ACR Appropriateness Criteria® Occupational Lung Diseases

Our plain-English summary of ACR Appropriateness Criteria® Occupational Lung Diseases, by Expert Panel on Thoracic Imaging, C.W. Cox, J.H. Chung, et al (Journal of the American College of Radiology, 2020).

The study

• Authors: Expert Panel on Thoracic Imaging, C.W. Cox, J.H. Chung, J.B. Ackman, M.F. Berry, B.W. Carter, P.M. de Groot, S.B. Hobbs, G.B. Johnson, F. Maldonado, B.L. McComb, B.C. Tong, C.M. Walker, J.P. Kanne
• Journal: Journal of the American College of Radiology
• Published: 2020;17(5S):S188-S197
• Type of article: Guideline
• Cited by: 11 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Ordering the appropriate diagnostic imaging for occupational lung disease requires a firm understanding of the relationship between occupational exposure and expected lower respiratory track manifestation. Where particular inorganic dust exposures typically lead to nodular and interstitial lung disease, other occupational exposures may lead to isolated small airway obstruction. Certain workplace exposures, like asbestos, increase the risk of malignancy, but also produce pulmonary findings that mimic malignancy. This publication aims to delineate the common and special considerations associated with occupational lung disease to assist the ordering physician in selecting the most appropriate imaging study, while still stressing the importance of a multidisciplinary approach. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Copyright © 2020 American College of Radiology. Published by Elsevier Inc. All rights reserved.

In plain English

This article is a clinical guideline, not a new study. An American College of Radiology expert panel reviewed published literature and rated which imaging tests are appropriate for people with workplace inhalation exposures such as silica dust, coal dust and asbestos fibers. The method lets expert opinion supplement evidence that is lacking or equivocal. For screening and surveillance of exposed workers, chest X-ray was rated usually appropriate. For suspected interstitial lung disease, or suspected airway disease, chest CT without contrast dye and chest X-ray were both rated usually appropriate, used together. When an X-ray already suggested interstitial lung disease, CT without contrast was the usually appropriate next test. For confirmed occupational lung disease with a suspected chest cancer, CT with contrast and image-guided needle biopsy were rated usually appropriate. The authors noted that asbestos raises cancer risk but can also cause findings that mimic cancer. They said further testing should be decided through multidisciplinary discussion. They also noted gaps in the evidence: no study had run a population-based CT screening and surveillance program specifically for occupational lung disease to examine benefit on illness or death.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Evidence-based clinical guideline (ACR Appropriateness Criteria). An expert panel reviewed the literature and rated imaging tests for five clinical scenarios. Under the method, expert opinion may supplement the evidence where it is lacking or equivocal.
• Who was studied: No study population. The guideline covers patients with occupational exposures in five scenarios: screening and surveillance, suspected interstitial lung disease, interstitial lung disease suspected on X-ray, suspected airway disease, and confirmed occupational lung disease with suspected thoracic neoplasm. The panel members were from US institutions, and the guideline was published in 2020.
• Exposure: Workplace inhalational exposures in general: inorganic particles such as silica dust, coal dust and asbestos fibers (pneumoconioses), organic dusts (hypersensitivity pneumonitis), and other inhalants.
• Main results:
  • Screening and surveillance of exposed workers: chest radiography was rated usually appropriate for initial imaging. CT chest without IV contrast was rated may be appropriate. CT with contrast, MRI and FDG-PET/CT were rated usually not appropriate.
  • In the screening setting, the panel stated that CT with IV contrast serves no purpose.
  • Suspected interstitial lung disease: chest CT without IV contrast and chest radiography were both rated usually appropriate as complementary initial tests.
  • Interstitial lung disease suspected on radiography: chest CT without IV contrast was rated usually appropriate as the next imaging study.
  • Suspected airway disease: chest CT without IV contrast and chest radiography were both rated usually appropriate for initial imaging.
  • Confirmed occupational lung disease with suspected thoracic neoplasm: CT chest with IV contrast and image-guided transthoracic needle biopsy were rated usually appropriate. Contrast CT was recommended because it better characterizes tumor invasion and spread.
  • The panel stated that asbestos exposure increases cancer risk but can also produce lung findings that mimic cancer.
• The authors' conclusion: The authors concluded that the choice among CT surveillance, PET/CT and lesion biopsy depends on the situation and should be made through multidisciplinary discussion.
• Limitations the authors state:
  • No studies have implemented a population-based CT screening and surveillance program specifically for occupational lung disease to examine benefit on illness or death. The authors noted that smaller studies have examined detection using reduced-dose CT.
  • No literature addresses how diffuse occupational lung disease affects the sensitivity or specificity of transthoracic needle biopsy.
  • The radiologist's level of expertise can affect how high-resolution CT is interpreted.
  • Chest CT has known limitations for diagnosing cancer and often requires other imaging or tests.

Topics

Medical terms in this study, explained in our Lexicon: Occupational Lung Disease, Occupational Exposure, Interstitial Lung Disease, Multidisciplinary Team.

Related studies

• ACR Appropriateness Criteria Review ACR Appropriateness Criteria® Occupational Lung Diseases — Expert Panel on Thoracic Imaging, L. Bacchus, et al. (2016)
• The role of oxygen free radicals in occupational and environmental lung diseases — V. Vallyathan, X. Shi (1997)
• Imaging of occupational lung disease — K.I. Kim, C.W. Kim, et al. (2001)
• SWORD '94: surveillance of work-related and occupational respiratory disease in the UK — D.J. Ross, B.A. Sallie, et al. (1995)
• Use of exhaled breath condensate to investigate occupational lung diseases — M. Corradi, P. Gergelova, et al. (2010)
• Relative importance of cigarette smoking in occupational lung disease — P.C. Elmes (1981)

Browse return to medical research.