Highlights & Basics
- Asbestosis onset occurs ≥10 years following the initial exposure to asbestos.
- Patients may be asymptomatic or have progressive shortness of breath.
- A chest radiograph is the preferred initial test.
- There is no definitive treatment.
- Cigarette smoking cessation is important to reduce risk of lung cancer.
- Prognosis is related to extent of fibrosis noted at diagnosis and past cumulative exposure to asbestos.
Quick Reference
History & Exam
Key Factors
occupational exposure
longer duration of exposure
smoking history
Other Factors
dyspnea on exertion
cough
crackles
indirect exposure
chest pain
clubbing
Diagnostics Tests
1st Tests to Order
chest x-ray: posterior-anterior (PA) and lateral
pulmonary function tests
Other Tests to consider
high-resolution CT chest
lung biopsy
bronchial lavage
Treatment Options
ongoing
all patients
advice on importance of not smoking
supportive care
pulmonary rehabilitation ± oxygen therapy
pleural decortication or lung transplant
Definition
Vignette
Common Vignette 1
Common Vignette 2
Other Presentations
Epidemiology
Etiology
Pathophysiology
Images
Posterior-anterior view of the chest with bibasilar linear interstitial changes consistent with asbestosis
Posterior-anterior view of the chest with "en face" pleural changes in the mid zones on the right and left (arrows)
Diffuse pleural thickening (arrowheads) and elevated left hemidiaphragm (dotted arrow)
Posterior-anterior view of the chest with "mesa"-like pleural thickening of the left diaphragm and "in-profile" pleural thickening of the mid zones of both the left and right lungs
CT scan of the chest showing multiple examples of pleural thickening most with calcification (arrows)
CT scan confirming symmetrical thickening (arrowheads) with a calcified pleural plaque (broken arrow, top right) and an area of rounded atelectasis (Blesovsky sign; dotted arrow, bottom right)
Diagnostic Approach
History
Physical examination
Investigations
Risk Factors
History & Exam
Tests
Differential Diagnosis
Idiopathic pulmonary fibrosis
Differentiating Signs/Symptoms
- Absence of history of significant exposure to asbestos after obtaining complete work and environmental history.
- Signs and symptoms same as for asbestosis.
Differentiating Tests
- Lung biopsy does not show asbestos bodies or quantification of mineral content of increased asbestos mineral fibers.
Differentiating Signs/Symptoms
- Patients with a history of rheumatoid arthritis, scleroderma, and systemic lupus erythematosus may develop pulmonary fibrosis.
- Absence of history of significant exposure to asbestos after obtaining complete work and environmental history.
- Same symptoms of dyspnea. Will have specific signs and symptoms of arthritis, skin rash, liver or renal disease related to the particular connective tissue disease.
Differentiating Tests
- Lung biopsy does not show asbestos bodies or quantification of mineral content of increased asbestos mineral fibers.
- Immunologic markers such as rheumatoid factor and antinuclear antibody are nonspecific and may be present in patient with asbestosis without connective tissue disease.[21]
Hypersensitivity pneumonitis (HP)
Differentiating Signs/Symptoms
- Absence of history of significant exposure to asbestos after obtaining complete work and environmental history.
- Respiratory symptoms are typically associated with acute exposure to causal antigen such bacteria or mold in silage or hay. With subacute or chronic HP this temporal association may not be appreciated.
Differentiating Tests
- Presence of IgG antibodies in the blood to the causal antigen, a ground glass appearance on high-resolution CT and granulomas on lung biopsy.
Differentiating Signs/Symptoms
- History of exposure to work with release of tungsten carbide into the air.
- Similar clinical presentation.
Differentiating Tests
- Lung biopsy has pathognomonic giant cells that are unique to the disease.
Silicosis
Differentiating Signs/Symptoms
- History of exposure to silica. In certain workplaces, such as foundries and mines, workers may be exposed to both silica and asbestos.[22]
- Similar clinical presentation.
Differentiating Tests
- Chest x-ray of silicosis is very different, with small rounded opacities initially beginning in the upper lobes. With progression, these smaller nodules conglomerate into large opacities (progressive massive fibrosis). Unlike asbestos exposure, there are no pleural changes seen.
- Lung biopsy shows pathognomonic silicotic nodules. Some patients with exposure to asbestos and silica may have radiographic and/or pathologic changes of mixed dust.
Sarcoidosis
Differentiating Signs/Symptoms
- Absence of history of significant exposure to asbestos after obtaining complete work and environmental history.
- Same respiratory symptoms, but also involves other organs.
Differentiating Tests
- Imaging shows hilar lymphadenopathy and predominantly upper lobe scarring.
- May be associated with hypercalcemia.
- Granulomas on biopsy.
Differentiating Signs/Symptoms
- History of taking medications such as amiodarone, nitrofurantoin, methotrexate, bleomycin and cyclophosphamide, or receiving radiation therapy.
- Same respiratory symptoms.
Differentiating Tests
- No differentiating investigations.
Criteria
- s: up to 1.5 mm
- t: 1.5 to 3.0 mm
- u: 3.0 to 10.0 mm.
- 12 point scale from 0/-, 0/0, 0/1, 1/0, 1/1, 1/2, 2/1, 2/2, 2/3, 3/2, 3/3, through 3/+.
- a: Site
- Chest wall
- Diaphragm
- Other.
- b: Calcification
- c: Width
- 1: up to one quarter of chest wall
- 2: between one quarter to one half of chest wall
- 3: more than half of chest wall.
- Evidence of structural change via radiographic imaging of lungs or histology from lung biopsy
- Evidence of plausible causation via an occupational or environmental history of significant exposure with the appropriate latency, or of a marker of exposure such as pleural thickening or increased asbestos mineral fiber in lung or bronchial lavage fluid; and
- Exclusion of alternative diagnoses.
Screening
Occupational exposure
- Those ages ≥50 years with a history of ≥5 years of asbestos exposure in combination with either a history of smoking at least 10 pack-years with no limit on time since quitting, or
- A history of asbestos-related parenchymal fibrosis.
General population
Treatment Approach
Specific interventions
- Advice on the importance of not smoking: the most important physician intervention given the synergy between cigarettes and asbestos for increasing the risk of lung cancer. The increased risk of lung cancer in nonsmoking asbestos workers is 5.2, in smoking nonasbestos-exposed individuals the risk is 10.8, but in smoking asbestos workers the risk of lung cancer is increased 53-fold.[24]
- Pulmonary rehabilitation: designed to reduce symptoms and optimize functional status. It involves exercise training, education, nutritional intervention and psychosocial support.[30] Although the evidence is low and there are no studies demonstrating long-term benefits, short-term improvements in functional exercise capacity, dyspnea, and quality of life are reported in two randomized control studies of patients with dust-related interstitial lung disease who participated in pulmonary rehabilitation.[31] There is low to moderate evidence from short-term studies and a few long-term studies showing a benefit in other types of interstitial lung disease.[32]
- Oxygen therapy: patients with progressive fibrosis and PaO₂ of ≤55 mmHg or oxygen saturation of ≤89% are candidates for oxygen therapy.[33] This improves exercise tolerance and reduces the risk of developing pulmonary hypertension and cor pulmonale.
- Lung transplant: patients with end-stage respiratory failure (PaO₂ <60 mmHg despite oxygen therapy) due to parenchymal disease are potential candidates for lung transplants.[34]
- Pleural decortication: rarely, a patient may develop diffuse pleural thickening of sufficient extent that pleural decortications should be considered.
General recommendations for chronic lung disease
Treatment Options
all patients
advice on importance of not smoking
Comments
- This is the most important physician intervention given the synergy between cigarettes and asbestos for increasing the risk of lung cancer.
- The increased risk of lung cancer in nonsmoking asbestos workers is 5.2, in smoking nonasbestos-exposed individuals the risk is 10.8, but in smoking asbestos workers the risk of lung cancer is increased 53-fold.[24]
supportive care
Comments
- Antibiotics should be given if there is evidence of infection, such as change in sputum production, fever and increasing dyspnea.
- Patients with evidence of obstructive airways disease should receive appropriate bronchodilator therapy.
pulmonary rehabilitation ± oxygen therapy
Comments
- Pulmonary rehabilitation is designed to reduce symptoms and optimize functional status. It involves exercise training, education, nutritional intervention, and psychosocial support. It is recommended for patients with exertional dyspnea to improve exercise tolerance.[30]
- Although the evidence is low to moderate and there are not enough studies demonstrating long-term benefits, short-term improvements in functional exercise capacity, dyspnea, and quality of life are reported in patients with interstitial lung disease who participate in pulmonary rehabilitation.[30] [31] [32]
- Patients with progressive fibrosis and PaO₂ of ≤55 mmHg or oxygen saturation of ≤89% are candidates for oxygen therapy.[33]
- Oxygen therapy improves exercise tolerance and reduces the risk of developing pulmonary hypertension and cor pulmonale.
pleural decortication or lung transplant
Comments
- A patient may develop diffuse pleural thickening of sufficient extent that pleural decortications should be considered. However, this is very rare and pleural thickening does not usually require treatment.
- Patients with end-stage respiratory failure (PaO₂ <60 mmHg despite oxygen therapy) due to parenchymal disease are potential candidates for lung transplants.[34]
Prevention
Primary Prevention
Secondary Prevention
Follow-Up Overview
Prognosis
Asbestosis
Pleural disease
Compensation
Monitoring
Complications
Citations
American Thoracic Society. Diagnosis and initial management of nonmalignant diseases related to asbestos. Am J Respir Crit Care Med. 2004 Sep 15;170(6):691-715.[Abstract][Full Text]
Wolff H, Vehmas T, Oksa P, et al. Asbestos, asbestosis, and cancer, the Helsinki criteria for diagnosis and attribution 2014: recommendations. Scand J Work Environ Health. 2015 Jan;41(1):5-15.[Abstract][Full Text]
Rom WN. Asbestosis, pleural fibrosis and lung cancer. In: Rom WN, Markowitz SB, eds. Environmental and occupational medicine 4th ed. Philadelphia: Lippincott Williams and Wilkins; 2007:298-316.
Markowitz SB, Levin SM, Miller A, et al. Asbestos, asbestosis, smoking, and lung cancer. New findings from the North American insulator cohort. Am J Respir Crit Care Med. 2013 Jul 1;188(1):90-6.[Abstract]
Banks DE, Shi R, McLarty J, et al. American College of Chest Physicians consensus statement on the respiratory health effects of asbestos. Results of a Delphi study. Chest. 2017 Sep 18;4(1):e000223.[Abstract][Full Text]
- National Institute for Occupational Safety and Health: chest radiography ILO classification
- OSHA: asbestos standard for general industry
- HSE: guidance for appointed doctors on medical surveillance of workers doing licensed work with asbestos
- HSE: guidance for doctors on medical surveillance of workers doing non-licensed work with asbestos
1. American Thoracic Society. Diagnosis and initial management of nonmalignant diseases related to asbestos. Am J Respir Crit Care Med. 2004 Sep 15;170(6):691-715.[Abstract][Full Text]
2. Wolff H, Vehmas T, Oksa P, et al. Asbestos, asbestosis, and cancer, the Helsinki criteria for diagnosis and attribution 2014: recommendations. Scand J Work Environ Health. 2015 Jan;41(1):5-15.[Abstract][Full Text]
3. Centers for Disease Control and Prevention. National Institute for Occupational Safety and Health. Work-related respiratory diseases: asbestosis. May 2017 [internet publication].[Full Text]
4. Rom WN. Asbestosis, pleural fibrosis and lung cancer. In: Rom WN, Markowitz SB, eds. Environmental and occupational medicine 4th ed. Philadelphia: Lippincott Williams and Wilkins; 2007:298-316.
5. Anderson HA, Lilis R, Daum SM, et al. Household-contact asbestos neoplastic risk. Ann NY Acad Sci. 1976 May;271(1):311-23.
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8. Begin R, Samet J, Shaikh RA. Asbestos. In: Harber P, Schenker MB, Balmes JR, eds. Occupational and environmental respiratory disease. St. Louis: Mosby-Year Book Inc; 1996:293-329.
9. Dupre JS, Mustard JF, Uffen RJ. Report of the Royal Commission on Matters of Health and Safety Arising from the Use of Asbestos in Ontario Vol I-III. Ontario Ministry of the Attorney General. Toronto, ON: Queen's Printer for Ontario;1984.
10. Egilman D, Fehnil C, Bohme SR. Exposing the myth of ABC "anything but chrysotile" a critique of the Canadian asbestos mining industry and McGill University chrysotile studies. Am J Ind Med. 2003 Nov;44(5):540-57.[Abstract]
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12. Suzuki Y, Kohyama N. Translocation of inhaled asbestos fibers from the lung to other tissue. Am J Ind Med. 1991;19(6):701-4.[Abstract]
13. Constantopoulos SH, Theodoracopoulos P, Dascalopoulos G, et al. Metsovo lung outside Metsovo. Endemic pleural calcifications in the ophiolite belts of Greece. Chest. 1991 May;99(5):1158-61.[Abstract]
14. Peipins LA, Lewin M, Campolucci S, et al. Radiographic abnormalities and exposure to asbestos-contaminated vermiculite in the community of Libby Montana, USA. Environ Health Perspect. 2003 Nov;111(14):1753-9.[Abstract]
15. Culver BH, Graham BL, Coates AL, et al. Recommendations for a Standardized Pulmonary Function Report. An Official American Thoracic Society Technical Statement. Am J Respir Crit Care Med. 2017 Dec 1;196(11):1463-72.[Abstract][Full Text]
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18. Ohar J, Sterling DA, Bleeker E, et al. Changing patterns in asbestos-induced lung disease. Chest. 2004 Feb;125(2):744-53.[Abstract]
19. Kilburn KH, Warshaw RH. Airway obstruction in asbestos-exposed shipyard workers with and without irregular opacities. Respir Med. 1990 Nov;84(6):449-55.[Abstract]
20. De Vuyst P, Dumortier P, Moulin E, et al. Diagnostic value of asbestos bodies in bronchoalveolar lavage fluid. Am Rev Respir Dis. 1987 Nov;136(5):1219-24.[Abstract]
21. deShazo RD, Daul CB, Morgan JE, et al. Immunological investigations in asbestos exposed workers. Chest. 1986 Mar;89(3 Suppl):162S-165S.[Abstract]
22. Rosenman KD, Reilly MJ. Asbestos-related x-ray changes in foundry workers. Am J Ind Med. 1998 Aug;34(2):197-201.[Abstract]
23. International Labour Office. Guidelines for the use of the ILO international classification of radiographs of pneumoconiosis. Occupational Safety and Health Series, No. 22. Revised edition 2011 [internet publication].[Full Text]
24. Selikoff IJ, Seidman H. Asbestos-associated deaths among workers in the United States and Canada, 1967-1987. Ann NY Acad Sci. 1991 Dec 31;643:1-14.[Abstract]
25. Markowitz SB, Levin SM, Miller A, et al. Asbestos, asbestosis, smoking, and lung cancer. New findings from the North American insulator cohort. Am J Respir Crit Care Med. 2013 Jul 1;188(1):90-6.[Abstract]
26. Lee PN. Relation between exposure to asbestos and smoking jointly and the risk of lung cancer. Occup Environ Med. 2001 Mar;58(3):145-53.[Abstract][Full Text]
27. Frost G, Darnton A, Harding AH. The effect of smoking on the risk of lung cancer mortality for asbestos workers in Great Britain (1971-2005). Ann Occup Hyg. 2011 Apr;55(3):239-47.[Abstract][Full Text]
28. Olsson AC, Vermeulen R, Schüz J, et al. Exposure-response analyses of asbestos and lung cancer subtypes in a pooled analysis of case-control studies. Epidemiology. 2017 Mar;28(2):288-99.[Abstract][Full Text]
29. Markowitz SB. Lung cancer screening in asbestos-exposed populations. Int J Environ Res Public Health. 2022 Feb 25;19(5):2688.[Abstract][Full Text]
30. Spruit MA, Singh SJ, Garvey C, et al. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med. 2013 Oct 15;188(8):e13-64.[Abstract][Full Text]
31. Dale MT, McKeough ZJ, Troosters T, et al. Exercise training to improve exercise capacity and quality of life in people with non-malignant dust-related respiratory diseases. Cochrane Database Syst Rev. 2015 Nov 5;(11):CD009385.[Abstract][Full Text]
32. Dowman L, Hill CJ, Holland AE. Pulmonary rehabilitation for interstitial lung disease. Cochrane Database Syst Rev. 2014 Oct 6;(10):CD006322.[Abstract][Full Text]
33. Suntharalingam J, Wilkinson T, Annandale J, et al. British Thoracic Society quality standards for home oxygen use in adults. BMJ Open Respir Res. 2017 Sep 18;4(1):e000223.[Abstract][Full Text]
34. Alalawi R, Whelan T, Bajwa RS. Lung transplantation and interstitial lung disease. Curr Opin Pulm Med. 2005 Sep;11(5):461-6.[Abstract]
35. Castleman BI. Asbestos: medical and legal aspects. 5th edition. New York: Aspen; 2005.
36. Banks DE, Shi R, McLarty J, et al. American College of Chest Physicians consensus statement on the respiratory health effects of asbestos. Results of a Delphi study. Chest. 2017 Sep 18;4(1):e000223.[Abstract][Full Text]
37. Kwak K, Paek D, Zoh KE. Exposure to asbestos and the risk of colorectal cancer mortality: a systematic review and meta-analysis. Occup Environ Med. 2019 Nov;76(11):861-71.[Abstract][Full Text]
38. Peng WJ, Mi J, Jiang YH. Asbestos exposure and laryngeal cancer mortality. Laryngoscope. 2016 May;126(5):1169-74.[Abstract][Full Text]
39. Pass HI, Levin SM, Harbut MR, et al. Fibulin-3 as a blood and effusion biomarker for pleural mesothelioma. New Eng J Med. 2013 Jul 1;188(1):90-6.[Abstract][Full Text]
40. US Preventive Services Task Force., Bibbins-Domingo K, Grossman DC, et al. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2016 Jun 21;315(23):2564-75.[Abstract][Full Text]
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Key Articles
Other Online Resources
Referenced Articles
Guidelines
Diagnostic
Summary
Asbestosis is diagnosed if linear interstitial fibrosis involving the lower lobes is present with an appropriate history of asbestos exposure and the absence of nonrespiratory manifestation of disease.Published by
American Thoracic Society
Published
2004
Summary
Diagnosis requires a history of significant exposure to asbestos in the past or detection of asbestos fibers or bodies in lung tissue.Published by
Finnish Institute of Occupational Health
Published
2014