The material appearing on this page has been re-produced from a booklet available from the Society and kindly printed by the Queensland Government, Division of Workplace Health and Safety.

INTRODUCTION

This paper was written as a patient education and support document by Mrs Ruth Dukes during her work as a Community Health Nurse for the Kingaroy Health Service, South Burnett District Health Service, Queensland Health. Following a search by the Rural Information Network of the Toowoomba Base Hospital, it was revealed that there was a great absence of patient care information, especially in the community setting.
Subsequent to discussions with clients and other carers of asbestos disease sufferers this paper was completed. It is hoped that users will be able to build on the information herein and pass their knowledge on to others in need.
I am also extremely indebted to Mrs Shirley White for her interest and valuable assistance in making this booklet available to those best able to benefit from it.

Written by R.Dukes (1993)
Second Edition 1996

Asbestosis: Information to Carers at Home and in the Community

DEFINITION AND INCIDENCE

Asbestosis is a disease characterised by diffuse pulmonary fibrosis owing to the inhalation of asbestos dust. Exposure occurs in numerous occupations, including asbestos mining and demolition work, roofing, ship building and refitting etc., materials such as shingles, cement, vinyl asbestos tiles, fireproof paint and clothing, brake linings, filters. etc., contain asbestos. The risk appears to lie in the manufacture, cutting and demolition of asbestos containing materials. Asbestos is a term applied to a group of minerals whose characteristic feature is to crystallise in fibrous form. There are many members of the group. Common amongst these are blue asbestos (crocidolite) and white or grey asbestos (chrysolite and amosite. Other forms of asbestos in use include anthophyllite, which has been used in Finland. Tremolite which is said to be part of the asbestos group, is found in some commercial tales in small quantity, and as a contaminant of other asbestos types.

It is important to be aware of the differences in the types of asbestos, since the sort of disease that each produces may be different. The results of exposure also depend on the amount of asbestos inhaled and may range from no affect at all, to any of the asbestos related conditions.

HOW ASBESTOS AFFECTS THE LUNGS

After inhalation, any particle gaining entry to the air passages must by-pass a number of protective mechanisms, in order to enter the air exchange chambers (alveoli) at the innermost parts of the lungs. It is important to understand that these protective systems incorporated into the function of the lung and upper respiratory tract remove all but a very small percentage of inhaled particles.The lungs are essentially two large air-containing sacs, coated on their outside surface with a fine thin membrane (the Pleura) and encased in a relatively rigid covering consisting of the ribs and muscles of the chest. The bronchial tubes conduct air from the mouth to the alveoli. If asbestos fibres are inhaled, they must first pass the filtration mechanisms of the nose and sinuses, and also avoid being attached to the sticky secretion of mucus, which extends from the nose and the mouth down to the fine tubes that lead to the small alveoli. The air tubes get smaller in diameter until they finally reach the finest tubes, called the respiratory bronchioles. All the air passages, except for the respiratory bronchioles are lined with fine hairs, as past the entrances to the respiratory bronchioles these fine hairs (cilia) disappear. The cilia move mucus to the throat to be swallowed or spat out. Also at this point the lining of the air passages ceases and the alveoli appear. The alveoli contain no real lining but merely a thin layer of stretched flattened cells, through which oxygen may quickly gain entry to the small blood vessels (or capillaries) which line the alveolar wall. Across the alveolar wall crosses oxygen and other gases from the atmosphere and the co, (carbon dioxide) produced by the body. Very small particles whose diameter are less than about 8 micrometres (i.e. millionths of a metre), barely visible with a high powered microscope, may eventually reach the alveoli. Most asbestos fibres have a diameter of 3 micrometres or less. Moreover crocidolite (blue asbestos) produces very tiny straight fibres often less than 0.1 micrometre in diameter and these tend to align themselves in the center of the air flow as it comes down the bronchial tubes. Because they are so thin, they do not tend to fall out of the air stream and therefore they have the least chance of adhering to the mucus. Blue asbestos fibres, being both straight and fine, have much the best chance, of all the asbestos types, of reaching the very end of the air flow into the lung. In this way they may eventually float up against the alveolar wall, sometimes piercing the lining cells of the alveolar. Other fibres, particularly chrysotile, are not straight but spiral. The effective diameter of these curly spiral fibres ensures that many hit against the sides of the bronchial tree, where they stick and are carried out by the action of the mucus moving upwards towards the throat, under the propulsive influence of the thousands of tiny cilia.

The tiny asbestos fibres in their smallest state are known as asbestos fibrils (or needles). Those reaching the alveoli are handled in two or three different ways by the body. Scavenger cells may wind themselves around a very small fibre and incorporate it into the cell, then carry it away to be taken out of the body through a lymph node eventually reaching the bowel. The fibres may also be coated with a yellowish-brown substance composed of an iron and protein compound. The coating forms in a regular segmented manner, often with a rounded or 'clouded' end. Eventually these coated fibres split between the segments and may then be picked up by the scavenger cells. Some fibres may however remain untouched by these mechanisms and can remain in the body, over a lifetime, with no apparent effect. The coated fibres are known as 'asbestos bodies'.

LUNG CHANGE DUE TO INHALATION OF ASBESTOS

(a) Asbestosis
Following inhalation of even relatively minute amounts of asbestos, there may occur the laying down of scar tissue (or fibrosis) in the lungs. This is distributed around the walls of the alveoli. It is often called 'interstitial fibrosis'. Its effect is to reduce the amount of oxygen taken from the inhaled air into the blood. Also the amount of waste carbon dioxide released from the blood to the air, which will be breathed out, is reduced.Such diminished gas diffusion may be noticed well before any changes can be seen on a chest X-ray. With further continued exposure the scar tissue increases in its amount and distribution. The lung becomes stiff and less elastic, so that shortness of breath occurs due to lessened oxygen diffusion and less efficient lung expansion. The scar tissue may distort the lung and change the lung architecture, but this occurs more so in cases of severe fibrosis following heavy exposure. Adhesions may also develop from lung to diaphragm and to the outer lining of the heart (the pericardium). On chest x-rays therefore, one sees the fibrosis as a clouding or 'ground glass appearance', characteristically at the lower third (or base) of each lung accompanied by a 'shaggy heart shadow', due to the adhesions.

(b) Pleural Plaques
Unrelated to the appearance of scar tissue within the lung, patches of thickening may appear on the lining of the chest wall and over the diaphragm in the pleural membrane that lines the chest. The same thing can occur over the pericardium (outer covering of the heart), where this membrane lies between the lungs. Such patches are known as "pleural plaques". They commonly occur before fibrosis, but may appear after fibrosis is well established. They may also appear in the absence of any other chest signs resulting from asbestos inhalation. They have minimal effect on lung function and do not go on to become malignant. Sometimes salts of calcium may form in the plaque which makes them appear striking on a chest x-ray. They may never be diagnosed in life, and may not affect general health in any way.

(c) Lung Cancer
Asbestos exposed workers who smoke are particularly prone to develop lung cancer. If diagnosed early it may be totally removed, but commonly the outlook is poor. Investigators at the Mount Sinai School of Medicine in New York have found that asbestos workers who smoke run an 8-times greater risk of developing lung cancer than smokers in the general population who do not work with asbestos. It should be noted that there is a lag period of some twenty five years to thirty five years between the time of first exposure and the diagnosis of lung cancer related to asbestos exposure.

(d) Mesothelioma
Some asbestos exposed workers after many years have developed mesothelioma, a rare cancer of the outer covering of the lung (the Pleura). Crocidolite (blue asbestos) has the most potent effect in producing this cancer, due to its very small diameter and straightness. The incidence of developing mesothelioma is greatly related to the fibre dimension rather than the chemical composition of the fibre. The pleura, which is normally about as thick as a cigarette paper, becomes markedly thickened when mesothelioma occurs, sometimes to as much as several centimetres. It may eventually totally enclose the lung.

Mesothelioma is extremely rare and is usually associated with significant asbestos exposure. However, the tumour is highly malignant and is often accompanied with chest pain of an order that is greater than other lung tumours. While it is exacerbated by tobacco smoking in conjunction with asbestos exposure, tobacco smoking in itself does not cause mesothelioma.

PHYSICAL SIGNS AND SYMPTOMS

In the passage of time the inhaled asbestos fibres accumulate in the alveoli gradually obliterating them with fibrous tissue that surrounds the fibres. There is fibrous pleural thickening and pleural plaque formation. The altered physiological pattern is that of restrictive lung disease with a decrease in lung volume, diminished gas transfer, and hypoxemia.

The patient has progressive shortness of breath, mild to moderate chest pain, loss of appetite, and weight loss. Right heart failure associated with respiratory embarrassment and respiratory failure occur as the disease progresses.

CARE AT HOME

Treatment:
Treatment attempts to relieve symptoms and prevent complications. It may include daily exercise, limits on Activity, dietary modifications, drug and oxygen therapy, chest physiotherapy and other measures.

Activity:
As far as possible and within the abilities of each person it is advisable to continue with daily activities and to engage in light exercise. Attempts should be made to develop the maximum chest expansion and to maintain stamina as best as possible. Since each person has different needs advice should be sought from the local physiotherapist or General Practitioner. However, some simple exercises include- Deep breathing. Breathing in whilst raising the arms above the head (slowly) and then exhaling whilst lowering the arms (slowly).Coughing performed after 5-6 deep breaths is useful to help bring up sputum. Walking is always a useful and non injurious activity and need only be when the person can manage 4-5 times a day. It may only be 5 minutes each time.Some people have benefited from the use of a stationary bicycle. The main point being to do very gentle warm up stretching exercises beforehand and to build up gradually. Cool down slow movements should be done afterwards.The use of low flow oxygen during exercises is advised if felt necessary. Exercising should be ceased if increased shortness of breath, heart fluttering, extreme fatigue, nausea or muscle cramps are experienced. Also if pallor, mottled or clammy skin occur, exercise should cease and if there is no relief of symptoms the doctor should be consulted.

Daily activities:
These should be planned so as to conserve valuable energy, and to best cope with dyspnoea. Some helpful hints include:
Alternate light and heavy tasks.
Rest frequently.
Use pursed-lip breathing during periods of greater activity.
Sit whenever possible to perform tasks, as standing uses 40% more energy than sitting.
Pull instead of lifting, use a cart or wagon to carry loads (eg. shopping, in the garden).

Diet:
A balanced nutritious diet is vitally important to provide the extra calories burned up just to breathe. The diet should be high protein and avoid an excess of carbohydrates. If undesired weight loss is a problem the diet should also be high in fats. A low fat diet should not be followed unless under a dietitian's supervision. There should be a high intake of fruit and vegetables which supply a large percentage of vitamins, minerals, fibre for the bowel and vital energy. Meat (red and white) and fish have an important part in the diet, as they provide certain basic elements and essential amino acids which are key elements for repair and building of cells, and the maintenance of bodily functions and immunity. To encourage appetite, attention to oral hygiene is important. When shortness of breath is interfering with enjoyment of food then the food should be chewed slowly. Small frequent meals will be more digestible and will reduce fatigue and swallowing air.When a productive cough is present then deep breathing and coughing exercises should be performed about an hour before meals, followed by 30 minutes of rest to prevent tiring. If a feeling of being bloated at meal times occurs then restrict gas-producing foods such as cabbages, brussels sprouts, onions, beans, apples and cantaloupe (rock mellon).Nutritious snacks may be more acceptable rather than a meal. These could include, fruit juices, soups containing vegetables and meat and pasta. As far as possible use whole foods and fresh foods rather than processed or packaged foods which are high in salt and low in vitamin value. Including fresh fruit, vegetables and bran in the diet will help reduce constipation. DRINK PLENTY OF WATER to also prevent constipation, keep the kidneys functioning well, to help combat the build up of toxins in the system, to help thin mucous secretions and assist expectoration. Weight control is very important to prevent becoming overweight which places undue stress on the breathing and expenditure of energy. As well, being underweight reduces the body's immune system, leaving it open to infection, and increases fatigue due to low energy reserves. Special low carbon dioxide producing diets can be designed in consultation with a dietitian. A powder called "Pulmo-care" is also available. Where weight gain or weight loss is recommended advice should be sought from a dietitian or physician.

Medication:
Medications should only be taken at the direction of the doctor, which includes any over the counter medicine such as cough medicine, nasal preparations and anti-histamines. All of these drugs whilst quite safe to use normally could interact adversely with more potent drugs prescribed by the doctor. They may combine to increase the desired action of a prescribed drug so that it has a dangerous effect that could be life threatening. (Some cough suppressants, sedatives and hypnotics cause respiratory depression.) Oxygen is also a medication which should be taken at the doctors prescription. When home medical oxygen, on a continuing basis, is prescribed then it is usually delivered from an oxygen concentrator. This device is set up by the community nurse and its use is explained. An oxygen concentrator increases the atmospheric concentration of oxygen from 21% to about 90%, and removes other elements from the air. If systems of restlessness, difficulty breathing and cyanosis, (a bluish discolouration of the mucous membranes and nail beds) do not improve with the use of oxygen at the prescribed flow rate then the doctor should be contacted. It is not advisable to turn up the flow rate without advice from the doctor.It is vitally important to discuss thoroughly with your doctor the desired effect and possible side effects of prescribed drugs. Most drugs have side effects, but only occasionally do they present as a problem. When a combination of drugs is taken, or when drugs are taken in larger doses, or over a prolonged period of time, then serious side effects may occur. The effect of some drugs may significantly reduce quality of life and may have irreversible effects on other organs and systems in the body. By understanding the expected outcomes of drug use the person can weigh the cost and benefit of medication in their treatment and quality of life.Some people find herbal preparations very beneficial, offering great relief to symptoms. Use of such medicaments should be made under the supervision of a reputable naturopath or herbalist, and also with the support of an informed doctor. In order to investigate the effect of herbal medicines it would be very helpful to keep a record of the type of preparations used, frequency of use, reasons for use and results. Side effects should be noted as well as good effects, no effect and detrimental effects. Such information could be of great help to other asbestosis sufferers.

Dental Care:
It should be noted that one of the side effects of drug therapy is excessive drying of oral secretions. This has a significant effect on dental health and requires particular attention. The outcome of such an absence of saliva around the teeth is to permit an excessive accumulation of dental plaque at the gum line that results in significant dental decay, or a "ring barking effect" on the teeth. Treatment of the decay is extremely difficult. However prevention of the problem is easier. The frequent use of artificial saliva drops in the mouth is most helpful. Such drops are readily available at a chemist.At least six monthly visits to the dentist are advisable to ensure dental decay does not progress to the extraction of teeth and the added burden of obtaining dentures and the associated interference with nutrition.

Physiotherapy :
It is very important to maintain a clear airway at all times and to ensure that mucous from the air passages is not allowed to build up and clog the small bronchioles. As has been stated deep breathing is very useful in assisting the expectoration of sputum. However sometimes chest physiotherapy may be necessary. It is not advisable to drain the patient with the head down as this is too distressing for breathing and too tiring. An alternative is to lie the person on their side and to perform firm but NOT VIGOROUS percussion first on one side then the other. Allow the person to rest between each side. Physiotherapy should be performed between meals, not directly before as this tires the person too much so as to prevent enjoyment of the meal. Also physiotherapy performed on a full stomach may be too uncomfortable and distressing, and may result in vomiting.

Avoiding Respiratory Infection:
The main risk to persons with a chronic respiratory disease, such as Asbestosis, is the common cold. As the lung's ability to exchange oxygen and carbon dioxide is already severely impaired any obstruction of the airways with excessive mucous is a serious embarrassment.

Points to remember:

Irritants such as smog, aerosol sprays, fumes and cigarette smoking will only exacerbate the respiratory system and make breathing more uncomfortable, tiring and therefore distressing. Excessive dust in the environment of the patient can also aggravate coughing and stimulate wheezing and discomfort. Cigarette smoking will increase mucus production, decrease ciliary motion and raise carboxyhaemoglobin levels. This all means the airways will be more clogged with mucus and shortness of breath will become more acute. Weather can also aggravate respiratory comfort. Blasts of cold or dry air can cause bronchospasm and dry air also thickens the mucus. Exposure to extremes of weather and wind should be reduced and the use of air conditioners is sometimes beneficial. Maintaining humidity between 40% and 50% with a portable humidifier can also be helpful to counteract the effects of the weather.

Sex:
Continuation of a sexual relationship is often severely disrupted by chronic respiratory distress. However, some may find by using a pursed-lipped technique of breathing and lying on the side may allow for sexual intercourse if desired. Sexual fulfillment is a normal human need and in the privacy of the home a couple should feel happy to explore ways of reaching that need. Couples may also feel very fulfilled without sexual intercourse. It is a personal choice.

CARING FOR THE CARERS

The avenues for enlisting support and information as shown above will address many of the evident problems of the carer and patient. However, the emotional, spiritual and individual needs of the carer can really only be addressed by the carer. This may include:

These are simply some thoughts that may be a little inspirational to you. If you have others pass them on.

References
1. BRUNNER LS, SUDDARTH D.S.: "Textbook of Medical-Surgical Nursing." 5th ed.
J.B Lippincott Company. 1984 Chapter 26 "Conditions of the Chest and Lower Respiratory Tract." p.533 2. Asbestos Diseases Society Inc: "Medical Effects of Asbestos Exposure" 3. LOB, S. et al: "Patient Teaching- Loose Leaf Library -- Chronic Obstructive Pulmonary Disease." p 42 -- 49. Other References GEORGE R.B., LIGHT R.W., MATHAY M.A., "Chest Medicine -- Essentials of Pulmonary and Critical Care Medicine." Baltimore M.D. Williams & Wilkins. 1990 DUNN M.M.: "Asbestos and the Lung;" Internal Medical Grand Rounds, Northwestern University Medical School, Chicago.Other Sources of Information and Support:Queensland Cancer Fund. Brisbane (07) 3257 1155 Asbestos Diseases Society Inc. 483 Charlotte St, North Perth. (09) 4446699 or 444 6665 (You may reverse the charges) Dr R. Ramsay, (Dental Surgeon) A.J. Medland Clinic, Annerley. Brisbane.