Chronic Beryllium Disease

Podcast Transcript

Raed Dweik:

Hello, and welcome to the Respiratory Exchange Podcast. I'm your host, Raed Dweik, chairman of the Respiratory Institute at Cleveland Clinic. This podcast is intended for healthcare providers and covers topics related to respiratory health and disease. My colleagues and I would be interviewing experts about timeless and timely topics in the areas of pulmonary, critical care, allergy, sleep, and infectious disease. I hope you enjoy today's episode.

Hello, everyone, and welcome to this episode of the Respiratory Exchange Podcast. I'm your host, Raed Dweik, Chairman of the Respiratory Institute at the Cleveland Clinic. And my guest today is Dr. Maeve MacMurdo, who is the director of our Occupational Lung Disease Program, and we'll be talking about beryllium exposure and disease. So, Maeve, welcome.

Dr. Maeve MacMurdo:

Thank you.

Raed Dweik:

So, let's start with, just in general, I think beryllium is a metal that not too many people know much about until they get to have to know about it, so can you tell us a little about beryllium?

Dr. Maeve MacMurdo:

Absolutely. So, beryllium, like you said, is one of those things which is really around everywhere. It's lightweight, it's very, very heat-resistant and so it's pretty widely used across a variety of fields ranging from things like aerospace, plane building, to ship building, and really everywhere in between. And it works fantastically for what it's intended to do, but it also has an unintended consequence, which is where I see beryllium come into play a lot.

Raed Dweik:

Yeah, I think I remember, one of its qualities is that it's lighter than aluminum and harder than steel. That's a very unusual property to have so that makes it very useful for many industries, especially in an alloy form, right?

Dr. Maeve MacMurdo:

Exactly, and I think that's the challenge is that because beryllium is so hard to replace, it really is pretty unique in what it does. It's strong, it's lightweight, it's also heavily heat resistant, so for things like atomic weapon development it really is the only choice.

Raed Dweik:

Yeah.

Dr. Maeve MacMurdo:

Which creates challenges when it creates problems.

Raed Dweik:

So, you mentioned some industries it's used in, like the typical ones. Can you tell us a little bit more about those?

Dr. Maeve MacMurdo:

Yeah, so when you think beryllium, and if you think back to your boards when you got that beryllium question stem, it's almost always a nuclear weapons worker or nuclear weapons manufacturer and that's where it was classically used. Beryllium really came to the forefront with the atomic energy division back in the, you know, 1940s, 1950s during the development of nuclear weapons and kind of that process. But it's still widely used both as an alloy and, again, space shuttle engineering, air flight engineering, ship building, anything when you need something which is going to be lightweight and heat resistant is really where it's utilized. And then some kind of strange places, too.

It's often found in cement, and it's also found in a lot of dental alloys, well, historically it was found in a lot of dental alloys. And so, we saw a lot of dental technicians that were exposed to beryllium before this was widely known.

Raed Dweik:

Yeah, I know it's even used in some golf clubs and mountain bikes because it's very light, as well, so I heard one quote that uh, uh, although these typical industries which you mentioned are not very wide-ranging, but they're like hundreds or even thousands of industries that use beryllium in one way or another.

Dr. Maeve MacMurdo:

Absolutely, and it makes it challenging because we really don't know how many workers are truly exposed to beryllium. They estimate around 150,000 workers, roughly, but in reality, because all these industries use these small amounts kind of here and there, it's probably closer to around 800,000 workers across the United States who are exposed.

Raed Dweik:

Oh, that's huge. So, what does that do to the lungs? What does beryllium exposure do to the lungs?

Dr. Maeve MacMurdo:

So, beryllium, again, in its inert form, is safe, so just touching beryllium's not gonna do anything. But when you cut or grind beryllium or beryllium alloys, the beryllium is released. And for people who are basically unlucky, beryllium can basically trigger an autoimmune response to cause something called sensitization where it changes the image to receive the pathway in a t-cells and make the body at risk for autoimmunity.

Raed Dweik:

Also, what I know of what, because there's some interaction between the environment and genetics, some people are more genetically susceptible to beryllium disease than others. Can you tell us a bit more about that?

Dr. Maeve MacMurdo:

Absolutely, So what we know is that for some people, there's an HLA mutation which increases the risk of developing sensitization, but even workers who do not have that mutation can develop sensitization, those who do, though, are more likely to become sensitized when they're exposed, and so that increases the risk, but it's really a mix of the environment, the kind of work you're doing and the kind of exposure that you have and your underlying genetics that all increase and will alter your risk of sensitization.

Raed Dweik:

Yeah, that's a very good point that you make that, while people with the gene mutation are more susceptible to sensitization and disease, people without it also get the disease so it's not uh, you know, uh, slam dunk. It's not that if you don't have it, you are safe, you can still get beryllium disease.

Dr. Maeve MacMurdo:

Absolutely. I think when they first found this mutation, people got really excited thinking well, we can screen for it and workers who have the gene can just not work there. But in reality, it's not a slam dunk. There are plenty of workers, in fact, a large number of workers who have sensitization who are not genetically predisposed. It really does come down to a lot of the work that you're doing, how long you're exposed for, and stuff we still don't really understand or know that well.

Raed Dweik:

Again, one of the, at least, benefits maybe? I don't know if it's called a benefit, is that beryllium disease is known to add exposure to metal beryllium. You know that's done in manufacturing settings. So, there should be a way for us to kind of screen for it, look out for it and, uh, are there methods to, uh, find out whether somebody has beryllium disease, or on their way to develop beryllium disease?

Dr. Maeve MacMurdo:

Yes, and so we can screen for sensitization with something called the LPT, the beryllium LPT. Which is a blood test.

Raed Dweik:

Lymphocyte proliferation.

Dr. Maeve MacMurdo:

Yes, sorry acronyms, I love my acronyms.

Raed Dweik:

Yeah.

Dr. Maeve MacMurdo:

It's a test which is very specific but not all that sensitive. It's only run in a couple of labs throughout the country. I think right now there's three or four labs total including us who can run the LPT because it requires a lot of expertise and interpretation and actually running the sample to get a good result. But we can use the LPT to screen workers who are exposed to beryllium and look for sensitization and I think I should probably clarify here. So, since sensitization is really almost like a flag for disease, being sensitized itself does not mean you have beryllium disease. But it means you are at risk for beryllium disease. Which I think is sometimes challenging for patients to understand and challenging for us to understand. It's kind of, it's the flashing orange light but it's not the red light quite yet.

Raed Dweik:

Yeah, the way I, I used to explain it to my patients is like there's exposure, and not everyone who's exposed gets sensitized or allergic, and then some of those sensitized move on to have the d- full spectrum of disease. So, it's really kind of multiple stages. Does that make sense?

Dr. Maeve MacMurdo:

Exactly. It's really a pathway and the challenge are, with beryllium, that we don't know when you're gonna cross that pathway. You can work with beryllium for years and years then become sensitized. Or you can work with it once and become sensitized. And so, we need to have this ongoing screening process. It's not enough to screen once and be done. You really require ongoing screening throughout the time you're exposed to beryllium and also once you're no longer exposed to beryllium. Because even after you've been exposed and have stopped being exposed, you can still develop sensitization, in theory.

Raed Dweik:

Yeah, that's a good point and I remember seeing these patients. I've seen people get sensitized then actually develop granulomas within three weeks of uh, of exposure and 30 years after exposure. There's really no rule of thumb to say once you're exposed, you're always at risk.

Dr. Maeve MacMurdo:

Exactly, and so screening right now is something that really has to happen again almost on an annual basis as long as you're exposed. The challenge is, so how we think about kind of formalizing screening and workers who have known exposure, it's pretty straightforward, but what we're seeing now is, like you mentioned, there are a lot of industries who will use beryllium where the exposures are the not known to the workers, or not even known potentially to the manufacturers, and those workers aren't always getting screened with the same frequency or according to the guidelines because again, they're not that classic slam dunk, I was exposed to beryllium, patient.

Raed Dweik:

I think that a good way to kind of segue into that is, who really should be screened for beryllium exposure and sensitization? As uh, you started mentioning that but if you are a clinician seeing a patient and who should you think about, you know, maybe testing for possible beryllium exposure, perhaps sensitization?

Dr. Maeve MacMurdo:

It's a good question. So, a lot of the workers who have known exposure are going to be screened for their employer. And that's usually how a screening should be occurring. I think for a clinician, again, it depends on the kind of where you're seeing the patient, say if you're a general palynologist seeing a patient who you think, hu, this doesn't quite add up. You've got maybe a, but this is not quite right, or things just aren't quite making sense. It's really anyone who's been working with beryllium full stop. There is no safe level of beryllium exposure to which you cannot become sensitized.

Now, OSHA recently dropped their permissible exposure limit, the PEL, to a much lower level, which should, in theory, reduce the risk of beryllium sensitization and decrease numbers. But the challenge is that, again, like I mentioned, that's great for employers who, again, aware they're using beryllium who are following the standard, but for smaller employers or maybe employers who maybe aren't necessarily aware of the standard, that may not change worker's exposure.

Raed Dweik:

Yeah, that's a good one. Before moving on to how we interpret the LPT screening test, there's some debate in the literature and among the industry as, like, are we doing screening or are we doing surveillance for these patients? You know?

Can you just kind of shed some light on that because screening is easy for the patient's sake, surveillance is more for making sure that the work conditions are appropriate. Can you speak to that a little bit?

Dr. Maeve MacMurdo:

I can, and I think that is a challenging debate, for sure. When I think about it really, I think about this as being screening for the patients because the reality is, like I mentioned, you can be exposed to high levels for years and not become sensitized until say you get exposed at low levels. There's no rhyme or reason. Surveillance is really looking for disease in the working population to try and, again, improve the working conditions. And if we see classes of sensitization occurring out of the blue, there certainly can be a clue something's not quite right in the workplace. Maybe an HVAC that's been broken, maybe something's not, again, being followed in terms of protocol, but in reality, because there's not that clear timeframe from exposure to disease, I think it really is screening for patients, not surveillance.

Raed Dweik:

Yeah, and the way I think about it, probably both are necessary and you need to do screening to make sure that you're protecting the individual patient, but you need to do surveillance to make sure that the work conditions are appropriate and, again, there's no, I guess, source for clusters, as you pointed out, too.

Dr. Maeve MacMurdo:

Exactly, I think, really, there's been a lot of work in this area and the LPT was a big step forward. I mean, historically, we didn't have this up until 1970s, 1980s really in widespread use and it's really changed how we practice and think about beryllium because initially we thought that, actually, we've gotten rid of chronic beryllium disease.

Raed Dweik:

Yeah.

Dr. Maeve MacMurdo:

And, uh, we hadn't, it turns out.

Raed Dweik:

This is a great segue interesting maybe asking you about, maybe tell us what is the Lymphocyte Proliferation Test, the LPT, how it is done, and how it's, uh, interpreted?

Dr. Maeve MacMurdo:

Perfect. So, basically the LPT is looking at the body's response to beryllium and it's looking for the, the abnormal cell proliferation in response to beryllium exposure. So, it literally is taking a blood sample and looking in real time and seeing what those cells do. It is a great test. It's very specific but it's not all that sensitive and so there is a risk of a false negative test especially people who are on steroids, if they're smoking potentially. Anything which can suppress the immune response, and it can, just again, be a bad day immune-wise. And so, that's why a single negative test is not necessarily, again, a slam dunk that you don't have beryllium sensitization. You really want to have ongoing testing.

A positive test is, is much more likely to be a true positive. But, because there is some variation, OSHA does actually require two positive tests to confirm the diagnosis of sensitization. So, either two positives, one positive, and one borderline, or three borderlines. And, to clarify that, because it's also not particularly necessarily obvious. So, when we're looking at testing, a positive is having more than two so basically cell responses greater than free standard. And so, if you've got more than two, it's a slam dunk positive. Two of those means your sensitized.

Raed Dweik:

Yeah.

Dr. Maeve MacMurdo:

If you've got some vary in there, that can ca- be a borderline and that can still be a sign of sensitization that's little bit harder sometimes to tease that out.

Raed Dweik:

And just so that, not to confuse our listeners into the detail. This is going to make more sense to people who look at these tests on a regular basis. Most are, uh, providers and listeners probably do not do this testing. The key is, identify the patients with potential history of exposure and send them to test. Mostly the centers that do the testing do the interpretation well just to kind of give our listeners a sense of how it's done because it's not a straightforward test. It's complicated, it needs a lot of preparation, needs a lot of expertise and, uh, the key is just to send the sample or the patient to a place that does that testing.

Dr. Maeve MacMurdo:

Exactly. And honestly, I think, really what I tell people is, if you've got any concerns of beryllium related disease, it's worth getting a patient seen at a specialized center, even just for a one time visit because this is kind of, as I'm saying, it's pretty complicated.

Raed Dweik:

Yeah.

Dr. Maeve MacMurdo:

And there's a lot of nuance and detail, but often times if you've made the diagnoses, and if you don't meet the diagnosis, kind of, what happens next?

Raed Dweik:

So yeah, what's the expectation, uh, once somebody, regardless of the criteria used, the positive, the two positive tests, or a positive, uh, a couple borderlines, what is next? So, somebody is identified as, in your terms, sensitized, what, what is next for them?

Dr. Maeve MacMurdo:

So, really the big this is thinking about surveillance for chronic beryllium disease. So, like I mentioned, sensitization is kind of the first check box in the pathway towards disease and chronic beryllium disease is basically an autoimmune disease that mimics sarcoidosis. It's inflammation in the lungs, primarily, which can happen actually really subtly. So, when we first discovered this disease and kind of beckoned the bad old days of beryllium exposure, people were really sick when they came in. They were profoundly shortness of breath, they had weight loss, they had cough, they were very, very fatigued, but since we we're screening for this and looking for this earlier and recognizing it, what I see now, especially because I am screening people who are beryllium sensitized, is a lot of people who have very mild disease.

It may look like asthma, they may just feel not quite right, again, they're still really physically active, so they're doing everything, but it's harder than it used to be. They're saying, you know, I'm wearing my mask, and I feel short of breath. I can only climb two flights of stairs, not three. This is not an obvious necessarily presentation, but then when you get the CAT scan and get the breathing test, things again, just don't look quite right. We can see reduction in FVC, reduction FEV1, reduction in DLCO function testing. It can really look like anything. Often it looks like asthma, and I see a lot of CBD, chronic beryllium disease, that mimics asthma in these workers. And then, very subtle changes often on the CAT scan. Classically, we talk about nodularity, but I see a lot of early diseases which kind of just doesn't look quite right.

Raed Dweik:

Yeah.

Dr. Maeve MacMurdo:

And again, that's a challenge.

Raed Dweik:

What also struck me as I evaluated these patients is that many of them are completely asymptomatic. They just show up based on a positive LPT and that's one of the main strengths for the lymphocyte proliferation test, test is that it identifies patients before they even develop any symptoms.

Dr. Maeve MacMurdo:

Absolutely, because the goal is to catch these workers early. It tells them, you know, chronic beryllium disease is treatable. It's one of the real occupational lung diseases where you really can treat this, control this and have you living a pretty normal life. But that stems from catching it early.

Raed Dweik:

Yeah.

Dr. Maeve MacMurdo:

If we don't catch it 'till it's advanced and, I have much less in the way of treatment options. If we catch you when you're asymptomatic, I often can just watch you and not have you on treatment and if things change, we start treatments right away, we get you back to feeling good.

Raed Dweik:

The purpose of testing is to determine whether they have chronic beryllium disease. Whether they've advanced from sensitization to disease, so what kind of test do you do for that and how accurate are they in making the diagnosis?

Dr. Maeve MacMurdo:

So, I kind of gave you a hint already when I was talking about what I'm looking for. But really when you're talking about screening for chronic beryllium disease, it's a combination of spirometry, so breathing tests, the CAT scan, abnormally high areas, and then the challenging thing is that, like I mentioned, this disease can be really, really subtle. The only way to really make a slam dunk diagnosis of chronic beryllium disease is to get a biopsy, a transbronchial biopsy. But even that's not 100 percent. But if you think about chronic beryllium disease especially early, it can be really patchy. Some parts of the lungs have granulomas, some parts don't. And so, the bronchoscopy may not capture that granulomatous inflammation, especially if patients are relatively well and not symptomatic. There are other things which can be helpful. So, the BAL LPT, lymphocyte proliferation on the BAL fluid if that's possible acronyms.

Raed Dweik:

Yes.

Dr. Maeve MacMurdo:

If that's positive, that's really helpful, and that's the strongest positive diagnosis of chronic beryllium disease. Similarly, even if the biopsy is negative, if we see a lot of lymphocytes on the bronchoalveolar lavage, the BAL, with imaging changes, that can also be enough to make a diagnosis sometimes. So, there's multiple pathways, but again, it requires a fair amount of knowledge on what the regulations are, and a fair amount of experience with seeing these patients with kind of these weird presentations of chronic beryllium disease.

Raed Dweik:

Yeah, I mean, just to make a point, I think you mentioned sarcoidosis earlier and most people, the only way they hear about chronic beryllium disease is that it's on the list of differential diagnoses for sarcoidosis so only a few specialized centers have seen enough patients to be able to recognize and diagnose them appropriately, this is why, as you mentioned, early referral once suspected is important.

I can't tell you how many times I've seen patients who've had a positive LPT but they were evaluated elsewhere, they had a normal spirometry, normal x-ray, normal CAT scan, and they were told they have nothing, they don't have the disease, but they come here, we do a bronchoscopy on them and they have granulomas of the lung. They may not have advanced clinically active, or like, significant limitations on the lungs, but that- they already have the disease and that's, I think, very important too, to make the diagnosis appropriate.

Dr. Maeve MacMurdo:

Hugely. I mean, it changes A) recognizing about ongoing work because, like you mentioned, again, these are often people who are young and healthy and working. And what we know from people with chronic beryllium disease or really the recommendation is to be out of the workplace. To be no longer exposed to beryllium. And so, making that diagnosis is really important and making that happen and also getting worker's compensation, which is again, really important because there are really skilled laborers doing often really challenging and very specialized work that plays well. And so, if they can't work that job anymore, we need to make sure that they have a way of being retained and getting compensated for that, too.

Raed Dweik:

Yeah, you mentioned a couple of things I want to follow up on. One is exposure, continued exposure. You know, when do you tell workers to no longer be exposed to beryllium? I know it's a tricky topic and whether they have sensitization or disease. Whether they can get another job or not so it's a lot of factors to think about. So, how do you approach that with your patients?

Dr. Maeve MacMurdo:

It's really a patient-centered discussion because, like you said, it's complicated and my general rule of thumb is that if you're sensitized, we know there is probably an increased risk of developing chronic beryllium disease if ongoing exposure. And so ideally, you would leave the workplace. I do have a lot of patients who don't leave the workplace at that point and again, like I said, these are skilled jobs and it's sometimes challenging to say, you know, I might have a risk of disease, let me change my entire life. Once you have chronic beryllium disease, I'm pretty firm that really, we need to get you out of the workplace because it's very hard to treat and control chronic beryllium disease if you've got ongoing exposure to beryllium. Not everyone does, but that's my recommendation.

I think one thing that's been really helpful and what I'm really grateful for is the EAOCPA which, sorry, another acronym. Basically, the reinvestment policy for people who've got beryllium related disease, which is a government policy, but basically, it's a program that reimburses these workers. Helps them get financial support for ongoing screening. And it's got a really, really well streamlined protocol to follow to get workers enrolled and registered which makes it a lot easier. I have workers who go for other pathways like the black lung pathway, which requires a lot of litigation, a lot of back and forth. The EAOCPA, there, again, beryllium pathway, is much more straightforward. It's really, do you have disease? Great, here you go. And that makes it a lot less stressful both for the workers and for employers.

Raed Dweik:

Yeah, and my conversation about exposure with patients, it's usually that, you know, we don't have direct evidence that, uh, continued exposure with worse- will worsen the disease, but the absence of that evidence doesn't mean it's not happening and it just makes sense clinically and medically that if you're allergic or sensitized to something, just to avoid it. You know, I think, uh, that's my general advice.

Dr. Maeve MacMurdo:

Yeah, I think that, I mean, there's no slam dunk evidence, but there are some cohorts, particularly people who have heavy exposure are machinists, where we saw that, again, those who had ongoing exposure did have an increased risk of CBD, so I think that's not necessarily a slam dunk, but I think it's enough that I would say, if it was me, I'll get out of there.

Raed Dweik:

Clearly, I think you and I would both recommend removal from exposure. What else? How else can you treat, uh, these patients and do you always treat them, or do you sometime watch and sometimes treat? What's your approach?

Dr. Maeve MacMurdo:

Again, I think this is where having a lot of experience and seeing all these patients is really helpful. So, I don't always treat. If people are not symptomatic, if they feel good, if their pulmonary function is stable, then I often will just watch and monitor. But, if things are progressing or if things are changing, even if things are still normal, I often start having a discussion about whether we should start treatment.

First line treatment is typically steroids or prednisone and that usually works really well. I've got a lot of patients I'm seeing currently who have got more of sort of small airway asthma like phenotype and I use a lot of inhaled steroids, too, which has actually been helpful in reducing the steroid dosing down. And then like sarcoid, that's steroid sparing agents actually also work really well here. Methotrexate, but I don't typically need to go that far. Depending on the MERN, I mean, there are a lot of options. This is one of those diseases that really is treatable. Very much so.

Raed Dweik:

Yeah, seems like it's all works around immunosuppression basically because, you explained it a little bit at the beginning, but maybe it's worth revisiting as we talk about treatment is that beryllium itself does not damage the lung. It's the lungs response, the immune system response to the beryllium that does the damage so, most treatment really focuses on reducing the immune response to beryllium.

Dr. Maeve MacMurdo:

Exactly. I basically tell patients that they have an autoimmune disease. It's not the beryllium that's causing a problem, it's the beryllium that triggered the pathway which is now active, and we need to turn it off.

Raed Dweik:

Yeah. That's an important point, but of course, if it were not for the beryllium this would not have happened. So, it's hard to say it's not causing the problem, but it's not directly causing the problem.

Dr. Maeve MacMurdo:

It's the, yeah. It's gasoline, it's not fire.

Raed Dweik:

Yeah, that's a, that's a, that's a good point, uh. So, now as if somebody is out there and this podcast is designed for, uh, providers, physicians, and other healthcare providers. Any advice for them and when to, uh, suspect and refer a patient and how to do that?

Dr. Maeve MacMurdo:

So, I think the big thing is, again, taking a thorough occupational history. I know I say this every time I talk to anybody about occupational diagnoses, but really it is where history matters. And I think the challenge with beryllium is that workers, like I said, may not always know they're exposed, but there are some clues, like ship building, like nuclear weapons, anything which sounds like it might use something that's lightweight and aerodynamic that's like kid of a hint.

I think if workers are worried, or if you are worried, or if you see sarcoid and you're kind of going, hu, that's when I think about referring and if they want to refer, I actually wrote the number down because I always forget my phone number which is embarrassing, but it's uh, 2164450746. It's a beryllium center phone line and I can put down my website, too, potentially, but basically just reach out to use and say I've got a patient who's being exposed to beryllium or I think night have been exposed, and we can kind of coordinate testing and next steps, advise what can be don't locally, and what needs to be done at the Cleveland Clinic and kind of take it from there.

Raed Dweik:

So, the best way is just maybe to reach out to you or call the Respiratory Institute or The Cleveland Clinic and they'll get an appointment with somebody that's, uh, that makes a lot of sense. So, as we wrap this up, this has been very helpful, I think very eye-opening. I hope our listeners will benefit from all the great information you have provided about beryllium exposure and disease.

Let me try to kind of wrap up with a few key points about this is that, you know, beryllium exposure, uh, may be happening in more locations than we think about. It's not just in primary mining and manufacturing. There are lots and lots of industries who use beryllium and alloys like anywhere from aerospace, nuclear weapons, but also things like computers, and things as even common as golf clubs and bicycles so they key is, if you are a worker, you know, or you have a worker with a, with a, to just do a detailed history, as you said, of, of exposure.

It can be clinically confused with sarcoidosis because of the same clinical presentation, so, this is where if you have somebody with sarcoid, but things don't add up, is to think about beryllium disease testing, or referral. There are some required screenings by OSHA for the, for this disease, so if somebody comes to you with a positive test, take it very seriously because that means, it doesn't necessarily mean they have beryllium disease, but it, it's a red flag, as you pointed to. You are moving down the path from exposure to sensitization, the next step will be disease and something that's worth evaluating.

And uh, the testing is not perfect. You know, the, the lymphocyte proliferation test we talked about, it's not perfect but it's the best tool we have now to identify these patients early. And you emphasized multiple times the importance of early referral if you suspect the patient has chronic beryllium disease, or beryllium sensitization. Anything else you'd like to add?

Dr. Maeve MacMurdo:

No, I think I just want to harp on, again, early referral really is key here. Beryllium is complicated and then workers comp is complicated and the EAOCPA pathway will almost streamline the most it's still not the most straightforward you'll ever get, so especially for patients who may need to leave their job, having someone who's seen a lot of chronic beryllium disease, you see the patient and kind of advice about next steps, can be really helpful and I think makes patients' lives significantly easier. So, if you're worried about beryllium, just refer.

Raed Dweik:

Wonderful. Thank you very much, Dr. MacMurdo, for this very useful podcast and again, this is Raed Dweik, chairman of the Respiratory Institute, host of this podcast, and my guest today was Dr. Maeve MacMurdo, who is the director of Occupational Lung Disease Program, and the focus of our discussion was beryllium exposure and disease. Thank you all for listening and have a great day.

Thank you for listening to this episode of the respiratory exchange. For more stories and information from Cleveland Clinic Respiratory Institute, you can follow us on twitter at CleClinicLungs or follow me at RaedDweikMD. Thank you.