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Occupational Lung Disease6 Thorax 19,96;51:632-637 .32632 Thorax 1 9.6;51:632-637 Occupational lung disease 6 Series editor: P S Burge Thorax: first published as 10.1136/thx.51.6.632 on 1 June 1996. Downloaded from Bysslnosis: a review R McL Niven, C A C Pickering Over the past two decades the cotton industry article will relate to the disease as described in in the United Kingdom has suffered from a these early epidemiological studies. major recession. Cheaply produced and sub- sidised imported cotton has decimated a major industry which was responsible for much ofthe Symptoms industrial wealth in the north west of England. The classical form ofbyssinosis is characterised With the diminishing industry, we are also by a feeling of chest tightness and difficulty in losing one of the most studied but least under- breathing which the worker experiences as stood occupational diseases, byssinosis. Our being most severe on the first day ofthe working own study of the working population of the week after a period of absence from work. The remaining Lancashire textile mills is now in its symptoms continue after the individual has seventh year, with up to 1500 workers having finished work and may even progress during been seen each year (although the recession the evening. However, they are perceived as has reduced this to 1000 in the last two years). being less troublesome on subsequent days. Of the original 10 mills included in the study, The reason for this lessening of symptoms only two remain in production. remains unknown. The early reports of the health of cotton The affected worker will not experience the workers describe a "work-related cough as- symptoms until he or she has worked for many sociated with a sensation ofuneasiness beneath years in the industry; indeed, it may be seen the sternum"' and later the unusual periodicity for the first time 25 years after starting to ofthe disease "all the workers have told us that work in the industry and is rare in individuals http://thorax.bmj.com/ the dust bothered them much less on the last continuously exposed for less than 10 years. days ofthe week than on Monday or Tuesday". This clearly distinguishes it from occupational The workers attributed this to the interruption asthma, and makes specific sensitisation an of work making them lose, in part, their habit- unlikely cause. uation to the dust.2 The duration and frequency ofthe symptoms Over a century later Sir Richard Schilling are used as the basis for the original clas- performed the first substantial epidemiological sification of the disease, which was later up- studies of cotton workers and described and dated to include impairment oflung function.67 on September 27, 2021 by guest. Protected copyright. classified the specific features recognised in The classification included clinical grades C 1/2 the UK as byssinosis.3 Over recent years new to C3 and functional grades FO to F3, based terminology has been introduced, dividing bys- on symptoms and ventilatory impairment, but into "acute" and "chronic" forms. Acute this grading system had important limitations. sinosis The clinical did not take into account byssinosis refers to the acute airways response grades of vo- the acute irritant effects of exposure to cotton which occurs in approximately a third dust or the changes in lung function which may lunteers exposed to cotton dust for the first occur in the absence of symptoms. time. Substantial falls in FEV, exceeding 30% It was traditionally accepted that the disease have been reported in artificial cardroom ex- progressed from one grade to another, pre- posures to cotton dust in cotton naive subjects.4 sumably as a result of continuing exposure. This type of response may account for the However, two longitudinal studies have shown substantial labour tumover observed during the that this is unlikely to be the case89 as, in both first year of employment in cotton spinning studies, individuals were seen to commence at mills. A study of Finnish cotton spinning mills grade 2 or 3 byssinosis without passing through reported that one in 10 employees left within the preceding grades. Individuals have also two weeks and one in four within three months been seen whose symptoms have remitted and North West Lung of taking up employment.5 The patho- who have therefore gone down grades despite Centre, physiological process underlying this response to cotton dust. Wythenshawe continuing exposure Hospital, is unknown, but probably represents a mixture Symptoms other than those described by South}noor Road, of acute irritant or toxic reactions following Schilling are seen in workers with byssinosis. Manchester M23 9LT, exposure to cotton dust. Chronic byssinosis is In our own study workers with byssinosis have UK R McL Niven applied to the symptoms and disability de- reported other symptoms, including cough and C A C Pickering scribed in the early epidemiological studies wheeze. Other workers describe cough and be most severe on the first of Correspondence to: which may develop after 20-25 years exposure wheeze to day Dr C A C Pickering. to cotton dust. The term byssinosis in this the working week but in the absence of chest Byssinosis: a review 633 WHO grading system for byssinosis and by our own field experience of asthmatic Classification Symptons subjects entering the industry and having to leave due to increasing asthmatic symptoms. Grade 0 No symptoms Byssinosis: Grade BI Chest tightness and/or shortness of breath on most of first Thorax: first published as 10.1136/thx.51.6.632 on 1 June 1996. Downloaded from days back at work Grade B2 Chest tightness and/or shortness of breath on the first and other days of the working week Respiratory physiology Respiratory tract irritation: Grade RTI I Cough associated with dust exposure Changes in lung function have frequently been Grade RTI 2 Persistent phlegm (i.e. on most days during 3 months of the demonstrated in cotton workers - both acutely, year) initiated or exacerbated by dust exposure Grade RTI 3 Persistent phlegm initiated or made worse by dust exposure across shift, and chronically - as estimated from either with exacerbations of chest illness or persisting for 2 cross sectional and prospective longitudinal years or more Lung function: studies. Some of these studies have shown Acute changes across shift falls which are larger on the first No effect A consistent' decline in FEV, of less than 5% or an increase in FEV, during the work shift working day of the week than on later days.3' 4 Mild effect A consistente decline of 5-10% in FEVI during the work shift These findings support the symptom period- Moderate effect A consistent' decline of 10-20% in FEV, during the work shift icity of the disease. However, in one study Severe effect A decline of 20% or more in FEVy during the work shift of byssinotic subjects, while the across shift fall Chronic changes No effect FEV,b 80% of predicted value' was largest on the first day ofthe working week, Mild to moderate effect FEVy1 60-79% of predicted value' the forced expiratory volume in one second Severe effect FEV," less than 60% of predicted valuec (FEV,) after the shift was lowest on the last a A decline occurring in at least three consecutive tests made after an absence from dust exposure day ofthe week and the across shift falls became of two days or more. bPredicted values should be based on data obtained from local populations or similar ethnic and progressively smaller during the study week.'5 social class groups. It may be that the extent of change in lung ' By a preshift test after an absence from dust exposure of two days or more. function associated with the working shift de- termines the severity of symptoms, perhaps combined with a degree of habituation or con- tightness, and therefore do not fulfil the criteria ditioning to a lower level of lung function. for byssinosis. This group of workers is very While most studies have concentrated on similar to those with byssinosis in terms oftheir forced expiratory volumes, some studies have demographic features and exposure histories, shown larger changes in the calibre of the small and it seems likely that these individuals are airways"" which have led to the suggestion suffering from the same disease process which that the disease process starts in the smaller is being expressed in a different way. peripheral airways.'9 Changes are greater for Respiratory disease and symptoms not tem- workers diagnosed as having byssinosis or porally related to the working environment are chronic bronchitis than in asymptomatic work- also more common in the cotton textile en- ers and this is not affected by the smoking http://thorax.bmj.com/ vironment. Berry described chronic bronchitis status of the individual.'520 as being more common among cotton workers,8 No changes in gas transfer have been dem- and a recent review of our own data on nearly onstrated in workers exposed to hemp, flax, or 3000 textile workers has confirmed these find- cotton,'7 but in a challenge study of previous ings. The size of the cohort allowed sufficient mill workers changes in arterial gas tensions numbers of never smoking cotton workers to were found and correlated to falls in FEV1 after be examined. The effect of current exposure exposure to hemp dust.2' to cotton compared with the control group was While several studies have shown that cotton on September 27, 2021 by guest. Protected copyright. found to be at least as important as smoking, workers as a cohort have lower lung function once other confounders had been accounted than predicted,2223 few have successfully ob- for.
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