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Industrial Health 2010, 48, 119–122 Field Report

Acute Expanded Perlite Exposure with Persistent
Reactive Airway Dysfunction Syndrome
Chung-Li DU1, Jung-Der WANG1, 2, Po-Chin CHU1, 2 and Yue-liang Leon GUO1, 2*

1Department of Environmental and Occupational Medicine, National Taiwan University Hospital, 17 Syujhou
Road, Taipei 100, Taiwan
2Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public

Health, Taiwan

Received December 25, 2008 and accepted June 23, 2009

Abstract: Expanded perlite has been assumed as simple nuisance, however during an acciden-
tal spill out in Taiwan, among 24 exposed workers followed for more than 6 months, three devel-
oped persisted respiratory symptoms and positive provocation tests were compatible with reac-
tive airway dysfunction syndrome. During simulation experiment expanded perlite is shown to
be very dusty and greatly exceed current exposure permission level. Review of literature and
evidence, though exposure of expanded perlite below permission level may be generally safe, pre-
cautionary protection of short term heavy exposure is warranted.

Key words: Expanded perlite, Spill, Provocation test, Simulation, Reactive airway dysfunction

Introduction Taiwan, because of abnormal pressure was noted in a
safety valve of liquid nitrogen tank (49.2 m3), replace-
Perlite, light gray to glossy black color porous glass ment of its evacuation valve was scheduled. The intro-
containing interstitial water, originates from volcanic duction of helium gas during the maintenance process
eruption. For industrial purpose, perlite is heated up to brings the pressure within the vacuum layer to accumu-
1,000 degree Celsius to become expanded perilte that is late and break out through the safety valve. The insula-
used as agriculture substrate, lightweight concrete aggre- tor material, consisting of mainly expanded perlite pow-
gate, packaging material, and construction and industrial der, had an accident explosion and spilling out. This
insulator for wall and floor and so on, according its var- caused large amount of powders to continue falling cov-
ious size. The expanded perilte has a high surface area, ering hundred meters of area. A woman staff in the out-
is fluffy white and insoluble in water. According to mate- side ground, unable to escape reported to have inhaled the
rial safety data sheet, expanded perlite is a mineral com- powder and developed symptoms of sore throat, persist-
posed of sodium, potassium, aluminum, silicate, and ed cough, and chest tightness. An industrial hygiene offi-
alpha-cristobatite & tridymite, and alpha-quartz, etc. cer and another security guard went over immediately to
depending on its ore body that dictating the substance’s check the accident and stayed at the polluted space with-
chemical composition. It is regarded as generally safe, out mask for several minutes. Later on more company
and the time weighted average of threshold limit value staffs wearing paper or carbon masks were dispatched to
(TLV-TWA) was 10 mg/m3 without short-term exposure clean the polluted ground using water jets and brooms for
limit1). several hours. Many of them also complained of eye and
throat irritation, cough and dyspnea afterwards.
Subjects and Methods For the exposed workers an initial health examination
at nearby hospitals was arranged though not all visited
In a factory located in one of the Science Park of doctors, and later on referred to our hospital, one of the
tertiary referral centers in Taiwan. The 24 cases had
*To whom correspondence should be addressed. onsets of respiratory irritation at the first or second day
E-mail: of their exposure to perlite, and their symptom varied and

7 7 △ △ mask/N95 91 92.4 female whole body guard.8 6 mask/N95 100.7 75.3 8 mask nil nil nil 9 cleaning of other grounds for several mask/N95 99. None exposure and protection condition. the prevalent symptoms observed among these Chest radiograph and pulmonary function tests (PFT).5 82. were off and on (for several months) before visiting function of 24 perlite exposed workers.7 21 cleaning of polluted cars nil nil nil nil 22 nil nil nil nil 23 later exposed for minutes nil 117. powder pouring down over 1 nil 104 113.7 114.1 113.6 smoking 1/2 PPD for 10 yr watching safety officer.6 12 △ △ N95 nil nil nil 13 N95 nil nil nil 14 △ △ mask/N95 108 112. ness complaint at the first exposure and thereafter with slight obstruction of PFT (%FEV1 <80). pulmonary of them had known prior history of lung diseases such as Table 1.1 80. For the other Results lightly exposed workers. symptoms. Industrial Health 2010.5 106.120 C-L DU et al.7 71.3 106.1 83.3 heart disease EKG normal hours provocation test negative 10 N95 100.9 83. symptoms.3 at 32 mg/ml 11 △ N95 116.4 smoking 1/2 PPD for 8 yr 15 N95 86. and throat irritation (in 7 patients).2. 48.7 82 16 mask/N95 98.8 91.4 17 mask/N95 117 117 87. means persistent symptoms. test results were all within normal limits (Table 2).4 86.4) had cough and chest tight- 16 mg/ml of methacholine inhalation.7 85. Among the 24 NTUH.3 18 △ mask/N95 93.8 123.3 84.3 5 △ △ △ mask/N95 96.7 84 19 △ N95 109. 3 mask 107 109.9 78 20 N95 102. using patients).8 95. 119–122 . eye irritation (in 11 patients). none remained symptomatic after 6 months of follow-up and their pulmonary function The results in Table 1 showed the previous history. exposure and protection condition.5 96. Positive result was defined as a 20% decrease victims had more than 6 months of respiratory symptoms in FEV1 (PC20) upon threshold value equal or less than and three of them (case 1.9 98. exposed 20 min in emergency 2 nil 86. were performed for them (in 12 patients).9 92.2 112 90.2 83.9 & cruise whole area later on 4 cleaning of tank area for several hours mask 88.4 84.4 105.2 81. pulmonary function of 24 expanded perlite exposed workers Irritation sites & symptoms Initial PFT at NTUH Protection Case no. workers up to 3 months after incident were cough (in 12 including non-specific broncho-provocation test. workers. The previous history.7 90. Many as well.3 85. at the scene for minutes. where questionnaire survey were performed. prior history of 24 Sanitary work for 1 h (after major cleaning) N95 nil nil nil asthma inhaler Rx When visit NTUH clinic △ means symptoms subsides. shortness of breath serial dosage of methacholine. Exposure conditions Past history & notes Dyspnea or (respirators) Cough Eye Throat FEV1 FVC FEV1/FVC chest tightness passing by.8 female.

As. Chest radiography was obtained in 22 workers histiopathological result. and serial provocation 15%.0 to 80.2% (such as methacholine challenge test). ers without history of pulmonary disease developed per.0 mg/ml).1 is the directly exposed exposure and symptoms (d) symptom less likely to woman staff (38 yr old).6% predicted). Cd. At concentrations of only).2 is the guard (55 yr improve away from work (e) objective (pulmonary func- old). cough or dys. tuberculosis or lung can. within min.5%) 3 (37. and pleural date. the average fall in FEV1 was approximately derline or no response (case 1&4). emphysema.4% to 93. In this accident. 1 to 4 mg/ml). The case workers have demonstrated all the above features. ed paint of the worksite or maybe from very small amount . ity of air hyper-reactiveness (AHR) to methacholine. In the incident described herein. Among the three persistent tom occurred within 24 h (c) no latency period between symptomatic workers.9%) 3 (37. which confirms positive bronchial low-up for 9 months and case 4 for 2 yr. frequency and extent of exposure. and thus it is also categorized as irritant induced occupational asthma7). while perlite had never been recognized in the above list. the case no. chronic bronchitis. there are 7 workers in the high exposed group perform pulmonary function test. The remaining per- sistent cough and dyspnea after a single heavy exposure lite powder on the ground was analyzed and it showed to expanded perlite. **: PC20 means provocation test is positive at methacholine ≤16 mg/ml that causes 20% drop in FEV1 from baseline. borderline (PC20. three exposed work. there cal examination last year. These three RADS and FEV1/FVC from 79. Lately recommended cardinal which were considered normal except minimal fibrotic diagnostic features of RADS3) are: (a) identification of change in 4. expanded perlite as revealed from material safety data utes or hours after a single. pnea) persisted for a longer period and usually non-spe- cer except one light exposed case with prior asthma his.5%) 3 (42. If the last con- These three cases have persistent symptoms even after centration inhaled was ≤16 mg/ml.5%) 0 (0%) 0 (0%) 0 (0%) group (n=16) grounds and lately *: Obstructive ventilation defect is defined as FEV1/FVC <80%.PERLITE CAUSE REACTIVE AIRWAY DYSFUNCTION SYNDROME 121 Table 2. his pulmonary function tion) test demonstrate obstruction (f) presence and per- tests showed improvement after one month of follow up sistence of non-specific bronchial hyper-responsiveness (FVC from 86. ≤1. case no. >16 mg/ml). although symptom persist. as shown in the literature RADS usually occurs to corrosive or irritating Discussion gas. increased lung marking in 3. cific challenge test is usually positive. The victims of expanded perlite incident exposure groups and the percentage of workers’ with persistent respiratory symptoms and impaired pulmonary function results Respiratory Respiratory With obstructive Meet PC20 Classification Exposure condition symptoms up symptoms more ventilation defect* criteria** to 3 months than 6 months first contactor. of reactive airway dysfunction syndrome (RADS)2) the They are unlikely to be the original constituents of victim’s symptoms will develop very quickly. vapor. by the sever- who had normal pulmonary function in periodical physi. on American Thoracic Society guidelines4). mild (PC20. (b) symp- thickening in 2 workers. fume or dust6) exposure. and are assumed to be contaminants from exfoliat- the asthma-like symptom (chest tightness. and with postitive tory. The follow up broncho-dilatation test showed bor. Nevertheless. According to the original definition some Cr. a 39 yr old worker cleaning the tank leakage area. developed persistent cough and were 4 degrees: moderate to marked (PC20.5%) group (n=8) or cleaning of tank leaking area Light exposure cleaning of other 6 (37.8%. and normal (PC20. PC20≤16 mg/ml. or theophylline and prednisolone (case 1 severity scheme (about 25%). >16 mg/ml. FEV1 from 86. 4 to 16 tion test showed persistent mild obstructive pattern. time. Heavy exposure immediate exposed. Hg (<5 ppm) and Pb (80 ± 5 ppm). place before this incident. His serial pulmonary func. 5 (62. all three cases of RADS have a tests are still positive (<16 mg/dl) for cases 1&2 after fol. mg/ml).1% to 90. either as an irritant6) or a sensitizer8). Based no. it was found that the treatment with beta-agonist inhaler plus anti-allergic (all percentage fall in FEV1 was similar across the AHR three cases).0%) was noted at the latest follow up. in this worker responsiveness to methacholine. high-intensity exposure and sheet. The three symptomatic persistent obstructive pulmonary function throughout the workers who become airway hyper-reactiveness (AHR) follow up course and diffusion capacity impairment have no previous exposure to sensitizers5) in their work- (75.4. dyspnea after this incident.

dust. do Pico GA (1996) Reactive airway dys- tories for up to 23 yr of exposure. the health effect of perlite exposure way syndrome. J Occup Med 18. there was no evidence function syndrome. The 12) Cooper WC.150 mg/m3. J Pharm Methods 9. of inside tank wall exfoliated paint. heavy exposed workers. Baur X (2000) Occupational dysfunction12) and their exposure of perlite is around the airway sensitizers: an overview of the perspective liter- permissible level13). Am J Respir Crit Care Med 172. Marcel Dekker. Using sand dust test However. Gautrin D (2007) Airway dust. ulate the three RADS cases are due to short term. low up for workers in perlite mining and processing fac- 7) Alberts WM. endotoxin and fire-retar- to our knowledge. 6. of pneumoconiosis by chest radiography or pulmonary 8) Kampen VV. we estimated the exposure level may be more than ers. DiPalma JR.2 purifying respirator is suggested to be placed near-by.122 C-L DU et al. 48. ACGIH. appropriate respiratory protection such as air machine and in a condition of pre-set pressure of 0. heavy Industrial Health 2010. Bernstein RL (1985) Reactive Thus. Occupational asthma. but only mineral wool. Ghezzo H. MPa (mega pascal. We also show that the heavy 14) Polatli M. Amenta symptomatic cases up to 6 months or more. we have followed 24 11) McMichael RF. According to our investigation. Thus. and which does not show free SiO2. Chest 122. 653–69. irritation and mild hemorrhage. was once reported in an orchid grower with pulmonary Bernstein IL et al. Though chronic exposure to sub-TLV concentration of ing pressure of nitrogen gas in the insulation layer before expanded perlite may not be hazardous.869 atm) to simulate fill. In: Asthma in the workplace. fiberglass or perlite: installer’s exposure mild effect on their pulmonary function was noted. Cockcroft DW (2002) Extrapolation of found in the upper brochi10). and perlite crystals were 4) Davis BE. They mainly expose to model study of perlite and fire bark dust on guinea pig expanded perlite. A recent study of Indian perlite ature. J Occup Med 28. the ng/m3 range)14) for more than 10 yr also revealed no Eriksen SS (2003) Cellulose building insulation versus clinical pulmonary silicosis or fibrosis cases. Thorax 62. 10) Cooper WC (1976) Pulmonary function in perlite work- ers. The safety offi- cer and two colleagues agrees that by visual comparison References the average air concentration was estimated to be around 191–4. methacholine PC20. In the simulation exper. we spec. Malo JL. Cincinnati. Weiss MA. Okyay E (2001) Perlite exposed group victims have a higher incidence and per. this is the first report of RADS asso. Chest 109. maybe also with trace metals which lungs. particle throughout the lungs with lymphoid aggregation 6) Mapp CE. 723–9. Erdinç M.01–0. Ann Occup Hyg 47. 304–7. The limitation of this material of expanded perlite powder was also analyzed study is lack of airway histological proof in these victims. we speculated by the dusty nature that the spill out airway dysfunction syndrome (RADS). Am J Ind Med 38. dant additives. Rasamussen TV. Thus. Blumenstein R. 2nd Ed. 1 MPa =9. Sargent EN (1986) Study of chest radi- victims’ symptoms developed shortly after exposure of ographs and pulmonary ventilatory function in perlite perlite and could persist even with beta-agonist treatment workers. Maestrelli P. fol. Schneider T. the initiative to the accident occurred. 1618–26. Environ sistent symptoms of respiratory distress. Brooks S (1999) Reactive air- Thirty years ago. Freedman AP. Chest 88. 2) Brooks SM. New York. Bernstein IL. Boschetto P. Jorgensen O. 119–122 . 280–305. up to a maximum of 24 months. guinea pigs exposed to higher concentration of perlite 5) Boulet K. 1499–500. workers exposed to very low level of expanded perilte (in 9) Breum NO. ciated with expanded perlite exposure.. expanded perlite powder was regulate the short term exposure limit of expanded per- stirred in the hood for 15 s and the chamber light was on lite to prevent workers from high level of exposure may so to visually simulate the cloudy leakage while dust con. 3) Gautrin D. However. The original raw exposure of dusty expanded perlite. Res 86. 238–41. J Occup Med 17. by inhalation of fibers. centration was simultaneously monitored. be further explored.). 209–17. were not related to respiratory distress or RADS. exposure and 4-year change in lung function. cause a lot of floated expanded perlite to be inhaled by 376–84. Barbieri EJ (1983) A small animal fied three cases fulfilling RADS. and identi- PS. 260–4. around 20–400 folds of TLV-TWA for 1) American Conference of Government Industrial expanded perlite. Fabbri LM (2005) and perivascular inflammatory response11). In a subsequent experiment. 13) Cooper WC (1975) Radiograph survey of perlite work- iment. 20–400 folds of STEL. (Eds. Erdinç E. it had been noted that expanded perlite chemical substances and physical agents in the work could be much dusty than any other fibrous powders9).2 mg/ml and 30 min per day in a special hyper responsiveness and risk of chest symptoms in an chamber for 24 wk were found to have intracellular dust occupational model. environment. 164–218. Merget R. From a study of insulation installer’s Hygienists (ACGIH) (2005) Threshold limit values for dust exposure.6 ± 5. 199–206.