Continuing Education Activity

Following its relatively recent birth in the 1700s from the pioneering work of Dr. Bernardino Ramazzini, occupational medicine has grown to encompass an array of respiratory conditions. One such condition is byssinosis, a collection of respiratory symptoms elicited by exposure to raw nonsynthetic textiles during their manufacturing process. Symptoms range from mild respiratory irritation, known colloquially as "Monday fever" due to its occurrence at the beginning of the workweek, to more severe chronic conditions like bronchitis and fibrosis. Over the years, byssinosis has been referred to as cotton worker's lung, brown lung disease, Monday fever, and mill fever. This activity reviews the cause, diverse respiratory symptoms, and pathophysiology of byssinosis. It also highlights the role of the interprofessional team in its prevention and management.

Clinicians participating in this activity can expect to achieve an understanding of the intricacies of byssinosis, its impact on respiratory health, and the evolving strategies for its management. Participants gain insights into the pivotal impact of Occupational Safety and Health Administration standards in enhancing detection and prevention since 1978.

Objectives:

• Apply knowledge of byssinosis pathophysiology in developing and adapting care plans, considering the inflammatory processes and long-term respiratory implications associated with the condition.

• Select and utilize appropriate diagnostic tools, such as imaging studies and laboratory tests, to aid in the accurate and timely diagnosis of byssinosis in affected individuals.

• Assess current guidelines and best practices in the clinical management of byssinosis, incorporating the latest advancements in treatment modalities and therapeutic approaches.

• Collaborate with an interprofessional team to develop and implement comprehensive strategies for preventing and managing byssinosis in occupational settings.

Introduction

Following its relatively recent birth in the 1700s from the pioneering work of Dr Bernardino Ramazzini, occupational medicine has grown to encompass an array of respiratory conditions. One such condition is byssinosis, a collection of respiratory symptoms elicited by exposure to raw, nonsynthetic textiles during their manufacturing process. Over the years, byssinosis has been referred to as cotton worker's lung, brown lung disease, Monday fever, and mill fever.

In 1978, the Occupational Safety and Health Administration (OSHA) published a mandatory standard regarding exposure to cotton dust in the workplace, which improved both the detection and prevention of byssinosis. Byssinosis is more common in people who work in the textile industry, where cotton fabrics are made. The disease is most common in the United States in Georgia, North and South Carolina, and Maryland.[1][2][3]

Etiology

The etiology of byssinosis lies in the inhalation of airborne particles generated during the processing of raw, nonsynthetic textiles, particularly cotton. Classically, exposure to cotton dust during the spinning and manufacturing process causes byssinosis. However, exposure to jute, flax, and hemp fibers has also been implicated in its development.[4] Recent studies identified that endotoxin released from the cell wall of bacteria within textile fibers contributes to byssinosis symptoms. 

Continuous exposure to these inhalants, often in occupational settings like textile mills, can result in persistent respiratory issues, including bronchitis and fibrosis. While the exact pathophysiological mechanisms are not fully elucidated, the role of these airborne particles in provoking inflammation and respiratory distress is central to the development of byssinosis. Understanding the etiology is crucial for implementing effective preventive measures and interventions to mitigate the impact of this occupational lung disease. People who smoke are at a high risk of acquiring the disorder.[5][6]

Epidemiology

Data published by the Centers for Disease Control (CDC) confirms a significant decline in reported deaths from byssinosis between 1979 and 2010; however, comprehensive epidemiological data are lacking. Globally, byssinosis is not rare. Based on some older data, the quoted prevalence of byssinosis in the United Kingdom is approximately 4%. In contrast, byssinosis is common in countries where cotton industries flourish, such as India, Pakistan, Nepal, Sri Lanka, and Bangladesh. In addition to the cotton industry, exposure to jute, hemp, and flex also cause byssinosis. The general population in these countries smokes heavily, which tends to exacerbate the symptoms. Despite modernization and the introduction of better working environments, byssinosis still is common in many parts of Pakistan, India, Indonesia, Ethiopia, Turkey, and Sudan.[4][7]

Pathophysiology

The underlying pathophysiology is likely secondary to endotoxin present in bacteria found in cotton. This endotoxin is a lipopolysaccharide found in the outer membrane of gram-negative bacteria, which reside within the cotton dust.[8] The presence of endotoxin causes a release of nitric oxide, which subsequently reacts with superoxide and leads to an inflammatory response that leads to subsequent fibrosis.[9] Exposure has been implicated as the key mediator of respiratory disease among these workers, with studies showing a decline in forced expiratory volume exhaled in the first second (FEV1) with endotoxin exposure. However, this is not uniform, and there seems to be a variable response with an even greater decline in FEV1 in those with polymorphisms in the tumor necrosis factor (TNF) gene.[10][11][12]

History and Physical

The beginning steps in yarn preparation produce the most cotton dust. Therefore, the closer to the beginning of the process a worker is, the higher the level of dust exposure and the greater the risk of experiencing a pulmonary reaction or response.

In the initial stages, symptoms manifest as frequent coughing, chest tightness, dyspnea, and, at times, wheezing, particularly within a few hours of exposure (or reexposure) to the workplace. Patients usually report symptoms towards the beginning of their work week and, thus, the term 'Monday fever.' This is in contrast to patients with occupational asthma who experience symptoms towards the end of their work week. Once exposure and lung irritation persist, patients will no longer have cyclical symptoms and progress to the chronic byssinosis state.[13] In conjunction with the above symptoms, cough with sputum production may also manifest, leading to a misdiagnosis of chronic obstructive pulmonary disease (COPD) or bronchitis.

Evaluation

There are no known diagnostic tests for byssinosis. However, acute exposure to cotton dust can result in a serological increase in leukocyte count. The diagnosis is often difficult because the condition can mimic asthma and many other pneumoconioses. Besides the physical exam, which is nonspecific, a chest x-ray is required to rule out other pathologies. The biggest clue to the disease is that the patient usually complains that the symptoms get worse when he or she comes to work on Monday (hence the name Monday disease) and gets better when off work.

In a small proportion of the patients, physical examination is notable for the presence of fine basilar rales.[14] X-ray examination demonstrates the presence of hyperlucency, diaphragm flattening, and emphysema.[4] Diffuse and ill-defined haziness, mainly in the lower lung fields, are also seen. A chest CT scan is usually performed when the diagnosis is uncertain, or one wants to rule out other disorders. The available literature on radiological findings is limited; however, ground-glass opacities distributed largely in a basal fashion with centrilobular nodules on high-resolution CT have been reported.[15]

Pulmonary function testing (PFT) can support suspected byssinosis by revealing a decline in FEV1 below 80% of their predicted values or a greater than 5% decline in their intrashift FEV1. The normal, physiologic 20 mL to 30 mL annual decline in FEV1 seems to be accelerated to a value closer to 50 mL/year in cotton workers.[16]

Treatment / Management

Exiting the work environment seems to be a beneficial approach for these patients. However, the available data on an annual FEV1 decline is conflicting. Early diagnosis and removal will likely lead to recovery in FEV1, but with disease progression, this change can be permanent.[10]

Symptomatic management with short- and long-acting, inhaled beta-agonists and possibly corticosteroid inhalers may be necessary. Bronchodilators may be required for many months to improve symptoms. A short course of steroids will help those with severe symptoms. It is vital that the patient stop smoking.[17][9]

Differential Diagnosis

The symptoms due to byssinosis of shortness of breath, chest tightness, and fever are found in many other diagnoses.[18] These diagnoses include the following:

• Asthma
• Pneumoconiosis due to other inhaled dust
  • Asbestosis
  • Silicosis
  • Berylliosis
  • Coal worker's lung
  • Farmer's lung
• Metal fume fever
• Polymer fume fever
• Interstitial lung fibrosis
• Hypersensitivity pneumonitis
• Sarcoidosis
• Pulmonary embolism
• Acute coronary syndrome

Prognosis

Most people recover uneventfully with treatment, given the avoidance of exposure to cotton. For those individuals who are misdiagnosed or untreated, chronic exposure to cotton can lead to eventual lung fibrosis and impaired lung function. Most of these individuals will require oxygen and have impaired exercise function.[16] Deaths from chronic exposure are not uncommon in Pakistan and India, where textile industries still flourish.[19][20] This illustrates the importance of early recognition and removal from cotton dust exposure.[1]

Complications

Complications of byssinosis include the following:

• Lung fibrosis
• Oxygen dependency
• Disability
• Reduced exercise tolerance
• Premature death

Postoperative and Rehabilitation Care

Once byssinosis is diagnosed, the patient must be told to avoid all exposure to cotton and other fabrics. One may require a career change to avoid further exposure to cotton. Physical rehabilitation may benefit patients who have had long-term exposure. Close follow-up with the primary physician is needed to monitor lung function.

Consultations

Once a patient is diagnosed with byssinosis, the patient should be referred to a pulmonologist for specialized care.

Deterrence and Patient Education

The best way to avoid byssinosis is by preventing exposure to the manufacturing process of cotton and other related fabrics. If this is not possible, the worker should wear an appropriate mask to avoid the inhalation of the particles.

Pearls and Other Issues

Prevention lies predominantly with raw textile processors' adherence to the OSHA regulations. This includes enforcement of respirator mask use, dust control with extractor fans and adequate ventilation, bactericidal treatment of raw products, and continued annual employee medical check-ups, including byssinosis symptom questionnaires, spirometry, and intrashift spirometry. Avoidance of tobacco use is likely to reduce the severity of symptoms; however, robust evidence proving this is lacking.

Enhancing Healthcare Team Outcomes

Diagnosing and managing byssinosis is not always easy and is best done with an interprofessional team that includes a primary care or occupational health physician, internist, pulmonologist, nurse practitioner, pathologist, and radiologist. The critical aspect of treatment is removing the patient from further exposure. Some patients may benefit from bronchodilators and steroid inhalers. Patients must be educated on discontinuing smoking and wearing a mask when working with cotton fabrics. 

The outlook for patients with byssinosis is guarded. While some patients do improve, many continue to have progression of the disease and develop severe respiratory distress even at rest.[21] Clinicians must have proficiency in interpreting pulmonary function tests and occupational exposure assessments. Health professionals should stay abreast of evolving medical knowledge and technologies related to byssinosis to deliver optimal patient care.

Physicians, advanced care practitioners, nurses, pharmacists, and other health professionals share responsibilities in byssinosis care. This includes early detection through regular screenings, prompt intervention, and ongoing patient education. Adhering to occupational safety guidelines and advocating for policy changes to enhance workplace conditions are collective responsibilities. Timely reporting of suspected cases and active participation in interdisciplinary teams contribute to effective patient care.

Healthcare professionals must communicate closely and coordinate care seamlessly to optimize patient outcomes. This involves integrating medical interventions, occupational health measures, and patient education into a cohesive care plan. Care coordination also extends to collaborating with external stakeholders, such as employers, occupational health specialists, and public health agencies, to ensure a unified and comprehensive approach to byssinosis prevention and management.