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 Work-Related Asthma Work-related asthma includes both occupational asthma and work-exacerbated asthma. Occupational asthma is new-onset asthma that is caused by exposure to either allergens or irritants in the... read more , reactive airways dysfunction syndrome Reactive airways dysfunction syndrome (RADS) and irritant-induced asthma Asthma is a disease of diffuse airway inflammation caused by a variety of triggering stimuli resulting in partially or completely reversible bronchoconstriction. Symptoms and signs include dyspnea... read more , toxic inhalations Irritant Gas Inhalation Injury Irritant gas inhalation injury is the result of inhalation of gases which, when inhaled, dissolve in the water of the respiratory tract mucosa and cause an inflammatory response. Irritant gas... read more , air pollution-related illness Air Pollution–Related Illness Air pollution–related illness is disease caused by harmful pollutants in the air or exacerbation of preexisting disease by those pollutants. Air pollution contributes significantly to a number... read more , or byssinosis Byssinosis Byssinosis is a form of reactive airways disease characterized by bronchoconstriction that occurs in cotton, flax, and hemp workers. Evidence suggests the etiologic agent is bacterial endotoxin... read more )
Lung parenchyma (eg, in pneumoconioses Coal Worker Pneumoconiosis Coal worker pneumoconiosis results from the inhalation of dust generated by the drilling, blasting, or crushing of coal and by the equipment and processes used to extract coal. Exposures in... read more , hypersensitivity pneumonitis Hypersensitivity Pneumonitis Hypersensitivity pneumonitis is a syndrome of cough, dyspnea, and fatigue caused by sensitization and subsequent hypersensitivity to environmental (frequently occupational or domestic) antigens... read more , or silicosis Silicosis Silicosis is caused by inhalation of respirable crystalline silica dust and is characterized by nodular pulmonary fibrosis. Chronic silicosis generally progresses insidiously and can advance... read more )
Inhalation exposures have long been known to be a risk factor for asthma (see Work-Related Asthma Work-Related Asthma Work-related asthma includes both occupational asthma and work-exacerbated asthma. Occupational asthma is new-onset asthma that is caused by exposure to either allergens or irritants in the... read more ). They are also recognized as a cause of COPD Chronic Obstructive Pulmonary Disease (COPD) Chronic obstructive pulmonary disease (COPD) is airflow limitation caused by an inflammatory response to inhaled toxins, often cigarette smoke. Alpha-1 antitrypsin deficiency and various occupational... read more (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 General reference 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... read more ).
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.
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 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.
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.