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Asbestosis. A Doctor's Guide to asbestos related diseases

The risk of asbestos-related lung disease increases with the duration and degree of exposure and also depends on the type of asbestos fibre. People exposed to asbestos often develop lung disease after a long latent period. [1] Asbestos exposure may cause:[2] 

The three main types of asbestos that have been used commercially are crocidolite (blue asbestos), amosite (brown) and chrysotile (white). All fibre types are dangerous. There was discussion in the literature that blue and brown asbestos were more dangerous than white. There is, however, sufficient evidence to suggest that chrysotile can be as carcinogenic as the other types.[3] 

Alveolar macrophages play a significant role in the aetiology of asbestosis-related diseases.[4] 

  • High-risk populations include construction trades, joiners, plumbers, electricians, painters, boilermakers, shipyard workers, railroad workers, asbestos miners and Navy veterans.[5]
  • The annual number of mesothelioma deaths in the UK is increasing, with 2,347deaths in 2010 compared with 153 in 1968.[6] 
  • The expected number of deaths amongst males is predicted to increase to a peak of 2,038 in the year 2016.[7] 
  • The World Health Organization (WHO) has estimated that 107,000 people worldwide die each year from mesothelioma, lung cancer, and asbestosis. Mesothelioma is still increasing in most European countries and in Japan but has peaked in the USA and Sweden.[8] 
  • The incidence of asbestos-related disease will continue to increase in developing countries because of the continued unregulated use of asbestos.
  • Exposure to cigarette smoke increases the risk of developing lung cancer in patients with a history of asbestos exposure.[9] 

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  • Some patients are entitled to compensation and should seek advice from the Department for Work and Pensions (see link under 'Further reading & references', below) or dedicated charity organisations.
  • Smoking cessation is important because smoking increases the risk of developing lung malignancy.
  • Influenza immunisation and pneumococcal immunisation should be given to patients with asbestosis or lung malignancy.

Pleural plaques

  • Pleural plaques usually affect the parietal pleura (especially adjacent to the sixth to ninth ribs and along the surface of the diaphragm) and they occur in 20-60% of people who have been exposed to asbestos.[10] 
  • Pleural plaques are usually asymptomatic but may cause chest pain. They remain benign and do not become malignant although there is some evidence that they may be an independent risk factor for mesothelioma.[11] There is some evidence that they may be associated with a restrictive pattern on lung function tests but this is not thought to be clinically relevant.[12] 
  • CT scan is more sensitive than a CXR and distinguishes pleural plaques from solid tumours.

Diffuse pleural thickening[13] 

  • Diffuse thickening of the pleura may occur after exposure to asbestos; however, other causes include previous haemothorax, tuberculosis, chest surgery, radiation, infection and exposure to drugs such as methysergide. It is therefore less specific to asbestos exposure than pleural plaques.
  • Extensive diffuse pleural thickening may cause breathlessness.
  • CXR findings of diffuse pleural thickening include a smooth continuous pleural density affecting at least 25% of the lateral chest wall, sometimes with blunting of the costophrenic angle.
  • Lung function tests may show a restrictive ventilatory defect.
  • CT scan and biopsy may be required to differentiate diffuse pleural thickening from mesothelioma.

Benign asbestos-related pleural effusion[5] 

  • Pleural effusions can occur within 10-20 years of asbestos exposure but may appear much later.
  • A pleural biopsy is usually required to differentiate between benign and malignant pleural effusions.
  • Benign effusions may require drainage if large and symptomatic but they may resolve spontaneously.
  • Asbestosis is a typical pneumoconiosis (interstitial lung disease caused by inhaled inorganic dusts) and is caused by inhalation of asbestos fibres, with a latent period of 20-30 years.
  • The development and severity of asbestosis is related to the degree and duration of asbestos exposure.
  • Presentation:
    • There is typically an initial gradual onset of breathlessness and reduced exercise tolerance, sometimes with productive cough and wheezing.
    • Progression of asbestosis may lead to fine bilateral inspiratory crackles, finger clubbing and cor pulmonale.
  • Investigations:
    • Pulmonary function tests show reduced gas transfer, reduced lung volumes, a restrictive ventilatory defect and exercise-related hypoxaemia.
    • CXR may be normal but usually shows bilateral lower zone interstitial changes, often with pleural plaques and thickening.
    • High-resolution CT scans are more sensitive than CXRs.
    • Biopsy and histological confirmation are not usually required.
  • Management:
  • Prognosis:
    • The prognosis of asbestosis is very variable and depends on the extent of lung involvement and the severity of COPD.

Lung cancer

  • Exposure to asbestos causes lung cancer independently of cigarette smoking.[9] 
  • Lung cancer is most closely associated with long thin asbestos fibres.[14] 
  • Asbestosis need not be present in a person developing lung cancer as a result of asbestos exposure.
  • The diagnosis and management are the same as those for all patients with lung cancer.

Mesothelioma

See separate article Malignant Mesothelioma.

Other cancers

Studies have also shown an association between asbestos exposure and cholangiocarcinoma.[15] There is evidence for an association between asbestos and urinary tract cancers.[16] A link with laryngeal cancer and lymphoma is less certain.[17]

  • Patients with asbestos-related lung disease may be eligible for compensation through the Industrial Injuries Disablement Benefit (IIDB) from the Department for Work and Pensions (see link in 'Further reading & references', below) or a civil law claim for damages from the employer at the time of asbestos exposure.
  • Under the UK Limitation Act 1980, patients have only three years in which to make a civil claim from the date they became aware of the asbestos-related disease caused by an act or omission of the proposed defendant.
  • Various charities can also provide help and support on compensation (see Asbestos Victims Support Groups Forum UK link in 'Further reading & references, below).

Asbestos-related diseases cannot be prevented in people who work with asbestos. However, its effects can be limited by health and safety measures combined with regular medical surveillance.

The control of industrial asbestos exposure in the UK is subject to the Asbestos Control Regulations 2012. These  specify the surveillance regimes required for people working with asbestos. The required schedule varies, depending on the degree of risk to the individual worker.[18] For those at highest risk, a medical check at least every two years is required. This involves an occupational and respiratory history, a respiratory examination and lung function tests. Routine CXRs are no longer perfomed due to concerns over unnecessary exposure to radiation but are arranged if clinically indicated.[19] 




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