Environmental &

Occupational Lung
Diseases
ARIANNA MOHIUDDIN

Pneumoconioses

Fibrotic lung disease due to inhalation of mineral dusts, found in

industrial settings

Characteristic latent period between exposure and onset of symptoms

History is very important! Obtain a detailed occupational history,

including type of job performed and age of first exposure. Must obtain
smoking history.

Generally progressive, no cure.

Coal workers pneumoconiosis, Silicosis, Asbestosis

Coal Workers Pneumoconiosis

CWP is caused by inhalation of coal dust

over a chronic period (>20 years).

Deposition of coal dust in alveolar

macrophages causes these to deposit in
lung interstitium, near bronchioles and
alveoli

Two forms of CWP are described:

Simple CWP individual coal macules (coal

deposition + pigment-laden alveolar
macrophages); usually asymptomatic

Complicated CWP with coalescence of coal

macules and PMF (progressive massive
fibrosis)

Coal Workers Pneumoconioses

Simple CWP
- 5-10 years old coal dust exposure
Small

rounded opacities; initially in the upper zones but progress to middle and lower zones with disease
advancement,

Small

emphysematous changes can occur especially with smoking

Usually

asymptomatic

Progressive Massive Fibrosis

Severe
Large
Both

progressive disease; reduced lifespan; severe dyspnea

opacities in lung can necrose and cavitate

restrictive and obstructive features

Melanoptysis
Poor

black sputum

prognosis

Caplans

Syndrome: + Rheumatoid artritis in a coal miner + Progressive massive fibrosis

CWP: History & Physical

History obtaining a good history is paramount. Ask about specific job, length of time
spent underground, and age at first exposure. Obtain a smoking history. The occupations
with the most exposure to inhalable coal dust are cutting-machine operator in descending
order are

cutting-machine operators>>roof bolters>train operators> motormen, brakemen, drivers, and

shuttle car operators>mechanics, electricians, and maintenance personnel.

Physical Exam

Simple CWP: Usually asymptomatic; patients may report cough + sputum production

Complicated CWP: cough, dyspnea, lung function impairment. Advanced disease cor pulmonale
associated with right ventricular heave, large A waves, hepatomegaly, and peripheral edema.

Fever, nigh sweats, and other constitutional symptoms suggest a secondary infective process.

Diagnosis is based on history of coal dust exposure and characteristic radiographic

findings.

Silicosis

Free silica (SiO2), aka crystalline quartz mining,

stonecutting, quarrying.

Diagnosis of silicosis is based on characteristic radiographic

findings with known history of silica exposure.

Acute silicosis: develops in workers with heavy

exposure; can occur in as little as 10 months. Clinical
syndrome resembles pulmonary alveolar proteinosis

Long-term, less intense exposure:

Simple silicosis: small round opacities in upper lobes;

calcification of hilar nodes can produce eggshell pattern

Complicated silicosis: coalescence of fibrotic nodules to

>1cm diameter

Progressive massive fibrosis: further enlargement of masses

Silica is toxic to alveolar macrophages; increased risk of

tuberculosis, fungi, and atypical mycobacteria

Also increased risk for autoimmune diseases RA &

scleroderma

Silicosis

Acute Silicosis

Develops after inhalation of high concentrations of silica.

Chronic Silicosis

Includes simple silicosis and progressive

massive fibrosis

Multiple upper lung nodules that are <10 mm

diameter, rounded

Appears 10-30 years after exposure

PMF: coalescence of nodules of chronic

silicosis + hilar LAN and egg-shell calcification

Diagnosis: history, imaging findings, and

exclusion of alternative etiologies

Tx: Supportive care

Symptoms develop within weeks to years after initial

exposure cough, weight loss, fatigue, pleuritic chest pain.

Associated with bilateral alveolar filling pattern; similar to

pulmonary alveolar proteinosis.

Diagnosis: history, imaging findings, BAL effulent (milky,

proteinaceous); exclusion of other etiologies

Tx: whole-lung lavage; supportive care

Silicosis Imaging
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Acute Silicosis
Bilateral alveolar filling in both
lower lung zones

Simple Silicosis

Progressive Massive
Fibrosis

Small rounded densities in

upper lung zones

End-stage silicosis complicated

by respiratory failure.

Asbestos-Related Disease

Asbestos is an umbrella term or different mineral silicates crysolite,

amosilite, antophylite, and crocidolite. Asbestos was widely used in
manufacturing due to its desirable properties sound absorption, high
tensile strength, and resistance to heat, fire, and electrical/chemical
damage. Asbestos was a common material in manufacture of textiles,
cement/floor tiles, ceilings, insulation, and in brake linings.

Asbestos materials began to be phased out in the US in the 1980s1990s. However, many older buildings still contain asbestos materials.

Occupational exposure: production of asbestos products mining,

milling, manufacturing; shipbuilding; construction; occurred primarily
in the early to mid-20th century

Bystanders: painters/ electricians who worked in asbestos-filled areas

Asbestos-related diseases include pleural and pulmonary fibrosis,

cancers of the respiratory tract, and pleural/peritoneal mesothelioma.

Asbestosis-Related Disease:
Asbestosis

Asbestosis

Diffuse interstitial fibrotic disease of the lung; related

directly to duration and intensity of exposure.

Moderate to severe exposure required before symptoms

manifest (~10 years)

Pathophysiology: oxidative injury to phagocytes is

speculated.

CXR/HRCT:

Pleural plaques thickening/calcification along parietal

pleura, predominantly in lower lung fields, diaphragm, and
cardiac border
Benign pleural effusions of serous or bloody exudate
Irregular linear opacities, which begin in the lower lung
fields and then spread upwards as the disease progresses.

PFT: restrictive pattern, decreased lung volumes,

decreased DLCO.
Therapy: supportive care

http://www.learningradiology.com/archives06/COW%20199Asbestos-related%20Pleural
%20Disease/asbestosrelatedcorrect.htm

Asbestosis-Related Disease: Lung

Cancer & Mesothelioma

Lung cancer: the most common malignancy associated with asbestos

exposure; most commonly squamous cell carcinoma, adenocarcinoma,
or bronchiogenic carcinoma. Latency period of 15-20 years between
exposure and development of disease. Significantly greater effect with
smoking and exposure to asbestosis.

Mesothelioma: pleural and peritoneal; no association with smoking

history. Can develop even after short-term asbestosis exposure (1-2
years), with development of tumor occurring up to 40 years after this
exposure.

50% of mesotheliomas metastasize, but the tumor is usually locally invasive,

with death usually occurring from local extension.

Malignant Mesothelioma