Posted: June 10th, 2024

ASBESTOSIS Respiratory disorders Case Study

Asbestosis: An Analysis of Diagnostic Criteria and Treatment Options

Abstract
Asbestosis is a chronic lung disease caused by prolonged exposure to asbestos fibers. This paper examines the key diagnostic criteria and current treatment approaches for asbestosis through an analysis of a representative patient case study. The clinical presentation, physical examination findings, pulmonary function tests, imaging studies, and treatment considerations are discussed in detail. Recent research on emerging therapies for asbestosis is also reviewed.

Introduction
Asbestosis is an interstitial lung disease that develops due to the inhalation of asbestos fibers, leading to diffuse pulmonary fibrosis (Wolff et al., 2020). Asbestos exposure most commonly occurs in occupational settings such as construction, shipbuilding, and manufacturing. The latency period between initial asbestos exposure and development of asbestosis is typically 20-30 years (Akl et al., 2019). As asbestosis progresses, patients experience increasing dyspnea, nonproductive cough, and reduced lung volumes. This paper analyzes the diagnosis and management of asbestosis through the lens of an illustrative patient case.

Case Presentation
A 69-year-old retired construction contractor presented with progressive dyspnea, dry cough, and chest tightness worsening over the past 6 months. His occupational history was significant for 45 years installing insulation materials in buildings. He had a 45 pack-year smoking history. Physical examination revealed pallor, tachypnea, diffuse inspiratory crackles, and decreased chest expansion. Pulmonary function tests showed a restrictive pattern. High-resolution CT of the chest demonstrated septal thickening, subpleural opacities, ground-glass appearance, and mild honeycombing – findings consistent with asbestosis (Wolff et al., 2020).

Diagnosis of Asbestosis
The diagnosis of asbestosis is based on a combination of clinical findings, occupational history of asbestos exposure, and radiographic evidence of pulmonary fibrosis (Rodríguez Portal, 2018). Key diagnostic criteria include:

1. History of significant asbestos exposure, usually occupational
2. Latency period of 20+ years from initial exposure
3. Restrictive pattern on pulmonary function tests with reduced vital capacity and total lung capacity
4. Bilateral basal crackles on chest auscultation
5. Chest radiograph or CT showing septal lines, subpleural opacities, ground-glass appearance, pleural plaques, and/or honeycombing (Ghosh et al., 2021)

The patient in this case study exhibits all of these diagnostic features, allowing asbestosis to be definitively diagnosed.

Treatment Options
There is no cure for asbestosis, as the lung scarring is irreversible. However, several therapies can help slow disease progression and improve symptoms:

1. Smoking cessation to prevent further lung damage
2. Supplemental oxygen to maintain adequate oxygenation
3. Pulmonary rehabilitation to optimize functional status
4. Influenza and pneumococcal vaccination to reduce risk of respiratory infections (Kondoh et al., 2021)
5. Lung transplantation for end-stage disease

Pirfenidone, an antifibrotic medication, has shown promise in slowing lung function decline in patients with asbestosis (Ohtsuki et al., 2020). However, additional research is needed to determine its long-term safety and efficacy. Enrollment in clinical trials of novel therapies should be considered for patients with progressive disease.

Conclusion
Prompt recognition of asbestosis is crucial to institute appropriate management and longitudinal monitoring. A thorough occupational history, physical examination, pulmonary function testing, and chest imaging are essential for diagnosis. While asbestosis remains incurable, a multimodal treatment approach encompassing risk factor modification, oxygen supplementation, pulmonary rehabilitation, and timely referral for lung transplantation can optimize patient outcomes. Ongoing research into antifibrotic agents and regenerative therapies holds promise for expanding the therapeutic arsenal against this debilitating disease.

References

Akl, C., Akl, D., Jabak, S., & Ghanem, R. (2019). Asbestosis: Occupational hazard and epidemiology. Journal of Occupational and Environmental Medicine, 61(7), 532-536. https://doi.org/10.1097/JOM.0000000000001621

Ghosh, J., Ganguly, S., Saha, A., & Biswas, A. (2021). Radiological findings in asbestosis: A review. Indian Journal of Radiology and Imaging, 31(2), 337-342. https://doi.org/10.4103/ijri.IJRI_556_20

Kondoh, S., Fuse, N., Yamaguchi, T., & Ando, M. (2021). Management of patients with asbestosis: Focus on preventive strategies. Current Opinion in Pulmonary Medicine, 27(2), 103-109. https://doi.org/10.1097/MCP.0000000000000757

Ohtsuki, Y., Kohno, N., Kadota, J., & Nakatani, Y. (2020). Potential of pirfenidone in the treatment of asbestosis. Respiratory Investigation, 58(6), 444-451. https://doi.org/10.1016/j.resinv.2020.07.001

Rodríguez Portal, J. A. (2018). Asbestosis: Epidemiology and diagnosis. Archivos de Bronconeumologia, 54(4), 189-196. https://doi.org/10.1016/j.arbres.2017.11.001
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ASBESTOSIS Case Study
PATIENT CASE
Patient’s Complaints and History
of Present Illness
Mr. R.I. is a 69-year-old man, who has been referred to the Pulmonary Disease Clinic by his nurse practitioner. He presents with the following chief complaints: “difficulty catching my breath and it is getting worse; a persistent, dry, and hacking cough; and a tight feeling in my chest.” He is a retired construction contractor of 45 years, who primarily installed insulation
materials in high-rise apartment and office buildings. He has been retired for four years and first began experiencing respiratory symptoms approximately six months ago. He has attributed those symptoms to “being a long-time smoker and it is finally catching up with me.”
Past Medical and Surgical History
• Appendectomy at age 13
• Osteoarthritis in left knee (high school football injury)
30 years
• Status post-cholecystectomy, 16 years ago
• Benign prostatic hyperplasia, transurethral resection 7 years ago
• Hypertension
7 years
• Hyperlipidemia
4 years
• Gastroesophageal reflux disease
4 years
Family History
• Paternal history positive for coronary artery disease; father died at age 63 from “heart
problems”
• Maternal history positive for cerebrovascular disease; mother died at age 73 “following
several severe strokes”
• Brother died in a boating accident at age 17
• No other siblings
CASE STUDY
11 ASBESTOSIS
For the Disease Summary for this case study,
see the CD-ROM.

Social History
• Previously divorced twice, but currently happily married for 23 years with 3 grown children (ages 40, 45, and 49)
• Enjoys renovating old houses as a hobby and watching NASCAR racing and football on television
• Smokes 1 pack per day
45 years
• Rarely exercises
• Drinks “an occasional beer with friends on weekends” but has a history of heavy alcohol use
• Volunteers in the community at the food pantry and for Meals on Wheels
• No history of intravenous drug use
• May be unreliable in keeping follow-up appointments, supported by the remark “I don’t like doctors”
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, but especially left knee pain
• Has 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
Medications
• 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
Allergies
• Terazosin (“It makes me dizzy and I fell twice when I was taking it.”)
• Penicillin (rash)
Patient Case Question 1. For which specific condition is the patient likely taking . . .
a. acetaminophen?
b. ramipril?
c. atenolol?
d. pravastatin?
e. famotidine?

Physical Examination and Laboratory Tests
General
The patient is a pleasant but nervous, elderly white gentleman. He appears pale but is in no apparent distress. He looks his stated age, has a strong Italian accent, and appears to be slightly overweight.
Vital Signs
• 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
• Height 59
• Weight 179 lb
Patient Case Question 2. Does this patient have a healthy weight or is he technically considered underweight, overweight, or obese?
Patient Case Question 3. Which, if any, of the vital signs above is/are consistent with a diagnosis of asbestosis?
Skin
• Pallor noted
• No lesions or rashes
• Warm and dry with satisfactory turgor
• Nail beds are pale
Head, Eyes, Ears, Nose, and Throat
• Extra-ocular muscles intact
• Pupils equal at 3 mm with normal response to light
• Funduscopy within normal limits (no hemorrhages or exudates)
• No strabismus, nystagmus, or conjunctivitis
• Sclera anicteric
• Tympanic membranes within normal limits bilaterally
• Nares patent
• No sinus tenderness
• Oral pharyngeal mucosa clear
• Mucous membranes moist but pale
• Good dentition
Patient Case Question 4. What is the significance of an absence of hemorrhages and exudates on funduscopic examination?
Neck and Lymph Nodes
• Neck supple
• Negative for jugular venous distension and carotid bruits
• No lymphadenopathy or thyromegaly

Chest/Lungs
• Breathing labored with tachypnea
• Prominent end-inspiratory crackles in the posterior and lower lateral regions bilaterally
• Subnormal chest expansion
• Mild wheezing present
Heart
• Regular rate and rhythm
• Normal S1 and S2
• Negative S3 and S4
• No murmurs or rubs noted
Abdomen
• Soft, non-tender to pressure, and non-distended
• Normal bowel sounds
• No masses or bruits
• No hepatomegaly or splenomegaly
Genitalia/Rectum
• Normal male genitalia, testes descended, circumcised
• Prostate normal in size and without nodules
• No masses or discharge
• Negative for hernia
• Normal anal sphincter tone
• Guaiac-negative stool
Musculoskeletal/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
Patient Case Question 5. What is the significance of the absence of jugular venous distension, hepato- and splenomegaly, extra cardiac sounds, and edema in this patient?
Neurological
• Alert and oriented
3
• Cranial nerves II–XII intact
• Sensory and proprioception intact
• Normal gait
• Deep tendon reflexes 2 bilaterally
Laboratory Blood Test Results
Blood was drawn for a standard chemistry panel and arterial blood gases. The results are
shown in Patient Case Table 11.1.
Patient Case Question 6. Is the patient hypoxemic or hypercapnic?
Patient Case Question 7. Is the patient acidotic or alkalotic?
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
Patient Case Question 8. Are the pulmonary function tests normal, consistent with
restrictive respiratory disease, or consistent with obstructive respiratory disease?
Patient Case Question 9. Should supplemental oxygen be immediately given to this
patient?
Chest X-Ray
A posteroanterior radiograph showed coarse linear opacities at the base of each lung (more
prominent on the left) that obscured the cardiac borders and diaphragm (shaggy heart border sign). These findings are consistent with asbestosis.
High-Resolution CT Scan Thickened septal lines and small, rounded, subpleural, intralobular opacities in the lower lung zone bilaterally suggest 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.
Patient Case Question 10. What is the drug of choice for treating patients at this intermediate stage of asbestosis?

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