Document 0qNeb0LkmxM6LmO9z95gONvoR

rfi 3A*SjE t.. . -vi " * St'S rr . * %.. c.,*.. .-T^u. \.v\ . 'viC*f*> ' : ***+.' ' Effect of Asbestos Dustv2 - Inhalation on Lung Function^: -*-. '. ... -. . - --'V,'. - MORRIS ELEINFEU). MO; 1. MESSITE, MO; O. KOOXMAN. MD:' AND J. SARFATY.BEE, NEW XORX ... -at- *'-r - 'vy. ' .'I ' The NAME asbestos'is used to cover a. unsegmented, in the respiratory bronchioles group of fibrous mineral silicates. Those of or imbedded in the fibrous tissue or both. commercial importance`include ohrysotile, a The pleura often shows dense fibrotic thick- ~ hydrated magnesium silicate; amosite, a ening and not'infreqtiently there are calcified magnesium iron silicate; and crocidolite, an pleural plaques over the pleural surfaces. They iron sodium silicate. Prolonged inhalation clinical and pathological features are indica-; . of significant amounts of asbestos dust over live of a pronounced dysfunction of the res an extended period of time can produce in pirator)- mechanism. This has been confirmed certain individuals a respiratory disorder by studies of pulmonary function which have known as asbest'osis. It is characterized pri- shown a disturbance in both ventilatory nwrih bv cough, dyspnea, basal crepitations, function and diffusion capacityA1 ' Most , a'- ' rcticulonodular shadowing of the chest studies to date have been confined to mdi- , .. \ .genogram. Clubbing and cyanosis are viduals who, having sustained exposure tor - usually seen in the more advanced stage of ..v this disorder. -Chronic bronchitis and em. physema arc associated with this disease, the asbestos dust, showed positive radiologic ,, evidence on the chest roentgenogram.' It is; the purpose of this report to present data on : emphysema being more of a localized than a diffuse obstructive type.- Cor pulmonale is the major complication and the usual cause .. of death from this disease. There is an in- the clinical and physiological findings in indi viduals who had sustained exposure to as- ;bestos dust of 14 years or more irrespective ` of the radiologic findings on the chest roent- - creased incidence of lung carcinoma associ- genogram. ' ated with asIwstosK The most consistent **. - *r . . patltological change is a dense fibrosis con- Material mud Methods staining macrophages with ahsorlied dust |>ar- The study group comprised 56 asbestos workers. r ' tides which in many areas obliterates the They were selected on the basis of having had an pulmonary architecture. A pattern of end exposure to asbestos dust, as asbestos insulators, arteritis with intimal hyperplasia consistent . . with pulmonary hypertension and bronchio- ' lwtasia are associated major findings. Rather for 14 years or more and no previous occupational dust exposure. Each worker underwent a detailed medical, social, and occupational history, a clinical examination. a...l2-lead electrocardiogram, a chest striking i> the presence of elongated, ter-. roentgenogram, and a battery of pulmonary func : ` minaUy cluhlied l>odies, both segmented and Submitted foe publication Feb 9, 1966; accepted ' Msrch.23. - From the Divition of industrial Hygiene, Depart'mem of Labor, New York, and tbe State itahenity of New York, Downstair Medical Center, Brooklyn. Reprint requests to the Division of Industrial Hypene. Department of Labor, <0 Centre St, New York I00r <Dr. KkinfeW). tion tests. The pulmonary .function tests included vital capacity (YC). one-second vital capacity -. .(VC), residual volume < RV), total lung capacity (TLC),. and pulmonary diffusion capacity for carbon monoxide (D1-,.). The vital' capacity and ' one-second vital - capacity were measured by a. Krogh spirometer and the volume changes of rite -spirometer were -electrically recorded on a Texas Arch 'Em-irm Health--I'ol 12,'June 1966 ' ,, i,. *<i. : ;r: : V' I**'*' -V- fcy-r .a*. U.t. * /* . `ef' y. Z tV+f'Z*jf'* # .r** a -4rt * m* ^ W ,, `at*' ^ *V ` ' rf'rvty.-i- * ' *. i;r> ; I VC ./ :*!*.*' AT>s.tt+*-S%x `r. v)*?* ',** .,,'*..'- .V>: . t # ,w .2 :i . *> ',r ,r4s />.. .... *4^ *^j.\ .. .' ... . , -1*' : '' -irfi:-.; ; - ,*< :!`-.'iff- : r-A . .. '-,wr- rr * -~*.*^i* ' r ;fr- . f r.% - : ? ?...; u , -v * - :'fi *.% * ..3"' ;.*?/ 1 .^ * s.,. yjW *- , - "`?*l z % i#*' * , . ; *** : ` ^ . ..*? ' ,(1 (" #' ** I ' Mwsioiocfc* C < KrfhMI Wi <* VC) *v <% pmSI--rt) Ttc t* mami) BV/TLC <* r*loft> Ol,. <Au> Ba/Ma) i viIm t ih ??% v aa - . cm:;.-. as a* >* ' k* '* * . is -.^v: a*4 r . <*.CI ua -. MS 'si . .*M " <*.*1 ." 7 M-S <l.*l i* V : 4 i .S,%- * i. t si^at tutu <0.01 N6 . C-t | . VV. v .1 * HUM K.*USl.t MS <0.01 1 '' ` mart <0.01 1 . .. sutut <0.#1 rect-rrter recorder. The residual volume was de> tenmned by a nitrogen dilution method using the doted circuit technique as recommended by Wright and Gillord.* All lung measurements were de termined at ambient temperature and pressure, saturated (ATPS). The values for residual volume were corrected for the dead space of the breathing tube and the phase -of expiration in which the subject was connected to the spirometer. The IXm was determined at rest by a single breath technique described by Ogilvie et a!.* Predicted values for vital capacity, residual volume, total teng capacity, and ratio of residual volume to total lung capadty were calculated on the basis of the best regression equation* of Xccdbam et aL* For Dt-*. the "observed readings were used. The con trol group was comprised of SO men whose occu pations varied and who had no prior occupational dust exposure. The 95%. confidence intervals for all the lung parameter* were based on the data obtained from tbe control groopv - Findings .. The predominant clinical and physiologic findings of the asbestos workers and controls are given in Tabic 1. .. Fig 1.--The pulmonary function data otxenred in control end asbesto* grenps are ummarized. The value* within die 95% confidence interval for each par*--err of pulmonary function are indicated by circle* within rectangles. Those drdcs above and bdow the rectangle* represent abnormally high or tew value*. The shaded cirdes identify die ecotrot group and the open circle* the ashesto* group. .< Clinical.--The asbestos workers ranged in age from 22 to 77 years, with a mean of 49.4 years. The mean age of tbe controls was 49.2 with a; Tange of 35 to 63 years. The mean ages of two groups were not signifi cantly different. Eighteen of the asbestos workers had a chronic cough for an average duration of 9.5 years. In 12 of the 18 the cough was productive. Three of die controls had a chronic oongh, the average duration being S3 years.. la all the cough was pro ductive. Nine of the asbestos workers had Arch &*viron HtaUk--Vrt IZ.Jfme 1966 ivy- ,'- . *7 - -4 spnca which in five was minimal, in three ..lodt-raic. and in one moderately severe. There were five individuals in the control gnup who had dyspnea and in all the dy>]>nea wa> of minimal degree. Lung crepi tations were present in 11 of the aslxrstos workers and in none of the controls, tight asbestos workers showed dubbing; the controls showed none. The comparative inci dences of cough, lung crepitations, and dub bing in the control and asltestos groups were statistically significant. A jxjsitive smoking history was obtained in !() of the asltestos workers and in 21 of the controls. The com parative incidence of smoking for the two groups was statistically significant. The cri terion tor a positive history of smoking was 20 cigarettes a day for a minimum of five years. Ructugcnoyraphic.--Twenty-one of the 56 asliestos workers had positive radiologic find ings of pulmonary infiltration. In eight of the workers, the infiltration was of grade l, in nine, of grade 2 and in four, of grade 3. The criteria for grade 1 was a reticulated earanee in the lower lung fields; for grade 2, a reticulonodularinfiltration involving ap proximately 50% of the total lung area; and for grade 3. a more diffuse reticulonodular infiltration involving more than 50% of the total lung area. In addition to the pulmonary infiltration, there was also a varying degree of obliteration of the costophrenic sinuses in 16 individuals and/or the cardiac borders in ten. Pleural calcification was observed in five instances. Two individuals showed emphysema which was localized to the left upper lobe in one and the right upper lobe in the other. Cardiac enlargement was found in one individual and was of minimal degree. None of the controls showed any pulmonary infiltration. Five individuals showed cardiac enlargement, all of minimal degree. Physiologic.--The values within the nor mal range for each parameter of pulmonary function studies are indicated by the circles within the rectangles shown in Fig 1. Those circles above arid below the rectangles lie outside the 95% confidence interval. Low values for vital capacity (less-than 74.0% predicted) were found in 17 of the 56 as bestos workers. No individual in the control group had a' value less than 74% predicted. Arch Environ Health--I'ol 12, June 1066 **<.--* i l*' 'l . - .2 '5r;7 J?.'v kw; : .. S&rV- * ' TtS W- * .... /! i- ",Z . ,T- -- . % $ -v. 5 bestos group ranged from 50.3 to 68.9 pre dicted. The single abnormal value in the control group was 69.4% -predicted. The ratio of residual volume to total lung ca- - podty was above 122.2% predicted in 16 /. of the asbestos group, the high values rang ing from 123.7 to 196.6% predicted. Two individuals in the control group had values above 122.2% predicted, namely 122.3 and 123.3% predicted. Eighteen of the asbestos workers had a less than 20.0 cc/mm Hg/min. No individual in the control.group had a value below this. Among the aslvestos workers, the low values ranged from 8.3 to 19.9 cc/mm Hg/min. With the exception of the mean residual volume and the one- second vital capacity, the mean values of the other pulmonary function parameters were significantly different between the two groups. Etnnronntcntal.--The asbestos dusts to which the asbestos workers were exjvssed were chrysotile and amosite. The degree to which each individual was exposed was dif-' ficult to estimate. However, of tlie 56 as bestos workers. 28 were exposed lietweeu S 14 and 19+ years, 9 were exposed between 20 and 24+ years, and 19 were exposed for over 24+ years. The mean duration ot exposure for the 56 workers was 24.3 }cars Fig 3.--The lung,function data observed in 20 asbestos workers without and 16 with positive radiological findings. The values within the 95% confidence interval for each parameter of pulmonary function are indicated by circles within rectangles. The shaded circles represent those without and the open circles those with positive radiological find ings. with a range of 14 to 57 years. Comment The data in Table 1 show that the as bestos workers as a group 'have a greater incidence of abnormal clinical and physio The low values in the asbestos group ranged from 42.9 to 72.1% predicted. The onesecond vital capacity was less than 65.7% in seven asbestos workers and in one control. In the asbestos group the low values ranged from 40.1 to 65.2. The one low value in the logic findings referable to the'.respiratory system than does the control group. The clinical picture characterized by cough, dys pnea, lung crepitations, and clubbing, al though not diagnostic, is consistent with sustained exposure to asbeMos dust. The controls was 60.7. Values for residual vol positive radiologic changes on the che>t ume above 128.5% predicted were found in roentgenogram, characterized by reticuhumd- seven asbestos workers and in one individual of the control group. The high values in the former ranged from 129.3 to 204.6% predicted and that in the latter was 156.9% predicted. The values for total lung capacity less than 69.8% predicted were found in eight asbestos workers and in one of the control group. The low values in the as ular shadowing, obscuration of the cardiac borders and/or costophrenic sinuses (Fig 2i are similar to what has been observed in previous studies of asbestos workers.4 These changes resemble those found in talcosis.4 It is noteworthy, as shown in Tabic 2, that when 16 of the 56 asbestos workers with positive radiological evidence were com- Arck Environ Health--Vet 12, litne 1966 ASBESTOS DUST ISHALATION--KLEINFELD ET AL 745 Table 2.--Clinical and Physiological Findings in Asbestos Workers With and Without * Pulmonary Infiltration ,,. r - '-r... . No. Ja Group Ac* (jrrl Venn lUitrr Eipoaurt tyr) Mon lUngr CUHtcal Cou*h Dytpnfi Ltmr orepitotkm* Clubbing Phrk4oeic VC predict**!) VCi VC) RV <<* predicted) TLC IS. predicted) RV/TLC predicted) (cc/mm Hf/mia! Without Filwnir laUireUoa SO 0.1 tl-4 Ko. 6 t 3 0 W. IMO % *6.8 10.* 16.0 0.0 M.123.0 - S.S*:1.7 With Pnhaoairy laflhrttiia . 1 K*. i * ( S *SJ 1(41 .* .. % *0.0 *6.8 IU 18.8 70.S:t.4 M.*:t*. M.#0.t 76.#2:S.S ]2*.t:6.S t F' N8 . MB NS MS NS NS <0.01 NS NS <8.01 NS <#.06 * Expreiwed m me*D vihMi aiandtrd errors Bawd on \L worker* pared with 20 of similar mean age and range and duration of exposure but having nega tive radiological findings, there were no sig nificant differences in the clinical findings I>rivvcen the two groups. However, those with i ive radiological evidence had a signifi cantly lower mean predicted vital capacity, total lung cajxicity, and DL. than those without such evidence. Although the lower values cannot be attributed to differences in duration of dust exposure of those with and uithout pOMtive radiologic changes, one can not exclude the possibility that the two groujs may have had different degrees of dust exposure. Unfortunately, as has already lx-cn mentioned, it was not jxtssible to esti mate the degrees of dust expo.sttre for each individual or for the groups as a whole. Although the mean values of the lung function parameters measured for the group of asltestos workers as a whole fall within the <>?'<' confidence limits for the control group, it can le seen in Fig 1 that an ap preciable mtmlier of asbestos workers fall outside these limits. This is particularly evi dent in vital capacity and in diffusion ca pacity parameters and to a lesser extent in the other {iarameters. Moreover, the propor tion of abnormal lung function readings for VC. VCi, TLC and I>~ in the group with \ `ve radiological evidence exceeded those in uie group with negative radiological find ings fFig 3). The greater proportion of abnormal values for one-second vital ca pacity in the asbestos group compared with the control and in those with positive radio-' logical findings compared with the negative group can lie ascribed to the greater nttmljer of smokers in these groups (Fig 1 and 3). In general, the correlation between the de gree of pulmonary function impairment and the clinical and roentgenographic findings was jKX>r for the exposed group as a whole and no consistent correlation could be found lx-tween the duration of exjwsure and lung function imjiairment in this group. The lack of a good correlation between the degree of pulmonary function impairment and the clin ical, roentgenographic, and environmental findings observed in the present study has also been reported by Bader et al.* This has also Ven noted in other pneumoconioses such as a coal workers' pneumoconiosis * and anthracosilicosis.* Summary and Conclusions Pulmonary function tests were performed on 56 workers engaged, in asbestos insula tion. The mean duration of exposure was 24.3 years with a range of 14 to 57 years.' The predominant symptoms were dyspnea (9) and cough (18). Basilar crepitations and clubbing were noted in 11 and 8, re spectively. The mean predicted values for Arch Environ Health--Vol 12, June 1966 'stitt'"- W ' p: : JSfrcc. ~ : 4-.r 5* . ;*r: nr' 74C ASBESTOS DUST INHALATION--KLEINFELD ET AL the various pulmonary function parameters ber of abnormal pulmonary function values measured were within the 95% confidence as compared to those without. In general, limits of the control group. However, an the correlation between the degree of pulmo appreciable number of asbestos workers had nary function impairment and the clinical values which fell outside these limits. This and radiological findings was poor for the was particularly evident in the vital ca exposed group as a whole and no consistent pacity and IK*. There were 16 who showed' . correlation could be found between the dura-. pulmonary infiltration on their chest roent ' tion of exposure and lung function impair ment in this group. genograms as compared to 40 without such Dr. Emanuel Lrrin of Maimonides Hospital of evidence. Those with positive radiologic Brooklyn and the State Univrrsitj of New York, findings had a proportionately greated num Downstate Medical Center, Brooklyn. NY reviewed the cheat roentgenograms. REFERENCES 1. Williams, R, and Hufh-Jooet, P.: The Significance of Lime Function Changes in Asbestosts, Thorax 15: 109, 1960. 2. Wright. G.W, and Gilford, SJL: A Method for the Simultaneous Measurement of Maximum Breathing Capacity, Pulmonary Volumine and Effective Lung Ventilation, 1 Thoroc Cardiov Surg 36:643, 1939. 3. Ogilvie, C.M. et al: Standardized Breath Hold ing Technique for Clinical Measurement of Diffusion Capacity of Lung for Carbon Monoxide, 1 Clinic Invest 34:1, 1957. 4. Needham, CD.; Hogan. M.C.; and McDonald, I.: Normal Standards for Lung Volumes, Intrapulmaoery Gas Mixing and Maximum Breathing Capacity, Thorax 9:313, 1954. 5. Oostfauizen, S.Fq Tberoo, CP.; and Sluts-Cremer, G.K.: Calcified Pleural Plaques in Asbestosts: An Investigatioo Into Their Significance, Med Proe 19:496, 1964. 6. Kleinfcld, M., et al: Effect of Talc Dust Inhala tion on Lung Function, Arch Environ Health 19:431, 1965. 7. Bader, M.E.: Bader. R.A.: and Setikoff. IX: Pulmonary Function in Asbestosis of Lung, Amer J Med 39:235, 1961. 8. Vorwald, AX, et al: Evaluation of Disability, Arch Environ Health 8:889-897 (June) 1 vM. 9. Higgins. I.T.T.: "Approach to Problem of Bron chitis in Industry: Studies in Agricultural Mining and Foundry Communities." in King, EX. and Fletcher. CM, (eds.): Industrial Pulmonary Diseases. Boston* Little, Brown It Co, 1960. chapt 16. r 205. INCREASING USE OF A TEAM APPROACH TO HEALTH CARE . . . the rise of specialization and the rapid decline in numbers of general practitionerhas resulted inevitably in an increasing tendency toward team practice involving tin- contribu tion of various specialists. As specialization increases, so does the need for coordination of the team that is.essential to care for the patient. The team that requires coordination includes both physicians with a variety of specialties and an ever-increasing number of allied health personnel with competence to perform more routine technical tasks. The physicianV knowl edge can no longer encompass the details of all procedures performed by other memlx-i- of the team. These developments require the attending physician to be a "coordinator" or "team leader" of a team that collaborates loosely to meet the needs of the patient. There is no dear alternative to the organization of the modern practice of medicine as a team effort--and the donor must be trained specifically to function as leader of .the team. Teamwork is mandatory in most activities of tlic modern world--industry, communication-, education--and it should not be impossible in tlie health sciences. The team leader, if he is to maintain his leadership, must recognize his responsibilities aud be prepared to mcel them. The team approach is manifesting itself in the hospital, the clinic, tin many kinds oi group practices that have come into use in the past half century. There is every likelil-~^I that the team approach to health care will expand in ust in decades ahead and that team- will become larger, more comprehensive in the range of skills included, and more complex in structure. This will further advance tb? institutionalization of health care and it has profound implications for the education of all persons entering medicine and tltc other health profes sions and occupations.--Coggeshall, L.T.: Planning for Medical Progress Through F.ducation, A Report Submitted to the Executive Council of the Association of American Medical Col1 leges, April 1965, p 25. Arch Environ Health--Vol 12, June 1966