Abstract
Purpose
To perform a critical review of a series of journal articles and Health Hazard Evaluation Reports (HHER) by the National Institute for Occupational Safety and Health (NIOSH), where they have described the incidence of fixed obstructive pulmonary disease in a population of workers exposed to butter flavorings.
Methods
The clinical presentations, diagnostic modalities frequently employed and a review of the pertinent clinical literature are discussed for constrictive bronchiolitis and bronchiolitis obliterans with intraluminal polyps; two distinct forms of bronchiolitis obliterans (BO). An analysis of the NIOSH reports and scientific articles is provided, followed by suggestions for evaluating this public and occupational health concern moving forward.
Findings
Cases of lung disease in the food flavorings industry discussed in the literature have not been sufficiently documented to allow the conclusion that BO has been caused by diacetyl or butter flavoring. Further research is required to establish the causative agent(s).
Conclusion
The diagnosis of bronchiolitis obliterans should be reserved for those individuals who have diagnostic lung biopsy findings, obtained and interpreted by clinicians who are experienced with this complex disorder.
Notes
Although mixers at the Agrilink plant were exposed to 30 times less butter flavoring than was measured at Gilster, and there were only one-third the number of workers at the plant, the authors claimed to have generated just as many suspected cases of BO as Gilster (ten at Agrilink and nine at Gilster-Mary Lee) and even reported on more lung biopsies (six compared to three) (Kanwal et al. 2006). All of those initially biopsied at Agrilink were smokers, and only one of the biopsies was reported to show signs of constrictive bronchiolitis, and not one of the pathology reports was described (NIOSH 2003a). Combining this with the cases identified through the questionable spirometry data and other noninvasive studies, NIOSH claimed a total of ten workers “may have bronchiolitis obliterans” out of 41 studied (NIOSH 2003a).
The findings have an associated P value of 0.8; that is, there is an 80% probability that the data could have occurred by chance.
Examples include extrinsic allergic alveolitis, nonspecific interstitial pneumonia, follicular bronchiolitis and lymphocytic interstitial pneumonia.
Abbreviations
- ATS:
-
American Thoracic Society
- BO:
-
Bronchiolitis obliterans
- BOOP:
-
Bronchiolitis obliterans organizing pneumonia
- BOS:
-
Bronchiolitis obliterans syndrome
- CB:
-
Constrictive bronchiolitis
- CDC:
-
Centers for Disease Control and Prevention
- CDHS:
-
California Department of Health Services
- COP:
-
Cryptogenic organizing pneumonia
- COPD:
-
Chronic obstructive pulmonary disease
- ERS:
-
European Respiratory Society
- FEV1:
-
Forced expiratory volume in one-second
- FVC:
-
Forced vital capacity
- HHER:
-
Health hazard evaluation report
- HRCT:
-
High resolution computed tomography
- ISHLT:
-
International Society for Heart and Lung Transplant
- NHANES:
-
National Health and Nutrition Examination Survey
- NIOSH:
-
National Institute of Occupational Safety and Health
- PFT:
-
Pulmonary function testing
- RADS:
-
Reactive airways dysfunction syndrome
- VATS:
-
Video-assisted thoracoscopic surgery
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Acknowledgments
We would like to thank Dr. Mark Burton of the Jackson Pathology Group, affiliated with Jackson-Madison County General Hospital in Jackson, TN for his helpful suggestions during the drafting of this manuscript. Support for Dr. Galbraith’s time spent during the drafting of this manuscript was provided by his employer (ChemRisk) which received no funding to prepare this manuscript. Dr. Weill has not been compensated for his time.
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Drs. Galbraith and Weill are consultants in litigation for companies that have produced butter flavorings and for companies that have been users of butter flavorings in their manufacturing processes where workers may have been exposed to flavorings. The research performed and opinions expressed are those of the authors.
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Galbraith, D., Weill, D. Popcorn lung and bronchiolitis obliterans: a critical appraisal. Int Arch Occup Environ Health 82, 407–416 (2009). https://doi.org/10.1007/s00420-008-0337-x
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DOI: https://doi.org/10.1007/s00420-008-0337-x