Smoking & Occupational Lung Diseases Flashcards
How many people smoke worldwide?
2bn people
How many people die from smoking a year?
5 million/ year
What’s the % of men and women in the UK that smoke?
Men: 17.5%
Women: 15.8%
Tobacco smoke:
Harmful substances and what they lead to.
- carcinogens leads to genetic mutations, lung cancer, mesothelioma
- CO leads to carboxyhaemoglobin
- impairs ciliary function leads to decreased MCE and hence more respiratory infections
- hyperplasia of goblet cells leads to increased mucus production
Increased risk of —– from smoking: (10)
- lung cancer
- mesothelioma
- bladder cancer
- renal cell cancer
- COPD
- ILD
- PVD
- IHD
- CVA
- Foetal Growth Retardation
Dependance and withdrawal of smoking:
- nicotine binds to nicotine acetylcholine receptors in the brain
- this leads to a release of neurotransmitters:
- increase in pleasure
- decrease in anxiety
- decrease in appetite
- nicotine addiction can lead to dependence
- smoking cessation is a physical and psychological withdrawal
Smoking cessation 5A’s
- ASK: identify smokers at every visit
- ADVISE: every patient who smokes to quit
- ASSESS: assess their willingness to quit
- ASSIST: provide access to counselling and prescribe pharmacotherapy
- ARRANGE: follow up
Evidence for smoking cessation
- strong evidence that smoking cessation improves morbidity, mortality and is cost-effective
- brief advice from GP helps 2% smokers stop = 75,000 ppl
- Quitline or stop smoking services
- smoking ban in public places
- smoking cessation clinics
What does NRT stand for?
Nicotine Replacement Therapy
Examples of NRT
- nicotine patches
- nicotine gum
- nicotine nasal spray
- inhalator
- e-cigarettes
NRT evidence
- clinical trials have shown that NRT doubles the chance of success of smokers wishing to stop
- NRT provides nicotine in a slower and safer way than cigarettes
- NRT doesn’t contain tar, CO or carcinogens
- NRT reduces withdrawal symptoms (irritability, depression, craving)
- very few people become addicted to NRT
Other treatments for smoking cessation:
- Buproprion (Zyban)
- Varenciline (champix)
- Hypnosis
- Acupuncture
- NICE smoking cessation guidelines 2018
Other treatments for smoking cessation: Buproprion (Zyban):
- what
- how does it work
- not suitable for
- anti-depressant
- increases dopamine levels
- people with a history of depression
Other treatments for smoking cessation: Varenicline (champix):
- binds to neuronal nicotinic Ach receptors
- partial agonist
- the most effective treatment for smoking cessation
- currently unavailable in the UK and Europe because of safety concerns
Order of effectiveness of smoking cessation therapies:
Buproprion, NRT, Varenicline
Varenicline, Buproprion, NRT
Occupational Lung Diseases: estimated incidence
20,000/year self - reported cases
Prevalence of occupational lung diseases:
130 cases/100,000 workers
Estimated deaths per year in the UK due to occupational lung diseases.
12,000 deaths/year
Occupational lung diseases have a long
latency
decades from last exposure to symptoms of disease
Improved health and safety measures in recent decades linked to occupational lung diseases.
- asbestos banned
- wearing of masks
- employers are held accountable
Type of occupational Lung Disease (3)(0)(2)(3):
- Occupational asthma
- Malignant:
- Lung cancer
- Mesothelioma
- Pneumoconiosis (mineral dust):
- coal workers lung
- asbestosis
- silicosis
Death caused by lung disease and % graph
Occupational history in relation to occupational lung diseases:
- detailed history of ALL occupations, right from the beginning
- Exposure to ALL material: type, duration, intensity, temporal relationship to onset of symptoms (improvement away from workplace?), availability of masks
- history of lung disease
- smoking history
- symptoms at work
- symptom improvement from workplace?
What is the most common occupational lung disease?
Occupational asthma
Incidence of occupational asthma
3000 cases a year
What % of adult-onset asthma has an occupational cause?
10-15%
Occupational asthma (3):
- can develop for the first time when individual is exposed to irritant or sensitisor
- Work- exacerbated asthma: pre-existing asthma made worse at work
- characterised by breathlessness and wheeze in the work place, which improves when away from that environment
Causes of Occupational Asthma:
- health care workers: latex
- Cleaners: sodium hydrochloride, ammonia, chlorine
- Hairdressers: hair spray, solvents
- Painters and decorators: solvents, acetone, toluene
- Bakers: flour
- Farmers: mushrooms
ETC
Features of occupational or work related asthma:
- symptoms occur in the workplace
- symptoms improve away from the work place
- reduced peak flow and spirometry at work
- identify allergen: not always possible
Challenge testing:
- check spirometry after exposure to the product
- check spirometry after exposure to placebo
- may need occupational respiratory specialist to diagnose
Management of occupational asthma:
- identify allergen/agent causing bronchoconstriction is possible
Workplace measures (6):
- health and safety review by employers
- appropriate masks FFP3
- adequate ventilation
- remove individual from area with increased risk
- re-deploy
- may be eligible for compensation if employer is negligent
Personal Measures (2):
- smoking cessation
- optimum asthma management
Pneumoconiosis definition
Lung fibrosis occurring as the result of inhalation of a variety of inorganic particles and mineral dust particles at work.
Examples of inorganic particles that cause pneumoconiosis (8):
- coal
- asbestos
- siderosis: iron and steel
- talc
- beryllium
- tin
- barium
- cobalt
What has been put in place to prevent pneumoconiosis occurring?
- strict regulations in place
- employers liable and can be prosecuted
- compensation for those affected
Pathophysiology of pneumoconiosis (3)(2):
- inert dust particles 1-4 micrometers get lodged in airways
- concentration needed to causes disease depends on the dust:
- high concentration of coal dust leading to Coal Worker’s Pneumoconiosis
- lower concentration of silica or asbestos needed for fibrosis to develop
- Pulmonary macrophages fill with dust leading to inflammation and fibrosis
Coal Worker’s Pneumoconiosis:
- common because?
- deaths per year?
- less common now?
- -
- Progressive —— Fibrosis
- What type of lung disease?
- was common in areas with coalmines
- 140 deaths/year
- less common now as fewer coalmines
- uncomplicated coal-worker’s pneumoconiosis
- progressive massive fibrosis: can lead to death:
- activation of alveolar macrophages (carbon-laden)
- progressive fibrosis leading to scarring causing stiff lungs
- restrictive lung disease
Progressive Massive Fibrosis causes (3):
- breathlessness
- cough
- weight loss
- can lead to death
Progressive Massive Fibrosis:
- shows extensive areas of fibrosis in the upper lobes
Silicosis: Which occupations are at risk? (7)
- Slate workers
- Potters
- Knife grinders
- Hard rock miners (gold, tin, iron, uranium)
- Sand-blasting
- Stone-cutting
- Foundry workers
Exposure to SILLICA
How many deaths per year due to silicosis?
10-20 deaths per year in the UK
Silicosis: Fibrotic Lung Disease:
- causes Fibrotic Lung Disease
- activation of macrophages
- restrictive lung function deficit
- eggshell calcification of lymph nodes
- risk factor for developing TB and lung cancer
Management of Pneumoconiosis:
- prevent or reduce further exposure in workplace:
- PPE
- Washing of face,body and clothing after
exposure = can affect other people in house like secondary smoking
- stop smoking
- monitor lung function
- Symptomatic Treatment:
- cough
- dyspnoea
- Long term oxygen therapy
- no specific treatment or cure for the disease itself
Asbestos Related Lung Disease: Benign (3):
- calcified pleural plaque
- benign pleural effusion
- benign pleural thickening
Asbestosis
Pulmonary Fibrosis caused by asbestos: fibers clumping into lumps causing irritation
Asbestos Related Lung Disease: Malignant (2):
- mesothelioma (cases expected to peak in 2020 reflecting latency period of 20-40 years)
- lung cancer (increased risk 7x in non-smoker, 9x in smoker)
benign asbestos
Arrows point to?
if they have pleural plaques very unlikely to develop cancer
If a CT shows pleural plaques, then patient has been exposed to
asbestos
If a patient with pleural plaques, pleura becomes irritated and hence has a pleural effusion, why do we worry?
- exposure to asbestos
- anyone exposed to asbestos with a pleural effusion is at risk of mesothelioma
Latency period of asbestos related lung diseases?
20-40 years
Which of the three benign conditions of asbestos related lung disease, do we have to investigate to make sure it is not malignant?
- benign pleural effusion
- benign pleural thickening
Treatment for asbesotsis?
None, trials going on
Can’t give antifibrotics
Asbestos fibers
- natural fiber from hydrated magnesium silicates: ampibole and serpentine
- Serpentine: white asbestos (chrysotile), curly fibers
- Amphiboles: blue asbestos (crocidolite), stiff fibers, 50 micrometers length
If a person has been exposed to asbestos and smokes, is coughing up blood, what are we worried about?
Lung cancer
Which type of asbestos fibers are more harmful and what can it cause?
- Amphiboles (blue, stiff) are more harmful than serpentine asbestos (white, curly)
- causes mesothelioma
- causes asbestosis
Examples of occupations with risk of asbestos exposure:
- plumbers
- car mechanics
- shipyard workers
- carpenters
- merchant navy
- construction workers
- electricians
- roofers
- power plant workers
- blacksmiths
- firefighters
- builders
- laggers
- chemical industry
Properties of Asbestos (7):
- Non-inflammable, even at high temperatures
- Insulation: heat, electricity, sound
- High tensile strength
- Durable
- Flexible
- Versatile
- Cheap
When was asbestos banned worlwide?
It wasn’t.
Banned in the UK in 1977.
Be aware patients that worked in other countries may have also been exposed, even if much younger.
Symptoms and Signs of Mesothelioma(4):
- persistent chest pain
- breathlessness
- weight loss
- unilateral pleural effusion (exudate)
Mesothelioma can affect the peritoneum, which is an
extension of the pleura into the abdomen
Mesothelioma imaging labelled
Management of Mesothelioma:
- surgery
- radiotherapy (not very effective)
- chemotherapy (not very effective)
- Symptomatic Management:
- pain
- dyspnoea
- nutrition
- Palliative care
Mesothelioma has a —– prognosis
poor
Mesothelioma is a restrictive disease of the airways.
True or False? Why?
False
Thickening of the pleura
Restricts VENTILATION
Rapid inhalation of powders and solvents can result in
- pneumonitis: inflammation of lungs
- bronchitis: inflammation of bronchi
- pneumonia
- pneumothorax: burst your alveoli by inhaling rapidly and causes pneumothorax
Why do many young people sniff glue and solvents?
- cheap
- easily obtainable
How many deaths from inhaling solvent, sniffing glue and paint thinners between 1983 and 2000?
1700 deaths
Crack cocaine and heroin, which are snorted through the nostrils can cause ——- and destroy the —— ——–.
- epistaxis (bleeding from the nasal cavity)
- nasal cartilage
Illegal Drugs and effect on lungs:
- cannabis
- cocaine
- amphetamines and heroin
- insufflation of poppers, amyl nitrates and toluene
- use of aerosol propellant gases with a plastic bag held over the mouth
- cannabis (class B): nasal issues, pulmonary toxicity, cough, bronchoconstriction, repeated infections
- cocaine is addictive, hence people may be dependant, can cause bronchoconstriction and repeated chest infections
- inhalation of crack cocaine can lead to pulmonary toxicity and epistaxis
- Inhalation of amphetamines and heroin is carried out by 2%
- insufflation of poppers, amyl nitrites and toluene can damage the lungs
- the use of aerosol propellant gases with a plastic bag held over the mouth has a high risk of hypoxia, aspiration, suffocation and respiratory arrest
Environmental Causes of Respiratory Disease:
- pollutant: a substance that contaminates the environment
- Toxin: low concentration of a naturally occurring poison produced within an organism, which can cause respiratory or other disease
Clinical impact of environmental causes of respiratory disease varies with (7):
- individual susceptibility
- comorbidities
- concentration of toxin/pollutant
- duration
- intensity (while exercising for example)
- route (skin vs inhaled)
- metabolism of toxin
Susceptibility to pollutants and toxins are determined by (3)(3):
- genetic factors
- co-morbidities
- environmental factors:
- cold weather
- heat waves
- smog
Risk of Air Pollution (5):
- increases cardiovascular and respiratory morbidity and mortality
- adversely affects lung development in children
- worse in urban areas due to traffic fumes
- caused by particulate matter
- Radon in soil, rock and ground water
Environmental Pollutants:
- Vehicle exhaled pollutants
- primary pollutants from fossil fuels: NO, SO2, CO, particulate matter
- secondary pollutants: from reactions between primary pollutants in the atmosphere
Particulate Matter
- soot
- metals
- can potentiate effect of airborne allergens
- can cause atopic sensitisation
- can trigger asthma exacerbation
Environmental Pollutant: NO sources:
- Outdoor Sources: vehicle exhausts, power stations
- Indoor sources: fuel burning cookers, fireplaces without flue, cigarette smoking
Environmental pollutant: The Impact of NO:
- exacerbation of asthma and COPD
- increased response to inhaled allergens
- increased risk of infection
- children are particularly susceptible
Environmental Pollutant: Ground Level OZONE: Sources:
- secondary pollutant
- heat and sunlight along with other volatile organic compounds forms nitric oxide and O3
Environmental Pollutant: Ground Level Ozone (O3): Impact:
- increased response to inhaled allergens
- increased response to inflammation
- decreased lung function
Inhaled allergens and irritants
Weather and Lung Disease:
- temperature changes associated with asthma and COPD exacerbation
- inhalation of cold, dry air can cause bronchoconstriction, possible due to the loss of water from the airways
- breathing hot, humid air can cause bronchoconstriction secondary to vagal mechanisms
- thunderstorms, increases the concentration of pollen debris and O3, leading to an allergic exacerbation of asthma
- Damp weather can lead to an increase in dust mites, mould and CO2 levels, which can cause bronchoconstriction
- Desert dust causes respiratory symptoms, acute exacerbation oof asthma and COPD
- weather forecasts now warn patients with respiratory disease about high pollen count and thunderstorms, which may help to reduce the risk of exacerbations
Which of the following can cause an exacerbation of asthma?
1 = cold air
2 = hot air
3 = thunderstorms
4 = traffic fumes
5 = all of the above
5
What is the most effective treatment for smoking cessation?
1 = advise and encouragement
2 = Buproprion (Zyban)
3 = hypnosis
4 = NRT
5 = Varenicline (champix)
5, however not currently available
Which of these statements about occupational asthma is true?
1 = symptoms improve at work
2 = spirometry shows obstruction at work
3 = will not respond to asthma treatment
4 = will not improve by using mask and
ventilation
5 = the allergen can always be identified
2
Which is the most common occupational lung disease?
1 = asbestosis
2 = asthma
3 = coal worker’s pneumonia
4 = mesothelioma
5 = silicosis
2
Which of these conditions does not usually cause any symptoms?
1 = asbestosis
2 = progressive massive fibrosis
3 = mesothelioma
4 = silicosis
5 = pleural plaques
5
