Pneumoconiosis

MEANING

Pneumoconiosis is a chronic lung disease caused due to the

inhalation of various forms of dust particles, particularly in
industrial workplaces, for an extended period of time. Hence it is
also said to be an occupational lung disease, which are a
particular subdivision of occupational related diseases that are
related primarily to being exposed to harmful substances,
whether they are gas or dusts, in the work place, and the
pulmonary disorders that may result from it. The severity and
type of pneumoconiosis depends on what the dust particles
comprise of; for example, small amounts of certain substances,
such as asbestos and silica, can lead to serious reactions, while
others may not be as harmfulCoalworker's pneumoconiosis

Various Types of Pneumoconiosis

• The most common types of pneumoconiosis are:

• coal workers’ pneumoconiosis, silicosis,

• asbestosis.

As is evident by their names, these pneumoconioses are caused

due to the inhalation of coal mine dust, silica dust, and asbestos
fibers. Usually, it takes several years for these pneumoconioses to
develop and manifest themselves. However, sometimes,
particularly with silicosis, it can develop quite rapidly, within a
short period of being exposed to large amounts of silica dust. In
their severe form, pneumoconioses often result in the impairment
of the lungs, disability, and even untimely death.

Asbestosis: This is caused due to the inhalation of fibrous

minerals that asbestos is made of. The exposure begins with the
baggers, who handle the asbestos by collecting them and
packaging them, to workers that make products out of them such
as insulation material, cement, and tiles, and people working in
the shipbuilding industry, and construction workers. It usually
takes about 20 years, or more, for the symptoms of asbestos
pneumoconiosis to manifest itself.

Silicosis: This type of pneumoconiosis occurs in people who

handle silica, generally as quartz, which is found in sandstone,
sand, granite, slate, certain types of clays, and so on. The people
who have the most amount of exposure to silica are those who
make glass and ceramic products, quarry workers, foundry
workers, silica millers, tunnel builders, miners, and sandblasters.
Silicosis leads to fibrosis within the lungs, which increases
progressively, and impairs the functioning of the lungs. It is
further exacerbated in people who smoke cigarettes.

Apart from the above mentioned pneumoconioses, there are also

other kinds such as: berylliosis, due to inhaling beryllium dust;
bauxite fibrosis, because of inhaling bauxite dust; siderosis, due
to inhaling iron dust; byssinosis, due to inhaling cotton dust.
Some of the other types of dusts that cause pneumoconiosis are:
aluminum, barium, antimony, graphite, kaolin, talc, mica, and so
on. There is also a type known as mixed-dust pneumoconiosis.
As far as public health is concerned, pneumoconiosis is
completely a man-made disease, which can be prevented with
adequate dust control and protective gear in the work place

Coal workers' pneumoconiosis (CWP), colloquially referred to as

Black Lung Disease, is caused by long exposure to coal dust. It is
a common affliction of coal miners and others who work with coal,
similar to both silicosis from inhaling silica dust, and to the long-
term effects of tobacco smoking. Inhaled coal dust progressively
builds up in the lungs and is unable to be removed by the body;
that leads to inflammation, fibrosis, and in the worst case,
necrosis.

Coal workers' pneumoconiosis, severe state, develops after the

initial, milder form of the disease known as anthracosis (anthrac -
coal, carbon). This is often asymptomatic and is found to at least
some extent in all urban dwellers[1] due to air pollution.
Prolonged exposure to large amounts of coal dust can result in
more serious forms of the disease, simple coal workers'
pneumoconiosis and complicated coal workers' pneumoconiosis
(or Progressive massive fibrosis, or PMF). More commonly,
workers exposed to coal dust develop industrial bronchitis[2],
clinically defined as chronic bronchitis (i.e. productive cough for 3
months per year for at least 2 years) associated with workplace
dust exposure. The incidence of industrial bronchitis varies with
age, job, exposure, and smoking. In nonsmokers (who are less
prone to develop bronchitis than smokers), studies of coal miners
have shown a 16%[3] to 17%[4] incidence of industrial bronchitis.

Pathogenesis

Coal dust is not as fibrogenic as is silica dust. Coal dust that

enters the lungs can neither be destroyed nor removed by the
body.

The particles are engulfed by resident alveolar or interstitial

macrophages and remain in the lungs, residing in the connective
tissue or pulmonary lymph nodes. Coal dust provides a sufficient
stimulus for the macrophage to release various products,
including enzymes, cytokines, oxygen radicals, and fibroblast
growth factors[10], which are important in the inflammation and
fibrosis of CWP. Aggregations of carbon-laden macrophages can
be visualised under a microscope as granular, black areas. In
serious cases, the lung may grossly appear black. These
aggregations can cause inflammation and fibrosis, as well as the
formation of nodular lesions within the lungs. The centres of
dense lesions may become necrotic due to ischemia, leading to
large cavities within the lung.

Appearance

The coal macule is the basic pathological feature of CWP, and has
a surrounding area of enlargement of the airspace, known as
focal emphysema.

Continued exposure to coal dust following the development of

simple CWP may progress to complicated CWP with progressive
massive fibrosis (PMF), wherein large masses of dense fibrosis
develop, usually in the upper lung zones, measuring greater than
1 cm in diameter, with accompanying decreased lung function.
These cases generally require a number of years to develop.
Grossly, the lung itself appears blackened. Pathologically, these
consist of fibrosis with haphazardly-arranged collagen and many
pigment-laden macrophages and abundant free pigment.
Radiographically, CWP can appear strikingly similar to silicosis. In
simple CWP, small rounded nodules (see ILO Classification)
predominate, tending to first appear in the upper lung zones. The
nodules may coalesce and form large opacities (>1 cm),
characterizing complicated CWP, or PMF.

Symptoms

Both CWP and mild complicated CWP are often asymptomatic or

only affect lung function slightly. When symptoms do occur,
shortness of breath and chronic cough are the most common.
Progression to PMF is marked by lung dysfunction, pulmonary
hypertension, and cor pulmonale. Unlike silicosis, patients with
CWP do not appear to have a substantial increased risk for
tuberculosis, but coal miners may experience significant silica
dust exposure, and therefore the accompanying risks. CWP is
associated with a variety of autoimmune abnormalities, including
rheumatoid arthritis (see Caplan's syndrome below) and
scleroderma[12].

Diagnosis

There are three basic criteria for the diagnosis of CWP:

1. Chest radiography consistent with CWP

2. An exposure history to coal dust (typically underground coal

mining) of sufficient amount and latency

3. Exclusion of alternative diagnoses (mimics of CWP)

Symptoms and pulmonary function testing relate to the degree of

respiratory impairment, but are not part of the diagnostic criteria.
As noted above, the chest X-ray appearance for CWP can be
virtually indistinguishable from silicosis. Chest CT, particularly
high-resolution scanning (HRCT), are more sensitive than plain X-
ray for detecting the small round opacities.

Symptoms of Pneumoconiosis

In its milder forms, pneumoconiosis may not have any symptoms.

However, when the symptoms do develop, they may be:

* Shortness of breath, particularly on exertion

* Wheezing

* Chronic coughing, which may or may not be accompanied by

mucus

If there is severe fibrosis of the lungs, it can become extremely

difficult to breathe, and when this occurs, it may lead to the
fingernails and lips getting a bluish tinge. In the advanced form of
pneumoconiosis, there may also be swelling in the legs due to
excessive strain on the heart.

TREATMENT

avoid being exposed to the dust causing the pneumoconiosis.

Medications that need to be inhaled will also be prescribed in
order to reduce the inflammation of the air passages and to open
up the bronchial tubes. In case the level of oxygen in the blood
goes below 90 percent, you will have to make arrangements at
home for additional oxygen, which you will have to breathe in
according to the directions given. Also, immunization with
pneumococcal and flu vaccines will also be recommended as a
protective measure against infections of the lungs. If a lung
infection does develop, antibiotics will most probably be
prescribed.

SURGICAL MANAGEMENT

In case the breathing problems are extreme, the only cure is a

lung transplant.

How can Pneumoconiosis be Prevented?

A protective mask should be worn when working with any of the

above-mentioned material, such as coal, asbestos, silica, and so
on. Also, governments should ensure that companies comply with
the permitted levels of dust regulations.

Pleurisy

Pleurisy (also known as pleuritis) is an inflammation of the

pleura,[1] the lining of the pleural cavity surrounding the lungs.
Among other things, infections are the most common cause of
pleurisy.

The inflamed pleural layers rub against each other every time the
lungs expand to breathe in air. This can cause sharp pain with
inhalation (also called pleuritic chest pain).
Symptoms

The main symptom of pleurisy is a sharp or stabbing pain in the

chest that gets worse with deep breathing, coughing or sneezing.
The pain may stay in one place, or it may spread to the shoulder
or back. Sometimes it becomes a fairly constant dull ache.

Depending on what's causing the pleurisy, one may have other

symptoms:

* Shortness of breath

* Cough

* Fever and chills

* Rapid, shallow breathing

* Unexplained weight loss

* Sore throat followed by pain and swelling in the joints

[edit] Causes

Pulmonary

Two-thirds of pleural infections arise from underlying lung

infections or penetrating thoracic trauma. Other sources of pleural
infections are vascular dissemination or extension from an intra-
abdominal source. [3]
 *

Pneumothorax: when the pleural space is disrupted air

collects between the parietal and visceral pleura. This is seen as a
pleural line beyond which no parenchymal markings are visible on
a chest radiograph.View image When this occurs in the setting of
accompanying pleural fluid (a hydropneumothorax), the fluid
exposed to air will often have increased eosinophils as a result.

Viral: coxsackie B virus is the most common cause of

infectious pleuritis. Echovirus can cause the syndrome Bornholm
pleurodynia, manifesting as pleuritis, fever, and chest muscle
spasms; the condition occurs in the late summer and affects
adolescents and young adults. Other viral aetiologies are
influenza, parainfluenzae, respiratory syncytial virus (RSV), and
CMV. [4]

Bacterial: Streptococcus species, Staphylococcus aureus,

enteric Gram-negative bacilli, and anaerobes are the principle
organisms causing pleural infections. They invariably result in the
formation of empyema if not promptly drained. [5]

Pulmonary embolus: when an effusion develops because of

nearby lung infarction, the fluid is typically sanguineous or
serosanguineous and may have predominance of neutrophils or
eosinophils. [6] [7]

Asbestos-related benign pleural disease: asbestos exposure

can result in parietal pleural plaques or diffuse pleural thickening,
usually many (>18) years after exposure. Benign asbestos pleural
effusions, however, can occur as early as 1 year after exposure
and are exudative with elevated eosinophils. [8] These usually
self-remit but may do so slowly over many months. Initial
presentation is usually with dyspnoea on exertion. Rarely patients
can present with pleuritic chest pain. [9]

Systemic

Infection: tuberculous pleuritis is the most common form of

extrapulmonary TB infection. [10] It is uncommon in the US, but
has increasing prevalence worldwide. [11]

Malignancy: primary lung cancer, mesothelioma (as a result of

asbestos exposure), or metastasis from lung, breast, lymphoma,
GI, or GU tumours. [12]

*
 Connective tissue disorders: a major cause of autoimmune
pleuritis. The most common connective tissue disorders are SLE,
rheumatoid arthritis, and Sjogren's syndrome.

Drugs reactions: drugs such as hydralazine, procainamide,

isoniazid, methyldopa, or chlorpromazine are associated with
development of lupus pleuritis. Other drugs such as minoxidil,
beta-blockers, amiodarone, bleomycin, methysergide,
methotrexate, cyclophosphamide, valproic acid, or nitrofurantoin
also cause pleuritis through still unclear mechanisms. [13] [Drug-
induced lung diseases] (external link)

Other conditions that may cause pleuritis, although it is rarely the

primary presenting symptom, include uraemia, [14] [15] familial
Mediterranean fever, [16] and other intra-abdominal processes
such as cirrhosis, pancreatitis, and peptic ulcer.

Cardiovascular

Post-cardiac injury syndrome: an autoimmune inflammatory

process involving pleura and pericardium secondary to cardiac
injury (either acute coronary syndrome or cardiac
surgery/trauma). [17]

*
 Aortic dissection: rare cause of pleuritis and is due to blood
leaking into the pleural space.

Viral infection is the most common cause of pleurisy. However,

many different conditions can cause pleurisy:

# lung infections, such as pneumonia and tuberculosis

# Other diseases such as systemic lupus erythematosus (lupus),

rheumatoid arthritis, cancer, liver diseases, and pulmonary
embolism

# Chest injuries

# Drug reactions

* Pneumothorax

* Bacterial infections like pneumonia and tuberculosis

* Autoimmune disorders like systemic lupus erythematosus (or

drug-induced lupus erythematosus) and rheumatoid arthritis

* Lung cancer, including lymphoma

* Other lung diseases like Cystic Fibrosis, sarcoidosis,

asbestosis, lymphangioleiomyomatosis, and mesothelioma

* Pulmonary embolism, a blood clot in the blood vessels that go

into the lungs

* Inflammatory bowel disease

* Familial Mediterranean fever, an inherited condition that

often causes fever and swelling in the abdomen or lung

* Infection from a fungus or parasite

* Heart surgery, especially coronary artery bypass grafting

 * High blood pressure

* Chest injuries

* Aortic dissection

* Can occur with no illness or infection

Some cases of pleurisy are idiopathic, meaning the cause cannot

be determined.

[edit] Diagnosis

A diagnosis of pleurisy or another pleural condition is based on

medical histories, physical exams, and diagnostic tests. The goals
are to rule out other sources of the symptoms and to find the
cause of the pleurisy so the underlying disorder can be treated.

[edit] Physical exam

A doctor uses a stethoscope to listen to the breathing. This

detects any unusual sounds in the lungs. A person with pleurisy
will have inflamed layers of the pleura that make a rough,
scratchy sound as they rub against each other during breathing.
This is called pleural friction rub, and it is a likely sign of pleurisy.

[edit] Diagnostic tests

Depending on the results of the physical exam, diagnostic tests

are sometimes performed.

Chest x-ray
A chest x-ray takes a picture of the heart and lungs. It may show
air or fluid in the pleural space. It also may show what's causing
the pleurisy –for example; pneumonia, a fractured rib, or a lung
tumor.

Sometimes an x-ray is taken while lying on the painful side. This

may show fluid that did not appear on the standard x-ray taken
while standing.

Computed tomography (CT) scan

A CT scan provides a computer-generated picture of the lungs

that can show pockets of fluid. It also may show signs of
pneumonia, a lung abscess, or a tumor.

Ultrasound

Ultrasonography uses sound waves to create pictures of the

lungs. It may show where fluid is located in the chest. It also can
show some tumors.

Magnetic resonance imaging (MRI)

Magnetic resonance imaging (MRI), also called nuclear magnetic

resonance (NMR) scanning, uses powerful magnets to show
pleural effusions and tumors.

Blood tests

Blood tests can detect bacterial or viral infection, pneumonia,

rheumatic fever, a pulmonary embolism, or lupus.

Arterial blood gas

In arterial blood gas sampling, a small amount of blood is taken

from an artery, usually in the wrist. The blood is then checked for
oxygen and carbon dioxide levels. This test shows how well the
lungs are taking in oxygen.

Thoracentesis

The illustration shows a person having thoracentesis. The person

sits upright and leans on a table. Excess fluid from the pleural
space is drained into a bag.

Once the presence and location of fluid is confirmed, a sample of

fluid can be removed for testing. The procedure to remove fluid in
the chest is called thoracentesis. The doctor inserts a small
needle or a thin, hollow, plastic tube through the ribs in the back
of the chest into the chest wall and draws fluid out of the chest.

Biopsy
Treatment

Treatment has several goals:

* Remove the fluid, air, or blood from the pleural space

* Relieve symptoms

* Treat the underlying condition

[edit] Procedures

If large amounts of fluid, air, or blood are not removed from the
pleural space, they may put pressure on the lung and cause it to
collapse.

The surgical procedures used to drain fluid, air, or blood from the
pleural space are as follows:

* During thoracentesis, a needle or a thin, hollow, plastic tube

is inserted through the ribs in the back of the chest into the chest
wall. A syringe is attached to draw fluid out of the chest. This
procedure can remove more than 6 cups (1.5 litres) of fluid at a
time.

* When larger amounts of fluid must be removed, a chest tube

may be inserted through the chest wall. The doctor injects a local
painkiller into the area of the chest wall outside where the fluid is.
A plastic tube is then inserted into the chest between two ribs.
The tube is connected to a box that suctions the fluid out. A chest
x-ray is taken to check the tube's position.

* A chest tube also is used to drain blood and air from the
pleural space. This can take several days. The tube is left in place,
and the patient usually stays in the hospital during this time.

* Sometimes the fluid contains thick pus or blood clots, or it

may have formed a hard skin or peel. This makes it harder to
drain the fluid. To help break up the pus or blood clots, the doctor
may use the chest tube to put certain medicines into the pleural
space. These medicines are called fibrinolytics. If the pus or blood
clots still do not drain out, surgery may be necessary.

] Medications

A couple of medications are used to relieve pleurisy symptoms:

* Paracetamol (acetaminophen) or anti-inflammatory agents to

control pain and decrease inflammation. Only indomethacin
(brand name Indocin) has been studied with respect to relief of
pleurisy.[2]

* Codeine-based cough syrups to control a cough

There may be a role for the use of corticosteroids (for tuberculous

pleurisy), tacrolimus (Prograf) and methotrexate (Trexall,
Rheumatrex) in the treatment of pleurisy. Further studies are
needed.

[edit] Lifestyle changes

The following may be helpful in the management of pleurisy:

* Lying on the painful side may be more comfortable

* Breathing deeply and coughing to clear mucus as the pain

eases. Otherwise, pneumonia may develop.

* Getting rest

[edit] Treating the cause

Ideally, the treatment of pleurisy is aimed at eliminating the

underlying cause of the disease.

* If the pleural fluid is infected, treatment involves antibiotics

and draining the fluid. If the infection is tuberculosis or from a
fungus, treatment involves long-term use of antibiotics or
antifungal medicines.

* If the fluid is caused by tumors of the pleura, it may build up

again quickly after it is drained. Sometimes antitumor medicines
will prevent further fluid buildup. If they don't, the doctor may
seal the pleural space. This is called pleurodesis. Pleurodesis
involves the drainage of all the fluid out of the chest through a
chest tube. A substance is inserted through the chest tube into
the pleural space. This substance irritates the surface of the
pleura. This causes the two layers of the pleura to squeeze shut
so there is no room for more fluid to build up.

* Chemotherapy or radiation treatment also may be used to

reduce the size of the tumors.

* If congestive heart failure is causing the fluid buildup,

treatment usually includes diuretics and other medicines.

The most common and known treatment for pleurisy is generally

to carry on as normal, ibuprofen and amoxicilin being common
treatments prescribed by doctors. Milder forms of Pleurisy can be
noticed by less inflammatres of the arms and legs. If this is the
case Pleurisy will clear of all symptoms within two weeks.

[edit] Alternative treatments

A number of alternative or complementary medicines are being

investigated for their anti-inflammatory properties, and their use
in pleurisy. At this time, clinical trials of these compounds have
not been performed.

Extracts from the Brazilian folk remedy Wilbrandia ebracteata

("Taiuia") have been shown to reduce inflammation in the pleural
cavity of mice.[3][4] The extract is thought to inhibit the same
enzyme, cyclooxygenase-2 (COX-2), as the non-steroidal anti-
inflammatory drugs.[4] Similarly, an extract from the roots of the
Brazilian Petiveria alliacea plant reduced inflammation in a rat
model of pleurisy.[5] The extract also reduced pain sensations in
the rats. An aqueous extract from Solidago chilensis has been
shown to reduce inflammation in a mouse model of pleurisy.[6]

[edit] Pleurisy root

Pleurisy root, or butterfly weed, was so named because it was

used by Native Americans to treat pleurisy. The root was said to
encourage coughing by thinning the mucus in the lungs. Pleurisy
root is not used much today because more effective medicines are
available.