2.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.
Asbestosis is defined as a type of pneumoconiosis caused by the inhalation of asbestos fibers.
In the 1920’s, scientists first recognized the link between asbestos and pulmonary fibrosis.
In the 1960’s, firmly established link between asbestos and both bronchogenic carcinoma and malignant mesothelioma.
Current strict regulation of asbestos has significantly decreased risk of developing 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.
8.Healthy Lung Tissue
9.Asbestos in Lung Tissue
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.
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
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.
Married with 3 grown children, aged 40, 45, and 49
Smokes 1 pack per day x 45 years
History of heavy alcohol use
Volunteers at community food pantry
No history of intravenous drug use
Known to unreliable in keeping follow up appointments, doesn’t like doctors
16.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
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
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
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
Weight = 179 lb
No lesions or rashes
Warm and dry with satisfactory turgor
Nail beds are pale
21.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
Tympanic membranes within normal limits bilaterally
No sinus tenderness
Oral pharyngeal mucosa clear
Mucous membranes moist but pale
22.Neck and Lymph Nodes
Negative for jugular venous distension and carotid bruits
No lymphadenopathy or thyromegaly
23.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
Regular rate and rhythm
Normal S1 and S2
Negative S3 and S4
No murmurs or rubs noted
Soft, non-tender to pressure, and non-distended
Normal bowel sounds
No masses of bruits
No hepatomegaly or splenomegaly
26.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
27.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
Alert and oriented x 3
Cranial nerves II-XII intact
Sensory and proprioception intact
Deep tendon reflexes 2+ bilaterally
31.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
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.
35.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.
36.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.
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.