PneumoconiosisPneumoconiosis. . SilicosisSilicosis. . SilicatosisSilicatosis. . Vibration diseaseVibration disease

Asist. O.S. Kvasnitska

Internal medicine department №2

•Recent decades have seen a marked increase in concern about the adverse health effects of hazardous exposures in the workplace and elsewhere in the environment

•Endless array of hazardous substances in industrial and agriculture sectors

•The lung – with its extensive surface area, high blood flow and thin alveolar epithelium– – is an important site of contact with these substances in the environment

Introduction

•Occupational lung diseases are a broad group of diagnoses caused by the inhalation of dusts, chemicals, or proteins

•“Pneumoconiosis” is the term used for the diseases associated with inhaling mineral dusts

•The severity of the disease is related to the material inhaled and the intensity and duration of the exposure

•Individuals who do not work in the industry can develop occupational disease through indirect exposure

•These diseases have been documented as far back as ancient Greece and Rome; the incidence of the disease increased dramatically with the development of modern industry.

Importance of occupational Importance of occupational lung diseaseslung diseases

Knowledge of cause may affect patient management and prognosis and may prevent further disease progression in the affected person

Establishment of cause may have significant legal, financial and social implications for the patient

The recognition of occupational and environmental risk factors can also have important public health and policy

Occupational and environmental lung diseases can also serve as important disease models

•Inorganic dust (consists of particles of minerals and metals)

•Organic dust (contains particles of plant and animal origin, and also microorganisms that are on them, and their waste products)

•Mixed dust

Industrial dust

Inorganic dust

Asbestos fibers underthe electron microscope Talc - hydrated aluminum silicate Сoal dust of mining enterprises

Organic dust

Dust generated during processing of raw cotton Moldy hay

ClassificationClassification 1996 1996 year,year, The Russian Academy of Medical The Russian Academy of Medical

Sciences Research institute of Health Sciences Research institute of Health MedicineMedicine

1. Pneumoconiosis, which develops by influence moderately and highly fibrogenic dust (with containing free silica more than 10 %) – silicosis, antracosilicosis, silicosiderhosis, silicisilicatosis

2. Pneumoconiosis, which develops by influence mild fibrogenic dust (with containing free silica less than 10 % or not containing it) – silicatosis (asbestosis, talcosis, caolinosis, olivinosis, nephelinosis, pneumoconiosis from exposure to cement dust) – carboconiosis (anthracosis, graphitosis, black-lung carbon disease etc.), polisher’s and emery’s pneumoconiosis, metalloconiosis or pneumoconiosis from exposure radiopaque dusts (siderosis, including of aerosol electric welding or gas cutting iron products, baritoz, stanioz, manganokonioz etc).

3. Pneumoconiosis, which develops by influence toxic-allergic aerosols (dust, which containing metals-allergens, plastic and other polymeric material compounds, organic dust etc) – berylliosis, aluminosis, farmer's lung and other hypersensitivity pneumonitis

International Labour organization, International Labour organization, Geneva. List of occupational Diseases Geneva. List of occupational Diseases (2002)(2002)1. Diseases caused by agents

1.1 Chemical agents ( 32 items)1.2 Physical agents ( 8 items )1.3 Biological agents ( infectious and

parasitic diseases contracted in an occupation where there is a par contracted in an occupation where there is a particular risk of contamination )

2. Diseases by target organ systems2.1 Occupational respiratory diseases2.2 Occupational skin diseases2.3 Occupational musculoskeletal disorders

International Labour organization, International Labour organization, Geneva. List of occupational Diseases Geneva. List of occupational Diseases (2002)(2002)

3. Occupational cancer ( 15 items )(Asbestos, Benzidine and compounds,

Bischloromethylether, chromium and compounds, coal tar, beta-naphthylamine, Vinylchloride, Benzene, Toxic nitro and amino derivatives of benzene, Ionizing radiations, Tar, pitch bitumen, mineral oil, and related compounds, coke oven emission, coke oven emission, wood dust ).

4. Other diseases4.1 Miner’s nystagmus

2.1 Occupational respiratory 2.1 Occupational respiratory diseasesdiseases

2.1.1 Pneumoconioses caused by sclerogenic mineral dusts

2.1.2 Bronchopulmonary disease caused by hard-metal dust

2.1.3 Bronchopulmonary disease caused by cotton, flax, hemp or sisal dust

2.1.4 Occupational asthma2.1.5 Extrinsic allergic alveolitis2.1.5 Siderosis2.1.6 Chronic obstructive pulmonary diseases2.1.7 Diseases caused by aluminium2.1.9 Upper airways disorders2.1.10 Any other respiratory disease not mentioned in

the proceeding items caused by an agent where the casual relationship is established

Basic principles of occupational lung Basic principles of occupational lung diseasesdiseasesCertain principles apply broadly to the full

range of occupational respiratory disorders

While a few environmental and occupational lung diseases may present with pathognomonic features, most are difficult to distinguish from disorders of nonenvironmental origin

A given substance in the workplace or environment can cause more than one clinical or pathologic entity

The etiology of many lung diseases may be multifactorial and occupational factors may interact with other factors

The dose of exposure is an important determinant of the proportion of people affected or the severity of disease

Individual differences in susceptibility to exposures do exist

The effects of a given occupational or environmental lung exposure occur after the exposure with a predictable latency interval

PathogenesisPathogenesisThe effects of an inhaled agent

depend on many factorsits physical and chemical

propertiesthe susceptibility of the exposed

personthe site of deposition within the

bronchial tree

Physical properties•physical state (solid particulates, mist, vapor and gases)•solubility•size, shape and density•concentration•penetrability•radioactivity

Chemical properties•alkalinity and acidity•fibrogenicity•antigenicity

Susceptibility of exposed person•Integrity of local defense mechanisms•Immunological status ( atopy, HLA type)•Airway geometry

Site of deposition•When airborne particles come in contact with the wall of the conducting airway or a respiratory unit they do not become airborne again•Governs the lung response substantially•Mechanisms of dust deposition:SedimentationInertial impactionDiffusionInterceptionElectrostatic precipitation

10- 5 μ - Upper Respiratory tract5 - 3 μ Mid respiratory tract3 - 1 μ Alveoli

PathogenesisSize of Dust

Clinical approach to the Clinical approach to the patient patient There are two important phases in the workup

of any patient with a potential occupational or environmental lung disease.

1.General approach: To define and characterize the nature and extent of the respiratory illness, regardless of the suspected origin

A detailed historyPhysical examinationAppropriate diagnostic tools2. To determine the extent to which the

disease or symptom complex is caused or exacerbated by an exposure at work or in the environment

Occupational and environmental history Occupational and environmental history – single most helpful tool in the – single most helpful tool in the

diagnostic workupdiagnostic workup1. Employment detailsJob titleType of industry and specific workName of employerYears employed2. Exposure informationGeneral description of job process and

overall hygieneMaterials used by worker and othersSpecific workplace exposuresVentilation / exhaust systemUse of respiratory protectionIndustrial hygiene informations provided

by the employer to the employee

3. Environmental nonoccupational factorsSmokingDietHobbies4. Details about past employments in

chronological order5. Other detailsDoes the patient think symptoms /

problem is related to anything at work?Are other workers affected?Work absenteeismPrior pulmonary problems and

medications used

Physical examinationsPhysical examinationsGenerally unrevealing about

specific causeIt is most helpful in ruling out

nonoccupational causes of respiratory symptoms or diseases (cardiac problems or connective tissue disorders)

Chest radiography Chest radiography - is the most - is the most important diagnostic test for important diagnostic test for occupational lung diseasesoccupational lung diseases

Limitations:Limitations:The chest radiographic findings

can be nonspecific.„ „ Conventional chest

radiography is insensitive, missing as many as 10 to 15 percent of cases with pathologically documented disease.

„ „ Interpersonal variations

ILO – International Classification of ILO – International Classification of radiographs of pneumoconiosis,1971, radiographs of pneumoconiosis,1971, 20022002

1. Film quality : Grades I to IV2. Small opacities:round opacities: p (<1.5mm)

q (1.5 –3mm)r (3 - 10mm)

Irregular opacities: s (<1.5mm)t (1.5 – 3mm)u (3 – 10mm)

ILO – International Classification ILO – International Classification of radiographs of of radiographs of pneumoconiosis,1971, 2002pneumoconiosis,1971, 2002

Profusion:Category 0: small rounded opacities absent or

less profuse than in category 1Category 1: small rounded opacities definitely

present but few in numberCategory 2: small rounded opacities numerous.

The normal lung markings are still visibleCategory 3: small rounded opacities very

numerous. The lung markings are partially or totally obscured

ILO – International Classification ILO – International Classification of radiographs of of radiographs of pneumoconiosis,1971, 2002pneumoconiosis,1971, 2002Large opacitiesCategory A: one or more large

opacities not exceeding a combined diameter of 5 cm

Category B: large opacities with combined diameter greater than 5 cm but does not exceed the equivalent of the right upper zone

Category C: bigger than B

ILO – International Classification of ILO – International Classification of radiographs of radiographs of pneumoconiosis,1971, 2002pneumoconiosis,1971, 2002

Pleural Abnormalities:Locationwidthextentdegree of calcificationOther abnormal features

Computed tomography•Conventional and HRCT scanning are highly

sensitive for diagnosis of pleural diseases and useful for improved visualization of parenchymal abnormalities.

•„ „ HRCT findings are usually non specific, but occasionally certain features and distribution pattern may suggest a specific cause and may help narrow the differential diagnosis

SilicosisSilicosisSilica is silicon dioxide, the oxide of silicon, chemical formula SiO2SiO2 is the most abundant mineral on earth; comprises large part of granite, sandstone and slate.Silicosis is lung disease caused by inhalation of fine silica dust; the dust causes inflammation and then scarring of the lungs. Scarring shows up on chest x-ray.Silicosis is one type of pneumoconiosis, the medical term for lung scarring from inhaled dust. Pneumoconiosis can also occur from inhaled asbestos (asbestosis), coal (coal workers’ pneumonconiosis), beryllium (berylliosis), and other respirable dusts.There is no effective treatment for any pneumoconiosis, including silicosis

Silica Dust Exposure – Risk Silica Dust Exposure – Risk FactorsFactors

Any work that exposes silica dust: ◦ mining◦ stone cutting◦ quarrying◦ road and building

construction◦ work with abrasives ◦ glass manufacturing◦ sand blasting◦ also, some hobbies can

involve exposure to silica (sculptor, glass blower) Silicosis -

Sandblasting

Silicosis – Foundry workSilicosis – Foundry work

Silicosis - Stone cutting

Silicosis – Glass Factory Silicosis – Glass Factory WorkersWorkers

Sumathi, 19, admitted to Government Hospital, Pondicherry, India, suffers from severe silicosis. She worked in the sand plant (where silica is sieved) of a glass-container manufacturing plant.

Silicosis – historySilicosis – history

Full description by Bernardino Ramazzini (1633-1714) in early 18th century. “...when the bodies of such workers are dissected, they have been found to be stuffed with small stones.” Diseases of Workers (De Morbis Artificum Diatriba, 1713).

Pathology

Fibrotic nodules develop by a

particular process in which fibrous tissue

is laid down in concentric rings around a central

core of silica particles as an

onion

Healthy Healthy lunglung

SilicosisSilicosis

ManifestionsManifestionsSymptomsshortness of breath

while exercising fever occasional bluish

skin at ear lobes or lips

fatigue loss of appetite

Three ‘types’ of silicosisThree ‘types’ of silicosisSimple chronic silicosis From long-term exposure

(10-20 years) to low amounts of silica dust. Nodules of chronic inflammation and scarring, provoked by the silica dust, form in the lungs and chest lymph nodes. Patients often asymptomatic, seen for other reasons.

Accelerated silicosis (= PMF, progressive massive fibrosis) Occurs after exposure to larger amounts of silica over a shorter period of time (5-10 years). Inflammation, scarring, and symptoms progress faster in accelerated silicosis than in simple silicosis. Patients have symptoms, especially shortness of breath.

Acute silicosis From short-term exposure to very large amounts of silica dust. The lungs become very inflamed, causing severe shortness of breath and low blood oxygen level.

Simple SilicosisSimple Silicosis

normal chest x-ray simple silicosis

Accelerated Silicosis Accelerated Silicosis (= Progressive Massive (= Progressive Massive

Fibrosis)Fibrosis)

normal chest x-ray PMF

Accelerated Silicosis (PMF)Accelerated Silicosis (PMF)

chest x-ray CT scan

Eggshell calcification – Eggshell calcification – almost exclusively almost exclusively silicosissilicosis

Silicosis – associated Silicosis – associated risksrisks

Having silicosis increases risk of contracting tuberculosis & lung cancer.

Degree of increased risk is highly variable; depends on several OTHER factors, including immune system & exposure history (for TB), and amount of lung scarring, age & smoking history (for cancer).

Silicosis also strongly associated with scleroderma and rheumatoid arthritis.

Other associations less well established: lupus, systemic vasculitis, end-stage kidney disease.

Diagnosis of silicosisDiagnosis of silicosis•Abnormal chest X-ray or chest CT scan •History of significant exposure to silica dust•Medical evaluation to rule out other causes of abnormal x-ray•Pulmonary function tests•Lung biopsy rarely used

Silicosis can be mis-Silicosis can be mis-diagnosed as something diagnosed as something elseelse

Silicosis can mimic:◦ Sarcoidosis (benign inflammation of unknown

cause)◦ Idiopathic pulmonary fibrosis (lung scarring

of unknown cause)◦ Lung cancer ◦ Several other lung conditions (chronic

infection, collagen-vascular disease, etc.)

Can usually make right diagnosis with detailed history (occupational & medical) or, rarely, a lung biopsy.

TreatmentTreatment Early revealing and change of

occupation to industry without dust. Oxygen therapy to improve lung

ventilation. Corticosteroids are used in the period

of fast progression, in Rheumatoid Silicosis.

Treatment of Heart failure Treatment of Complication (Pleuritis,

Pneumonia, Tuberculosis) Symptomatic Therapy.

Silicatosis (Asbestosis)Silicatosis (Asbestosis) Parenchymal lung fibrosis with or without pleural involvement

due to inhalation of asbestos fibres. 5- 20 years to develop Inflammation from fibres causes scarring (fibrosis) and

stiffening of the lung. This causes less oxygen exchange. Damage leads to bronchitis, bronhiectasis.

Damage leads to pleural changes (pleuritis, spikes, enlargement of lymph nodes at the lung hila (containing asbestos).

It is more dangerous than silicosis as it predisposes to bronchogenic carcinomabronchogenic carcinoma and mesotheliomamesothelioma of the pleura and peritoneum

Symptoms – shortness of breath, a dry, persistant cough , chest tightness, deformed, club-shaped fingers

Asbestos fibersAsbestos fibers

Chest X- Ray :

Interstitial pneumoscelerosis

Diagnostic Particularities:

a) In sputum - asbestos bodies

b) In skin - asbestos Warts (containing asbestos)

Diagnosis of Asbestosis

Typical dumbbell shaped ferruginous bodies seen in a bronchial washing specimen

asbestos warts

ComplicationsComplicationsBronchogenic carcinomaMesothelioma

65-year-old asymptomatic man who had been employed in construction and demolition 65-year-old asymptomatic man who had been employed in construction and demolition for over forty years Radiologic Findings PA (A) and lateral (B) chest radiographs for over forty years Radiologic Findings PA (A) and lateral (B) chest radiographs demonstrate the presence of bilateral, relatively symmetric, multi-focal, discontinuous demonstrate the presence of bilateral, relatively symmetric, multi-focal, discontinuous areas of pleural thickening and calcification primarily distributed along the areas of pleural thickening and calcification primarily distributed along the anterolateral and posterolateral chest wall and domes of each hemidiaphragm. The anterolateral and posterolateral chest wall and domes of each hemidiaphragm. The apices and costophrenic angles are spared. Lesions seen en face on the frontal exam apices and costophrenic angles are spared. Lesions seen en face on the frontal exam (A) exhibit scalloped morphology, whereas those seen in profile on the lateral exam (B) (A) exhibit scalloped morphology, whereas those seen in profile on the lateral exam (B) appear more linear confirming the lesions change morphology from one orthogonal appear more linear confirming the lesions change morphology from one orthogonal plane to the next and are therefore pleural-based. plane to the next and are therefore pleural-based. Diagnosis: Asbestos-Related Pleural PlaquesDiagnosis: Asbestos-Related Pleural Plaques

A B

Coal Worker's Coal Worker's Pneumoconiosis (CWP)Pneumoconiosis (CWP)CWP is a lung disease that results from

breathing in dust from coal, graphite, or man-made carbon over a long period of time

Necessary to differentiate from silico-tuberculosis, disseminated tuberculosis, metastatic lung cancer, and other diffuse infiltrative pulmonary diseases

The disease is divided into 2 categories: simple CWP and complicated CWP or progressive massive fibrosis (PMF)

ParticularitiesParticularitiesSlow growth, benign character of

current, active phagocytosis, saved lung protective mechanism.

Causes chronic bronchitis, lung emphysema

Radiological investigation – interstitial or interstitial nodular fibrosis of the lung.

Symptoms and Symptoms and DiagnosisDiagnosis

Simple CWP:It is said to exist in the presence of

radiological opacities < 1cm in diameter.

It is benign disease if no complications. Cough, expectoration and dyspnea are

frequently present.Slight decrease in FVC and FEV1/FVC

Simple CWP

Minute opacities are diffusely scatterred throughout both lung fields, providing a crude measure of excessive exposure. Early pneumoconiosis is essentially a focal disorder and may produce little physiologycal disorders

Complicated CWP (PMF):Is diagnosed when large opacity of 1cm or more in diameter is observed in the chest X-ray.Pathologically it is characterized by large masses of black colored fibrous tissue. The large lesions may cavitate as a result of ischemic necrosis or infection (T.B)The severe stages of PMF cause cough and often disabling shortness of breath. Pulmonary function test reveals decreased FVC, FEV1/FVC and increased residual volume

These pictures show complicated coal workers pneumoconiosis. There are diffuse, small, light areas (more than 1 cm) in all areas on both sides of the lungs. There are large light areas which run together with poorly defined borders in the upper areas on both sides of the lungs.

If coal worker's pneumoconiosis occurs with rheumatoid arthritis it is called Caplan syndrome.

Caplan's syndrome (or Caplan's disease) is a combination of rheumatoid arthritis and pneumoconiosis  that manifests as intrapulmonary nodules, which appear homogenous and well-defined on chest X-ray

Caplan's syndrome presents with Cough, shortness of breathfeatures of rheumatoid arthritis (painful joints and

morning stiffness)Examination should reveal tender, swollen MCP

joints and rheumatoid nodules Auscultation of the chest may reveal

diffuse rales that do not disappear on coughing or taking a deep breath.

Other types of occupational lung Other types of occupational lung diseasedisease

Byssinosis Byssinosis is a narrowing of the

airways caused by inhaling cotton, flax, or hemp particles.

The substance or substances in the material that cause the disease are not known, but it is believed that the protein component rather than the cellulose or mineral constituents is responsible

Other types of occupational Other types of occupational lung diseaselung disease

Hypersensitivity PneumonitisHypersensitivity Pneumonitis (also referred

to as “extrinsic allergic alveolitis”) is an immunologic-induced, non-IgE mediated inflammatory pulmonary disease. It affects primarily the interstitium, alveoli, and terminal airways, and is caused by prolonged, repeated inhalation of organic dusts or certain chemicals (Farmer’s lung, Bagassosis etc.)

Other types of occupational Other types of occupational lung diseaselung diseaseOccupational AsthmaReversible airflow obstruction

caused by workplace exposuresWith latency period (sensitization)Without latency period (irritant)Causes: a broad group of

vegetable, animal products, chemicals, metals-referred to as “asthmagens”

““New” Occupational LungNew” Occupational LungDiseasesDiseases

Popcorn workers lungObstructive airways disease, some

with bronchitis obliteransCaused by a ketone (diacetyl) in the

artificial butter flavoring used in microwave popcorn processing

Kreiss et al., NEJM 2002; 347: 330-8

Prevention of Prevention of occupational lung occupational lung diseasesdiseasesRespirators

Prevention of Prevention of occupational lung occupational lung diseasesdiseasesVentilation and exhaust systems

Occupational disease, caused by influence

physical factors.Vibration disease

Vibration disease - an occupational disease caused by exposure to vibration. This pathology was first described by Lörig in 1911 as a syndrome of stonecutters dead fingers, and in 1955 it was named vibration disease

OCCUPATIONAL VIBRATION - OCCUPATIONAL VIBRATION - A SHORT HISTORYA SHORT HISTORY

1839 - Pneumatic tools were first used in French mines 1862 - Primary Raynaud's Phenomenon (Raynaud's Disease) identified. 1911 - Professor Loriga first described vascular spasm in the hands of

Italian miners using pneumatic tools. 1918 - Alice Hamilton studied miners using drills in limestone quarries

describing spastic anaemia of the hands. 1930-40s - Cases of white finger were identified studies in fettlers,

riveters, boot and shoe industry workers and users of electrical powered rotating tools

1950s - Research links signs and symptoms in nerves, bones, joints and muscles with vibrating tools.

1968-69 - After 12-14 years of continuous chain saw use widespread complaints of VWF (Vibration white finger) in operators.

1975 - Scale for assessing the extent of vascular injury associated with vibration white finger published by Taylor-Pelmear

1985 - VWF becomes a prescribed disease for Industrial Injuries Disablement Benefit purposes

1987 - Stockholm scale for assessment of VWF published. Standard for measurement of vibration published in BS 6842.

WHAT IS VIBRATION?WHAT IS VIBRATION?

FrequencyAmplitude

Acceleration

TYPES OF VIBRATION

low-frequency (8 – 15 Hz)medium-frequency (16 – 64 Hz)high-frequency (more than 64 Hz)Dangerous for the development of disease is the vibration with the frequency 16 – 250 Hz.

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VIBRATION EXPOSURE

Segmental (Local) Vibration ‘Segment of body’ such as hand-transmitted

vibration (known as hand-arm vibration or HAV)

Whole Body Vibration Vibration transmitted through the seat or

feet (known as whole-body vibration or WBV)

ACTING DIRECTIONS OF THE MECHANICAL

VIBRATIONS TRANSMITTED TO THE

WHOLE BODY THROUGH THE SUPPORTING AREA

IndustryIndustry Type of Type of VibrationVibration

Common Source of Common Source of VibrationVibration

Agriculture Whole body Tractors

Construction Whole body Local

Heavy equipment vehicles Pneumatic tools, Jackhammers

Forestry Whole body Local

Tractors Chain saws

Furniture manufacture

Local Pneumatic chisels

Machine tools Local Vibrating hand tools

Textile Local Sewing machines, Looms

Transportation Whole body Vehicles

Mining Whole body Local

Vehicle operation Rock drills

 

PATHOGENESIS: LOCAL EFFECTS

These effects occur under the influence of afferent impulses in the spinal cord neurons, sympathetic ganglia, and the reticular formation of the brain, including the levels of autonomic-vascular centers.

The state of regional circulation disturbs, there are specific manifestations of vasospasm. The greater the altered vibration sensitivity, so vasospasm is significant.

Direct mechanical damage and irritation of smooth muscle cells of blood vessels is expressed, which contributes to their spasm or atony. Further dystrophic changes develops.

Pathological process is in general has character of angiotrophoneurosis that at some stage has a tendency to generalize. However, trophic disorders relate primarily to the neuromuscular and musculoskeletal system, especially the shoulder girdle muscles, bones and joints.

In parallel with the progressive decline in the perception of vibration in vibration disease pain, tactile and thermal sensitivity disturbed.

Vibrational excitation irradiating to neighboring areas, especially in the vasomotor center, changing the functional state of the peripheral vessel. Later irritation radiating to vasomotor, pain and temperature centers if the disease development of vibration centers in stagnant excitation (parabiosis).

PATHOGENESIS: CENTRAL EFFECTS

PATHOGENESISDefeat ofCardiovascular systemNervous systemLocomotor systemMetabolismDecreasing of Vibrational sensitivityAlgesthesia (pain sensitivity)Tactile sensitivityThermoesthesia (temperature sensitivity)

TYPES OF VIBRATION

DISEASEVibration disease from local vibration impact

Vibration disease from general vibration impact

Vibration disease from combine vibration (local and general) impact

CLASSIFICATIONI. Initial stage (mild

manifestation)II. Moderately expressed

(dystrophic disorders)III.Expressed (irreversible

organic changes)IV.Generalized (very rare)

MAIN SYNDROMES IN VIBRATION

DISEASE1. Angiodistonic syndrome 2. Angiospastic syndrome 3. Syndrome of vegetative polyneuritis4. Syndrome of vegetative myofascitis5. Syndrome of somatic neuritis

(cubital, median), plexitis, radiculitis6. Diencephalic syndrome with

neurocirculatory disturbance7. Vestibular syndrome

ANGIODISTONIC SYNDROME

Main symptoms The nature of vibration and the stage of disease at which a given syndrome

Vegetative-vascular disease in the limbs, impaired capillary blood circulation (atonic or spastic-atonic state)

At high-frequency vibration and overall in the early stages, with the midrange - in elementary and moderate stages, the low-frequency vibrations - in all stages

ANGIOSPASTIC SYNDROME

Main symptoms The nature of vibration and the stage of disease at which a given syndrome

White finger attack, spasms of the capillaries, skin temperature violation, marked reduction of vibration sensitivity preferentially localized to the hands and feet

At high-frequency vibration in severe stages, and the stage of generalization, with a total of vibration - in the initial stages and marked

SYNDROME OF VEGETATIVE

POLYNEURITISMain symptoms The nature of

vibration and the stage of disease at which a given syndrome

Pain phenomena, violation of skin sensitivity, reduced skin temperature, vegetative symptoms

At low-frequency vibrations - in the initial stages, with a total of vibration - in the initial stages

SYNDROME OF VEGETATIVE

MYOFASCITISMain symptoms The nature of

vibration and the stage of disease at which a given syndrome

Painful phenomena, vascular disorders, changes in sensitivity by peripheral or segmental type

At low-frequency vibration (especially in the presence of static stress and significant return impact) and less frequently in middle frequency vibration in various stages

SYNDROME OF SOMATIC NEURITIS

Main symptoms The nature of vibration and the stage of disease at which a given syndrome

Electoral amyotrophy, impaired of sensitivity and reflex areas

Low-frequency vibration, combined with significant blowback, with emphasis trauma tool in severe stages

DIENCEPHALIC SYNDROME WITH

NEUROCIRCULATORY DISTURBANCE

Main symptoms The nature of vibration and the stage of disease at which a given syndrome

Generalized vascular disorders and crises (cerebral, coronary), metabolic endocrine disorders

At high-frequency vibration (local and general) in the terminal stage

VIBRATION DISEASE FROM THE ACTION OF

LOCAL VIBRATION (HAND ARM VIBRATION, VIBRATION

WHITE FINGER)

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HAND ARM HAND ARM VIBRATIONVIBRATION

WHAT IS HAV?HAV is vibration transmitted from work processes into

workers’ hands and arms. It can be caused by operating hand-held power tools such as road breakers, hand-guided equipment such as lawn mowers, or by holding materials being processed by machines such as pedestal grinders.

 WHEN IS IT HAZARDOUS?Regular and frequent exposure to high levels of

vibration can lead to permanent injury. This is most likely when contact with a vibrating tool or process is a regular part of a person’s job.  

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HAND ARM HAND ARM VIBRATIONVIBRATION

WHAT SORT OF TOOLS AND EQUIPMENT CAN CAUSE VIBRATION INJURY? Chainsaws Concrete breakers/road drills Hammer drills Hand-held grinders Hand-held sanders Nut runners Pedestal grinders Power hammers and chisels Powered lawnmowers Riveting hammers and bolsters Strimmers/brush cutters Swaging machines.

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93HAND ARM VIBRATIONHAND ARM VIBRATION

Moderate vibration

High vibration

impact wrenches

chain saws

percussive tools

• jack hammers

• scalers

• riveting or chipping hammers

grinders

sanders

jig saws

HAND ARM VIBRATION HAND ARM VIBRATION - CAUSES & EFFECTS- CAUSES & EFFECTS

Neurological component Vascular component Muscular and soft tissue component

HAND ARM VIBRATION - CAUSES & EFFECTS

WHAT INJURIES CAN HAV CAUSE?Regular exposure to HAV can cause a

range of permanent injuries to hands and arms including damage to the:

Blood circulatory system (e.g. vibration white finger)

Sensory nervesMusclesBonesJoints

CLASSIFICATIONІ — initial manifestations:1) Peripheral angiodystonic syndrome

of the upper extremities, including fingers with rare angiospasm;

2) neuro-sensory upper limb polyneuropathy

CLASSIFICATIONII — mild manifestations:1) Peripheral angiodystonic syndrome of the upper extremities with frequent fingers angiospasm;

2) neuro-sensory polyneuropathy syndrome of upper extremities with:

a) frequent fingers angiospasm;b) persistent vegetative and trophic disorders on the hands;

c) with degenerative disorders device support and movement of the upper limbs and their zone (miofibrosis, periartrosis, arthritis);

d) cervical-brachial plexopathy;e) with cerebral angiodystonic syndrome.

CLASSIFICATIONIII - pronounced symptoms:1) sensory motor polyneuropathy

syndrome of the upper extremities;2) Encephalopolineuropathy syndrome;3) syndrome polineuropathy with

generalized angiospasm.

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STOCKHOLM WORKSHOP SCALES

VASCULAR COMPONENT

Stage Grade Description0 No attacks 1v Mild Occasional attacks

affecting only the tips of one or more fingers

2v Moderate Occasional attacks affecting distal and middle (rarely also proximal)phalanges of one or more fingers

3v Severe Frequent attacks affecting all phalanges of most fingers

4v Very severe As in stage 3, with trophic changes in the fingertips

STOCKHOLM WORKSHOP SCALES

SENSORINEURAL COMPONENT

Stage Grade Description0 Vibration-exposed but

no symptoms1sn Mild Intermittent numbness

with or without tingling2sn Moderate Intermittent or

persistent numbness, reduced sensory perception

3sn Severe Intermittent or persistent numbness, reduced tactile discrimination and/or manipulative dexterity

Numerical scoring of vascular symptoms of HAVS (after Griffin,

1982)

VIBRATION INDUCED GANGRENE

ATROPHY OF MUSCLES DURING VIBRATION DISEASES

DIAGNOSIS OF HAVSHistory of symptomsHistory of vibration exposureVarious clinical tests to exclude other disordersObjective measurement of vascular, neurological and

musculoskeletal function:Vascular tests:Finger systolic blood pressuresRewarming time after cold provocationNeurological tests:Clinical tactile threshold testsThermal thresholdsVibrotactile thresholdsNerve conductive velocityMusculoskeletal function:Finger dexterityHand grip force

VASCULAR TESTSFinger systolic blood pressuresRewarming time after cold

provocation

NEUROLOGICAL TESTS

Clinical tactile threshold testsThermal thresholdsVibrotactile thresholdsNerve conductive velocity

MUSCULOSKELETAL FUNCTION

Finger dexterityHand grip force

DIAGNOSIS OF VIBRATION DISEASE FROM EXPOSURE TO LOCAL VIBRATION

The typical additional signs of vascular disorders1.     Symptom of "white spot". You ask a patient to clench

firmly the first of hand and through 5 sec quickly unclench it. In a norm the white spots which appeared have to vanish in 5 sec. If spots do not disappear quickly – the test is positive

2. Pile’s symptom. A pulse is found on both radial arteries, and then by rapid motion lift up the hands of patient. Thus a pulse can vanish on a few seconds. Such test is positive.

3. Test on reactive hyperemia. You impose a cuff on a shoulder and pump a pressure 180 - 200 mm of Hg. Then ask to lift hands up, in 2 min. to put hands down, take cuff off and write down time of hand’s reddening. In a norm the reddening begins in 1,5 - 2 sec. and passes in 15 sec. Lengthening of this time testifies to the spasm of vessels, and shortening - about their atony

DIAGNOSIS OF VIBRATION DISEASE FROM EXPOSURE TO LOCAL VIBRATION

The typical additional signs of vascular disorders4. Boholyepov’s test. A patient stretches both hands with

the unbended fingers ahead. At that you pay attention on colouring of skin, state of veins and capillary net of nail bed of fingers. Then a patient lifts a right hand up, and put down a left on 30 sec. After it, returns hands in previous position. We look after the change of vein and capillary circulation of blood. Normally, the changes of blood filling are normalized in 30 sec. At insufficiency of circulation of blood, pallor or cyanosis, which arose up disappear slower, than the more expressed is a disorder of peripheral circulation of blood.

DIAGNOSIS OF VIBRATION DISEASE FROM EXPOSURE TO LOCAL VIBRATION

The typical additional signs of vascular disorders5. Cold test. The hands of explored are dipped into

a cold water (+10°С) on 5 min. At albication of fingers the test is considered positive. Pay attention on prevalence and intensity of the process, mark the time of renewal of skin temperature after cooling. Normally it does not exceed 20 min. At patients with vibration disease there is an acute deceleration of renewal of skin temperature.

8–Channel Temperature Monitor

CAPILLAROSCOPE

DIAGNOSTIC OF SENSORY DURING

VIBRATION DISEASE

DIAGNOSTIC OF SENSORY DURING

VIBRATION DISEASE

TREATMENT Therapeutic interventions Pharmaceutical agents for the

treatment of HAVS1. Calcium antagonists2. Alpha-adreno receptor

antagonists3. Antifibrinolytics4. Prostaglandin analogues Surgical interventions for HAVS

WHOLE BODY VIBRATION

І — initial manifestation:1) angiodystonic syndrome (cerebral or

peripheral);2) neuro-vestibular syndrome;3) sensory syndrome (neuro-sensory)

polyneuropathy of the lower extremities.

WHOLE BODY VIBRATION

II - moderate symptoms:1) cerebro-peripheral angiodystonic

syndrome;2) sensory syndrome (neuro-sensory)

polyneuropathy in combination:a) polyradiculoneuropathy syndrome;b) secondary lumbosacral radicular

syndrome (due to degenerative disc disease of the lumbar spine);

c) with functional disorders of the nervous system (neurasthenia syndrome).

WHOLE BODY VIBRATION

III - pronounced symptoms:1) sensorimotor polyneuropathy

syndrome;2) dyscirculatory encephalopathy

syndrome in combination with peripheral neuropathy syndrome (encephalopolineuropathy)

VIBRATION DISEASE FROM

THE INFLUENCE OF GENERAL VIBRATION

Syndromes of vibration disease conditioned by general vibration: - cerebral-peripheral,- angiodistonic,- vegetative-vestibular, - vegetative-sensory polyneuropathy.

SENSORY DECREMENT BY THE PERIPHERAL TYPE

Roentgenograms can reveal ossific formations and centers of osteosclerosis. In a spinal column, the changes in intervertebral disks and joints prevail, mainly of degenerative-dystrophic character.

PROPHYLAXIS The contra-indications to the employment

on the work related with influence of vibration are

chronic diseases of the peripheral nervous system obliterating endarteritis Raynaud's disease angina pectoris, arterial hypertension of ІІ -III stages, endocrine disease (diabetus mellitus) ulcer disease neuritis, polyneuritis stable hearing loss of any aetiology, otosclerosis chronic gynecological diseases

PREVENTION

Development of HAV is dose related, meaning that effective control procedures should be:

• reducing the intensity of the vibration• reducing the duration of the exposure to vibration

• early recognition of signs and symptoms• identifying vibration sensitive individuals

CONTROLS

Buy lower vibration toolsA link to the European Hand Arm

Vibration Database is in the Links and References

at the end of this presentation

Tape existing handles with vibration dampening tape

Regularly maintain and balance hand tools

Use full fingered anti-vibration gloves

Suspend tools from tool balancers to reduce hand grip force

REMOTE CONTROL VIBRATORY PLATE

OPERATOR VIBRATION EXPOSURE - ZERO

VIBRATION REDUCED BREAKER

Keep the moil point sharpBreak a little at a timeDon’t get jammedDon’t force anti-vibration handlesStop breaker before pulling out

MECHANISATION REMOVES THE RISK

MACHINE-MOUNTED PICK REPLACES HAND-OPERATED BREAKERS

Thanks for attention!Thanks for attention!