Flavorings-Related Lung Disease

by CDC

This Topic Page provides a resource for findings and recommendations by the National Institute for Occupational Safety and Health (NIOSH) to reduce the risk of severe obstructive lung disease (bronchiolitis obliterans) associated with occupational exposures to flavorings.

In August 2000, the Missouri Department of Health and Senior Services requested technical assistance from NIOSH in an investigation of bronchiolitis obliterans in former workers of a microwave popcorn plant in Jasper, Missouri. Bronchiolitis obliterans is a serious lung disease that is irreversible. The Missouri request led to intensive NIOSH research performed in collaboration with the microwave popcorn industry and flavorings manufacturers. The findings from that research provided a basis for a 2004 NIOSH Alert, "Preventing Lung Disease in Workers Who Use or Make Flavorings." In addition to the full Alert in English, a Summary Sheet from the Alert is available in Spanish. Although much remains unknown regarding the toxicity of flavoring-related chemicals, employers and workers can take steps to address working conditions and work practices that place workers at risk.

Symptoms

The main respiratory symptoms experienced by workers affected by bronchiolitis obliterans include cough (usually without phlegm) and shortness of breath on exertion. The severity of the lung symptoms can range from only a mild cough to severe cough and shortness of breath on exertion. These symptoms typically do not improve when the worker goes home at the end of the workday or on weekends or vacations. Usually these symptoms are gradual in onset and progressive, but severe symptoms can occur suddenly. Some workers may experience fever, night sweats, and weight loss. Before arriving at a final diagnosis, doctors of affected workers initially thought that the symptoms might be due to asthma, chronic bronchitis, emphysema, pneumonia, or smoking.

Medical testing may reveal several of the following findings:

Spirometry, a type of breathing test :often shows fixed airways obstruction (i.e., difficulty blowing air out fast and no improvement with asthma medications), sometimes shows restriction (i.e., decreased ability to fully expand the lungs).

Lung volumes may show hyperinflation (i.e., too much air in the lungs due to air trapping beyond obstructed airways).

Diffusing capacity of the lung (DLCO) is generally normal, especially early in the disease.

Chest X-rays are usually normal but may show hyperinflation.

High-resolution computerized tomography scans of the chest at full inspiration and expiration may reveal heterogeneous air trapping on the expiratory view as well as haziness and thickened airway walls.

Lung biopsies may reveal evidence of constrictive bronchiolitis obliterans (i.e., severe narrowing or complete obstruction of the small airways). An open lung biopsy, such as by thoracoscopy, is more likely to be diagnostic than a transbronchial biopsy. Special processing, staining, and review of multiple tissue sections may be necessary for a diagnosis.

Treatment

Workers should be promptly referred for further medical evaluation if they have persistent cough; persistent shortness of breath on exertion; frequent or persistent symptoms of eye, nose, throat, or skin irritation; abnormal lung function on spirometry testing; or accelerated decline in lung function. Physicians should advise workers about any suspected or confirmed medical condition that may be caused or aggravated by work exposures, about recommendations for further evaluation and treatment, and specifically about any recommended restriction of the worker's exposure (including removal from the workplace) or use of personal protective equipment. Severe cases may not respond to medical treatment. Affected workers generally notice a gradual reduction or cessation of cough years after they are no longer exposed to flavoring vapors, but shortness of breath on exertion persists. Several with very severe disease were placed on lung transplant waiting lists. Workers exposed to flavorings may also experience eye, nose, throat, and skin irritation. In some cases, chemical eye burns have required medical treatment.

Control

In order of preference, according to standard occupational health practices, NIOSH recommends that employers minimize occupational exposures to flavorings or flavoring ingredients by:

• Substituting a material or materials that may be less hazardous, after carefully evaluating potential substitutes
• Using engineering controls such as closed systems, isolation, or ventilation
• Instituting administrative controls such as housekeeping and work practices
• Educating employers and employees to raise their awareness of potential hazards and controls
• Using personal protective equipment where needed as an adjunct to primary engineering or administrative controls
• Monitoring occupational exposures and the status of workers health, tracking potential symptoms or cases, and reporting such symptoms or cases to NIOSH and state health departments

NIOSH does not have authority under the Occupational Safety and Health Act to issue regulations.

About the Author

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