Characteristics and Prevalence of Domestic and Occupational Inhalational Exposures Across Interstitial Lung Diseases

Published:February 20, 2021DOI:


      Inhalational exposures are increasingly recognized as contributing factors in interstitial lung disease (ILD). However, the characteristics of both exposures and exposed patients are not well understood. We hypothesized that domestic and occupational inhalational exposures would be common and associated with differences in demographics, clinical characteristics, and transplant-free survival in patients with all forms of ILD.

      Research Question

      What is the prevalence of inhalational exposures across all ILD diagnoses, and are these exposures associated with differences in demographics, clinical characteristics, and transplant-free survival?

      Study Design and Methods

      Patients from a tertiary ILD clinic underwent an interview designed to capture inhalational exposures including occupational, home, hobbies, and tobacco. Demographic and survival data were collected from the electronic medical record. Survival analysis was performed using Cox regression to compare exposed vs unexposed patients and adjusted for gender-age-physiology score and smoking.


      One hundred and fifty-six patients seen between May and October 2018 were analyzed. Patients had a wide variety of multidisciplinary diagnoses, with a minority of patients with hypersensitivity pneumonitis (14%). One hundred and one patients (65%) had potentially relevant inhalational exposures. More men than women had a history of any exposure (82% vs 51%; P < .001), occupational exposure (66% vs 14%, P < .001), and multiple exposures (56% vs 26%, P < .001), respectively. White race was associated with bird and hobby exposure. Patients with any exposure had worse transplant-free survival (unadjusted hazard ratio, 2.58; 95% CI, 1.13-5.92; P = .025), but this was not statistically significant after adjustment (hazard ratio, 1.82; 95% CI, 0.77-4.27; P = .17).


      A standardized interview revealed most patients across all types of ILD had potentially relevant inhalational exposures. Exposures were markedly different based on demographics and were associated with worse transplant-free survival, but this survival difference was not significant after multivariable adjustment. Identification and avoidance of exposures represent actionable targets in ILD management.

      Key Words


      ATS (American Thoracic Society), CTD (connective tissue disease), CTD-ILD (connective tissue disease-associated interstitial lung disease), EMR (electronic medical record), GAP (gender-age-physiology), HP (hypersensitivity pneumonitis), HRCT (high-resolution CT), ILD (interstitial lung disease), IPAF (interstitial pneumonia with autoimmune features), IPF (idiopathic pulmonary fibrosis), MDD (multidisciplinary diagnosis), PAF (population attributable fraction)
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        • Hutchinson J.
        • Fogarty A.
        • Hubbard R.
        • McKeever T.
        Global incidence and mortality of idiopathic pulmonary fibrosis: a systematic review.
        Eur Respir J. 2015; 46: 795-806
        • Fernandez Alvarez R.
        • Martinez Gonzalez C.
        • Quero Martinez A.
        • Blanco Perez J.J.
        • Carazo Fernandez L.
        • Prieto Fernandez A.
        Guidelines for the diagnosis and monitoring of silicosis.
        Arch Bronconeumol. 2015; 51: 86-93
        • Diego Roza C.
        • Cruz Carmona M.J.
        • Fernandez Alvarez R.
        • et al.
        Recommendations for the diagnosis and management of asbestos-related pleural and pulmonary disease.
        Arch Bronconeumol. 2017; 53: 437-442
        • Morisset J.
        • Johannson K.A.
        • Jones K.D.
        • et al.
        Identification of diagnostic criteria for chronic hypersensitivity pneumonitis: an international modified Delphi survey.
        Am J Respir Crit Care Med. 2018; 197: 1036-1044
        • Baumgartner K.B.
        • Samet J.M.
        • Coultas D.B.
        • et al.
        Occupational and environmental risk factors for idiopathic pulmonary fibrosis: a multicenter case-control study.
        Am J Epidemiol. 2000; 152: 307-315
        • Awadalla N.J.
        • Hegazy A.
        • Elmetwally R.A.
        • Wahby I.
        Occupational and environmental risk factors for idiopathic pulmonary fibrosis in Egypt: a multicenter case-control study.
        Int J Occup Environ Med. 2012; 3: 107-116
        • Blanc P.D.
        • Annesi-Maesano I.
        • Balmes J.R.
        • et al.
        The occupational burden of nonmalignant respiratory diseases. An Official American Thoracic Society and European Respiratory Society Statement.
        Am J Respir Crit Care Med. 2019; 199: 1312-1334
        • Rocha L.F.
        • Luppino Assad A.P.
        • Marangoni R.G.
        • Del Rio A.P.
        • Marques-Neto J.F.
        • Sampaio-Barros P.D.
        Systemic sclerosis and silica exposure: a rare association in a large Brazilian cohort.
        Rheumatol Int. 2016; 36: 697-702
        • Winterbottom C.J.
        • Shah R.J.
        • Patterson K.C.
        • et al.
        Exposure to ambient particulate matter is associated with accelerated functional decline in idiopathic pulmonary fibrosis.
        Chest. 2018; 153: 1221-1228
        • Johannson K.A.
        • Vittinghoff E.
        • Lee K.
        • et al.
        Acute exacerbation of idiopathic pulmonary fibrosis associated with air pollution exposure.
        Eur Respir J. 2014; 43: 1124-1131
        • Lee S.H.
        • Kim D.S.
        • Kim Y.W.
        • et al.
        Association between occupational dust exposure and prognosis of idiopathic pulmonary fibrosis: a Korean national survey.
        Chest. 2015; 147: 465-474
        • De Sadeleer L.J.
        • Verleden S.E.
        • De Dycker E.
        • et al.
        Clinical behaviour of patients exposed to organic dust and diagnosed with idiopathic pulmonary fibrosis.
        Respirology. 2018; 23: 1160-1165
        • Trethewey S.P.
        • Walters G.I.
        The role of occupational and environmental exposures in the pathogenesis of idiopathic pulmonary fibrosis: a narrative literature review.
        Medicina (Kaunas). 2018; 54: 108
      1. hpLung. Accessed March 1, 2020.

        • Offerman S.R.
        • Rauchwerger A.S.
        • Nishijima D.K.
        • et al.
        Use of an electronic medical record "dotphrase" data template for a prospective head injury study.
        West J Emerg Med. 2013; 14: 109-113
        • Liu H.
        • Patel D.
        • Welch A.M.
        • et al.
        Association between occupational exposures and sarcoidosis: an analysis from death certificates in the United States, 1988-1999.
        Chest. 2016; 150: 289-298
        • Fischer A.
        • Antoniou K.M.
        • Brown K.K.
        • et al.
        An official European Respiratory Society/American Thoracic Society research statement: interstitial pneumonia with autoimmune features.
        Eur Respir J. 2015; 46: 976-987
        • Ryerson C.J.
        • Vittinghoff E.
        • Ley B.
        • et al.
        Predicting survival across chronic interstitial lung disease: the ILD-GAP model.
        Chest. 2014; 145: 723-728
        • Schmajuk G.
        • Trupin L.
        • Yelin E.
        • Blanc P.D.
        Prevalence of arthritis and rheumatoid arthritis in coal mining counties of the United States.
        Arthritis Care Res. 2019; 71: 1209-1215
        • Fisher J.H.
        • Kolb M.
        • Algamdi M.
        • et al.
        Baseline characteristics and comorbidities in the CAnadian REgistry for Pulmonary Fibrosis.
        BMC Pulm Med. 2019; 19: 223
        • Ilar A.
        • Alfredsson L.
        • Wiebert P.
        • Klareskog L.
        • Bengtsson C.
        Occupation and risk of developing rheumatoid arthritis: results from a population-based case-control study.
        Arthritis Care Res (Hoboken). 2018; 70: 499-509
        • Miyake Y.
        • Sasaki S.
        • Yokoyama T.
        • et al.
        Occupational and environmental factors and idiopathic pulmonary fibrosis in Japan.
        Ann Occup Hyg. 2005; 49: 259-265
        • Paolocci G.
        • Folletti I.
        • Torén K.
        • et al.
        Occupational risk factors for idiopathic pulmonary fibrosis in Southern Europe: a case-control study.
        BMC Pulm Med. 2018; 18: 75
        • Centers for Disease Control and Prevention, The National Institute for Occupational Safety and Health (NIOSH)
        Electronic health records (EHRs) and patient work information.
        (Accessed March 1, 2020.)
        • Kalchiem-Dekel O.
        • Galvin J.R.
        • Burke A.P.
        • Atamas S.P.
        • Todd N.W.
        Interstitial lung disease and pulmonary fibrosis: a practical approach for general medicine physicians with focus on the medical history.
        J Clin Med. 2018; 7 (:476)
        • NIOSH
        National Occupational Research Agenda for Respiratory Health.
        2019 ( Accessed March 1, 2020.)
        • Yusen R.D.
        • Edwards L.B.
        • Dipchand A.I.
        • et al.
        The Registry of the International Society for Heart and Lung Transplantation: Thirty-third Adult Lung and Heart-Lung Transplant Report-2016; Focus Theme: Primary Diagnostic Indications for Transplant.
        J Heart Lung Transplant. 2016; 35: 1170-1184
        • Eng A.
        • 't Mannetje A.
        • McLean D.
        • Ellison-Loschmann L.
        • Cheng S.
        • Pearce N.
        Gender differences in occupational exposure patterns.
        Occup Environ Med. 2011; 68: 888-894
        • Marie I.
        • Gehanno J.F.
        • Bubenheim M.
        • et al.
        Prospective study to evaluate the association between systemic sclerosis and occupational exposure and review of the literature.
        Autoimmun Rev. 2014; 13: 151-156
        • Dumas O.
        • Varraso R.
        • Boggs K.M.
        • et al.
        Association of occupational exposure to disinfectants with incidence of chronic obstructive pulmonary disease among US female nurses.
        JAMA Netw Open. 2019; 2e1913563
        • Sack C.
        • Vedal S.
        • Sheppard L.
        • et al.
        Air pollution and subclinical interstitial lung disease: the Multi-Ethnic Study of Atherosclerosis (MESA) air-lung study.
        Eur Respir J. 2017; 50 (:1700559.)
        • Hunninghake G.M.
        • Quesada-Arias L.D.
        • Carmichael N.E.
        • et al.
        Interstitial lung disease in relatives of patients with pulmonary fibrosis.
        Am J Respir Crit Care Med. 2020; (;201(10):1240-1248.)
        • Salisbury M.L.
        • Hewlett J.C.
        • Ding G.
        • et al.
        Development and progression of radiologic abnormalities in individuals at risk for familial ILD.
        Am J Respir Crit Care Med. 2020; (;201(10):1230-1239.)