Bronchiolitis obliterans


Bronchiolitis obliterans, also known as obliterative bronchiolitis, constrictive bronchiolitis and popcorn lung, is a disease that results in obstruction of the smallest airways of the lungs due to inflammation. Symptoms include a dry cough, shortness of breath, wheezing and feeling tired. These symptoms generally get worse over weeks to months. It is not related to cryptogenic organizing pneumonia, previously known as bronchiolitis obliterans organizing pneumonia.
Causes include breathing in toxic fumes, respiratory infections, connective tissue disorder or complications following a bone marrow or heart-lung transplant. Symptoms may not occur until two to eight weeks following toxic exposure or infection. The underlying mechanism involves inflammation that results in scar tissue formation. Diagnosis is by CT scan, pulmonary function tests or lung biopsy. A chest X-ray is often normal.
While the disease is not reversible, treatments can slow further worsening. This may include the use of corticosteroids or immunosuppressive medication. A lung transplant may be offered. Outcomes are often poor, with most people dying in months to years.
Bronchiolitis obliterans is rare in the general population. It, however, affects about 75% of people by ten years following a lung transplant and up to 10% of people who have received a bone marrow transplant from someone else. The condition was first clearly described in 1981. Prior descriptions occurred as early as 1956, with the term "bronchiolitis obliterans" used first by Reynaud in 1835.

Signs and symptoms

Bronchiolitis obliterans results in worsening shortness of breath, wheezing, and a dry cough. The symptoms can start gradually, or severe symptoms can occur suddenly. These symptoms represent an obstructive pattern that is non-reversible with bronchodilator therapy, and need to be related to various lung insults. These insults include inhalation damage, post transplant auto-immune injury, post-infectious disease, drug reactions, and several auto-immune diseases.

Causes

Bronchiolitis obliterans has many possible causes, including collagen vascular disease, transplant rejection in organ transplant patients, viral infection, Stevens–Johnson syndrome, Pneumocystis pneumonia, drug reaction, aspiration and complications of prematurity, and exposure to toxic fumes. Toxins implicated in the condition include diacetyl, sulfur dioxide, nitrogen dioxide, ammonia, chlorine, thionyl chloride, methyl isocyanate, hydrogen fluoride, hydrogen bromide, hydrogen chloride, hydrogen sulfide, phosgene, polyamide-amine dyes, mustard gas and ozone. It can also be present in patients with IBD, systemic lupus erythematosus, juvenile idiopathic arthritis, rheumatoid arthritis, GERD, IgA nephropathy, and ataxia telangiectasia. Activated charcoal has been known to cause it when aspirated. The ingestion of large doses of papaverine in the vegetable Sauropus androgynus has caused it. Additionally, the disorder may be idiopathic.

Lung transplant

Bronchiolitis obliterans is a common complication in lung transplants because transplanted lungs are at greater risk of alloimmunization as compared to healthy lungs. The disease is often termed bronchiolitis obliterans syndrome in the setting of post lung transplantation and hematopoietic stem cell transplant. Patients who develop BOS post lung transplant vary in disease latency and severity. Patients often initially have normal lung function on pulmonary function testing and have normal chest radiographs. As the disease progresses they begin to have symptoms of shortness of breath, cough, and wheezing as their lung function declines. The Journal of Heart and Lung Transplantation published updated guidelines in 2001 for grading the severity of BOS. The original guidelines and classification system were published in 1993 by the International Society for Heart and Lung Transplantation. Their scoring system is based on the changes in FEV1 in patients from their baseline. When patients are first diagnosed with BOS they have their baseline lung function established by doing pulmonary function testing at the time of diagnosis. The BOS scoring system is as follows:
BOS 0: FEV1 > 90% of baseline and FEF25-75 > 75% of baseline
BOS 0-p: FEV1 81-89% of baseline and/or FEF25-75 <= 75% of baseline
BOS 1: FEV1 66-80% of baseline
BOS 2: FEV1 51-65% of baseline
BOS 3: FEV1 50% or less of baseline
The scoring system shows an increased severity of the disease as the BOS number increases.
Elevated levels of bile acid and inflammatory proteins linked to GERD and microaspiration suggest that these factors may lead to the development of bronchiolitis obliterans in lung transplant recipients.

Hematopoietic stem cell transplant

Bronchiolitis obliterans affects up to 5.5% of people who have received HSCT. One of the biggest risk factors after HSCT is the development of GVHD with a 14% risk. Other risk factors post transplant including tobacco use, age of donor, age of recipient, lower baseline FEV1/FVC ratio, non-caucasian race, peripheral and lower circulating IgG levels. Studies have, however, shown mixed results regarding these other risk factors. There has been an association shown between the increased use of peripheral stem cells and the risk of developing bronchiolitis obliterans. Also, research has shown an increased risk for developing the disease within the first year of transplant if the person is infected with respiratory syncytial virus or parainfluenza virus within the first 100 days post transplant.

Toxic exposure

There are many industrial substances that are known to cause bronchiolitis obliterans.
Industrial workers who have presented with BO have been:
  • nylon-flock workers
  • workers who spray prints onto textiles with polyamide-amine dyes
  • battery workers who are exposed to thionyl chloride
  • workers at plants that use or manufacture diacetyl
Diacetyl is a chemical used to produce the artificial butter flavoring in many foods such as candy and microwave popcorn and occurring naturally in wines. This first came to public attention when eight former employees of the Gilster-Mary Lee popcorn plant in Jasper, Missouri developed bronchiolitis obliterans. Due to this event, bronchiolitis obliterans began to be referred to in the popular media as "popcorn lung" or "popcorn workers lung". It is also referred to as "flavorings-related lung disease".

Post-infectious

Typically found in young children and is the most common cause at this age. Generally occurs after a viral infection of adenovirus, measles, mycoplasma, CMV, influenza, and parainfluenza. Swyer-James syndrome is a rare complication of bronchiolitis obliterans caused by measles or adenovirus. Post-infectious bronchiolitis obliterans is most common in the southern hemisphere particularly in countries such as Brazil, Argentina, Australia, Chile and New Zealand. There was a large prevalence of the disease in these areas during the 1990s and early 2000s. In one hospital in Buenos Aires, the Ricardo Gutiérrez Children's hospital, the disease accounted for 14% of their inpatient respiratory population from 1993 to 2002. As such, much of the information about post-infectious bronchiolitis obliterans has come from research out of South America. The most significant risk factors for the disease are infection with adenovirus and the need for ventilator support. In contrast with another cause of bronchiolitis obliterans in children, Steven's Johnson's syndrome, post-infectious bronchiolitis obliterans tends to be a chronic but non-progressive disease. The disease can have varying impact on children and their quality of life, which has been studied by lung function tests, as well as their exercise tolerance. Children with lower lung function based on their pulmonary function testing, have lower exercise tolerance, which compounds the impact of the disease on cardiovascular function as they are not able to maintain age appropriate aerobic fitness. This ultimately affects their activities of daily living and their quality of life going forward.

Burn pits

A form of BO is starting to present in Iraq and Afghanistan veterans. It has been attributed to veterans being exposed to trash burn pits. Veterans present with shortness of breath and other asthma-like symptoms. The only way to diagnose this condition is by doing a lung biopsy as chest X-rays and CT scans come back as normal. The US government still denies that there is any correlation between burn pits and health problems, but has started an "Airborne Hazards and Open Burn Pit Registry" to begin tracking the health of veterans who were exposed to burn pits to see if there is a connection.

E-cigarettes

The American Lung Association listed use of flavored e-cigarettes as a risk factor for BO in 2016. Health Canada has, however, seen no cases as of 2023. Public Health England writes that the association has come about as "some flavourings used in e-liquids to provide a buttery flavour contain the chemical diacetyl… However, diacetyl is banned as an ingredient from e-cigarettes and e-liquids in the UK." The UK National Health Service's website states that "vaping does not cause 'popcorn lung.

Mechanism

The underlying mechanism involves injury and inflammation of epithelial and sub-epithelial cells. These cells then lose the ability to repair the tissue, in particular they lose the ability to regenerate the epithelial or outermost layer, leading to the excess growth of cells that cause scarring. There are multiple pathways of the disease including fibrotic, lymphocytic, and antibody-mediated that have been described. However, while each pathway has a more unique starting point and cause, the result is still injury and inflammation leading to scarring of the lung tissue. The scarred tissue then makes the expiration phase of respiration more difficult, leading to air not being expelled from the lungs. This is termed "air-trapping", which can be seen on medical imaging. Since the scarring is non-reversible, the disease generally does not improve over time, and depending on the inciting can progress to death.