurvilinearlines510mminlengththat
appeartobeparalleltothepleuralsurface(Fig.2561).
FIGURE2561

Asbestosis:A.Frontalchestradiographshowsbilateralcalcifiedpleuralplaquesconsistentwithasbestos

relatedpleuraldisease.Poorlydefinedlinearandreticularabnormalitiesareseeninthelowerlobesbilaterally.B.
Axialhighresolutioncomputedtomographyofthethoraxobtainedthroughthelungbasesshowsbilateral,
subpleuralreticulation(blackarrows),representingfibroticlungdiseaseduetoasbestosis.Subpleurallinesare
alsopresent(arrowheads),characteristicof,thoughnotspecificfor,asbestosis.Calcifiedpleuralplaques
representingasbestosrelatedpleuraldisease(whitearrows)arealsoevident.
Pulmonaryfunctiontestinginasbestosisrevealsarestrictivepatternwithadecreaseinbothlungvolumesand
diffusingcapacity.Theremayalsobeevidenceofmildairflowobstruction(duetoperibronchiolarfibrosis).
Nospecifictherapyisavailableforthemanagementofpatientswithasbestosis.Thesupportivecareisthesame
asthatgiventoanypatientwithdiffuseinterstitialfibrosisofanycause.Ingeneral,newlydiagnosedcaseswill
haveresultedfromexposuresthatoccurredmanyyearsbefore.
Lungcancer(Chap.89)isthemostcommoncancerassociatedwithasbestosexposure.Theexcessfrequencyof
lungcancer(allhistologictypes)inasbestosworkersisassociatedwithaminimumlatencyof1519years
betweenfirstexposureanddevelopmentofthedisease.Personswithmoreexposureareatgreaterriskof
disease.Inaddition,thereisasignificantinteractiveeffectofsmokingandasbestosexposurethatresultsin
greaterriskthanwhatwouldbeexpectedfromtheadditiveeffectofeachfactor.
Mesotheliomas(Chap.263),bothpleuralandperitoneal,arealsoassociatedwithasbestosexposure.Incontrast
tolungcancers,thesetumorsdonotappeartobeassociatedwithsmoking.Relativelyshorttermasbestos
exposuresof12yearsorless,occurringupto40yearsinthepast,havebeenassociatedwiththe
developmentofmesotheliomas(anobservationthatemphasizestheimportanceofobtainingacomplete
environmentalexposurehistory).Althoughtheriskofmesotheliomaismuchlessthanthatoflungcanceramong
asbestosexposedworkers,over2000caseswerereportedintheUnitedStatesperyearatthestartofthe
twentyfirstcentury.
Although~50%ofmesotheliomasmetastasize,thetumorgenerallyislocallyinvasive,anddeathusuallyresults
fromlocalextension.Mostpatientspresentwitheffusionsthatmayobscuretheunderlyingpleuraltumor.In
contrasttothefindingsineffusionduetoothercauses,becauseoftherestrictionplacedonthechestwall,no
shiftofmediastinalstructurestowardtheoppositesideofthechestwillbeseen.Themajordiagnosticproblemis
differentiationfromperipherallyspreadingpulmonaryadenocarcinomaoradenocarcinomathathasmetastasized
topleurafromanextrathoracicprimarysite.Althoughcytologicexaminationofpleuralfluidmaysuggestthe
diagnosis,biopsyofpleuraltissue,generallywithvideoassistedthoracicsurgery,andspecial
immunohistochemicalstainingusuallyarerequired.Thereisnoeffectivetherapy.
Sinceepidemiologicstudieshaveshownthat>80%ofmesotheliomasmaybeassociatedwithasbestosexposure,
documentedmesotheliomainapatientwithoccupationalorenvironmentalexposuretoasbestosmaybe
compensable.

Silicosis
Inspiteofbeingoneoftheoldestknownoccupationalpulmonaryhazards,freesilica(SiO2),orcrystallinequartz,
isstillamajorcauseofdisease.Themajoroccupationalexposuresincludeminingstonecuttingemploymentin
abrasiveindustriessuchasstone,clay,glass,andcementmanufacturingfoundryworkpackingofsilicaflour
andquarrying,particularlyofgranite.Mostoften,pulmonaryfibrosisduetosilicaexposure(silicosis)occursina
doseresponsefashionaftermanyyearsofexposure.
Workersheavilyexposedthroughsandblastinginconfinedspaces,tunnelingthroughrockwithahighquartz
content(1525%),orthemanufactureofabrasivesoapsmaydevelopacutesilicosiswithaslittleas10monthsof
exposure.Theclinicalandpathologicfeaturesofacutesilicosisaresimilartothoseofpulmonaryalveolar

proteinosis(Chap.261).Thechestradiographmayshowprofusemiliaryinfiltrationorconsolidation,andthereis
acharacteristicHRCTpatternknownas"crazypaving"(Fig.2562).Thediseasemaybequitesevereand
progressivedespitethediscontinuationofexposure.Wholelunglavagemayprovidesymptomaticreliefandslow
theprogression.
FIGURE2562

Acutesilicosis.Thishighresolutioncomputedtomographyscanshowsmultiplesmallnodulesconsistentwith
silicosisbutalsodiffusegroundglassdensitieswiththickenedintralobularandinterlobularseptaproducing
polygonalshapes.Thishasbeenreferredtoas"crazypaving."
Withlongterm,lessintenseexposure,smallroundedopacitiesintheupperlobesmayappearonthechest
radiographafter1520yearsofexposure(simplesilicosis).Calcificationofhilarnodesmayoccurinasmanyas
20%ofcasesandproducesacharacteristic"eggshell"pattern.Silicoticnodulesmaybeidentifiedmorereadilyby
HRCT(Fig.2563).Thenodularfibrosismaybeprogressiveintheabsenceoffurtherexposure,with
coalescenceandformationofnonsegmentalconglomeratesofirregularmasses>1cmindiameter(complicated
silicosis).Thesemassescanbecomequitelarge,andwhenthisoccurs,thetermprogressivemassivefibrosis
(PMF)isapplied.Significantfunctionalimpairmentwithbothrestrictiveandobstructivecomponentsmaybe
associatedwiththisformofsilicosis.
FIGURE2563

Chronicsilicosis.A.Frontalchestradiographinapatientwithsilicosisshowsvariablysized,poorlydefined
nodules(arrows)predominatingintheupperlobes,B.Axialthoraciccomputedtomographyimagethroughthe
lungapicesshowsnumeroussmallnodules,morepronouncedintherightupperlobe.Anumberofthenodules
aresubpleuralinlocation(arrows).
Becausesilicaiscytotoxictoalveolarmacrophages,patientswithsilicosisareatgreaterriskofacquiringlung
infectionsthatinvolvethesecellsasaprimarydefense(Mycobacteriumtuberculosis,atypicalmycobacteriaand
fungi).Becauseoftheincreasedriskofactivetuberculosis,therecommendedtreatmentoflatenttuberculosisin
thesepatientsislonger.Anotherpotentialclinicalcomplicationofsilicosisisautoimmuneconnectivetissue
disorderssuchasrheumatoidarthritisandscleroderma.Inaddition,therearesufficientepidemiologicdatathat
theInternationalAgencyforResearchonCancerlistssilicaasaprobablelungcarcinogen.

Other,lesshazardoussilicatesincludefuller'searth,kaolin,mica,diatomaceousearths,silicagel,soapstone,
carbonatedusts,andcementdusts.Theproductionoffibrosisinworkersexposedtotheseagentsisbelievedto
berelatedeithertothefreesilicacontentofthesedustsor,forsubstancesthatcontainnofreesilica,tothe
potentiallylargedustloadstowhichtheseworkersmaybeexposed.
Othersilicates,includingtalcdusts,maybecontaminatedwithasbestosand/orfreesilica.Fibrosisand/orpleural
orlungcancerhavebeenassociatedwithchronicexposuretocommercialtalc.

CoalWorker'sPneumoconiosis(CWP)
OccupationalexposuretocoaldustcanleadtoCWP,whichhasenormoussocial,economic,andmedical
significanceineverynationinwhichcoalminingisanimportantindustry.SimpleradiographicallyidentifiedCWPis
seenin~10%ofallcoalminersandinasmanyas50%ofanthraciteminerswithmorethan20years'workonthe
coalface.Theprevalenceofdiseaseislowerinworkersinbituminouscoalmines.
Withprolongedexposuretocoaldust(i.e.,1520years),small,roundedopacitiessimilartothoseofsilicosismay
develop.Asinsilicosis,thepresenceofthesenodules(simpleCWP)usuallyisnotassociatedwithpulmonary
impairment.MuchofthesymptomatologyassociatedwithsimpleCWPappearstobeduetotheeffectsofcoal
dustonthedevelopmentofchronicbronchitisandCOPD(Chap.260).Theeffectsofcoaldustareadditiveto
thoseofcigarettesmoking.
ComplicatedCWPismanifestedbytheappearanceonthechestradiographofnodulesrangingfrom1cmin
diametertothesizeofanentirelobe,generallyconfinedtotheupperhalfofthelungs.Asinsilicosis,this
conditioncanprogresstoPMFthatisaccompaniedbyseverelungfunctiondeficitsandassociatedwith
prematuremortality.Despiteimprovementsintechnologytoprotectcoalminers,casesofPMFstilloccurinthe
UnitedStatesatadisturbingrate.
Caplan'ssyndrome(Chap.321),firstdescribedincoalminersbutsubsequentlyfoundinpatientswithsilicosis,
includesseropositiverheumatoidarthritiswithcharacteristicpneumoconioticnodules.Silicahasimmunoadjuvant
propertiesandisoftenpresentinanthraciticcoaldust.

ChronicBerylliumDisease
Berylliumisalightweightmetalwithtensilestrengththathasgoodelectricalconductivityandisvaluableinthe
controlofnuclearreactionsthroughitsabilitytoquenchneutrons.Althoughberylliummayproduceanacute
pneumonitis,itisfarmorecommonlyassociatedwithachronicgranulomatousinflammatorydiseasethatis
similartosarcoidosis(Chap.329).Unlessoneinquiresspecificallyaboutoccupationalexposurestoberylliumin
themanufactureofalloys,ceramics,orhightechnologyelectronicsinapatientwithsarcoidosis,onemaymiss
entirelytheetiologicrelationshiptotheoccupationalexposure.Whatdistinguisheschronicberylliumdisease
(CBD)fromsarcoidosisisevidenceofaspecificcellmediatedimmuneresponse(i.e.,delayedhypersensitivity)to
beryllium.
Thetestthatusuallyprovidesthisevidenceistheberylliumlymphocyteproliferationtest(BeLPT).TheBeLPT
comparestheinvitroproliferationoflymphocytesfrombloodorbronchoalveolarlavageinthepresenceof
berylliumsaltswiththatofunstimulatedcells.Proliferationisusuallymeasuredbylymphocyteuptakeof
radiolabeledthymidine.
Chestimagingfindingsaresimilartothoseofsarcoidosis(nodulesalongseptallines)exceptthathilar
adenopathyissomewhatlesscommon.Aswithsarcoidosis,pulmonaryfunctiontestresultsmayshowrestrictive
and/orobstructiveventilatorydeficitsanddecreaseddiffusingcapacity.Withearlydisease,bothchestimaging
studiesandpulmonaryfunctiontestsmaybenormal.Fiberopticbronchoscopywithtransbronchiallungbiopsy

usuallyisrequiredtomakethediagnosisofCBD.Inaberylliumsensitizedindividual,thepresenceof
noncaseatinggranulomasormonocyticinfiltrationinlungtissueestablishesthediagnosis.Accumulationof
berylliumspecificCD4+Tcellsoccursinthegranulomatousinflammationseenonlungbiopsy.CBDisoneofthe
beststudiedexamplesofgeneenvironmentinteraction.SusceptibilitytoCBDishighlyassociatedwithhuman
leukocyteantigenDP(HLADP)allelesthathaveaglutamicacidinposition69ofthechain.
Othermetals,includingaluminumandtitaniumdioxide,havebeenrarelyassociatedwithasarcoidlikereactionin
lungtissue.Exposuretodustcontainingtungstencarbide,alsoknownas"hardmetal,"mayproducegiantcell
interstitialpneumonitis.Cobaltisaconstituentoftungstencarbideandisthelikelyetiologicagentofboththe
interstitialpneumonitisandtheoccupationalasthmathatmayoccur.Themostcommonexposurestotungsten
carbideoccurintoolanddye,sawblade,anddrillbitmanufacture.Diamondpolishingmayalsoinvolveexposure
tocobaltdust.ThesameGlu69polymorphismoftheHLADPchainthatconfersincreasedriskofCBDalso
appearstoincreasetheriskofcobaltinducedgiantcellinterstitialpneumonitis.
Inpatientswithinterstitiallungdisease,oneshouldalwaysinquireaboutexposuretometalfumesand/ordusts.
Especiallywhensarcoidosisappearstobethediagnosis,oneshouldalwaysconsiderpossibleCBD.

OtherInorganicDusts
Mostoftheinorganicdustsdiscussedthusfarareassociatedwiththeproductionofeitherdustmaculesor
interstitialfibroticchangesinthelung.Otherinorganicandorganicdusts(seecategoriesinTable2561),along
withsomeofthedustspreviouslydiscussed,areassociatedwithchronicmucushypersecretion(chronic
bronchitis),withorwithoutreductionofexpiratoryflowrates.Cigarettesmokingisthemajorcauseofthese
conditions,andanyefforttoattributesomecomponentofthediseasetooccupationalandenvironmental
exposuresmusttakecigarettesmokingintoaccount.Moststudiessuggestanadditiveeffectofdustexposure
andsmoking.Thepatternoftheirritantdusteffectissimilartothatofcigarettesmoking,suggestingthatsmall
airwayinflammationmaybetheinitialsiteofpathologicresponseinthosecasesandcontinuedexposuremay
leadtochronicbronchitisandCOPD.

OrganicDusts
Someofthespecificdiseasesassociatedwithorganicdustsarediscussedindetailinthechaptersonasthma
(Chap.254)andhypersensitivitypneumonitis(Chap.255).Manyofthesediseasesarenamedforthespecific
settinginwhichtheyarefound,e.g.,farmer'slung,maltworker'sdisease,andmushroomworker'sdisease.Often
thetemporalrelationofsymptomstoexposurefurnishesthebestevidenceforthediagnosis.Threeoccupational
exposuresaresingledoutfordiscussionherebecausetheyaffectthelargestproportionsofworkers.
CottonDust(Byssinosis)
Workersoccupationallyexposedtocottondust(butalsotoflax,hemp,orjutedust)intheproductionofyarnsfor
textilesandropemakingareatriskforanasthmalikesyndromeknownasbyssinosis.Exposureoccurs
throughoutthemanufacturingprocessbutismostpronouncedintheportionsofthefactoryinvolvedwiththe
treatmentofthecottonbeforespinning,i.e.,blowing,mixing,andcarding(straighteningoffibers).Theriskof
byssinosisisassociatedwithbothcottondustandendotoxinlevelsintheworkplaceenvironment.
Byssinosisischaracterizedclinicallyasoccasional(earlystage)andthenregular(latestage)chesttightness
towardtheendofthefirstdayoftheworkweek("Mondaychesttightness").Inepidemiologicstudies,depending
onthelevelofexposureviathecardingroomair,upto80%ofemployeesmayshowasignificantdropinFEV1
overthecourseofaMondayshift.
Initiallythesymptomsdonotrecuronsubsequentdaysoftheweek.However,in1025%ofworkers,thedisease

maybeprogressive,withchesttightnessrecurringorpersistingthroughouttheworkweek.After>10yearsof
exposure,workerswithrecurrentsymptomsaremorelikelytohaveanobstructivepatternonpulmonaryfunction
testing.Thehighestgradesofimpairmentgenerallyareseeninsmokers.
Reductionofdustexposureisofprimaryimportancetothemanagementofbyssinosis.Dustlevelscanbe
controlledbytheuseofexhausthoods,generalincreasesinventilation,andwettingprocedures,butrespiratory
protectiveequipmentappearstoberequiredduringcertainoperationstopreventworkersfrombeingexposedto
levelsofcottondustthatexceedthecurrentOSHApermissibleexposurelevel.Regularsurveillanceofpulmonary
functionincottondustexposedworkersusingspirometrybeforeandaftertheworkshiftisrequiredbyOSHA.All
workerswithpersistentsymptomsorsignificantlyreducedlevelsofpulmonaryfunctionshouldbemovedtoareas
oflowerriskofexposure.
GrainDust
Worldwide,manyfarmersandworkersingrainstoragefacilitiesareexposedtograindust.Thepresentationof
obstructiveairwaydiseaseingraindustexposedworkersisvirtuallyidenticaltothecharacteristicfindingsin
cigarettesmokers,i.e.,persistentcough,mucushypersecretion,wheezeanddyspneaonexertion,andreduced
FEV1andFEV1/FVC(forcedvitalcapacity)ratio(Chap.252).
Dustconcentrationsingrainelevatorsvarygreatlybutcanbe>10,000g/m3approximatelyonethirdofthe
particles,byweight,areintherespirablerange.Theeffectofgraindustexposureisadditivetothatofcigarette
smoking,with~50%ofworkerswhosmokehavingsymptoms.Amongnonsmokinggrainelevatoroperators,
approximatelyonequarterhavemucushypersecretion,aboutfivetimesthenumberthatwouldbeexpectedin
unexposednonsmokers.Smokinggraindustexposedworkersaremorelikelytohaveobstructiveventilatory
deficitsonpulmonaryfunctiontesting.Asinbyssinosis,endotoxinmayplayaroleingraindustinducedchronic
bronchitisandCOPD.
Farmer'sLung
Thisconditionresultsfromexposuretomoldyhaycontainingsporesofthermophilicactinomycetesthatproducea
hypersensitivitypneumonitis(Chap.255).Apatientwithacutefarmer'slungpresents48hafterexposurewith
fever,chills,malaise,cough,anddyspneawithoutwheezing.Thehistoryofexposureisobviouslyessentialto
distinguishthisdiseasefrominfluenzaorpneumoniawithsimilarsymptoms.Inthechronicformofthedisease,
thehistoryofrepeatedattacksaftersimilarexposureisimportantindifferentiatingthissyndromefromother
causesofpatchyfibrosis(e.g.,sarcoidosis).
Awidevarietyofotherorganicdustsareassociatedwiththeoccurrenceofhypersensitivitypneumonitis(Chap.
255).Forpatientswhopresentwithhypersensitivitypneumonitis,specificandcarefulinquiryaboutoccupations,
hobbies,andotherhomeenvironmentalexposuresisnecessarytouncoverthesourceoftheetiologicagent.

ToxicChemicals
Exposuretotoxicchemicalsaffectingthelunggenerallyinvolvesgasesandvapors.Acommonaccidentisonein
whichthevictimistrappedinaconfinedspacewherethechemicalshaveaccumulatedtotoxiclevels.Inaddition
tothespecifictoxiceffectsofthechemical,thevictimoftensustainsconsiderableanoxia,whichcanplaya
dominantroleindeterminingwhethertheindividualsurvives.
Table2562listsavarietyoftoxicagentsthatcanproduceacuteandsometimeslifethreateningreactionsinthe
lung.Alltheseagentsinsufficientconcentrationshavebeendemonstrated,atleastinanimalstudies,toaffectthe
lowerairwaysanddisruptalveolararchitecture,eitheracutelyorasaresultofchronicexposure.Someofthese
agentsmaybegeneratedacutelyintheenvironment(seebelow).

Table2562SelectedCommonToxicChemicalAgentsthatAffecttheLung

AcuteEffectsfromHighor
AccidentalExposure

ChronicEffects
fromRelatively
LowExposure

Nasalirritation,cough

Asthma,chronic
bronchitis,
hypersensitivity
pneumonitis

Agent(s)

SelectedExposures

Acid
anhydrides

Manufactureofresin
esters,polyester
resins,
thermoactivated
adhesives

Acidfumes:
H2SO4,
HNO3

Manufactureof
fertilizers,chlorinated
organiccompounds,
dyes,explosives,
rubberproducts,metal
etching,plastics

Mucousmembraneirritation,
followedbychemical
pneumonitis23dayslater

Bronchitisand
suggestionofmildly
reducedpulmonary
functioninchildren
withlifelong
residentialexposure
tohighlevels

Acroleinand
other
aldehydes

Byproductofburning
plastics,woods,
tobaccosmoke

Mucousmembraneirritant,
decreaseinlungfunction

Upperrespiratory
tractirritation

Ammonia

Refrigeration
petroleumrefining
manufactureof
fertilizers,explosives,
plastics,andother
chemicals

Sameasforacidfumes,but
bronchiectasisalsohasbeen
reported

Upperrespiratory
tractirritation,
chronicbronchitis

Cadmium
fumes

Smelting,soldering,
batteryproduction

Mucousmembraneirritant,
acuterespiratorydistress
syndrome(ARDS)

Chronicobstructive
pulmonarydisease
(COPD)

Formaldehyde

Manufactureofresins,
leathers,rubber,
metals,andwoods
laboratoryworkers,
embalmersemission
fromurethanefoam
insulation

Sameasforacidfumes

Nasopharyngeal
cancer

Halidesand
acidsalts(Cl,
Br,F)

Bleachinginpulp,
paper,textileindustry
manufactureof
chemicalcompounds
syntheticrubber,
plastics,disinfectant,
rocketfuel,gasoline

Mucousmembraneirritation,
pulmonaryedemapossible
reducedFVC12yrsafter
exposure

Upperrespiratory
tractirritation,
epistaxis,
tracheobronchitis

Byproductofmany

Increaseinrespiratoryrate

Conjunctival

Hydrogen
sulfide

followedbyrespiratoryarrest,
lacticacidosis,pulmonary
edema,death

irritation,chronic
bronchitis,recurrent
pneumonitis

Mucousmembraneirritation,
dyspnea,cough,wheeze,
pulmonaryedema

Upperrespiratory
tractirritation,
cough,asthma,
hypersensitivity
pneumonitis,
reducedlung
function

Nitrogen
dioxide

Silage,metaletching,
explosives,rocket
fuels,welding,by
productofburning
fossilfuels

Cough,dyspnea,pulmonary
edemamaybedelayed412
hpossibleresultfromacute
exposure:bronchiolitis
obliteransin26wks

Emphysemain
animals,?chronic
bronchitis,
associatedwith
reducedlung
functioninchildren
withlifelong
residentialexposure

Ozone

Arcwelding,flour
bleaching,
deodorizing,
emissionsfrom
copyingequipment,
photochemicalair
pollutant

Mucousmembraneirritant,
pulmonaryhemorrhageand
edema,reducedpulmonary
functiontransientlyinchildren
andadults,andincreased
hospitalizationwithexposureto
summerhaze

Excess
cardiopulmonary
mortalityrates

Phosgene

Organiccompound,
metallurgy,
volatilizationof
chlorinecontaining
compounds

Delayedonsetofbronchiolitis
andpulmonaryedema

Chronicbronchitis

Sulfurdioxide

Manufactureofsulfuric
acid,bleaches,
coatingofnonferrous
metals,food
processing,
refrigerant,burningof
fossilfuels,woodpulp
industry

Mucousmembraneirritant,
epistaxis,bronchospasm
(especiallyinpeoplewith
asthma)

Chronicbronchitis

Isocyanates
(TDI,HDI,
MDI)

industrialprocesses,
oil,otherpetroleum
processesandstorage

Productionof
polyurethanefoams,
plastics,adhesives,
surfacecoatings

Firefightersandfirevictimsareatriskofsmokeinhalation,animportantcauseofacutecardiorespiratoryfailure.
Smokeinhalationkillsmorefirevictimsthandoesthermalinjury.Carbonmonoxidepoisoningwithresulting
significanthypoxemiacanbelifethreatening(Chap.e50).Syntheticmaterials(plastic,polyurethanes),when
burned,mayreleaseavarietyofothertoxicagents(suchascyanideandhydrochloricacid),andthismustbe
consideredinevaluatingsmokeinhalationvictims.Exposedvictimsmayhavesomedegreeoflowerrespiratory
tractinflammationand/orpulmonaryedema.
Exposuretocertainhighlyreactive,lowmolecularweightagentsusedinthemanufactureofsyntheticpolymers,

paints,andcoatings(diisocyanatesinpolyurethanes,aromaticaminesandacidanhydridesinepoxies)are
associatedwithahighriskofoccupationalasthma.Althoughthisoccupationalasthmamanifestsclinicallyasif
sensitizationhasoccurred,anIgEantibodymediatedmechanismisnotnecessarilyinvolved.Hypersensitivity
pneumonitislikereactionsalsohavebeendescribedindiisocyanateandacidanhydrideexposedworkers.
FluoropolymerssuchasTeflon,whichatnormaltemperaturesproducenoreaction,becomevolatilizedupon
heating.Theinhaledagentscauseacharacteristicsyndromeoffever,chills,malaise,andoccasionallymild
wheezing,leadingtothediagnosisofpolymerfumefever.Asimilarselflimited,influenzalikesyndromemetal
fumefeverresultsfromacuteexposuretofumesorsmokecontainingzincoxide.Thesyndromemaybegin
severalhoursafterworkandresolveswithin24h,onlytoreturnonrepeatedexposure.Weldingofgalvanized
steelisthemostcommonexposureleadingtometalfumefever.
Twootheragentshavebeenrecentlyassociatedwithpotentiallysevereinterstitiallungdisease.Occupational
exposuretonylonflockhasbeenshowntoinducealymphocyticbronchiolitis,andworkersexposedtodiacetyl
usedtoprovide"butter"flavorinthemanufactureofmicrowavepopcornandotherfoodshavedeveloped
bronchiolitisobliterans(Chap.261).
WorldTradeCenterDisaster
AconsequenceoftheattackontheWorldTradeCenter(WTC)onSeptember11,2001,wasrelativelyheavy
exposureofalargenumberoffirefightersandotherrescueworkerstothedustgeneratedbythecollapseofthe
buildings.EnvironmentalmonitoringandchemicalcharacterizationofWTCdusthasrevealedawidevarietyof
potentiallytoxicconstituents,althoughmuchofthedustwaspulverizedcement.Possiblybecauseofthehigh
alkalinityofWTCdust,significantcough,wheeze,andphlegmproductionoccurredamongfirefightersand
cleanupcrews.Newcoughandwheezesyndromesalsooccurredamonglocalresidents.Initiallongitudinalfollow
upofNewYorkfirefighterssuggeststhatheavierexposuretoWTCdustisassociatedwithaccelerateddeclineof
lungfunction.Ongoingfollowupwillprovidedataonwhethermassiveexposuretothisirritantdusthasledtothe
developmentofchronicrespiratorydisease.

OccupationalRespiratoryCarcinogens
Exposuresatworkhavebeenestimatedtocontributeto10%ofalllungcancercases.Inadditiontoasbestos,
otheragentseitherprovenorsuspectedtoberespiratorycarcinogensincludeacrylonitrile,arseniccompounds,
beryllium,bis(chloromethyl)ether,chromium(hexavalent),formaldehyde(nasal),isopropanol(nasalsinuses),
mustardgas,nickelcarbonyl(nickelsmelting),polyaromatichydrocarbons(cokeovenemissionsanddiesel
exhaust),secondhandtobaccosmoke,silica(bothminingandprocessing),talc(possibleasbestoscontamination
inbothminingandmilling),vinylchloride(sarcomas),wood(nasalcanceronly),anduranium.Workersatriskof
radiationrelatedlungcancerincludenotonlythoseinvolvedinminingorprocessinguraniumbutalsothose
exposedinundergroundminingoperationsofotheroreswhereradondaughtersmaybeemittedfromrock
formations.

AssessmentofDisability
Patientswhohavelungdiseasemaynotbeabletocontinuetoworkintheirusualjobsbecauseofrespiratory
symptoms.Disabilityisthetermusedtodescribethedecreasedabilitytoworkduetotheeffectsofamedical
condition.Physiciansaregenerallyabletoassessphysiologicdysfunction,orimpairment,buttheratingof
disabilityforcompensationoflossofincomealsoinvolvesnonmedicalfactorssuchastheeducationand
employabilityoftheindividual.Thedisabilityratingschemedifferswiththecompensationgrantingagency.For
example,theU.S.SocialSecurityAdministrationrequiresthatanindividualbeunabletodoanywork(i.e.,total
disability)beforeheorshewillreceiveincomereplacementpayments.Manystateworkers'compensation

systemsallowforpaymentsforpartialdisability.IntheSocialSecurityschemenodeterminationofcauseisdone,
whereasworkrelatednessmustbeestablishedinworkers'compensationsystems.
Forrespiratoryimpairmentrating,restingpulmonaryfunctiontests(spirometryanddiffusingcapacity)areusedas
theinitialassessmenttool,withcardiopulmonaryexercisetesting(toassessmaximaloxygenconsumption)used
iftheresultsoftherestingtestsdonotcorrelatewiththepatient'ssymptoms.Methacholinechallenge(toassess
airwayreactivity)canalsobeusefulinpatientswithasthmawhohavenormalspirometrywhenevaluated.Some
compensationagencies(e.g.,SocialSecurity)haveproscribeddisabilityclassificationschemesbasedon
pulmonaryfunctiontestresults.Whennospecificschemeisproscribed,theGuidelinesoftheAmericanMedical
Associationshouldbeused.
Evaluatingrelationtoworkexposurerequiresadetailedworkhistory,aspreviouslydiscussedinthischapter.
Occasionally,aswithsomecasesofsuspectedoccupationalasthma,challengetotheputativeagentinthework
environmentwithrepeatedpulmonaryfunctionmeasuresmayberequired.

GeneralEnvironmentalExposures
OutdoorAirPollution
In1971,theU.S.governmentestablishednationalairqualitystandardsforseveralpollutantsbelievedtobe
responsibleforexcesscardiorespiratorydiseases.PrimarystandardsregulatedbytheU.S.Environmental
ProtectionAgency(EPA)designedtoprotectthepublichealthwithanadequatemarginofsafetyexistforsulfur
dioxide,particulatesmatter,nitrogendioxide,ozone,lead,andcarbonmonoxide.Standardsforeachofthese
pollutantsareupdatedregularlythroughanextensivereviewprocessconductedbytheEPA.(Fordetailson
currentstandards,gotohttp://www.epa.gov/air/criteria.html.)
Pollutantsaregeneratedfrombothstationarysources(powerplantsandindustrialcomplexes)andmobile
sources(automobiles),andnoneoftheregulatedpollutantsoccursinisolation.Furthermore,pollutantsmaybe
changedbychemicalreactionsafterbeingemitted.Forexample,sulfurdioxideandparticulatematteremissions
fromacoalfiredpowerplantmayreactinairtoproduceacidsulfatesandaerosols,whichcanbetransported
longdistancesintheatmosphere.Oxidizingsubstancessuchasoxidesofnitrogenandvolatileorganic
compoundsfromautomobileexhaustmayreactwithsunlighttoproduceozone.Althoughoriginallythoughttobe
confinedtoLosAngeles,photochemicallyderivedpollution("smog")isnowknowntobeaproblemthroughoutthe
UnitedStatesandinmanyothercountries.Bothacuteandchroniceffectsoftheseexposureshavebeen
documentedinlargepopulationstudies.
Thesymptomsanddiseasesassociatedwithairpollutionarethesameasconditionscommonlyassociatedwith
cigarettesmoking.Inaddition,decreasedgrowthoflungfunctionandasthmahavebeenassociatedwithchronic
exposuretoonlymodestlyelevatedlevelsoftrafficrelatedgasesandrespirableparticles.Multiplepopulation
basedtimeseriesstudieswithincitieshavedemonstratedexcesshealthcareutilizationforasthmaandother
cardiopulmonaryconditionsandmortalityrates.Cohortstudiescomparingcitiesthathaverelativelyhighlevelsof
particulateexposureswithlesspollutedcommunitiessuggestexcessmorbidityandmortalityratesfrom
cardiopulmonaryconditionsinlongtermresidentsoftheformer.Thestrongepidemiologicevidencethatfine
particulatematterisariskfactorforcardiovascularmorbidityandmortalityhaspromptedtoxicologicinvestigations
intotheunderlyingmechanisms.Theinhalationoffineparticlesfromcombustionsourcesprobablygenerates
oxidativestressfollowedbylocalinjuryandinflammationinthelungsthatinturnleadtoautonomicandsystemic
inflammatoryresponsesthatcaninduceendothelialdysfunctionand/orinjury.Recentresearchfindingsonthe
healtheffectsofairpollutantshaveledtostricterU.S.ambientairqualitystandardsforozone,oxidesofnitrogen,
andparticulatematteraswellasgreateremphasisonpublicizingpollutionalertstoencourageindividualswith

significantcardiopulmonaryimpairmenttostayindoorsduringhighpollutionepisodes.

IndoorExposures
Secondhandtobaccosmoke(Chap.395),radongas,woodsmoke,andotherbiologicagentsgeneratedindoors
mustbeconsidered.Severalstudieshaveshownthattherespirableparticulateloadinanyhouseholdisdirectly
proportionaltothenumberofcigarettesmokerslivinginthathome.Increasesinprevalenceofrespiratory
illnesses,especiallyasthma,andreducedlevelsofpulmonaryfunctionmeasuredwithsimplespirometryhave
beenfoundinthechildrenofsmokingparentsinanumberofstudies.Recentmetaanalysesforlungcancerand
cardiopulmonarydiseases,combiningdatafrommultiplesecondhandtobaccosmokeepidemiologicstudies,
suggestan~25%increaseinrelativeriskforeachcondition,evenafteradjustmentformajorpotential
confounders.
Exposuretoradongasinhomesisariskfactorforlungcancer.Themainradonproduct(radon222)isagasthat
resultsfromthedecayseriesofuranium238,withtheimmediateprecursorbeingradium226.Theamountof
radiuminearthmaterialsdetermineshowmuchradongaswillbeemitted.Outdoors,theconcentrationsare
trivial.Indoors,levelsaredependentonthesources,theventilationrateofthespace,andthesizeofthespace
intowhichthegasisemitted.Levelsassociatedwithexcesslungcancerriskmaybepresentinasmanyas10%
ofthehousesintheUnitedStates.Whensmokersresideinthehome,theproblemispotentiallygreater,sincethe
molecularsizeofradonparticlesallowsthemtoattachreadilytosmokeparticlesthatareinhaled.Fortunately,
technologyisavailableforassessingandreducingthelevelofexposure.
Otherindoorexposuresofconcernarebioaerosolsthatcontainantigenicmaterial(fungi,cockroaches,dust
mites,andpetdanders)associatedwithanincreasedriskofatopyandasthma.Indoorchemicalagentsinclude
strongcleaningagents(bleach,ammonia),formaldehyde,perfumes,pesticides,andoxidesofnitrogenfromgas
appliances.Nonspecificresponsesassociatedwith"tightbuildingsyndrome,"perhapsbettertermed"building
associatedillness,"inwhichnoparticularagenthasbeenimplicated,haveincludedawidevarietyofcomplaints,
amongthemrespiratorysymptomsthatarerelievedonlybyavoidingexposureinthebuildinginquestion.The
degreetowhich"smells"andothersensorystimuliareinvolvedinthetriggeringofpotentiallyincapacitating
psychologicalorphysicalresponseshasyettobedetermined,andthelongtermconsequencesofsuch
environmentalexposuresareunknown.

PortalofEntry
Thelungisaprimarypointofentryintothebodyforanumberoftoxicagentsthataffectotherorgansystems.For
example,thelungisarouteofentryforbenzene(bonemarrow),carbondisulfide(cardiovascularandnervous
systems),cadmium(kidney),andmetallicmercury(kidney,centralnervoussystem).Thus,inanydiseasestateof
obscureorigin,itisimportanttoconsiderthepossibilityofinhaledenvironmentalagents.Suchconsiderationcan
sometimesfurnishtheclueneededtoidentifyaspecificexternalcauseforadisorderthatmightotherwisebe
labeled"idiopathic."
GlobalConsiderations
Indoorexposuretobiomasssmoke(wood,dung,cropresidues,charcoal)isestimatedtoberesponsiblefor~3%
ofworldwidedisabilityadjustedlifeyears(DALYs)lost,duetoacutelowerrespiratoryinfectionsinchildrenand
COPDandlungcancerinwomen.Thisburdenofdiseaseplacesindoorexposuretobiomasssmokeasthe
secondleadingenvironmentalhazardforpoorhealth,justbehindunsafewater,sanitation,andhygiene,andis
3.5timeslargerthantheburdenattributedtooutdoorairpollution.
Morethanonehalfoftheworld'spopulationusesbiomassfuelforcooking,heating,orbaking.Thisoccurs
predominantlyintheruralareasofdevelopingcountries.Becausemanyfamiliesburnbiomassfuelsinopen

stoves,whicharehighlyinefficient,andinsidehomeswithpoorventilation,womenandyoungchildrenare
exposedonadailybasistohighlevelsofsmoke.Inthesehomes,24hmeanlevelsoffineparticulatematter,a
componentofbiomasssmoke,havebeenreportedtobe230timeshigherthantheNationalAmbientAirQuality
StandardssetbytheU.S.EPA.
Epidemiologicstudieshaveconsistentlyshownassociationsbetweenexposuretobiomasssmokeandboth
chronicbronchitisandCOPD,withoddsratiosrangingbetween3and10andincreasingwithlongerexposures.In
additiontothecommonoccupationalexposuretobiomasssmokeofwomenindevelopingcountries,menfrom
suchcountriesmaybeoccupationallyexposed.BecauseofincreasedmigrationtotheUnitedStatesfrom
developingcountries,cliniciansneedtobeawareofthechronicrespiratoryeffectsofexposuretobiomass
smoke,whichcanincludeinterstitiallungdisease(Fig.2564).Evidenceisbeginningtoemergethatimproved
stoveswithchimneyscanreducebiomasssmokeinducedrespiratoryillnessinbothchildrenandwomen.
FIGURE2564

Histopathologicfeaturesofbiomasssmokeinducedinterstitiallungdisease.A.Anthraciticpigmentis
seenaccumulatingalongalveolarseptae(arrowheads)andwithinapigmenteddustmacule(singlearrow).B.A
highpowerphotomicrographcontainsamixtureoffibroblastsandcarbonladenmacrophages.

FurtherReadings
AldrichTKetal:LungfunctioninrescueworkersattheWorldTradeCenterafter7years.NEnglJMed
362:1263,2010[PubMed:20375403]
BalmesJR:Whensmokegetsinyourlungs.ProcAmThoracSoc7:98,2010[PubMed:20427578]
ChenTMetal:Outdoorairpollution:Overviewandhistoricalperspective.AmJMedSci333:230,2007[PubMed:
17435417]
CummingsKJetal:Areconsiderationofacuteberylliumdisease.EnvironHealthPerspect117:1250,2009
[PubMed:19672405]
CurrieGPetal:Anoverviewofhowasbestosexposureaffectsthelung.BMJ339:b3209,2009
JerrettMetal:Longtermozoneexposureandmortality.NEnglJMed360:1085,2009[PubMed:19279340]
ReesD,MurrayJ:Silica,silicosisandtuberculosis.IntJTubercLungDis11:474,2007[PubMed:17439668]
RomieuIetal:ImprovedbiomassstoveinterventioninruralMexico:Impactontherespiratoryhealthofwomen.
AmJRespirCritCareMed180:649,2009[PubMed:19556519]
SamuelG,MaierLA:Immunologyofchronicberylliumdisease.CurrOpinAllergyClinImmunol8:126,2008
[PubMed:18317020]
SuganumaNetal:Reliabilityoftheproposedinternationalclassificationofhighresolutioncomputedtomography
foroccupationalandenvironmentalrespiratorydiseases.JOccupHealth51:210,2009[PubMed:19372629]

TornK,BlancPD:Asthmacausedbyoccupationalexposuresiscommonasystematicanalysisofestimatesof
thepopulationattributablefraction.BMCPulmMed9:7,2009[PubMed:21698743]

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Allrightsreserved.
YourIPaddressis192.245.221.105

Asbestosis:A.Frontalchestradiographshowsbilateralcalcifiedpleuralplaquesconsistentwithasbestos
relatedpleuraldisease.Poorlydefinedlinearandreticularabnormalitiesareseeninthelowerlobesbilaterally.B.
Axialhighresolutioncomputedtomographyofthethoraxobtainedthroughthelungbasesshowsbilateral,
subpleuralreticulation(blackarrows),representingfibroticlungdiseaseduetoasbestosis.Subpleurallinesare
alsopresent(arrowheads),characteristicof,thoughnotspecificfor,asbestosis.Calcifiedpleuralplaques
representingasbestosrelatedpleuraldisease(whitearrows)arealsoevident.
Acutesilicosis.Thishighresolutioncomputedtomographyscanshowsmultiplesmallnodulesconsistentwith
silicosisbutalsodiffusegroundglassdensitieswiththickenedintralobularandinterlobularseptaproducing
polygonalshapes.Thishasbeenreferredtoas"crazypaving."
Chronicsilicosis.A.Frontalchestradiographinapatientwithsilicosisshowsvariablysized,poorlydefined
nodules(arrows)predominatingintheupperlobes,B.Axialthoraciccomputedtomographyimagethroughthe
lungapicesshowsnumeroussmallnodules,morepronouncedintherightupperlobe.Anumberofthenodules
aresubpleuralinlocation(arrows).
Histopathologicfeaturesofbiomasssmokeinducedinterstitiallungdisease.A.Anthraciticpigmentis
seenaccumulatingalongalveolarseptae(arrowheads)andwithinapigmenteddustmacule(singlearrow).B.A
highpowerphotomicrographcontainsamixtureoffibroblastsandcarbonladenmacrophages.