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Asbestosis

Asbestoses

Asbestosis is a pneumoconiosis caused by inhaled asbestos fibers. It is marked by pulmonary fibrosis.[1]


Presentation

The presentation of patients after asbestos exposure is not immediate. The symptoms often do not appear for several decades after exposure. This latency may be shortened if the intensity of exposure to asbestosis is high [7][8].
The most common presenting feature of asbestosis is dyspnea on exertion, which once started is progressive in nature. Other may also complain of a dry non-productive cough. Presence of a productive cough indicates a concomitant respiratory tract infection. Vague chest pain or discomfort is also a common complaint in patients with advanced disease.
Physical exam may reveal rales which are primarily heard at the lung bases and in the lower posterior area beneath the scapula.
Clubbing of the digits may be seen in 50% of patients but has no correlation to the severity of the disease.
With advanced disease, there will be decreased expansion of the chest that clinically correlates with restrictive ventilatory impairment and reduced vital capacity. Patients with Cor pulmonale may have varying degrees of cyanosis, hepatojugular reflux, jugular venous distension and pedal edema. Most patients with end stage lung disease appear cachectic, out of breath and moribund.

Cough
  • Persistent, dry cough - This troublesome cough, which often makes it difficult to sleep and eat, may be accompanied by chest pain. The victim may also find blood in the sputum. 8.[slideshare.net]
  • Ultrasonic, cool-mist humidifiers or controlled coughing can loosen bronchial secretions. Regular exercise helps maintain and improve lung capacity.[encyclopedia.com]
  • Cough Individuals with Asbestosis usually have a persistent cough that may or may not bring out saliva. A productive cough suggests a respiratory infection or a concomitant bronchitis.[hxbenefit.com]
  • This can cause a series of symptoms, including: Shortness of breath Persistent dry cough Chest tightness and pain Fatigue Loss of weight and appetite Crackling sound when breathing The stiffening of the lungs causes the coughing, discomfort and crackling[asbestos.com]
  • Initially, the person has no symptoms and later, dry cough and progressive shortness of breath occur.[health-tutor.com]
Pleural Effusion
  • Pleural effusion stemming from asbestos exposure can lead to pleurisy.[pleuralmesothelioma.com]
  • Benign asbestos-related pleural effusion Pleural effusions can occur within 10-20 years of asbestos exposure but may appear much later [ 2 ] . A pleural biopsy is usually required to differentiate between benign and malignant pleural effusions.[patient.info]
  • Also certain immunizations can be administered to attempt to prevent complications that can occur due to the asbestosis condition such as pleural effusion and malignant mesothelioma.[pneumoconiosis.org.uk]
  • If left untreated, Asbestosis patients can develop complications like Pleural Effusion and Malignant Mesothelioma. The latter disease is a deadly one and can cause death in 75% of sufferers within a year.[hxbenefit.com]
  • effusions, usually no symptoms Asbestos fiber detection: H&E, Prussian blue, incineration and EM Gross images Images hosted on other servers: Pleural plaque Microscopic (histologic) description Early: interstitial pneumonia with desquamative features[pathologyoutlines.com]
Dry Cough
  • Persons with advanced cases of the disease have a dry cough . The increased cardiac effort needed to perfuse the lungs may induce a secondary heart disease called cor pulmonole.[britannica.com]
  • Initially, the person has no symptoms and later, dry cough and progressive shortness of breath occur.[health-tutor.com]
  • Persistent, dry cough - This troublesome cough, which often makes it difficult to sleep and eat, may be accompanied by chest pain. The victim may also find blood in the sputum. 8.[slideshare.net]
  • Asbestosis signs and symptoms can include: Shortness of breath A persistent, dry cough Loss of appetite with weight loss Fingertips and toes that appear wider and rounder than normal (clubbing) Chest tightness or pain When to see a doctor If you have[mayoclinic.org]
  • Likewise, patients with these diseases will experience many of the same symptoms, such as: Wheezing or dry cough Shortness of breath Pain in the abdomen or chest Difficulty breathing (or respiratory complications) Anemia Muscle weakness Fever Shortness[maacenter.org]
Rales
  • Asbestosis is diagnosed by a signature sound in the lungs, known as basal crackles or rales, and by X-ray images that show specific irregularities. Diminished lung volume and flow may also signify asbestosis.[angeloslaw.com]
  • When listening to the chest with a stethoscope, the provider may hear crackling sounds called rales. These tests may help diagnose the disease: Chest x-ray CT scan of the lungs Lung function tests There is no cure.[medlineplus.gov]
  • Vague chest pain or discomfort is also a common complaint in patients with advanced disease.Physical exam may reveal rales which are primarily heard at the lung bases and in the lower posterior area beneath the scapula.Clubbing of the digits may be seen[symptoma.com]
  • Also known as "rales", they are usually detected near the end of a full inspiration. When diagnosing asbestosis, chest x-rays will show small irregular opacities (spots in x-ray film where the x-rays could not "see" through the tissue).[ccohs.ca]
  • Inspiratory basilar rales, restrictive impairment, small airway obstruction, and gas exchange disturbances in pulmonary function are considered valuable information for clinical diagnosis, for occupational health practice, and for attribution purposes[sjweh.fi]
Pulmonary Disorder
  • The first modern evidence of fibrotic pulmonary disorder in an asbestos worker was discovered in an autopsy performed by Dr Montague-Murray in England in 1899, and reported on in 1907.[asbestosassociation.com.au]
  • Retrieved 2009-12-20 . a b c d e f g "Asbestosis - Pulmonary Disorders" . Merck Manuals Professional Edition . May 2014 . Retrieved 19 December 2017 . a b "Asbestosis symptoms and treatments" . NHS Inform . 6 April 2017 .[en.wikipedia.org]
  • Other non-cancer disorders Inhalation of asbestos fibres may cause other non-cancerous pleural and pulmonary disorders. Asbestosis, along with mesothelioma and lung cancer, are typical diseases of long-term exposure to asbestos.[anses.fr]
Fatigue
  • Tiredness and fatigue: The scarring and inflammation of lungs can also reduce the ability to exchange oxygen and carbon dioxide, which can lead to a reduction in lung function and subsequently cause fatigue.[robertsjackson.co.uk]
  • Because the body relies on oxygen for energy, chronic breathing difficulties lead to fatigue and weight loss.[asbestos.com]
  • Other symptoms include: a persistent cough wheezing fatigue or extreme tiredness pain in your chest or shoulder in more advanced cases, clubbed (swollen) fingertips Diagnosis If you have any of the symptoms mentioned above, you should discuss this with[blf.org.uk]
  • Symptoms of this can include: shortness of breath persistent cough wheezing extreme tiredness (fatigue) pain in your chest or shoulder in more advanced cases, clubbed (swollen) fingertips When to see your GP See your GP if you have the symptoms above[nhs.uk]
Chest Pain
  • pain where as only 1(one) with parenchymal disease reported chest pain.[ehjournal.biomedcentral.com]
  • Other symptoms of advanced asbestosis include chest pain, hoarseness, and restless sleep. Patients who have asbestosis often have clubbed (widened and thickened) fingers.[encyclopedia.com]
  • Main symptoms that may be present in an asbestosis sufferer are - Chest pain Clubbing of the fingers Cough Nail abnormalities Shortness of breath Tightness in the chest Asbestosis treatment There is no current cure for asbestosis, although stopping exposure[pneumoconiosis.org.uk]
  • These symptoms are most commonly: Shortness of breath Persistent cough Chest pain Weight loss Mesothelioma patients experience much more severe symptoms as their disease progresses.[mesotheliomaguide.com]
Cyanosis
  • Patients with Cor pulmonale may have varying degrees of cyanosis, hepatojugular reflux, jugular venous distension and pedal edema. Most patients with end stage lung disease appear cachectic, out of breath and moribund.[symptoma.com]
  • Clinical features may include: Progressive shortness of breath Cough Inspiratory crackles Cyanosis Clubbing Complications of asbestos exposure Lung cancer can result from asbestos exposure and is the most common malignancy associated with it.[lecturio.com]
  • Physical findings of crackles, clubbing, or cyanosis are associated with increased risk for asbestos-related mortality [ 16 , 17 ]. In our study nearly 40% of Asbestosis workers had either rates or rhonchi.[ehjournal.biomedcentral.com]
  • Other indications of asbestosis include abnormal lung sounds on examination, changes in the ends of the fingers and toes (" clubbing "), a blue tinge to the fingers or lips (" cyanosis "), and failure of the right side of the heart ("cor pulmonale").[medicinenet.com]
Lip Cyanosis
  • Other indications of asbestosis include abnormal lung sounds on examination, changes in the ends of the fingers and toes (" clubbing "), a blue tinge to the fingers or lips (" cyanosis "), and failure of the right side of the heart ("cor pulmonale").[medicinenet.com]
Hepatojugular Reflux
  • Patients with Cor pulmonale may have varying degrees of cyanosis, hepatojugular reflux, jugular venous distension and pedal edema. Most patients with end stage lung disease appear cachectic, out of breath and moribund.[symptoma.com]
Insomnia
  • In some people, theophyllines have been known to cause a number of side effects including: headaches, nausea, insomnia, vomiting, irritability, and stomach upsets.[hse.ie]

Workup

The diagnosis of asbestosis is based on the following:

  • One must obtain a thorough history and take into account the dose and duration of exposure to asbestos. It is important to known the type of work one was performing and if any body protection was used (garments, gloves or masks).
  • Always ask for an old chest x-ray to determine if the disease was present earlier and it has progressed, as compared to the present chest x-ray.
  • Determine degree of dyspnea - whether it is at rest, exercise or during sleep
  • Any prior treatment for heart failure as some patients may have developed right heart failure
  • Laboratory blood tests are not specific for diagnosis of asbestosis exposure but a blood gas is needed to determine hypoxia and hypercarbia.
  • Gallium citrate scan is not recommended as it is not specific for asbestosis.
  • Even though some healthcare workers make the diagnosis of asbestosis based on the history and physical, errors in diagnosis can occur because there are many other interstitial lung diseases that can present with similar features of asbestosis. When using the history to make the diagnosis, it is important to keep in mind that there is a long latent period between exposure and development of symptoms. Many cases of medical malpractice have resulted when the diagnosis of asbestosis is missed because of reliance on just the history and physical exam.

Radiography

  • Chest x-ray will show diffuse reticulonodular infiltrates in the middle and lower lung segments. Honeycombing may be seen in advanced disease. Typically there will be thickening of the lower and middle pleural wall. Sometimes a large calcified pleural plaque on the diaphragmatic pleura may be seen.
  • CT scan is always done in a patient with asbestosis. The Ct scan can determine the size and location of any pleural lesion, presence of effusion, invasion of the chest wall or other structures, or atelectasis. CT scan is also excellent at defining the fibrosis. Even in people with normal chest xrays, the CT scan will reveal presence of abnormalities

Pulmonary Function Test
Pulmonary function tests are performed in patients with asbestosis but are not specific. The CO diffusing capacity is decreased and may be the earliest abnormality seen. As the disease advances, the patient will develop reduction in total lung capacity and vital capacity. However, these features are nonspecific and can be seen in many other restrictive lung disorders.


Oximetry
Pulse oximetry will usually reveal hypoxia which may be exacerbated in the presence of right heart failure and cor pulmonale. In the clinic, the pulse oximetry can be performed at rest and during exercise and can quickly reveal the severity of hypoxemia


Bronchoalveolar Lavage and Bronchoscopy
The role of bronchoscopy and bronchoalveolar lavage in making the diagnosis of asbestosis is limited. It is only helpful when trying to make a diagnosis of an infection or determining the cause of a sudden wheeze in an elderly individual. During bronchoscopy, the airways can be lavaged and the fluid is collected to assess the number of asbestos fibers. If there is more than one asbestos body/ml of lavage from the airways, then the probability of high exposure to asbestos is likely. Bronchoscopy should not be used to perform a lung biopsy as the tissue yield is inadequate and false negatives are high.

Lung biopsy
Lung biopsy is necessary to make the diagnosis of asbestosis and rule out other disorders. In addition, the lung biopsy may reveal the absence or presence of a malignancy. The biopsy specimen is usually viewed under light and electron microscopy and reveal presence of fibrosis and asbestosis bodies. A grading system has been developed to assess the severity of asbestosis related fibrosis. It is important to note that presence of asbestosis bodies alone is not diagnostic for the disorder because sometimes the pathologist may observe these bodies in individuals who have had no exposure or have had only a transient exposure to asbestos


Biopsy of the pleura
Pleural thickening can occur with asbestosis and it is difficult to know if this is a benign or malignant lesion. Hence a biopsy is required. This is usually done in the operating room via an open procedure because the yield from a needle biopsy is not sufficient to make the diagnosis of a malignancy. Even though pleural plaques can occur with several other medical disorders, the presence of plaques and dyspnea should be a good indicator of prior exposure to asbestos.

X-Ray Abnormal
  • X-ray abnormalities include thickening of the lining of the lungs and tiny lines marking the lower portions of the lungs. However, up to 20% of patients have completely normal-appearing chest X-rays.[medicinenet.com]
Restrictive Pulmonary Function
  • Diffuse pleural thickening can be associated with mild (or, rarely, moderate to severe) restrictive pulmonary function deficits such as decreased ventilatory capacity.[atsdr.cdc.gov]
  • Diffuse pleural thickening can be associated with mild, or rarely moderate or severe, restrictive pulmonary function defects. Low exposures from work-related, household, and natural sources may induce pleural plaques.[sjweh.fi]
Decreased Lung Compliance
  • This fibrosis can lead to Reduced lung volumes, Decreased lung compliance, Impaired gas exchange, Restrictive pattern of impairment, Obstructive features due to small airways disease, and Progressive exertional dyspnea with an insidious onset.[atsdr.cdc.gov]
Pleural Effusion
  • Pleural effusion stemming from asbestos exposure can lead to pleurisy.[pleuralmesothelioma.com]
  • Benign asbestos-related pleural effusion Pleural effusions can occur within 10-20 years of asbestos exposure but may appear much later [ 2 ] . A pleural biopsy is usually required to differentiate between benign and malignant pleural effusions.[patient.info]
  • Also certain immunizations can be administered to attempt to prevent complications that can occur due to the asbestosis condition such as pleural effusion and malignant mesothelioma.[pneumoconiosis.org.uk]
  • If left untreated, Asbestosis patients can develop complications like Pleural Effusion and Malignant Mesothelioma. The latter disease is a deadly one and can cause death in 75% of sufferers within a year.[hxbenefit.com]
  • effusions, usually no symptoms Asbestos fiber detection: H&E, Prussian blue, incineration and EM Gross images Images hosted on other servers: Pleural plaque Microscopic (histologic) description Early: interstitial pneumonia with desquamative features[pathologyoutlines.com]

Treatment

  • Once the diagnosis of asbestosis has been made, the goal of the treatment is to prevent any further exposure and manage the symptoms. The patient should be strongly advised to discontinue smoking [9].
  • The severity of the lung disease and functional impairment should be studied and treatment individualized. Then a follow up plan must be developed to monitor the patient. This may involve regular pulmonary function tests, arterial blood gases, and obtain serial chest x-ray or CT scans. The patient’s oxygen status must be assessed at rest and with exercise to determine if hypoxemia occurs at rest or with exercise.
  • Supplemental oxygen may be required while ambulation or at night time.
  • If the patient has an upper respiratory tract infection or pneumonia, appropriate antibiotic treatment is needed.
  • All patients with asbestosis should be immunized against pneumococcal pneumonia and influenza.
  • Many patients with end stage lung disease are cachectic, immobile and bedridden. These patients may require appropriate palliative care. Relief from shortness of breath must be provided. During the terminal phase of the disease, comfort and supportive care is needed.
  • Once asbestosis has developed, there is no effective medication. Even though both corticosteroids and a variety of immunosuppressive agents have been tried, the course of the disorder is not altered.
  • For patients who develop wheezing, bronchodilators are useful.
  • Patients who have developed lung cancer or a mesothelioma need to be referred to a thoracic surgeon. Most patients are either not candidates for surgery or the cancer is too far advanced

Prognosis

The prognosis for most individuals after prolonged exposure to asbestos has to be guarded. The symptoms of asbestosis are not immediate and often present after several decades. However, once the symptoms start, they are progressive and can be debilitating. The majority of patients will develop lung related complications such as:

Risk factors for chronic respiratory insufficiency include:


• Duration and intensity of asbestosis exposure
• Degree of shortness of breath
• Continued use of tobacco
• Combined pulmonary and pleural involvement
• Chest X-ray and CT scan imaging showing honeycombing
• Bronchoalveolar lavage with high number of inflammatory cells


Malignancy
Prolonged exposure to asbestos is known to cause lung cancer and mesotheliomas of the upper respiratory tract (pharynx, larynx), esophagus, kidney and biliary tract. The combination of tobacco and asbestos has a synergistic effect on the development of lung cancer. Individuals who smoke and have asbestosis exposure are at a very high risk for development of lung cancer than people who do not smoke [6].


Asbestosis, when it coexists with other lung disorders like COPD, emphysema, bronchitis, bronchiectasis or idiopathic fibrosis, can severely worsen the symptoms and worsen the quality of life. Most of these patients develop severe dyspnea and have no exercise tolerance. Asbestosis also worsens the symptoms of asthma and over time, even bronchodilators do not have an effective response.
Many studies have shown that asbestosis has a high morbidity and mortality rate. The disorder leads to premature termination of employment and numerous visits to the hospital.

Etiology

Asbestos exposure in most countries occurs during manufacture of the following products:

  • Making asbestos paper for insulation and filters
  • Incorporation of asbestos cement in shingles, sheets, pipes and clapboards
  • Use in motor vehicles brake lining and clutch facings
  • Preparing dry wall products containing asbestos
  • Making of vinyl asbestos floor tiles
  • Manufacture of textile products such as felt, cord, rope and yarn
  • Manufacture of spray products for thermal, acoustic and fireproofing

Occupations with high risk of asbestosis include the following:


• Boilermakers
• Car mechanics who work on brake linings and clutches
• Insulation workers
• Janitors
• Pipefitters
• Plumbers
• Roofers
• Steamfitters
• Welders


When there is uncontrolled removal of asbestos from the environment studies show that even within a few months, individuals can have very high levels of asbestos fibers in the airways.

Epidemiology

Asbestos exposure was significant nearly half a century ago. Almost every country was using asbestos related products and hence many people were exposed to it. By the 1980s, there was awareness of the dangers of asbestos, and thus, the use of asbestos products declined gradually in most western countries. At present, there are no solid data on the number of people somehow exposed to asbestosis. In the USA, experts indicate that there may be less than a few hundred cases of patients presenting with asbestos related lung disease. Strict governmental regulation of use of asbestos products in the home and better means of protecting the worker has significantly reduced the risk of asbestosis development. However, individuals who have been exposed to asbestos in previous decades continue to be at risk for the pneumoconiosis and other related disorders.
In most western countries, the use of asbestosis is strictly regulated. However in developing countries there is evidence that the use of asbestos is not regulated and in fact asbestos related health disease is rapidly increasing. The reason why asbestos continues to be used in developing countries is because it is cheap, readily available and has exceptional insulating properties.

Sex distribution
Age distribution

Pathophysiology

The incidence of asbestosis is variable and greatly dependent on the cumulative dose of inhaled fibers over many years. Those individuals who have high and prolonged exposure tend to have a higher incidence of asbestosis. Every single type of asbestos fiber studied so far has been shown to induce fibrosis of the lung. Inhalation of the crocidolite fibers are also known to cause malignant lesions of the lung and pleura. Fibers which are less than 3 microns tend to induce fibrosis as they are able to penetrate the cell lining. Thicker fibers are incompletely phagocytised and remain in the lung where they continue to generate an inflammatory reaction. Besides influx of inflammatory cells, there is generation of oxygen free radicals which damage the lung enzymes, proteins and endothelial cell lining [5].
The ability of asbestosis fibers to induce inflammation depends on individual susceptibility, immunological factors and respiratory clearance. Overall, people who tend to smoke have poor airway clearance and are more likely to see progression of disease with asbestosis. Asbestos leads to development of intense fibrosis of the lung, which is most common at the bases. In addition, the ongoing inflammation initiates pleural thickening and plaques.
There is also evidence that some people who are exposed to asbestos fibers of the amphibole type may develop an autoimmune reaction, with generation of autoantibodies. Further research shows that asbestos related lung disease is slightly more common in people who have positive serology for antinuclear antibodies. These patients were also more prone to developing more intense fibrosis of the lung and large pleural plaques, then individuals who were seronegative for anti nuclear antibodies.

Prevention

To prevent asbestosis, one needs to restrict the use of asbestos in the home and workplace. Anyone exposed to asbestos must discontinue all further exposure by either changing the job or home. This is to prevent further exposure and decrease the risk of developing asbestos related lung disease. Unfortunately, once asbestos exposure has occurred, the disease continues even though the exposure had discontinued. Smoking cessation is highly recommended.

Summary

Asbestos are naturally occurring fibers that are extremely heat resistant and have superb insulating properties. For decades, these two properties of asbestos have led to its widespread use in the home and industry. Microscopically, asbestos fibers vary from 1-12 microns in size and may be curved (serpentine asbestos) or straight (amphibole). Over the years several subtypes of amphibole fibers have been recognized, namely actinolite, anthophyllite, crocidolite, amosite and tremolite. Of these, chrysotile is by far the most common type of asbestos fiber produced and used in the manufacturing industry. Asbestos was widely used in the industry until reports started to appear in the late 60s that people who were exposed to it were developing severe restrictive lung disease, lung cancer and mesotheliomas. It was not until a decade later that it was finally concluded that asbestos exposure was not benign and hence, its use started to decline in most western countries. In the manufacturing industry, strict guidelines were introduced to limit the levels of asbestos in the environment. Further workers were asked to wear proper garments and masks when working with asbestos related product. The use of asbestos as insulation in the home continued until the late 80s but sporadic reports exist that asbestos can be found in dry wall made in china [2][3][4].

Patient Information

Asbestos was a common product once used in the home and manufacturing industry to make a variety of products. However, because of the risk of developing severe lung disease and cancer, the use of asbestos has declined in most western countries. Today, people who work in the manufacturing industry are at the highest risk, but because of awareness and use of appropriate garments and masks, there has been a significant decrease in asbestos associated lung disease. When uncontrolled asbestos exposure occurs, the inhaled fibers can cause severe lung fibrosis and increase the risk of lung and pleural cancer. The patients usually present several decades after the initial exposure. Treatment is immediate cessation of exposure. Besides oxygen, there is no definitive therapy for asbestosis. Patients need to be monitored for life as some may develop right heart failure, severe lung fibrosis and even cancer.

References

Article

1. Cullinan P, Reid P Pneumoconiosis. Prim Care Respir J. 2013 Jun;22(2):249-52.
2.Gulati M, Redlich CA. Asbestosis and environmental causes of usual interstitial pneumonia. Curr Opin Pulm Med. 2015 Mar;21(2):193-200.
3.Norbet C, Joseph A, Rossi SS, Bhalla S, Gutierrez FR. Asbestos-Related Lung Disease: A Pictorial Review. Curr Probl Diagn Radiol. 2014 Oct 30. pii: S0363-0188(14)00117-0.
4.Bernstein DM. The health risk of chrysotile asbestos. Curr Opin Pulm Med. 2014 Jul;20(4):366-70.
5.Liu G, Cheresh P, Kamp DW. Molecular basis of asbestos-induced lung disease. Annu Rev Pathol. 2013 Jan 24;8:161-87.
6.Campbell K, Brosseau S, Reviron-Rabec L, Bergot E, Lechapt E, Levallet G, Zalcman G. Malignant pleural mesothelioma: 2013 state of the art]. Bull Cancer. 2013 Dec;100(12):1283-93.
7. Dang GT, Barros N, Higgins SA, Langley RL, Lipton D. Descriptive review of asbestosis and silicosis hospitalization trends in North Carolina, 2002-2011. N C Med J. 2013 Sep-Oct;74(5):368-75.
8. Donaldson K, Poland CA, Murphy FA, MacFarlane M, Chernova T, Schinwald A. Pulmonary toxicity of carbon nanotubes and asbestos - similarities and differences. Adv Drug Deliv Rev. 2013 Dec;65(15):2078-86.
9. Prazakova S, Thomas PS, Sandrini A, Yates DH. Asbestos and the lung in the 21st century: an update. Clin Respir J. 2014 Jan;8(1):1-10.

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