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exposure to reduce the risk of rapid progression, as well as further longitudinal investigation into interventions that delay progression.
Diagnostic Considerations
HRCT of the chest offers greater detail and sensitivity for detecting silicosis compared with chest radiography. In two Australian case series of AS silicosis, 35 – 43 % of affected workers had abnormal HRCT scans showing silicosis despite normal chest radiographs. 74, 75 An Italian study similarly found that among 24 workers diagnosed with silicosis on HRCT, only 10 had abnormal chest radiographs. 83 Based on this higher sensitivity for early disease, regulatory agencies in Western Australia and California have replaced chest radiographs with mandatory chest CT scans for screening, in addition to spirometry and medical exams.
8, 34, 105
Pulmonary function testing reveals heterogeneous abnormalities, with a restrictive ventilatory defect observed most frequently. 4, 8, 46 However, obstructive or mixed ventilatory defects were found in 16 – 33 % of workers with AS silicosis. 4, 8, 46 Nevertheless, a substantial proportion of AS workers with abnormal chest CT findings have preserved pulmonary function, particularly at the time of initial diagnosis. In an Italian case series of individuals with abnormal CT scans, only 33 % exhibited abnormal spirometry, whereas 50 % had impaired DLCO. 106 Notably, even among workers with PMF, spirometry remained normal in 47.1 % of cases in an Australian series. 8 Accordingly, compared with chest CT, pulmonary function testing has poor sensitivity as a screening test for silicosis. Still, it may serve as an important indicator of disease progression and functional impairment.
Current Treatment Gaps and Challenges Treatment of Co-occurring Disease and Supportive Care
Because silicosis is frequently complicated by autoimmune disease and infections, clinicians should perform a thorough history and physical examination at the time of diagnosis, with particular attention to coexisting autoimmune disease, pulmonary infections, and malignancy. Autoimmune screening serologies( such as antinuclear antibody) and tuberculosis screening( with interferon gamma release assay or tuberculin skin test) should be performed. If symptoms or imaging are consistent with infection, sputum bacterial, fungal, and Acid Fast Bacillus staining and cultures, and Mycobacterium tuberculosis polymerase chain reaction testing should be considered. 2 Because respirable crystalline silica is a carcinogen, lung cancer may arise with or without silicosis, 107, 108 and distinguishing cancer from PMF can be challenging, warranting a low threshold for investigation with serial imaging or biopsy of suspicious nodules. Appropriate assessment for obstructive lung diseases, including asthma and COPD, should be performed, and these conditions treated with appropriate inhaler therapy. 98 Symptoms, including chronic cough and chest pain, should be addressed to improve quality of life.
People with silicosis often experience exercise limitation, fatigue, anxiety, depression, and substance misuse. 109, 110 Referral to pulmonary rehabilitation, mental health, and patient support programs is recommended.
Supportive care with oxygen therapy should be provided to patients with silicosis and hypoxemia, as supplemental oxygen improves exercise capacity and health-related quality of life in patients with interstitial lung disease and exertional or resting hypoxemia. 111 – 113 Additionally, expert consensus and clinical guidelines recommend oxygen therapy for symptomatic relief of dyspnea and prevention of organ dysfunction in hypoxemic patients with fibrotic lung disease, including silicosis.
111, 114
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