Autor : Rey, Darío R.1
1 Director of the Pulmonology Specialization Career, UBA (University of Buenos Aires)
https://doi.org/10.56538/ramr.HTLB2960
Correspondencia : Darío R. Rey. E-mail: darioraul.rey@gmail.com
ABSTRACT
There are a lot of risks
unrelated to tobacco that can cause COPD, so the burden of non-smoking COPD is
much greater than previously thought. In the Third World countries, there is a significant number of non-tobacco-related risk agents
capable of causing COPD.
The pathogenesis of COPD and its
relationship with occupational exposure to dust, gases, and fumes is not fully
understood. Further experimental and epidemiological research on a larger scale
is needed to confirm the relationship between these two variables.
Approximately 15 % of COPD is
related to work, and aggravated by smoking. New agents causing COPD continue to
be reported and published.
Women exhibit a different
clinical manifestation of COPD and, under similar exposures, are more prone to
developing the disease compared to men.
Personal protection for workers
is of particular importance since it is challenging to assess the nature of
dust, smoke, or gases, their ambient concentration, and the duration of the
exposure.
Key words: COPD, Biomass, Tasks
RESUMEN
Existen
un número importante de riesgos no relacionados al tabaco pasible de provocar
la EPOC por lo que la carga de la EPOC no tabáquica es mucho mayor de lo
pensado. En los países del 3er. Mundo, hay importantes agentes de peligro no
relacionados al tabaco pasibles de provocar la EPOC.
No
está aclarada la patogenia de la EPOC y su relación con la exposición laboral a
polvos, gases y humos. Son necesarias más investigaciones experimentales y epidemiológicas
de mayor magnitud, para confirmar la relación entre estas 2 variables.
Aproximadamente
el 15 % de la EPOC relacionada con el trabajo, está agravada por el tabaquismo
y continúan publicándose nuevos agentes que causan EPOC.
Las
mujeres presentan una manifestación clínica diferente de la EPOC siendo, –ante
exposiciones semejantes–, más propensas a desarrollar la enfermedad que los
hombres.
La
protección personal de los trabajadores es de importancia, ya que es
dificultoso valorar la naturaleza del polvo, humo o gases, su concentración
ambiente y el tiempo de exposición.
Palabras
clave: EPOC,
Biomasa, Tareas
Received: 02/12/2023
Accepted: 08/31/2023
Chronic Obstructive Pulmonary
Disease (COPD) is a condition resulting from a constant limitation of the
airflow and gradually progressive respiratory symptoms culminating in the
destruction of the lung parenchyma. It is a complex condition with different
mechanisms and components that contribute to its physiopathology and clinical
presentation. After cerebrovascular and cardiovascular diseases, it
constitutes the third leading cause of mortality. In Argentina, the EPOC.AR
study conducted by Chazarreta et al between May 2014
and May 2016 estimated that there were approximately 2,300,000 cases of COPD,
among which 309 were related to occupational exposure, without specifying the
occupation. The study also highlighted a high number of both misdiagnoses and
underestimated cases.1-4 Frequently, in highly industrialized countries, statistics
are challenging to compile. In the developing world, which includes Argentina,
the task is even more difficult.
ASSOCIATION BETWEEN COPD AND COVID 19
Most COPD patients are of
advanced age and often have frequent comorbidities. So, at present and also
during the pandemic, patients diagnosed with COVID 19 experience a worse
outcome, including higher mortality rates, elevated hospitalization rates, and
consequently, a possible admission to the Intensive Care Unit (ICU).5,6
COPD – PREVALENCE
The estimated global prevalence
of COPD is 13.1 %, with disparities ranging from 11.6 % to 13.9 % across different
regions of the world. These indicators are crucial in recognizing the
importance of COPD as a global public health issue and essential to identify
effective prevention and treatment measures. Since the studies by Oswald and
Fletcher, certainly the prevalence of COPD is strictly related to smoking,
which is acknowledged as the main evolutionary predisposing factor of the
disease in 55-75 % of cases.7-
9
COSTS RELATED TO HEALTHCARE SYSTEMS
COPD constitutes a significant
burden on the healthcare system, but precise costs are difficult to estimate. Herse et al calculated the COPD-related costs in Finland
during 1996-2006, and, based on changes in smoking behavior and the projected
population, they estimated costs for 2007-2030 using a mathematical model.
Between 1996-2006, annual costs related to COPD were €100-110 million, with a decrease in
direct costs and an increase in indirect costs. The model predicted a 60 %
increase (up to €166 million/year by 2030), attributed to healthcare expenses
due to the aging of the population, which leads to an increased need for
hospitalization. They conclude by reporting that, unless strategies change,
there will be a significant rise in direct costs by 2030.10
In economic terms, COPD is also a
disease of great importance. According to Gibson et al, direct healthcare costs
per year for COPD amount to approximately €23.3 billion in the European Union.
Exacerbations, which may require hospitalization, as well as comorbidities,
contribute significantly to this cost.11
COPD AND BIOMASS
Salvi and Barnes published a review on the evidence of COPD related to
biomass fuel, occupational exposure to gases and dust, chronic asthma,
respiratory infections in childhood, pulmonary tuberculosis, ambient air pollution,
and low socioeconomic status.
The study suggests that there is a significant number of non-tobacco-related risk agents
capable of causing COPD. It is estimated that the burden of non-smoking-related
COPD is much higher than previously thought: around 3 billion people are
exposed to biomass fuel smoke compared to 1 billion smokers. This suggests that
exposure to biomass smoke could be the largest universal risk factor for COPD.12
The understanding of biomass
exposure-induced COPD is still a not well-defined subject of debate. Meneghini et al compared 2 groups: 16 non-smoking COPD
patients exposed to biomass (mean time 133 hours/year) and 15 smoking COPD
patients (mean 48 packs/year). Patients underwent spirometry,
chest CT scan, a 6-minute walk test, and induced sputum.
The results showed that
non-smokers with COPD exposed to biomass had functional values analogous to the
smoking COPD group but exhibited more hypoxemia and dyspnea, lower blood
pressure, and lower oxygen saturation. Smoking COPD patients exhibited more
emphysema in the CT scan, thicker bronchial walls, and lymphomononuclear
cells as well as Interleukins 6 and 8 in sputum.
This phenotype may be associated
with a ventilation-t perfusion mismatch leading to hypoxemia, with less visible
damage to the pulmonary parenchyma and the bronchial compartment as evaluated
by tomography. The conclusion suggests the need for further studies on this
phenotype to understand hypoxemia and its consequences, to assess the prognosis
and therapeutics.13
Exposure to these pollutants can
cause lung inflammation and lead to chronic respiratory symptoms. The study of
Chen et al reported that those who cooked 21 times a week had a higher risk of
suffering from chronic bronchitis than those who did it 9 times in the same
period.14
In Thailand, information on
biomass household cooking and the effects of smoke is limited. Juntarawijit explored risk factors and respiratory symptoms
in subjects who were in charge of cooking. They randomly selected 1,134 households
and collected data on their activities for the following 30 days through a
questionnaire. Rhinitis, chronic cough, and dyspnea were the most common symptoms
associated with the number of hours spent cooking in the kitchen and the number
of dishes prepared. Even cooking with clean fuel can quantitatively increase
the risk of respiratory difficulties and symptoms.15
Finally, Li et al investigated
the use of “solid fuels” for cooking and heating (coal, wood) compared to
“clean fuels” (gas, electricity) and the risk of developing COPD. They
monitored 475,827 adults (30-79 years) without COPD for 9 years. In this
prospective cohort study, they reported 9,835 cases of COPD associated with the
use of coal and wood, limited to women and smokers.16
COPD AND OCCUPATIONAL EXPOSURE
Regarding COPD, in many
countries, especially those in the third world, there is
a significant number of non-tobacco-related risk agents capable of causing
COPD. Publications from 50 years ago already mentioned the possibility that
occupational factors could cause COPD.
Around 2003, the American
Thoracic Society assessed the accumulated evidence regarding the role of
occupational factors in the pathogenesis of COPD, establishing that
approximately 15 % of cases could be attributed to occupational exposure.17,18
Subsequently, several
publications arrived at similar conclusions associating COPD with workplace
exposure. However, a comprehensive national study conducted in the United
States from 1994 to 1998 estimated the prevalence of COPD and its relationship
with jobs in the industry. Investigating a cohort of 9,823 subjects aged
30-75, adjusted by age, smoking status, pack-years, body mass index, and
socioeconomic status, cases of COPD attributed to work were estimated at 19.2
%, rising to 31.1 % in non-smokers.19-
21
In their publication, Fishwick et al list a lengthy catalog of occupations that
can induce occupational COPD, including: construction workers, individuals
exposed to silicon carbide foundries, coke ovens, railway workers, and those in
the wood industry using paint or welding.22
In the United States, railway
workers have been exposed to diesel exhaust gases since diesel locomotives were
introduced after World War II. By 1959, 95 % of their locomotives were diesel.
Diesel exhaust gases are a mixture of extra-fine particles covered in organic
substances and vapors. Limited information exists about whether this exposure
can cause or worsen obstructive lung diseases.
Hart et al conducted a study of
cases and causes of death in railway workers between
1981-1982, and found 536 cases of COPD and 1,525 controls whose death
wasn’t related to diesel gases. Adjusted by age, smoking status, and race,
locomotive engineers and conductors exposed to diesel gases had a higher risk
of mortality from COPD, which increased proportionally to years of work. They
conclude by stating that more studies are needed to evaluate whether the risk
is apparent with new-generation engines (which emit much less gas).23
1. COPD and coke
Coke is produced by mixing and
heating coal at 1000-1400˚C in the absence of oxygen. Its manufacturing
is one of the most environmentally polluting industrial processes, as it
involves the distillation of tar and light oils during the procedure. In China
alone, there are 1,900 coke plants producing 180 million tons and employing
300,000 workers in their furnaces, who are exposed to emissions containing
polycyclic aromatic hydrocarbons and volatile organic compounds. Epidemiology
has revealed that workers with prolonged exposure have a significantly higher
risk of lung cancer, as these emissions have adverse health effects.24
Hu et al investigated 712 coke
oven workers and 211 controls in China, measuring concentrations of
benzene-soluble fraction and quantitatively estimating individual cumulative
exposure. They gathered information on smoking and respiratory symptoms, and
performed a spirometry.
The authors found that
benzene-soluble fraction levels exceeded legal limits and that coke workers had
a higher risk of experiencing cough, chronic expectoration, and functional
impairment. In smokers, the risk of COPD was 58 times higher than in
non-smokers not exposed to coke.25
2. COPD related to livestock and agricultural activities
In agriculture and livestock
farming, there is a risk of respiratory morbidity and mortality. In a 2007
publication, Lamprecht et al reported studies conducted
on 1,258 adults engaged in agricultural and livestock activities. They included
a spirometry and a questionnaire on work activities,
smoking habits, and previous lung conditions. 30.2 % of farmers suffered from
airway obstruction. In this population, the risk of irreversible obstruction
attributable to rural tasks was 7.7 %, thus agriculture was considered a risk
factor.26
In a study involving 4,735
Norwegian farmers, Eduard et al measured exposure to dust, spores, endotoxins,
bacteria, mites, ß-D glucans, fungal antigens,
organic and inorganic dust, silica, ammonia, and hydrogen sulfide. They also evaluated
lung function and symptoms.
Exposure to most agents predicted
respiratory morbidity, with significant associations found for ammonia,
hydrogen sulfide, and inorganic dust.
Livestock farmers were more
likely to have chronic bronchitis. Farmers with atopy
had a significantly lower FEV1 (forced expiratory volume in one second). In
the latter group, the effects of agriculture and specific exposure were substantially
higher, and they were more susceptible to developing COPD.26
3. COPD and automotive work
In automobiles, combustion gases
constitute a substantial source of pollution and a health hazard. Traffic
police are exposed to these gases, and the pulmonary involvement can be
asymptomatic. Naik et al conducted a spirometry study on 136 traffic police officers who worked
for more than 6 months in the Kashmir Valley (India), as well as 140 unexposed
controls of the same age and gender. Among the 136 traffic police officers,
11.2 % had abnormal lung function tests compared to 3.6 % of the 140 controls.
Both the FEV1 and the forced vital capacity (FVC) showed a marked decrease,
with 5.8 % exhibiting an obstructive pattern and 5.1 % a restrictive pattern.
Exposure to exhaust gases for more than 10 years was notably associated with
lung function abnormalities (p = 0.038). The authors suggest that, in addition
to protective measures, personnel should undergo a periodic evaluation of their
lung functions.27
In highly industrialized
countries, occupational lung diseases, especially asthma, have surpassed
pneumoconiosis (caused by inadequate mineral extraction in mining deposits) as
the most significant cause of work-related respiratory conditions.28- 30
4. COPD related to excavation and formwork activities
As a complement to a publication
from 2001, Oliver et al conducted an 18-month investigation on 343 workers
engaged in tunnel excavation and formwork exposed to respirable
silica concentrations exceeding legal limits. This investigation involved
questionnaires, clinical-radiographic examinations, and an examination of the
relationship between these factors and work activities, including breaking
cement walls, spillage from formwork chipping, and tunnel excavation/mining. No
cases of silicosis were found in X-rays performed.
The overall prevalence of chronic
bronchitis, asthma, dyspnea, and medically diagnosed asthma was 10.7 %, 25 %,
29 %, and 6.6 %, respectively. Breaking cement walls was associated with
chronic bronchitis and asthma. Those involved in tunnel construction exposed to
silica and cement dust have a higher risk of suffering from respiratory diseases,
which varies according to the different work activities. The authors emphasize
the importance of exposure and suggest that tunnel construction with formwork
could be associated with a higher risk, compared to traditional methods.31
5. COPD in non-smoking and passive smoking at work
Passive smoking is associated
with a higher risk of coronary heart disease and lung cancer, with an unknown risk-free
exposure level. Findings suggest that the prevalence rate of passive smoking
exposure among non-smoking workers is 10 %.
Though relatively low, this
represents 12.5 million workers exposed 2-3 times per week in the United
States.
As of late 2010, 26 states in the
U.S. had comprehensive smoke-free workplace laws, except for southern states,
possibly contributing to the 11.6 % of non-smoking workers exposed to passive
smoking.
A study by Calvert et al
investigated the national prevalence of workplace exposure to potential skin
hazards, passive smoking, and outdoor work in several industries and
occupations, along with the national prevalence of chronic exposure to vapors,
gas, dust, and fumes.
Among 17,524 adults who worked
during the 12 months prior to the interview, the highest prevalence was
recorded in construction, mining, and agriculture. For outdoor work,
occupational exposure was more common in agriculture (85 %), construction (73
%), and mining (65 %). Finally, exposure to vapors, gas, dust, and fumes was
more common among mining workers (67 %), agriculture (53 %), and construction
(51 %).
They identified the industries
and occupations with the highest prevalence of potentially hazardous workplace
exposure and provided goals for intervention and research activities.32
COPD has always been considered a
condition predominantly affecting males, due to its strong association with
smoking. However, the increase in smoking habits among women has led to COPD becoming
increasingly prevalent in this gender.
A study published in the U.S.
comparing two cohorts from different periods revealed that the prevalence of
COPD in women, confirmed by spirometry, had increased
from 50.8 to 58.2 per 1000, while in men, it had decreased from 108.1 to 74.3
per 1000 in the same period. Similar trends were observed in Australia, the
Netherlands, and Canada, but in third-world countries, it is still higher in
males. Morbidity has remained stable since 1995, but mortality, which was
always higher in men, showed similar risks for both genders from 2000 to 2010.
According to Aryal
et al, women with COPD may exhibit a different pattern of comorbidities
compared to men: a higher tendency for chronic bronchitis, osteoporosis, and
depression symptoms but better survival after exacerbation episodes.33- 35
6. COPD and disinfectant agents
Exposure to disinfectants has
been associated with pulmonary conditions, including asthma, in healthcare
workers. Despite the biological evidence of the association between antiseptics
and the risk of COPD, data on this association are scarce. In 2019, Dumas et al
investigated and published in a prospective cohort study of nurses their
findings on the relationship between exposure to disinfectants and the
incidence of COPD. They conducted biennial questionnaires tracking 116,429
nurses, including those without a history of COPD, using data collected from
2009 to 2015.
Over nearly 369,000 person-years
of follow-up, 582 nurses reported having COPD. The periodic use of
disinfectants solely for cleaning medical instruments and surfaces was
associated with the incidence of the condition. Exposure to several
disinfectants at high concentrations (hydrogen peroxide, glutaraldehyde,
chlorine, alcohol, and quaternary ammonium compounds) showed a significant
relationship with the incidence of COPD, and this association did not vary
based on smoking habits or prior asthma status.
The results suggest that the
regular use of chemical disinfectants among nurses may be a risk factor for
developing COPD. If confirmed, strategies should be developed to reduce
exposure while remaining compatible with infection control in medical
environments.36
7. Occupational COPD and gender differences
The study by Eng
examined gender differences in occupational exposure models to investigate
whether the identified discrepancies were due to gender disparities in
employment and/or gender-specific objections within tasks.
To do so, they selected 1,431 men
and 1,572 women adjusted by age through telephone interviews. Women: women
had 30 % higher probabilities of engaging in monotonous tasks and high-speed
jobs, as well as exposure to disinfectants, textile dust, and hair dyes. Men:
men had 2-4 times higher possibilities of exposure to irregular schedules,
loud noises, night shifts, vibrating tools, gases, and dust.
Even within the same occupation,
significant differences existed in occupational exposure patterns. Therefore,
gender should be taken into account in the research of occupational health.37
In conclusion, it is important to
consider the following:
1. There is a constant
correlation between COPD and occupational exposure to noxious substances, regardless
of the age of the worker and tobacco consumption.
2. The pathogenesis of COPD and
its relationship with occupational exposure to dust, gases, and fumes is not
fully understood. Further experimental and epidemiological research on a
larger scale is needed to confirm the relationship between these two
variables.
3. A thorough literature review
revealed that approximately 15 % of COPD is related to work, and aggravated by
smoking. New agents causing COPD continue to be reported and published.
4. Women exhibit a different
clinical manifestation of COPD and, under similar exposures, are more prone to
developing the disease compared to men.
5. Personal protection for
workers is of particular importance since it is challenging to assess the
nature of dust, smoke, or gases, their ambient concentration, and the duration
of the exposure.
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