respiratory disorders related to inhalation of airborne dust are the most important group of occupational diseases . workplace exposures are strongly associated with an increased risk of chronic obstructive pulmonary disease ( copd ) . chronic bronchitis often associated with emphysema has been reported as the most frequent respiratory disease , with cement exposure followed by silicosis and mixed dust fibrosis . there are very few studies assessing the actual cement dust exposure and related risk in construction workers . a 75-year - old woman  nonsmoker , and construction laborer involved in mixing concrete and tiling  had exposure to cement dust for 30 years . she had been using gas stove for cooking for approximately 1 - 2 hours daily . she presented with a history of cough with expectoration and breathlessness on exertion since 20 years . this condition was medical research council ( mrc ) grade 1 to begin with , and gradually progressed to mrc grade 4 at the time of presentation . there was no history of any systemic disease . on examination , she was tachypnoeic and had bilateral pedal edema and elevated jugular venous pressure . chest x - ray [ figure 1 ] showed low flat diaphragms , hyperinflation , and cardiomegaly , with dilated pulmonary arteries . biochemical investigations were normal including alpha-1 antitrypsin levels ( 226 mg / dl ) . management with controlled oxygen therapy , inhaled corticosteroids , and bronchodilators along with noninvasive ventilation stabilized her condition . mean pulmonary artery pressure ( pap ) was 77 mm hg , and there was dilatation of the right ventricle and right atrium , with good left ventricular function and no valvular or septal defects detected . high - resolution computed tomography ( hrct ) of the thorax [ figure 2 ] showed changes in centrilobular emphysema , with diffuse air trapping . spirometry showed forced vital capacity ( fvc - 1.36 l ) ( 60% predicted ) , forced expiratory volume in 1 second ( fev1 - 0.62 l ) ( 32% predicted ) , and fev1/fvc ratio at 45% , suggesting severe obstructive abnormality with poor post - bronchodilator reversibility . x - ray chest , posteroanterior ( pa ) view high - resolution computed tomography of the thorax copd is a leading cause of morbidity and mortality worldwide , with smoking being the most important predisposing factor , followed by environmental exposure . data from the flow study of 1,202 subjects with copd suggest that workplace exposures are strongly associated with an increased risk of copd . workers at increased risk for chronic obstructive lung diseases include coal miners , construction workers handling cement , metal workers exposed to heat from furnaces , transport workers , grain handlers , cotton workers , and workers in paper mills . unfortunately , the impact of smoking as a risk factor for copd was perceived as so overwhelming that the interest in other risk factors faded away . recognition of work - relatedness for airway diseases is difficult since these are multifactorial diseases that are strongly associated with nonoccupational exposures . american thoracic society conducted a systematic epidemiologic review and concluded that approximately 15% of copd cases may be attributable to workplace exposures . a recent study by dement et al . showed statistically significant associations for copd , with exposures to asbestos , silica , welding , cement dusts , and some tasks associated with exposures to paints , solvents , and removal of paints . portland cement commonly known as cement is a fine , grayish green powder with an aerodynamic diameter in the range of 0.05 - 5 m , which is produced by heating ground cement rock or other limestone - bearing materials into a fused clinker , which is subsequently ground into a fine powder . various studies have shown the evidence of copd in cement factory employees , few with conflicting results.[69 ] increased mortality has been noted from copd among construction workers exposed to organic dust as compared to unexposed construction workers . it is yet to be determined whether these effects are directly due to cement dust or mediated by a metabolic product of cement dust . cement dust particles can cause a disease due to the chemical nature of cement dust and its irritant , sensitizing and pneumoconiotic properties . the main routes of entry of cement dust particles into the body are the respiratory and gastrointestinal tracts . the deposition of inhaled particles is influenced by the physical and chemical properties of the inhaled agent and also by various host factors . the physical properties of importance include particle size and density , shape and penetrability , surface area , electrostatic charge , and hygroscopicity . the deposition of inhaled material is primarily dependent on particle size in the forms of an aerodynamic diameter . it has been suggested that the reduced fev1 % in cement factory workers may be due to reflex bronchospasm triggered by inhaled irritant cement dust or as a result of type 1 hypersensitivity reaction . the severity of the impairment of respiratory function has been shown to depend on years of exposure . animal studies reveal that cement dust induces atrophic and hypertrophic changes in the nasal and pharyngeal mucosa as well as chronic exfoliative bronchitis . one of the studies suggests that cement dust exposure may decrease lung and thoracic compliance by impairing intercostal muscle performance . a significantly higher percentage of neutrophils was observed in cement production workers during the exposed period compared with the non - exposed period . another study concluded that exposure to cement dust decreased the physiological activity of polymorphonuclear neutrophils in cement mill workers . a study carried out in 2006 - 07 to assess the actual cement dust exposure among construction workers concluded that the highest level of inhalable dust is at the construction site observed for concrete repairs , floor screed layers , and tile setters ; in comparison , these exposures were lower than those found in cement plants . cement mortar for setting ceramic tiles is composed of portland cement and sand . the joints between the tiles filled with a grout , which may be portland cement base , epoxy base , furans , or latex . tile grout is again a mixture of portland cement , fillers , pigments , and additives , which when mixed with water is used to fill the gaps between the tiles on walls and floors . our patient has used both white or black cement and masonry sand at her workplace . she was a nonsmoker , presented with a history of chronic airway obstruction after 30 years of cement exposure and had normal alpha-1 antitrypsin level . there was no exposure to biomass fuel or passive smoking , and hence emphysema is most likely cement exposure - related . although there are many studies showing a relationship between cement exposure in industrial workers and respiratory disorders , no case of emphysema related to cement exposure working at a construction site has been reported earlier .
although , smoking is considered the most important predisposing factor in development of emphysema ; environmental exposures also play an important role . there have been several studies on work related respiratory symptoms and ventilatory disorders among employees of cement industry . 
 we report a case of cement exposure related emphysema in 75 years old woman construction worker .