Environmental and occupational pulmonary diseases result from inhalation of dusts, chemicals, gases, fumes, and other airborne exposures. The lungs are continually exposed to the external environment and are susceptible to a host of environmental and occupational challenges. Pathologic processes can involve any part of the lungs, including the
Airways (eg, in work-related asthma, reactive airways dysfunction syndrome, toxic inhalations, air pollution-related illness, or byssinosis)
Lung parenchyma (eg, in pneumoconioses, hypersensitivity pneumonitis, or silicosis)
Pleura (eg, in asbestos-related diseases)
Inhalation exposures have long been known to be a risk factor for asthma (see Work-Related Asthma). They are also recognized as a cause of COPD (chronic obstructive pulmonary disease) that is not related to smoking. The American Thoracic Society estimates the population-attributable fraction of COPD related to occupational exposures to be about 15% (1).
Clinicians should take an occupational and environmental history in all patients, asking specifically about industry and job tasks, past and current exposures, and whether symptoms are temporally related to work, home, or other environments. More detailed questions follow any positive response.
General reference
1. Balmes J, Becklake M, Blanc P, et al. American Thoracic Society Statement: Occupational contribution to the burden of airway disease. Am J Respir Crit Care Med 2003;167(5):787-797. doi:10.1164/rccm.167.5.787
Prevention
Prevention of environmental and occupational pulmonary diseases centers on reducing or eliminating exposure (primary prevention). Exposure can be reduced or eliminated using the hierarchy of controls, in the order of most to least effective:
Elimination (eg, removing the hazard from the workplace)
Product substitution (eg, using safer, less toxic materials)
Engineering controls (eg, enclosures, ventilation systems, safe clean-up procedures)
Administrative controls (eg, limiting the number of people exposed to hazardous conditions)
Personal protective equipment (eg, respirator, dust mask)
Although respirators reduce exposure, they are the least preferred type of control. They should be considered when more effective interventions are not feasible or do not sufficiently reduce the hazard. Respiratory protection typically is worn for high-risk specific tasks and not for an entire workday.
When a respirator is required to protect the employee's health, the employee should be enrolled in their employer-mandated written respiratory protection program, which includes medical evaluation and annual respiratory fit testing to ensure proper fit. Medical evaluation includes assessment of whether the patient is able to tolerate the type of respirator that will be used in the workplace given their health status.
Medical surveillance is a form of secondary prevention. In medical surveillance, scheduled evaluations, such as spirometry or chest imaging, are conducted to identify disorders early when exposure reduction and other interventions might help reduce long-term consequences. The United States Occupational Safety and Health Administration (OSHA) mandates medical surveillance for select exposures such as asbestos and silica.
More Information
The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
Blanc PD, Annesi-Maesano I, Balmes JR, et al: The Occupational Burden of Nonmalignant Respiratory Diseases. An Official American Thoracic Society and European Respiratory Society Statement. Am J Respir Crit Care Med 2019 Jun 1;199(11):1312-1334.
United States Department of Labor, Occupational Safety and Health Administration, Standard Number 1910.134 - respiratory protection
European Agency for Safety and Health at Work: Respiratory Protection Equipment — Requirements and Selection. Published 17/06/2003. Updated 17/20/2020.
