John P. Cunha, DO, is a U.S. board-certified Emergency Medicine Physician. Dr. Cunha's educational background includes a BS in Biology from Rutgers, the State University of New Jersey, and a DO from the Kansas City University of Medicine and Biosciences in Kansas City, MO. He completed residency training in Emergency Medicine at Newark Beth Israel Medical Center in Newark, New Jersey.
Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
Most people with mesothelioma have shortness of breath. Other signs and symptoms of mesothelioma include, chest pain and cough. As the disease progresses, signs and symptoms like shortness of breath increase, and weight loss, decreased appetite, and night sweats can develop. Local invasion by the tumor can cause voice changes, loss of function of the diaphragm, and symptoms specific to the area and involvement of adjacent structures.
Asbestos is a family of naturally occurring silica compounds (similar to, but not the same as, the silica of window glass and computer chips) found in rocks and soil. These substances form fibers with varying shapes and sizes and are found throughout the earth. There are three commonly available types of asbestos:
There are two major groups of fibers, the amphiboles and chrysotile fibers, and all three have been associated with cancerous and non-cancerous lung disease.
The risk of developing asbestos-related lung cancer varies between fiber types. Studies of groups of patients exposed chrysotile fibers show only a moderate increase in risk. On the other hand, exposure to amphibole fibers or to both types of fibers increases the risk of lung cancer by two fold. Although the Occupational Safety and Health Administration (OSHA) has a standard for workplace exposure to asbestos (0.2 fibers/milliliter of air), there is debate over what constitutes a safe level of exposure. While some believe asbestos-related disease is a "threshold phenomenon," which requires a certain level of exposure for disease to occur, others believe there is no safe level of asbestos.
In most buildings, asbestos does not become airborne. However, surfaces that are damaged or disturbed can cause asbestos to become inhalable. High concentrations can occur after cutting, sanding, or remodeling asbestos- containing materials.
Reducing asbestos exposure involves either the removal or sealing of asbestos-containing materials. Inexperienced attempts to remove asbestos can release dangerous levels of the fibers.
Asbestos has been used frequently in a variety of building materials for insulation and as a fire retardant, and in brake pads in cars. Today, it is found most commonly in older homes - in pipes, furnaces, roof shingles, millboard, textured paints, coating materials, and floor tiles.
Lung disease from exposure to asbestos can be divided into three main types: 1) asbestosis, 2) disease of the lining of the lung (pleura), and 3) lung cancer.
All of the commonly available commercial forms of asbestos have been linked to cancerous and non-cancerous lung disease.
Depending on their shape and size, asbestos fibers deposit in different areas of the lung. Fibers less than 3 mm easily move into the lung tissue and the lining surrounding the lung (pleura). Long fibers, greater than 5 mm (1/5 inch), cannot be completely broken down by scavenger cells (macrophages) and remain in the lung tissue. These asbestos fibers can cause inflammation. Substances damaging to the lungs are then released by the cells of inflammation that are responding to the foreign asbestos material. The persistence of these long fibers in the lung tissue and the resulting inflammation seem to initiate the process of cancer formation.
As inflammation and damage to tissue around the asbestos fibers continues, the resulting scarring can extend from the small airways to the larger airways and the tiny air sacs (alveoli) at the end of the airways. Some of these fibers can move to the surface of the lung where they form plaques (white-gray regions of scarred tissue) in the tissue lining of the lung (pleura). In severe cases of asbestosis, scarring of both the lung and its lining tissue can occur.
Asbestos-related lung disease occurred at very high rates toward the middle of the 20th century, when patients who were exposed decades earlier to asbestos eventually developed disease. British asbestos workers were among the first who were observed to have lung cancer related to asbestos.
About 125 million people worldwide are exposed to asbestos in the workplace, and most people with lung disease from asbestos exposure were exposed to it from:
Some workers have been exposed to high concentrations of asbestos in:
Continuing sources of exposure are asbestos removal and general construction industries. The delay between exposure to asbestos and the development of cancer can be anywhere from 10 to 40 or more years.
Despite not using asbestos in construction materials for the last 30 years, the number of deaths from asbestosis has increased over the past two decades. A 2009 study to assess the incidence of asbestos-related deaths concluded that the death rate is not expected to decrease sharply in the next 10 to 15 years. Each year in the US, asbestos exposure kills about 12,000 to 15,000 people. Some World Trade Center rescue and recovery workers have asbestos exposure lung disease.
Asbestosis is a process of lung tissue scarring caused by asbestos fibers. Because many other diseases also lead to lung scarring, other causes must be excluded first when a patient is found to have lung scarring (pulmonary fibrosis). Patients with particular X-ray findings or biopsy results must also have a remote history of asbestos exposure and a characteristically delayed development of the condition in considering asbestosis as a diagnosis. Smoking appears to increase the frequency and/or the rate of progression of asbestosis, possibly by preventing the efficient elimination of inhaled fibers from the airways.
The clinical symptoms usually include slowly progressing shortness of breath and cough, often 20 to 40 years after exposure to asbestos. Breathlessness advances throughout the disease, even without further asbestos inhalation. In the absence of cigarette smoking, sputum (mucus coughed up from the lungs) production and wheezing are uncommon. The exception is workers who have been exposed to very high concentrations of asbestos fibers. Those workers may also develop symptoms as soon as 10 years after exposure. Other indications of asbestosis include abnormal lung sounds on examination, changes in the ends of the fingers and toes ("clubbing"), a blue tinge to the fingers or lips ("cyanosis"), and failure of the right side of the heart ("cor pulmonale").
Chrysotile is the only form of asbestos that is currently in production today. Despite their association with lung cancer, chrysotile products are still used in 60 industrialized and developing countries, according to the industry-sponsored Asbestos Institute. Chrysotile is still being used in cement building materials (90% of the world production of chrysotile), friction materials, gaskets, and certain plastics.
Although the asbestos industry proclaims the "safety" of chrysotile fibers, which are now imbedded in less "friable" and "dusty" products, little is known about the long term effects of current asbestos products because of the long delay to the development of disease. In spite of their potential health risks, the durability and cheapness of these products continue to attract commercial applications. Asbestosis remains a significant clinical problem even after marked reductions in on-the-job exposure to asbestos. Again, this is due to the long period of time between exposure and the onset of disease.
Breathing abnormalities can be identified with lung function tests (pulmonary function tests or PFTs) or exercise tests that are performed at specialized laboratories. Asbestosis can produce both obstruction of airflow and restriction of lung inflation. In addition, the disease can affect the ability to transfer oxygen into the blood. With advanced disease, patients may have markedly reduced blood oxygen at rest and may need supplementary oxygen.
X-ray abnormalities include thickening of the lining of the lungs and tiny lines marking the lower portions of the lungs. However, up to 20% of patients have completely normal-appearing chest X-rays. These patients may demonstrate more subtle changes on computerized X-ray studies (computerized tomography, or CT scans). Up to 30% of patients with a normal chest X-ray who have been exposed to asbestos will have an abnormal high resolution (high definition) CT. The CT scan may be very useful in separating true asbestosis from other conditions that may have similar findings. However, even a CT scan may not identify disease of the lining of the lung (pleural disease) in patients with asbestosis. The proper role of CT scanning has not been fully established.
Laboratory testing studies may be abnormal (certain antibodies and markers of inflammation), but they do not specifically suggest asbestosis.
Occasionally, a biopsy and microscopic examination of the lung is used to diagnose asbestosis. Under microscopic examination, certain coated fibers (asbestos bodies) can be seen in association with a pattern of scarring. The amount of both coated and uncoated (transparent) asbestos has been linked to the severity of asbestosis. Because other particles may resemble asbestos, a conclusive identification may require scanning electron microscopy. Currently, detection of asbestos fibers in the lung tissue and fluids (sputum, secretions) can be used to make the diagnosis, along with a history of asbestos exposure and characteristic X-ray or CT results.
The currently available commercial form of asbestos, chrysotile, does not form asbestos bodies as easily as previously used fibers.
Patients with asbestosis, like others with chronic lung disease, are at a higher risk of serious infection, low oxygen levels in the blood, and heart failure. These patients also may not recover as quickly from viral and bacterial infections. In addition, they may be at increased risk for certain fungal and unusual infections that take advantage of diseased or scarred lung tissue. The medical management of these patients should focus special attention on preventing and rapidly treating these infections. Flu and pneumococcal vaccinations are a part of routine care for these patients. There is, however, no treatment or cure for asbestosis. In particular, steroid and immune-based therapies have not been shown to benefit these patients.
Other key elements in treating patients with asbestosis are smoking cessation, early detection of worsening disease or cancer, and avoidance of further exposure to asbestos. Supplemental oxygen during exercise or at rest (depending on the need) may be provided to improve daily function.
Another type of lung disease that is linked to asbestos exposure involves the lining of the lungs, called the pleura. Harmless disease of the pleura is often the only manifestation of asbestos exposure. There are a number of different changes that can occur in the pleura with asbestos exposure. Pleural plaques may develop from fibers that migrate out to the outside edge of the lungs and cause scarring of the pleura. Pleural "calcification" may occur from calcium deposits in areas of prior damage.
Fluid may accumulate around the lung. This fluid collection, called a pleural effusion, can be the first sign of asbestos-related disease. Often, these fluid collections have no associated symptoms, resolve on their own, and recur sporadically. However, some patients may experience pain or bleeding around their lungs. "Diffuse pleural thickening," which means a generalized thickening of the lining of the lung, can occur as well. The thickened pleura may form a peel of scar tissue and even affect the lung's ability to expand. This condition may cause a significant shortness of breath. Diffuse pleural thickening is considered a later-onset consequence of repeated fluid accumulations.
Although exposure to asbestos alone can lead to lung cancer, the risk increases dramatically in smokers of cigarettes or other forms of tobacco.
Lung cancer in asbestos-exposed and unexposed individuals is similar in both the type of cancer and its signs and symptoms. The link between cigarette smoking, asbestos, and cancer of the lung itself does not apply to cancer of the lining of the lung (malignant mesothelioma ). Diagnosis and treatment of lung cancer is a complex topic and a pulmonary specialist should be involved in the workup of a suspected lung cancer.
Asbestos is the only known risk factor for malignant mesothelioma, a cancer that affects the tissue lining the lung (pleura) or abdomen (peritoneum). Malignant mesothelioma is not associated with cigarette smoking but is strongly linked with the degree of asbestos exposure. However, 20% to 40% of patients with malignant mesothelioma have no prior asbestos exposure. In malignant mesothelioma, there is a very long duration between exposure and the onset of disease, usually greater than 30 years.
Other malignancies have been linked to asbestos, including cancers of the voice box (larynx), upper throat (oropharynx), kidney, esophagus, and gallbladder.
The basic principle for asbestos is to leave material that is in good condition alone. Periodic inspection and maintenance by an expert in asbestos abatement should be undertaken for areas with sealed or contained asbestos. Local health, environmental, and building safety officials are good sources for local and state regulations on asbestos handling, disposal, and certified workers. If you discover even a very small amount of asbestos in your building, contact a professional for repair, removal, or remodeling.
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Pulmonary fibrosis is scarring throughout the lungs. Pulmonary fibrosis can be caused by many conditions including chronic inflammatory processes, infections, environmental agents, exposure to ionizing radiation, chronic conditions, and certain medications. Symptoms include
Treatment options are dependent on the type of pulmonary fibrosis; lung transplant and/or medications are options.
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