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‘Popcorn Lung': Making a Historically Difficult Diagnosis
‘Popcorn Lung': Making a Historically Difficult Diagnosis

Medscape

time18-06-2025

  • Health
  • Medscape

‘Popcorn Lung': Making a Historically Difficult Diagnosis

Among the many things that the Industrial Revolution gave rise to was the potential for more rapid spread of public health crises. Communicable diseases such as cholera, typhus, and tuberculosis all spiked during this era due to urbanized living, increased mass communication, and still-evolving sanitation safety measures. The early 20th century also marked increased prevalence of occupational respiratory illnesses, such as silicosis, chronic obstructive pulmonary disease (COPD), and a newly-identified condition — bronchiolitis obliterans — that in many ways has puzzled healthcare professionals ever since. First diagnosed in 1901 among healthy factory workers who were exposed to nitrogen dioxide, this fibrosing obstructive lung disease has earned the moniker 'popcorn lung' because of its connection to an outbreak at a factory 25 years ago. That outbreak in Jasper, Missouri, was among workers who inhaled diacetyl, a synthetic flavoring agent for microwavable popcorn. Although the disease can also be caused by other harmful food production exposures. Characterized by a dry cough, shortness of breath, wheezing, and inflammation that results in partial or complete obliteration of the lung's smallest airways and irreversible scaring, the disease continues to be difficult to diagnose. The disease also is more challenging to care for the longer it goes undetected. While it frequently develops in patients who undergo lung transplant and is associated with rheumatic conditions and various respiratory infections, bronchiolitis obliterans is rare and can masquerade as other common pulmonary diseases when symptoms aren't properly recognized. Difficult Diagnosis In August 2000, employees at Gilster-Mary Lee Corporation, a food manufacturing and distribution company, experienced a similar set of respiratory issues, including cold-like symptoms that didn't improve with medication. The National Institute for Occupational Safety and Health (NIOSH) and the Missouri Department of Health and Senior Services launched an investigation. 'There was this clustering of workers who had developed severe obstructive airway disease and were initially being variously diagnosed with conditions such as emphysema, but, for the most part, they were never smokers,' explained Cecile S. Rose, MD, MPH, a board-certified pulmonology and occupational medicine physician at National Jewish Health, Denver. 'The NIOSH began looking at the workers' epidemiologically and sampling the air. They found that this exposure to diacetyl-containing butter flavoring was the cause. And that's when we began to realize that these types of chemicals, even though they had been stored in very large vats that had lids and were recognized as safe for ingestion, were never safe to be inhaled in large quantities.' The most likely symptoms of 'popcorn lung' are a persistent cough, plus or minus wheezing, and shortness of breath that worsens with physical exertion — none of which are particularly distinctive. 'The typical symptoms are very nonspecific and are not temporally linked to exposure,' said Rose. 'They are insidious. They creep up. And the symptoms don't help you very much in terms of linking the exposure to the risk of lung disease or its symptoms. But sometimes patients will describe upper airway irritation symptoms, such as sore throat, or eye burning.' But there are additional symptoms that can complicate diagnosis. According to Jim Mendez, PhD, CRNP, ANP-BC, clinical associate professor and adult primary care nurse practitioner in the M. Louise Fitzpatrick College of Nursing at Villanova University, Villanova, Pennsylvania, the full spectrum of signs can also include fatigue and chest discomfort. Another troubling indication can be when wheezing is present and does not respond to standard asthma medications, Mendez said. Eric Costanzo, DO, director of Medical Intensive Care and director of the Pulmonary and Critical Care Fellowship Program at Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune City, New Jersey, said that patients will also often experience nonspecific symptoms that can resemble conditions such as asthma or COPD, including exertional dyspnea and low-grade fever. Weight loss may also be seen, he said. 'But the pathology itself can happen for a number of different reasons, just by virtue of the fact that the lungs have only a few ways to respond to injury — and this injury pattern of bronchiolitis obliterans is one of those ways,' said Amy Hajari Case, MD, chief medical officer of the Pulmonary Fibrosis Foundation and director of the Pulmonary Fibrosis Care Center at Piedmont Healthcare in Atlanta. 'There is inflammation and obliteration of the bronchioles, and it's a situation where the inflammation creates airflow obstruction on the smallest level that sets up a clinical picture that we can now recognize.' Functional Testing Can Speed Diagnosis Before a diagnosis can be confirmed, pulmonary function tests are essential to help detect the restricted airflow typical of the condition, suggests Shawn George, DO, an internal medicine physician at Yorktown Health, Vernon Hills, Illinois. 'A computed tomography scan can show damage to the airways, but a biopsy might be needed to confirm the diagnosis.' The disease is more common among patients who undergo bone marrow or lung transplants, a form of chronic allograft rejection, referred to as defined as 'bronchiolitis obliterans syndrome.' According to research conducted by the Cleveland Clinic, approximately 50% of patients who undergo lung transplants will develop bronchiolitis obliterans syndrome within 5 years of surgery while approximately 10% of marrow recipients will develop bronchiolitis obliterans syndrome within 5 years. 'Patients can have this type of lung injury related to some of the transplant immunology that occurs,' said Case. 'It can also happen because of certain types of viral or bacterial infections that set up a more acute situation.' These include respiratory syncytial virus and measles, particularly in children. According to Costanzo, rheumatoid arthritis, systemic lupus erythematosus, and inflammatory bowel disease-related lung disease can also be triggers. 'Histologically they differ from other lung diseases characterized by concentric fibrosis of the bronchioles and eventual obliteration of the airway lumen,' said Costanzo. Treatment Approaches and Suggestions Quality of life and disease management can be difficult for patients, said Case. 'There isn't a well-defined standard of care practice for how to help people improve their lung function and there isn't extensive data to guide management in this condition. The first thing to do is to halt any culprit exposure to immediately keep the patient from having continued lung damage.' Assuming that can be accomplished, there are a range of over-the-counter and prescription options that Case and other physicians are willing to try for their patients. 'Cough suppressants and inhaled bronchodilators are used for symptom management, as well as oxygen therapy if the patient is hypoxemic,' said Case. 'Pulmonary rehabilitation is also utilized for its various benefits, and other treatments such as macrolide antibiotics, systemic steroids, and immunosuppression are tried on an individual basis. But this is a condition that in many cases doesn't respond well to the things that we do. And so patients do not get that same relief as other patients for which we do have a lot of tools and a lot of evidence for using them, even if that condition is not going to go away, such as COPD.' When it comes to syndrome patients, treatments might also include extracorporeal photopheresis and total lung irradiation. In the worst of all types of cases, patients will require lung transplant. 'One percent of transplants are listed as being for bronchiolitis obliterans for all different etiologies,' said Case. Vagaries of Vaping Another potential cause of bronchiolitis obliterans, but for which more substantial evidence is needed, is use of a vape to inhale nicotine-based chemicals, including those that contain diacetyl. Prior to the COVID-19 pandemic, a rash of e-cigarette or vaping-associated lung injury (EVALI) cases had been seen in hospitals across the country. According to CDC data, more than 2800 hospitalizations and nearly 70 US deaths reported as of February 2020 among people of all ages were attributed to the use of e-cigarettes and vaping products, particularly those containing vitamin E acetate (VEA). 'While the association between vaping and popcorn lung is a concern that has received widespread media attention, it remains less common in clinical practice,' said Dr. Mendez. 'Some flavored e-cigarettes have been found to contain diacetyl; however, there have been very few confirmed cases of bronchiolitis obliterans directly attributable to vaping. What we are seeing more frequently are other vaping-related lung injuries, such as EVALI, which can mimic some of the same respiratory symptoms but represents a different disease process. There is some indication that one of the primary causative agents in EVALI is VEA, although there may be other causes. Continued research and regulation are needed to fully understand the long-term pulmonary risks associated with vaping.' Costanzo said he believes there's a correlation to be concerned about between an increasing prevalence of bronchiolitis obliterans in recent years driven by the popularity of vaping products. Rose is convinced that time will prove a direct causation. 'It might not be as obvious as it was for workers who were exposed to large quantities, but chronic vaping of these chemicals could lead to substantial adverse lung health outcomes in the longer term,' she said. 'The [people] who are vaping regularly might seem fine, but if they're doing that every day for the next 10 years, we might start to see affects. Or they might have more accelerated decline in lung function without having many other symptoms.' Case said she has already seen enough incidences to determine a link. 'For me, the evidence is there,' she said. 'When we talk about vaping-associated lung diseases, bronchiolitis obliterans is one of them.' 'But the problem of lack of clarity is that you can put anything into a vape. Because there is so much variability, it's become more difficult to pin down what can cause this by vaping. There are so many additives to the flavors,' continued Case. 'We need to talk about this as being generally harmful because you lose the weight of evidence when we try to get more specific on something that we just don't have enough information on. And as vaping has become more prevalent, it stands to reason that the people who are more susceptible to lung injury from it will experience it at a higher rate.' Protocols for Better Awareness Greater awareness and suspicion of 'popcorn lung' is needed in the presence of certain symptoms and occupational hazards, experts suggest. 'When a clinician sees signs of emphysema or small airways disease in never smokers, their alarms for work-related or exposure-related lung disease should go up,' said Rose. 'The most important thing is to take a careful occupational history — take the time to ask patients about what they spend their time doing. If they're working in food production or fragrance, that should trigger an understanding that there could be a risk to artificial chemicals or flavorings that can confer risk for lung disease. We're very well-conditioned to taking a careful history for those patients who smoke, but we need the same to be true for vaping now too. We also need to take into account things like hookah or other types of inhalants that may confer risk for small airway diseases.' There's also a significant need to improve awareness of the disease among the general public, especially for those who work in high-risk settings and/or use a vape or similar device. 'The person experiencing it probably doesn't know anyone else who has been diagnosed,' said Case. 'There's not a drug being promoted to treat it. We need to promote self-advocacy and advocacy for loved ones. When our patients are experiencing these symptoms, it's an important message that they need to know. The old medical adage says, 'when you hear hoofbeats think horses, not zebras,' but this is truly one of the zebras. It's being missed.' Case, Costanzo, and Mendez reported no relevant financial disclosures.

Terrifying video reveals Boeing workers' fears over 'shoddy' 787 jets at plant where doomed Air India Dreamliner was built
Terrifying video reveals Boeing workers' fears over 'shoddy' 787 jets at plant where doomed Air India Dreamliner was built

Daily Mail​

time13-06-2025

  • General
  • Daily Mail​

Terrifying video reveals Boeing workers' fears over 'shoddy' 787 jets at plant where doomed Air India Dreamliner was built

A frightening video shows ten Boeing engineers admit they would not fly on the 787 Dreamliner jets they were building like the Air India plane that crashed Thursday. Workers at the South Carolina plant alleged the Dreamliners were being built by 'underskilled' and 'uncaring' factory workers who were in 'some cases on drugs'. One whistleblower claimed '90 percent' of the problems reported on the 787 plane were 'getting swept away' and 'hushed up'. The 2014 footage, which was first published by Al Jazeera last year, has resurfaced in wake of the tragic Air India plane crash that killed at least 265 people on Thursday. It was shot in the same plant where the ill-fated Air India plane was constructed. That Dreamliner flew for the first time in 2013 and left the plant in January 2014 bound for the Asian airline. The London -bound 787 Dreamliner began losing height moments after take-off and crashed in a fireball over a residential area in the Ahmedabad. Only one of the 242 people on board survived and as many as 24 people on the ground were also killed in what was the world's worst aviation disaster in a decade. The plane that crashed on Thursday flew for the first time in 2013 and was delivered to Air India in January 2014 - the same year the secret factory video was recorded. It remains unclear what caused Thursday's tragedy, with mechanical failure or pilot error among the possible causes that investigators will now work to identify. An undercover employee approached 15 workers at random and asked one simple question: 'Would you fly on one of these planes?' A Boeing 787 Dreamliner began losing height moments after take-off and crashed in a fireball over a residential area in the Ahmedabad The plane that crashed on Thursday (pictured) flew for the first time in 2013 and was delivered to Air India in January 2014 - the same year the secret factory video was recorded Five employees said they would travel on the 787 Dreamliner, but most revealed they had little faith in the aircraft they were building. 'I wouldn't fly on one of these planes,' one worker said, the video revealed. 'Because I see the quality of the f***ing s*** going down around here.' But more concerning were the workers' allegations that their colleagues were looking for and doing drugs while on the clock. 'It's all coke and painkillers and, what's the other one?' a worker said. Another replied: 'You can get weed here. You can get some really good weed here. They don't drug test nobody. 'There's people that go out there on lunch and smoke one up.' Thursday's crash was the first involving a Dreamliner since the wide-body jet began flying commercially in 2011, according to the Aviation Safety Network database. But Boeing's safety and quality control has been under scrutiny for years after a series of incidents and crashes involving the company's other fleets. Boeing was deemed responsible for three high-profile accidents involving its 737 MAX narrow-body planes in recent years, including two fatal crashes. Just six days ago the plane maker reached a $1.1billion deal with the Justice Department to avoid prosecution over crashes involving a 737 Max plane that killed 346 people in Ethiopia and Indonesia in 2018 and 2019 respectively. Both disasters were later traced to faulty flight control systems, leading to the worldwide grounding of the 737 Max fleet for nearly two years. The 737 is a design dating back to the 1960s, with the Max crashes blamed on huge new engines bolted onto the middle-aged air frame design to boost the planes' range and capacity. Computer systems designed to counterbalance the Max's unwieldy proportions were initially too complicated to use and ultimately led to the Ethiopian and Indonesian crashes, investigators ruled. Boeing's reputation was further damaged in January 2024 when a door plug blew off another new 737 Max, shortly after the plane operated by Air Alaska took of from Portland Airport. No-one was injured or killed, but investigators say that if someone had been sitting in the empty seat next to the door plug and had their seatbelt off, tragedy may well have ensued. The incident led to the departure of then-CEO Dave Calhoun, as well as head of commercial planes and its board chair. The Air India plane that crashed in the city of Ahmedabad was more than a decade old. It first flew in late 2013 and was delivered to Air India in January 2014. Since then, it accumulated more than 41,000 flight hours, including 420 hours during 58 flights in May and 165 hours during 21 flights in June, according to aviation data analytics firm Cirium and flight tracking website FlightRadar24. That length of service means the crash may not have been caused by a lapse in Boeing's standards. Poor maintenance performed by Air India mechanics, pilot error or even external factors like a bird strike may have been to blame. There is also a chance that the plane may have fallen victim to an act of foul play, with anti-terrorism investigators conducting a probe into the crash too. Indestructible 'black box' recorders have already been recovered from the wreckage and should provide data that enables investigators to determine the cause of the crash in the coming months. Before the crash, airline executives had voiced greater confidence in Boeing's rebound in deliveries and in Ortberg's leadership after years of reputational damage for the plane maker. The public has not yet caught on, however. Last month, the Axios Harris poll of 100 recognizable corporate brands by reputation put Boeing at 88th, same as in 2024. The wide-body 787 planes have had a strong safety record. They were grounded in 2013 due to battery issues, but no one was reported injured. Boeing shares were down 5 percent on Thursday after the Air India crash and shares of Spirit AeroSystems, a key supplier, and GE Aerospace, which makes engines for the jet, also fell about 2 percent each. Boeing's outstanding debt also sold off modestly after the crash. The investigation into the Air India plane crash is focusing on the engine, flaps and landing gear, a source told Reuters on Friday, as the aviation regulator ordered safety checks on the airline's entire Boeing-787 fleet. Air India and the Indian government are looking at several aspects of the crash including issues linked to its engine thrust, flaps, and why the landing gear remained open as the plane took off and then came down within moments, the source said. The probe is also looking at whether Air India was at fault, including on maintenance issues, the insider added. A possible bird-hit is not among the key areas of focus, the source said, adding that teams of anti-terror experts were part of the investigation process. The government is considering whether it should ground the Boeing-787 fleet in the country during the probe, the source said. Air India has more than 30 Dreamliners that include the Boeing 787-8 and 787-9 versions. A source in Air India told Reuters there had been no communication so far from the government on the possible grounding. Separately, India's aviation regulator ordered Air India to conduct additional maintenance actions on its Boeing 787-8/9 aircraft equipped with GEnx engines, including 'one-time check' of the take-off parameters before the departure of every flight from midnight of June 15. The airline has also been instructed to introduce 'flight control inspection' - checks to ensure control systems are working properly - in transit inspection, and to conduct power assurance checks, meant to verify the engine's ability to produce the required power, within two weeks. The aviation ministry said that investigators and rescue workers had recovered the digital flight data recorder - one of the two black boxes on the plane - from the rooftop of the building on which the jet crashed. There was no information on the cockpit voice recorder, the other black box, which is also crucial to the crash probe. Earlier on Friday, rescue workers had finished combing the crash site and were searching for missing people and bodies in the buildings as well as for aircraft parts that could help explain why the plane crashed soon after taking off. Indian Prime Minister Narendra Modi was briefed by officials on the progress of rescue operations when he visited the crash site in his home state of Gujarat on Friday. Modi also met some of the injured being treated in hospital. 'The scene of devastation is saddening,' he said in a post on X.

In the heart of ‘Silicon Malaysia', spiralling living costs dent big chip dreams
In the heart of ‘Silicon Malaysia', spiralling living costs dent big chip dreams

South China Morning Post

time19-05-2025

  • Business
  • South China Morning Post

In the heart of ‘Silicon Malaysia', spiralling living costs dent big chip dreams

Despite headline-grabbing investments, factory workers in Kulim struggle to make ends meet as the cost of rent and other essentials surges At a quiet coffee shop on the outskirts of Kulim's sprawling industrial zone, Azmin unscrews the cap of his mineral water bottle, exhales deeply, and reflects on the gap between the ambitious promises of 'Silicon Malaysia' and the reality on the ground. From his vantage point as a recruiter for one of the region's fastest-growing semiconductor production hubs, the tech sector's promises of abundant job opportunities feel hollow. 'We haven't had much demand lately,' Azmin told This Week in Asia, requesting to be identified by only his first name for fear of losing future business. 'The last round of recruitment we handled was a few months ago for 20 people at a smaller factory.' While the government paints a picture of booming industry and economic transformation, Azmin sees another side of the story. Development has raised land prices, with houses and rents surging in an area that was once oil palm plantations and farmland. The result has been good for property speculators, but bad for everyone else, he said. A decade ago, Azmin bought a modest home for 95,000 ringgit (US$22,100). Today, similar houses fetch at least 300,000 ringgit. Kulim Hi-Tech Park, established 30 years ago, was built on 5,600 acres (2,300 hectares) of cleared farmland to support Penang's semiconductor boom. Azmin's family, originally from Penang, were among the first to spot the park's potential. German chipmaker Infineon's facility at Kulim Hi-Tech Park. Photo: Shutterstock Over the years, big names like Austria's AT&S and German chipmaker Infineon have moved in. Infineon last year pledged €5 billion (US$5.6 billion) to expand its facility, while AT&S recently launched a 5 billion ringgit (US$1.2 billion) plant in the park. Newsletter Every Saturday SCMP Global Impact By submitting, you consent to receiving marketing emails from SCMP. If you don't want these, tick here {{message}} Thanks for signing up for our newsletter! Please check your email to confirm your subscription. Follow us on Facebook to get our latest news. But for many, these headline-grabbing investments do not translate into prosperity. 'It's good that there are jobs, but factory workers earn just 1,700 ringgit,' Azmin said, referencing Malaysia's minimum wage. 'Renting a place in Kulim will cost at least 700 ringgit now. If a factory worker has a wife and two children, they won't have anything left after spending on necessities.' Kulim, home to about 120,000 people, was hit hard by pandemic-era lockdowns and has struggled to recover from the economic scars of Covid-19. Official figures show nearly 10 per cent of the district's population lives in poverty. But industry leaders argue that the tech sector offers some of the best pay in Malaysia. Workers in the electrical and electronics sector earn double the national average wage, according to the Malaysian Semiconductor Industry Association. 'With competition [in the industry], salaries will continue to move [upwards],' said the association's president, Wong Siew Hai. AT&S reports that entry-level engineers at its Kulim facility earn starting salaries of around 5,000 ringgit, while it says factory line workers take home over 3,000 ringgit a month – well above the minimum wage. A worker inspects semiconductor chips at a chip packaging company in Malaysia. Photo: Reuters Resource drain? Malaysia's government aims to attract 500 billion ringgit (US$116 billion) in semiconductor investments and produce 60,000 engineers and technicians by 2030. Kulim Hi-Tech Park management announced plans in November to double its area to 12,000 acres (4,900 hectares), highlighting the high demand for industrial space. However, rapid industrialisation comes at a cost. Semiconductor plants and data centres are notoriously resource-intensive, consuming vast amounts of electricity and clean water. Malaysia's water services commission warned earlier this year that existing data centres were already pushing water supplies to the brink. In Selangor, Negeri Sembilan and Johor states, the 101 data centres present collectively require 808 million litres (213.5 million gallons) of water daily, yet current infrastructure can only supply less than 20 per cent of that demand. A man wades through flood waters in Malaysia's Johor state in 2023. Photo: AFP The issue is not a lack of rainfall – Malaysia receives more than 970 million cubic metres (34.3 billion cubic feet) annually – but rather poor water management. 'We are already experiencing serious water issues despite the fact that we are water rich,' said Chan Ngai Weng, president of conservation group Penang Water Watch. Chan stressed the need for industrial users to adopt sustainable practices, including water recycling and rainwater harvesting. Without these measures, he warned, the rush to expand industrial capacity could leave household taps dry. 'Silicon Malaysia' may yet deliver on its promises, but for Kulim's workers and small businesses, the benefits so far are unevenly distributed. In the race to build the future, who will be left behind in the rush for progress?

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