Occupational and Environmental Health
Severe silicosis in engineered stone fabrication workers: An emerging epidemic
Silicosis is an irreversible fibrotic lung disease caused by inhalation of respirable forms of crystalline silica. Silica exposure is also associated with increased risk for mycobacterial infections, lung cancer, emphysema, autoimmune diseases, and kidney disease (Leung CC, et al.; Bang KM, et al. ). Engineered stone is a manufactured quartz-based composite increasingly used for countertops in the United States where imports of engineered stone for this use have increased around 800% from 2010 to 2018. With this, reported silicosis cases among engineered stone fabrication workers have risen. Silica content in different stones varies from up to 45% in natural stones (granite) to >90% in engineered stone and quartz. The act of cutting, grinding, sanding, drilling, polishing, and installing this stone puts workers with direct and indirect contact with these tasks at risk for hazardous levels of inhaled silica exposure (OSHA et al. ).
A growing number of cases associated with stone fabrication have been reported worldwide (Kramer MR, et al.; Kirby T. ). The CDC recently published a report of 18 cases of accelerated silicosis over a two-year period among engineered stone fabrication workers. The majority of patients were aged <50 years, five patients had autoimmune disease, two patients had latent TB, and two died (Rose C, et al. ). Thus, the experience of engineered stone fabrication workers appears to parallel that of patient exposed to silica in other occupations.
Control measures (see resources below) for silica exposure, prevention, and medical surveillance have been updated since 2016 at the federal level prompting a recent revision of OSHA’s National Emphasis Program for respirable crystalline silica as of February 2020 (OSHA,, published February 5, 2020). Despite these measures, enforcement within the stone fabrication industry remains challenging. Small-scale operations with limited expertise in exposure control combined with high density of immigrant workers with limited health-care access and potential threat of retaliation have limited compliance with updated standards (Rose C, et al. ).
Silicosis is preventable, and efforts to minimize workplace exposure and enhance medical surveillance of stone fabrication workers should be prioritized.
Useful resources for silica workplace control measures:
Sujith Cherian MD, FCCP
Haala Rokadia MD, FCCP
Steering Committee Members
Palliative and end-of-life care
Building primary palliative care competencies in the CHEST community
The CHEST community cares for many patients with serious illnesses characterized by a high risk of mortality, burdensome symptoms or treatments, and caregiver distress, which negatively impact quality of life (QOL) (Kelly, et al.). Specialist palliative care (PC) clinicians work in partnership with other specialties to optimize QOL and alleviate suffering for seriously ill patients (i.e., advanced or chronic respiratory disease and/or critical illness).
Referral for specialist PC integration should be based on the complex needs of patients and not prognosis. PC can and should be delivered alongside disease-directed and life-prolonging therapies. Early PC referral in serious illness has been associated with improved QOL, better prognostic awareness, and, in some instances, increased survival. Additionally, reductions in medical costs at the end-of-life have been observed with early PC integration (Parikh, et al.). However, patients with chronic or advanced respiratory diseases often receive PC late, if at all (Brown, et al. ). This might be explained by significant shortages within the PC workforce, misconceptions that PC is only delivered at the end of life, and limited proficiency or comfort in primary PC delivery. Primary PC competencies have already been defined for pulmonary and critical care clinicians (Lanken, et al. ). The Palliative and End-of-Life Care NetWork is focused on promoting awareness of specialty PC while providing education and resources to support primary PC competencies within the CHEST community. Look for NetWork-sponsored sessions at the annual meeting and follow conversations on social media using the hashtag #CHESTPalCare.
Dina Khateeb, DO
I am a new respiratory therapist and a team member
It’s 11:00 pm and relatively quiet in the ICU. Then, that all too familiar sound, Code Blue. I rush to the room and assess the situation. As a new grad, this is one of the skills I am still developing; balancing my adrenaline with critical thinking in order to help manage the situation. Whether it is an unplanned extubation, acute respiratory failure, or cardiac arrest, as the respiratory therapist, I am there to bring an expertise to the assessment and management of airway and breathing. Once the crisis is resolved, my work is not done. I remain at the bedside to ensure ventilator management, explain to the family the respiratory interventions, and work with the medical team to implement the best plan of care.
As the bedside RT, I have unique perspective and training. My education prepared me with the knowledge base to work in this arena, but I still have so much to learn. And, as a new grad, one of the biggest lessons I have learned so far is to speak up. Whether it is during rounds, a code situation, or just conversations with the team. I owe it to my patients to advocate for their care and provide the expertise that I bring to the team. To the doctor or nurse, I hope you will give me that opportunity to help care for our patients; to learn; and even teach to improve that care.
What’s new in the sleep apnea treatment pipeline?
While weight loss in obese patients with sleep apnea is an effective treatment strategy, researchers honed in on a particular site of impact – the tongue fat (Wang SH, et al.). After a weight loss program, they studied the changes in the tongue, pterygoid, lateral pharyngeal wall, and abdominal fat volumes using MRI. It turned out that reduced tongue fat volume was the primary mediator associated with AHI improvement. The authors suggested a reduction in tongue fat volume may be a potential OSA treatment strategy. Future studies will tell whether this is feasible and effective.
Recently, the FDA approved a new medication to treat residual daytime sleepiness in patients with sleep apnea – solriamfetol. Like other wake-promoting agents, it acts on the central nervous system and improves the reuptake of dopamine and norepinephrine. We look forward to head-to-head studies with current agents (modafinil or armodafinil).
Though not entirely new, two devices have been gaining popularity for sleep apnea treatment. Both are nerve stimulators: one designed for obstructive sleep apnea, is a hypoglossal nerve stimulator; the other, a treatment for central sleep apnea, is a phrenic nerve stimulator. They are slowly gaining popularity, though their invasive nature, patient selection criteria, and cost may limit their widespread adaption. More importantly, data on long-term outcomes and impact on hard endpoints such as mortality and reduction in cardiovascular morbidity are sparse.
Ritwick Agrawal, MD, MS, FCCP
Steering Committee Member
The long and winding treatment road of advanced lung cancer: Long-term outcomes with immunotherapy
Immune checkpoint inhibitors (ICIs) have transformed the landscape in advanced non-small cell lung cancer (NSCLC) treatment, extending progression-free survival (PFS) and overall survival (OS).
is approved in advanced NSCLC with ≥50% PD-L1 expression based on KEYNOTE-024 trial.1 Recent updated analysis of KEYNOTE 024 trial2 showed that patients with advanced NSCLC treated with pembrolizumab had a median OS of 30.0 months compared with 14.2 months for those treated with chemotherapy. More recently, 5-year outcomes of KEYNOTE-001 trial3 showed that OS was 23.2% for treatment-naive patients and 15.5% for previously treated patients with no grade 4 or 5 treatment-related adverse events.
is approved for the treatment of patients with advanced NSCLC with progression of disease after standard chemotherapy (regardless of PD-L1 expression) based on CHECKMATE 017/057 trials.4,5 OS at 5 years in recently presented pooled analysis of these trials was 13.4% in nivolumab arm compared to 2.6% in docetaxel arm with a PFS of 8% and 0% respectively.6,7 Median duration of response was 19.9 months vs 5.6 months. At 5 years, almost one-third of patients who responded to the nivolumab were without disease progression. Similarly, a recent 5-year analysis of patients with advanced NSCLC treated with nivolumab showed OS of 16%, identical for squamous and nonsquamous histology. 75% of 5-year survivors were without disease progression.8
Treatment with immunotherapy in advanced NSCLC has resulted in a dramatic change in outcomes with a small percent of patients able to achieve durable responses.
Hiren Mehta, MD, FCCP
Steering Committee Member
3. J Clin Oncol. 2019; 37:2518.