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Diagnosis and Initial Management of Nonmalignant Diseases Related to Asbestos

A recent official statement of the American Thoracic Society (1) contains statements that are not supported by the literature:

1. "The clinical evaluation...should consider subjective symptoms as well as objective findings..." (p. 695). "The diagnosis of asbestosis is ideally based on an accurate exposure history, obtained whenever possible directly from the patient...." (p. 695).
   
2. "Plaques are indicators of increased risk for the future development of asbestosis..." (p. 707).
   
3. "These obstructive findings may be due to asbestos-induced small airway disease. Thus, mixed restrictive and obstructive abnormalities do not rule out asbestosis or necessarily imply that asbestos has not caused an obstructive functional impairment..." (p. 701). "In general, the magnitude of the asbestos effect on airway function is relatively small. This effect, by itself, is unlikely to result in functional impairment or the usual symptoms and signs of chronic obstructive pulmonary disease. However, if superimposed on another disease process, the additional loss of [lung] function due to the asbestos effect might contribute significantly to increased functional impairment, especially in persons with low lung function" (p. 708). "Tobacco smoking is the predominant cause of airway obstruction in asbestos-exposed workers who smoke...." (p. 710).
   
4. "A chest film...showing characteristic signs of asbestosis in the presence of a compatible history of exposure is adequate for diagnosis of the disease: further imaging procedures are not required" (p. 696). "The positive predictive value of the minimally abnormal chest film alone in making the diagnosis of asbestosis may fall below 30% when exposure to asbestos has been infrequent and exceed 50% when it has been prevalent" (p. 710).
   

Many of the statements are conflicting or inaccurate. Patient histories and subjective symptoms are unreliable, particularly in legal proceedings (2). Pleural plaques are evidence of exposure and do not indicate a greatly increased risk for asbestos-related disease in those workers with equal exposure and no radiologically visible plaques (3). The implication that asbestos contributes to clinically significant COPD is not supportable (4). The role of the International Labour Organization (ILO) B-reader chest X-ray interpretation has recently come into question (5, 6).

Dorsett D. Smith

University of Washington Seattle, Washington

FOOTNOTES

Conflict of Interest Statement: D.D.S. has no financial relationship with any asbestos manufacturer or commercial entity but has been an expert witness for the defense in asbestos litigation.

REFERENCES

1. American Thoracic Society. Diagnosis and initial management of nonmalignant diseases related to asbestos. Am J Respir Crit Care Med 2004;170:691–715.[Free Full Text]
2. Agostoni P, Smith DD, Schoene R, Robertson H, Butler J. Evaluation of breathlessness in asbestos workers: results of exercise testing. Am Rev Respir Dis 1987;135:812–816.[Medline]
3. Smith DD. Plaques, cancer and confusion. Chest 1994;105:8–9.[Free Full Text]
4. Smith DD. Does asbestos exposure cause obstructive airways disease? [letter] Chest 2004;126:1000.[Free Full Text]
5. Janower ML, Berlin L. "B" Reader's radiographic interpretations in asbestos litigation: is something rotten in the courtroom? Acad Radiol 2004;11:841–842.[Medline]
6. Gitlin JN, Cook LL, Linton OW, Garrett-Mayer E. Comparison of "B" readers' interpretations of chest radiographs for asbestos related changes. Acad Radiol 2004;11:843–856.[Medline]

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