m. amini (md) [email protected]. a 45 y/o man non-smoker with history of 15 years working at...
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A 45 y/o man non-smoker with history of 15 years working at
rubber industry Presented with dyspnea, cough and
phlegm in recent few years Physical examination reveals nothing
specific
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Chest radiography showed here
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Spirometery showed these values:FEV1= 44% with BD 3% FVC= 65% with BD 5% FEV1%= 50%
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What is the diagnosis?
Does it relate to my work history?
What about prognosis?
Is it treatable?
How much does it cost?
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Chronic obstructive pulmonary disease (COPD) is a disease state
characterized by airflow limitation
that is not fully reversible
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Chronic bronchitis, or the presence of cough and sputum production for at least 3 months
in each of two consecutive years,
remains a clinically and epidemiologically useful term.
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Emphysema, or destruction of the gas-exchanging surface of the lung (alveoli)
is a pathological term that is often (but
incorrectly) used clinically
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cough and sputum may precede the development of airflow limitation
conversely, some patients develop airflow limitation without chronic cough and sputum production.
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Occupational COPD develops slowly
the airflow limitation is chronic
does not reverse when exposure is discontinued
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So, diagnosis by methods similar to occupational asthma, is not feasible
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Epidemiologically, the identification of occupational COPD is based on
observing excess occurrence of COPD among exposed workers
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COPD is currently the fourth leading cause of death in the world
and further increases in its prevalence and mortality can be predicted in the coming decades
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Cigarette smoking is undoubtedly the main cause of COPD in the population
average decline in FEV1 in smokers is faster (60 ml/yr) than in non-smokers (30 ml/yr)
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As only 15 to 20% of smokers develop clinically significant COPD
6% of persons with COPD in the United States are never smokers
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A sizeable proportion of the cases of COPD in a society (average 15%)
may be attributable to workplace exposures
dusts, noxious gases/vapours, and fumes (DGVFs)
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The industries with increased risk include RubberPlasticsand leather manufacturingbuilding services textile manufacturingand construction.
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The fraction of cases in a population that arise because of certain exposures
is called population attributable risk (PAR)
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The American Thoracic Society (ATS) calculated that PAR for COPD was about 15%
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Smoking and occupational exposures had greater than additive effects
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A cohort of more than 317000 Swedish male
construction workers was followed from 1971 to 1999
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There was a statistically significant increase mortality
from COPD among those with any airborne exposure (relative risk 1.12)
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Thus, physicians must be aware of the potential occupational etiologies for
obstructive airway disease and should consider them in every patient with COPD
An occupational history should be the first step in the initial evaluation of the patient
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The length of time exposed to the agent
the use of personal protective equipment such as respirators,
and a description of the ventilation and
overall hygiene of the workplacequantify exposure from the patient's history
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Visit to the workplace by experts in occupational hygiene
material safety data sheets for workplace chemicals
manufacturers of the workplace substance
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Mild FEV1 ≥80% predicted, FEV1/FVC <0.7
Moderate 50% ≤ FEV1 <80% predicted, FEV1/FVC
<0.7 Severe
30% ≤ FEV1 <50% predicted, FEV1/FVC <0.7
Very severe FEV1 <30% predicted, FEV1/FVC <0.7
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Directions about the management and prevention of work-related diseases
can be applied to COPD as well
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understanding the patient's occupational exposure
Removal of the respiratory irritants
substitution of non-toxic agents
are the best approach because they eliminate the work-related COPD hazard.
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If substitution is not possible
ongoing maintenance of engineering controls
and improving work area ventilation
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Administrative controls (e.g., transfer to another job or change in work practices)
and personal protective equipment (e.g., masks or respirators)
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workers with COPD
may continue to work in their usual jobs if
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their exposure to the inciting agent is diminished via proper engineering controls or respiratory protective equipment
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The total annual cost to the National Health Service for the treatment of COPD is
thought to be £491,652,000 in direct costs
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