Asbestosis

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Asbestosis

• A Case study
• By Erica Ducker

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What is Asbestos?

• Consists of naturally occurring silicate
  minerals.
• In the 19th Century, it was increasingly mined
  and used because of its ability to absorb sound,
  its high tensile strength, resistance to fire,
  heat, electrical damage, and affordability.

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Asbestosis

• Asbestosis is defined as a type of pneumoconiosis
  caused by the inhalation of asbestos fibers.
• In the 1920s, scientists first recognized the
  link between asbestos and pulmonary fibrosis.
• In the 1960s, firmly established link between
  asbestos and both bronchogenic carcinoma and
  malignant mesothelioma.
• Current strict regulation of asbestos has
  significantly decreased risk of developing
  asbestosis.

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Asbestosis

• Causes no symptoms in the early stages.
• Progressive cough, shortness of breath, weakness,
  fatigue develop over time.
• Clinical asbestosis is decreasing in frequency
  but asbestos-related lung cancer deaths are
  becoming more common.

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Healthy Lung Tissue
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Asbestos in Lung Tissue
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The Patient

• 69 year old man.
• Retired construction contractor of 45 years.
• Primarily installed insulation materials in
  high-rise apartment and office buildings.
• Been retired for 4 years and began experiencing
  respiratory symptoms approximately 6 months ago.

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Medical History

• Appendectomy at age 13
• Osteoarthritis in left knee (high school football
  injury) x 30 years
• Status post-cholecystectomy, 16 years ago
• Benign prostatic hyperplasia, transurethral
  resection 7 years ago
• Hypertension x 7 years
• Hyperlipidemia x 4 years
• Gastroesophageal reflux disease x 4 years

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Family History

• Paternal history of coronary heart disease.
  Father died age 63 from heart problems.
• Material history of cerebrovascular disease.
  Mother died at age 73 after a series of strokes.
• Brother died in boating accident at age 17.
• No other siblings.

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Social History

• Married with 3 grown children, aged 40, 45, and
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• Smokes 1 pack per day x 45 years
• Rarely exercises
• History of heavy alcohol use
• Volunteers at community food pantry
• No history of intravenous drug use
• Known to unreliable in keeping follow up
  appointments, doesnt like doctors

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Review of Systems

• Denies rash, nausea, vomiting, diarrhea, and
  constipation
• Denies headache, chest pain, bleeding episodes,
  dizziness, and tinnitus
• Denies loss of appetite and weight loss
• Reports minor visual changes recently corrected
  with stronger prescription bifocal glasses.
• Complains of generalized joint pain, especially
  left knee pain
• Never been diagnosed with chronic obstructive
  pulmonary disease or any other pulmonary disorder
• Denies paresthesias and muscle weakness
• Negative for urinary frequency, dysuria,
  nocturia, hematuria, and erectile dysfunction

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Medications

• Acetaminophen 325 mg 2 tabs po Q 6H PRN
• Ramipril 5 mg po BID
• Atenolol 25 mg po QD
• Pravastatin 20 mg po QD
• Famotidine 20 mg po Q HS

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General

• Pleasant but nervous, elderly white gentleman
• Appears pale but is in no apparent distress
• Looks his stated age
• Strong Italian accent
• Appears to be slightly overweight

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Vital Signs

• Blood pressure (sitting, both arms) average
  131/75 mm Hg
• Pulse 69 beats per minute
• Respiratory rate 29 breaths per minute and
  slightly labored
• Temperature 98.6 F
• Pulse oximetry 95 on room air
• Height 59
• Weight 179 lb

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Skin

• Pallor noted
• No lesions or rashes
• Warm and dry with satisfactory turgor
• Nail beds are pale

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Head, Eyes, Ears, Nose, and Throat

• Extra-ocular muscles intact
• Pupils equal at 3mm with normal response to light
• Funduscopy within normal limits (no hemorrhages
  or exudates)
• No strabismus, nystagmus, or conjunctivitis
• Sclera anicteric
• Tympanic membranes within normal limits
  bilaterally
• Nare patent
• No sinus tenderness
• Oral pharyngeal mucosa clear
• Mucous membranes moist but pale
• Good dentition

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Neck and Lymph Nodes

• Neck supple
• Negative for jugular venous distension and
  carotid bruits
• No lymphadenopathy or thyromegaly

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Chest and Lungs

• Breathing labored with tachypnea
• Prominent end-inspiratory crackles in the
  posterior and lower lateral regions bilaterally
• Subnormal chest expansion
• Mild wheezing present

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Heart

• Regular rate and rhythm
• Normal S1 and S2
• Negative S3 and S4
• No murmurs or rubs noted

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Abdomen

• Soft, non-tender to pressure, and non-distended
• Normal bowel sounds
• No masses of bruits
• No hepatomegaly or splenomegaly

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Genitalia and Rectum

• Normal male genitalia, testes descended,
  circumcised
• Prostate normal in size and without nodules
• No masses of discharge
• Negative for hernia
• Normal anal sphincter tone
• Guaiac-negative stool

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Musculoskeletal and Extremities

• No clubbing, cyanosis, or edema
• Muscle strength 5/5 throughout
• Peripheral pulses 2 throughout
• Decreased range of motion, left knee
• No inguinal or axillary lymphadenopathy

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Neurological

• Alert and oriented x 3
• Cranial nerves II-XII intact
• Sensory and proprioception intact
• Normal gait
• Deep tendon reflexes 2 bilaterally

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Laboratory Blood Test Results

• Na..142 meq/L
• K..4.9 meq/L
• Cl....105 meq/L
• HCO3 ...22 meq/L
• BUN..12 mg/dL
• Cr.0.9 mg/dL
• Glu, fasting..97 mg/dL
• Ca.9.1 mg/dL
• Hb..15.9 g/dL
• Hct.41

WBC.9,200/mm3 plt..430,000/mm3 pH
...7.35 PaO2.83 mm
Hg PaCO2..47 mm Hg
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Pulmonary Function Tests (Spirometry)

• Vital capacity, 3200 cc
• Inspiratory reserve volume, 1700 cc
• Expiratory reserve volume, 1000 cc
• Tidal volume, 500 cc
• Total lung capacity, 4500 cc

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Chest X-Ray

• Posterior anterior radiograph showed coarse
  linear opacities at the base of each lung, more
  prominent on the left.
• Cardiac borders and diaphragm obscured.
• Consistent with findings of asbestosis cases.

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High-Resolution CT Scan

• Thickened septal lines and small, rounded,
  subpleural, intralobular opacities in the lower
  lung zone bilaterally- suggests fibrosis.
• Ground-glass appearance involving air spaces in
  the upper lung zone bilaterally suggests
  alveolitis.
• Small, calcified diaphragmatic pleural plaques
  and mild honeycomb changes with cystic spaces
  less than 1 cm were seen bilaterally and are
  consistent with asbestosis.

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Discussion of Treatment

• No cure for asbestosis.
• Treatments are all supportive.
• Management of disease by prevention of further
  injury or inhalation of asbestos.
• Cease smoking highly recommended.
• Prompt attention to possible respiratory
  infections.
• Supplemental oxygen given if patient is
  hypoxemic.
• Other supportive treatments to remove secretions
  from the lungs.
• Patient is monitored for development of lung and
  pleural cancers.
• Hospice care is given if disease progresses to
  terminal phase.

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Conclusion

• Exposure to asbestos can cause lung cancer,
  pleural cancer, and pulmonary fibrosis.
• Complications of pulmonary fibrosis include
  pulmonary hypertension, heart failure, and
  progressive respiratory insufficiency.
• Both the severity of the disease and prognosis
  are directly related to the history of exposure
  to asbestos fibers.
• Patients that develop lung cancer have a very
  poor prognosis.

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• Questions?

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• Thank you for your attention.