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Occupational Respiratory Health

A special issue of International Journal of Environmental Research and Public Health (ISSN 1660-4601). This special issue belongs to the section "Occupational Safety and Health".

Deadline for manuscript submissions: closed (31 January 2020) | Viewed by 46078

Special Issue Editor


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Guest Editor
Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD 4810, Australia
Interests: occupational health and safety; ergonomics; biomechanics; public health; human system interface; rehabilitation; respiratory health
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

We are organizing a Special Issue on the impact of particle emissions on respiratory health in occupational environments in the International Journal of Environmental Research and Public Health. The venue is a peer-reviewed scientific journal that publishes articles and communications in the interdisciplinary area of environmental health sciences and public health. For detailed information on the journal, we refer you to https://0-www-mdpi-com.brum.beds.ac.uk/journal/ijerph. 

Improving respiratory health is an important objective for the mining, construction and processing industries and policy makers. Respiratory health refers to preventing disease of the respiratory tract, and prolonging life of those exposed to excessive levels of respiratory hazards, promoting health and well-being. Occupational environments, including above ground and underground mines, construction sites, tunneling sites, power plants, workshops, farms, processing plants and transportation systems may affect the respiratory health of workers and the public, through individual exposure levels (e.g., dust particle exposure), activity patterns (e.g., heavy physical work), pre-existing medical conditions and individual resilience. Research, both in indoor workplaces and open areas, and in both developing and developed countries, can offer a critical guide for policy efforts and planning for occupational and environmental health, and inform proactivity to improve productivity.

This Special Issue is open to any subject area related to the impact of particle emissions on occupational respiratory health. The listed keywords suggest just a few of the many possibilities.

Prof. Dr. Gunther Paul
Guest Editor

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. International Journal of Environmental Research and Public Health is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2500 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • Underground mining
  • Open-cut mining
  • Engineered stone processing
  • Construction
  • Tunneling
  • Farming
  • Food processing
  • Public health
  • Occupational health
  • Environmental health
  • Environmental exposure
  • Particle exposure
  • Particle emission
  • Particle imission
  • Coal Mine Dust Lung Disease (CMDLD)
  • Black lung
  • Coal Worker Pneumoconiosis (CWP)
  • Progressive Massive Fibrosis (PMF)
  • Silicosis
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Asbestosis
  • Emphysema
  • Occupational asthma
  • Ventilation
  • Water spraying
  • Personal Dust Monitor (PDM)
  • Personal Protective Equipment (PPE)

Published Papers (10 papers)

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Research

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19 pages, 9156 KiB  
Article
Helium–Oxygen Mixture Model for Particle Transport in CT-Based Upper Airways
by Mohammad S. Islam, YuanTong Gu, Arpad Farkas, Gunther Paul and Suvash C. Saha
Int. J. Environ. Res. Public Health 2020, 17(10), 3574; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph17103574 - 20 May 2020
Cited by 15 | Viewed by 2800
Abstract
The knowledge of respiratory particle transport in the extra-thoracic pathways is essential for the estimation of lung health-risk and optimization of targeted drug delivery. The published literature reports that a significant fraction of the inhaled aerosol particles are deposited in the upper airways, [...] Read more.
The knowledge of respiratory particle transport in the extra-thoracic pathways is essential for the estimation of lung health-risk and optimization of targeted drug delivery. The published literature reports that a significant fraction of the inhaled aerosol particles are deposited in the upper airways, and available inhalers can deliver only a small amount of drug particles to the deeper airways. To improve the targeted drug delivery efficiency to the lungs, it is important to reduce the drug particle deposition in the upper airways. This study aims to minimize the unwanted aerosol particle deposition in the upper airways by employing a gas mixture model for the aerosol particle transport within the upper airways. A helium–oxygen (heliox) mixture (80% helium and 20% oxygen) model is developed for the airflow and particle transport as the heliox mixture is less dense than air. The mouth–throat and upper airway geometry are extracted from CT-scan images. Finite volume based ANSYS Fluent (19.2) solver is used to simulate the airflow and particle transport in the upper airways. Tecplot software and MATLAB code are employed for the airflow and particle post-processing. The simulation results show that turbulence intensity for heliox breathing is lower than in the case of air-breathing. The less turbulent heliox breathing eventually reduces the deposition efficiency (DE) at the upper airways than the air-breathing. The present study, along with additional patient-specific investigation, could improve the understanding of particle transport in upper airways, which may also increase the efficiency of aerosol drug delivery. Full article
(This article belongs to the Special Issue Occupational Respiratory Health)
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11 pages, 826 KiB  
Article
Air Pollution Emissions 2008–2018 from Australian Coal Mining: Implications for Public and Occupational Health
by Michael Hendryx, Mohammad Saidul Islam, Guang-Hui Dong and Gunther Paul
Int. J. Environ. Res. Public Health 2020, 17(5), 1570; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph17051570 - 29 Feb 2020
Cited by 38 | Viewed by 6867
Abstract
Occupational exposure limits for respirable coal dust are based on exposure during working hours, but coal miners may experience additional community-based exposures during nonworking hours. We analyzed Australia National Pollutant Inventory (NPI) data for the years 2008–2018 to estimate air pollutants (metals, nitrogen [...] Read more.
Occupational exposure limits for respirable coal dust are based on exposure during working hours, but coal miners may experience additional community-based exposures during nonworking hours. We analyzed Australia National Pollutant Inventory (NPI) data for the years 2008–2018 to estimate air pollutants (metals, nitrogen oxides, particulate matter ≤ 10 micrometers (PM10) and ≤2.5 micrometers (PM2.5)) originating from coal mines. PM10 levels from community-based air monitors in Queensland and New South Wales were also compared between mining and nonmining communities. Results indicated that tons of coal mined increased over the study period, and that levels of particulate matter, metals, and nitrogen oxides increased significantly over time as well. Coal mines accounted for 42.1% of national PM10 air emissions from NPI sites. PM2.5 from coal mines accounted for 19.5% of the national total, metals for 12.1%, and nitrogen oxides for 10.1%. Coal mining occurred in 57 different post codes; the 20 coal-mining post codes with the highest PM10 emissions were home to 160,037 people. Emissions of all studied pollutants were significantly higher from coal mining sites than from other types of NPI sites. Results from community-based air monitoring stations indicated significantly higher population PM10 exposure in coal mining communities than in nonmining communities. The health of the public at large is impacted by coal mining, but to the extent that miners also live near coal mining operations, their total exposure is underestimated by consideration of exposure only during working hours. Full article
(This article belongs to the Special Issue Occupational Respiratory Health)
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19 pages, 9128 KiB  
Article
Airflow and Particle Transport Prediction through Stenosis Airways
by Parth Singh, Vishnu Raghav, Vignesh Padhmashali, Gunther Paul, Mohammad S. Islam and Suvash C. Saha
Int. J. Environ. Res. Public Health 2020, 17(3), 1119; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph17031119 - 10 Feb 2020
Cited by 24 | Viewed by 3611
Abstract
Airflow and particle transport in the human lung system is influenced by biological and other factors such as breathing pattern, particle properties, and deposition mechanisms. Most of the studies to date have analyzed airflow characterization and aerosol transport in idealized and realistic models. [...] Read more.
Airflow and particle transport in the human lung system is influenced by biological and other factors such as breathing pattern, particle properties, and deposition mechanisms. Most of the studies to date have analyzed airflow characterization and aerosol transport in idealized and realistic models. Precise airflow characterization for airway stenosis in a digital reference model is lacking in the literature. This study presents a numerical simulation of airflow and particle transport through a stenosis section of the airway. A realistic CT-scan-based mouth–throat and upper airway model was used for the numerical calculations. Three different models of a healthy lung and of airway stenosis of the left and right lung were used for the calculations. The ANSYS FLUENT solver, based on the finite volume discretization technique, was used as a numerical tool. Proper grid refinement and validation were performed. The numerical results show a complex-velocity flow field for airway stenosis, where airflow velocity magnitude at the stenosis section was found to be higher than that in healthy airways. Pressure drops at the mouth–throat and in the upper airways show a nonlinear trend. Comprehensive pressure analysis of stenosis airways would increase our knowledge of the safe mechanical ventilation of the lung. The turbulence intensities at the stenosis sections of the right and left lung were found to be different. Deposition efficiency (DE) increased with flow rate and particle size. The findings of the present study increase our understanding of airflow patterns in airway stenosis under various disease conditions. More comprehensive stenosis analysis is required to further improve knowledge of the field. Full article
(This article belongs to the Special Issue Occupational Respiratory Health)
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12 pages, 311 KiB  
Article
Platinum Mine Workers’ Exposure to Dust Particles Emitted at Mine Waste Rock Crusher Plants in Limpopo, South Africa
by Maasago M. Sepadi, Martha Chadyiwa and Vusumuzi Nkosi
Int. J. Environ. Res. Public Health 2020, 17(2), 655; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph17020655 - 19 Jan 2020
Cited by 8 | Viewed by 4207
Abstract
The South African mining industry is one of the largest producers of platinum (Pt) in the world. Workers in this industry are exposed to significant amounts of dust, and this dust consists of particles sizes that can penetrate deep inside the respiratory region. [...] Read more.
The South African mining industry is one of the largest producers of platinum (Pt) in the world. Workers in this industry are exposed to significant amounts of dust, and this dust consists of particles sizes that can penetrate deep inside the respiratory region. A cross-sectional study was conducted to evaluate dust exposure risk at two Pt mine waste rock crusher plants (Facility A and B) in Limpopo, South Africa. Workers’ demographic and occupational information was collected through a structured questionnaire, a walk-through observation on facilities’ processes, and static dust sampling for the collection of inhalable and respirable dust particles using the National Institute for Occupational Safety and Health (NIOH) 7602 and the Methods for Determination of Hazardous Substance (MDHS) 14/4 as guidelines. Only 79% of Pt mine workers, used their respiratory protective equipment (RPE), sixty-five percent were exposed to work shifts exceeding the recommended eight hours and 8.8% had been employed for more than ten years. The mean time-weighted average (TWA) dust concentrations between Facility A and B showed a significant difference (p < 0.026). The Pt mine’s inhalable concentrations (range 0.03–2.2 mg/m3) were higher than the respirable concentrations (range 0.02–0.7 mg/m3), however were all below the respective international and local occupational exposure limits (OELs). The Pt mine’s respirable crystalline silica (SiO2) quartz levels were all found below the detectable limit (<0.01 mg/m3). The Pt miners had increased health risks due to accumulated low levels of dust exposure and lack of usage of RPE. It is recommended that an improved dust control program be put in place which includes, but is not limited to, stockpile enclosures, tire stops with water sprays, and education on the importance of RPE usage. Full article
(This article belongs to the Special Issue Occupational Respiratory Health)
10 pages, 312 KiB  
Article
Asbestos-Related Lung Cancer: A Hospital-Based Case-Control Study in Indonesia
by Anna Suraya, Dennis Nowak, Astrid Widajati Sulistomo, Aziza Ghanie Icksan, Elisna Syahruddin, Ursula Berger and Stephan Bose-O’Reilly
Int. J. Environ. Res. Public Health 2020, 17(2), 591; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph17020591 - 16 Jan 2020
Cited by 11 | Viewed by 6704
Abstract
Indonesia has limited data on asbestos-related diseases despite abundant use. This study investigated the risk of occupational asbestos exposure for lung cancer development, utilizing a hospital-based case-control study. Subjects were patients who received a thoracic CT scan at Persahabatan Hospital, Jakarta. The cases [...] Read more.
Indonesia has limited data on asbestos-related diseases despite abundant use. This study investigated the risk of occupational asbestos exposure for lung cancer development, utilizing a hospital-based case-control study. Subjects were patients who received a thoracic CT scan at Persahabatan Hospital, Jakarta. The cases had primary lung cancer confirmed by histology, the controls were negative for lung cancer. The cumulative occupational asbestos exposure was calculated by multiplying the exposure intensity by the years of exposure. The exposure intensity was obtained by adopting the weighted arithmetic mean value of asbestos exposure from a job-exposure matrix developed in Korea. The primary data analysis was based on logistic regression. The study included 696 subjects, with 336 cases and 360 controls. The chance of lung cancer for subjects exposed to asbestos was doubled (OR = 2.04, 95% CI = 1.21–3.42) compared with unexposed, and subjects with a cumulative asbestos exposure of 10 fiber-years or more even showed an OR of 3.08 (95% CI = 1.01–9.46). The OR of the combined effect between smoking and asbestos was 8.7 (95% CI = 1.71–44.39); the interaction was consistent with an additive and multiplicative risk model. Asbestos exposure is associated with a higher chance of lung cancer. Improved policies are needed to protect the population from asbestos hazards. Full article
(This article belongs to the Special Issue Occupational Respiratory Health)
9 pages, 298 KiB  
Article
Prevalence of Respiratory Health Symptoms among Landfill Waste Recyclers in the City of Johannesburg, South Africa
by Nonhlanhla Tlotleng, Tahira Kootbodien, Kerry Wilson, Felix Made, Angela Mathee, Vusi Ntlebi, Spo Kgalamono, Moses Mokone, Karen Du Preez and Nisha Naicker
Int. J. Environ. Res. Public Health 2019, 16(21), 4277; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph16214277 - 04 Nov 2019
Cited by 12 | Viewed by 3503
Abstract
In developing countries, waste sorting and recycling have become a source of income for poorer communities. However, it can potentially pose significant health risks. This study aimed to determine the prevalence of acute respiratory symptoms and associated risk factors for respiratory health outcomes [...] Read more.
In developing countries, waste sorting and recycling have become a source of income for poorer communities. However, it can potentially pose significant health risks. This study aimed to determine the prevalence of acute respiratory symptoms and associated risk factors for respiratory health outcomes among waste recyclers. A cross-sectional study was conducted among 361 waste recyclers at two randomly selected landfill sites in Johannesburg. Convenience sampling was used to sample the waste recyclers. The prevalence of respiratory symptoms in the population was 58.5%. A persistent cough was the most common symptom reported (46.8%), followed by breathlessness (19.6%) and rapid breathing (15.8%). Approximately 66.4% of waste recyclers reported exposure to chemicals and 96.6% reported exposure to airborne dust. A multivariable logistic regression analysis showed that exposure to waste containing chemical residues (OR 1.80, 95% CI 1.01–3.22 p = 0.044) increased the odds of respiratory symptoms. There was a significant difference in respiratory symptoms in landfill sites 1 and 2 (OR 2.77, 95% CI 1.03–7.42 p = 0.042). Occupational health and safety awareness is important to minimize hazards faced by informal workers. In addition, providing waste recyclers with the correct protective clothing, such as respiratory masks, and training on basic hygiene practices, could reduce the risks associated with waste sorting. Full article
(This article belongs to the Special Issue Occupational Respiratory Health)
14 pages, 797 KiB  
Article
Spirometric Pulmonary Restriction in Herbicide-Exposed U.S. Vietnam War Veterans
by Yasmin Cypel, Stella E. Hines, Victoria J. Davey, Stephanie M. Eber and Aaron I. Schneiderman
Int. J. Environ. Res. Public Health 2019, 16(17), 3131; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph16173131 - 28 Aug 2019
Cited by 1 | Viewed by 3761
Abstract
Spirometric restriction in herbicide-exposed U.S. Army Chemical Corps Vietnam War veterans was examined because no published research on this topic in Vietnam War veterans exists. Spirometry was conducted on 468 veterans who served in chemical operations in a 2013 study assessing the association [...] Read more.
Spirometric restriction in herbicide-exposed U.S. Army Chemical Corps Vietnam War veterans was examined because no published research on this topic in Vietnam War veterans exists. Spirometry was conducted on 468 veterans who served in chemical operations in a 2013 study assessing the association between chronic obstructive pulmonary disease (COPD) and herbicide exposure. Exposure was verified based on blood serum values of 2,3,7,8-tetrachlorodibenzo-p-dioxin. Further, the association between herbicide exposure and spirometry restriction (forced expiratory volume in one second (FEV1)/forced vital capacity (FVC) ≥ lower limit of normal (LLN) and FVC < LLN) was tested after adjustment for military characteristics, selected anthropometrics, and other predictors using multivariable regression. Spirometric restriction in herbicide sprayers (15.7%, 95% CI: 10.6, 20.9) was almost twice that of nonsprayers (9.91%, 95% CI: 5.9, 13.9) (p = 0.081). While spirometric restriction was not significantly associated with herbicide exposure (adjusted odds ratio (aOR) = 1.64, 95% CI: 0.82, 3.29) despite the greater prevalence of restriction in sprayers versus nonsprayers, spirometric restriction was significantly associated with race/ethnicity (aOR = 3.04, 95% CI: 1.36, 6.79) and waist circumference (aOR = 2.46, 95% CI: 1.25, 4.85). Because restrictive pulmonary disease may result from chemically-induced inflammation or sensitivity, research on chemical exposures and restriction in veterans should continue. Future study should include full pulmonary function testing, targeted research designs, and a wider set of explanatory variables in analysis, such as other determinants of health. Full article
(This article belongs to the Special Issue Occupational Respiratory Health)
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11 pages, 306 KiB  
Article
Evaluating Latent Tuberculosis Infection Test Performance Using Latent Class Analysis in a TB and HIV Endemic Setting
by Shahieda Adams, Rodney Ehrlich, Roslynn Baatjies, Nandini Dendukuri, Zhuoyu Wang and Keertan Dheda
Int. J. Environ. Res. Public Health 2019, 16(16), 2912; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph16162912 - 14 Aug 2019
Cited by 8 | Viewed by 3239
Abstract
Background: Given the lack of a gold standard for latent tuberculosis infection (LTBI) and paucity of performance data from endemic settings, we compared test performance of the tuberculin skin test (TST) and two interferon-gamma-release assays (IGRAs) among health-care workers (HCWs) using latent class [...] Read more.
Background: Given the lack of a gold standard for latent tuberculosis infection (LTBI) and paucity of performance data from endemic settings, we compared test performance of the tuberculin skin test (TST) and two interferon-gamma-release assays (IGRAs) among health-care workers (HCWs) using latent class analysis. The study was conducted in Cape Town, South Africa, a tuberculosis and human immunodeficiency virus (HIV) endemic setting Methods: 505 HCWs were screened for LTBI using TST, QuantiFERON-gold-in-tube (QFT-GIT) and T-SPOT.TB. A latent class model utilizing prior information on test characteristics was used to estimate test performance. Results: LTBI prevalence (95% credible interval) was 81% (71–88%). TST (10 mm cut-point) had highest sensitivity (93% (90–96%)) but lowest specificity (57%, (43–71%)). QFT-GIT sensitivity was 80% (74–91%) and specificity 96% (94–98%), and for TSPOT.TB, 74% (67–84%) and 96% (89–99%) respectively. Positive predictive values were high for IGRAs (90%) and TST (99%). All tests displayed low negative predictive values (range 47–66%). A composite rule using both TST and QFT-GIT greatly improved negative predictive value to 90% (range 80–97%). Conclusion: In an endemic setting a positive TST or IGRA was highly predictive of LTBI, while a combination of TST and IGRA had high rule-out value. These data inform the utility of LTBI-related immunodiagnostic tests in TB and HIV endemic settings. Full article
(This article belongs to the Special Issue Occupational Respiratory Health)
10 pages, 299 KiB  
Article
High Prevalence of Respiratory Symptoms among Particleboard Workers in Ethiopia: A Cross-Sectional Study
by Akeza Awealom Asgedom, Magne Bråtveit and Bente Elisabeth Moen
Int. J. Environ. Res. Public Health 2019, 16(12), 2158; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph16122158 - 18 Jun 2019
Cited by 15 | Viewed by 3338
Abstract
Work in the wood industry might be associated with respiratory health problems. The production of particleboard used for furniture making and construction is increasing in many countries, and cause dust, endotoxin and formaldehyde exposure of the workers. The aim of the study was [...] Read more.
Work in the wood industry might be associated with respiratory health problems. The production of particleboard used for furniture making and construction is increasing in many countries, and cause dust, endotoxin and formaldehyde exposure of the workers. The aim of the study was to assess the prevalence of respiratory symptoms and to measure lung function among Ethiopian particleboard workers using Eucalyptus trees as the raw material. In total 147 workers, 74 from particleboard production and 73 controls, participated in the study. Mean wood dust in the particleboard factories was measured to be above recommended limit values. Particleboard workers had a mean age of 28 years and the controls were 25 years. They had been working for 4 and 2 years, respectively. Lung function test was done using spirometry following American Thoracic Society (ATS) recommendations. Respiratory symptoms were collected using a standard questionnaire of ATS. Particleboard workers had higher prevalence of wheezing, cough, cough with sputum production, phlegm, and shortness of breath compared to controls. Lung function status was similar in the two groups. The symptoms might be related to the work in the factories. Longitudinal studies are recommended to explore the chronic impact of work in particleboard factories on respiratory health. Full article
(This article belongs to the Special Issue Occupational Respiratory Health)

Review

Jump to: Research

28 pages, 8137 KiB  
Review
A Review of Respiratory Anatomical Development, Air Flow Characterization and Particle Deposition
by Mohammad S. Islam, Gunther Paul, Hui X. Ong, Paul M. Young, Y. T. Gu and Suvash C. Saha
Int. J. Environ. Res. Public Health 2020, 17(2), 380; https://0-doi-org.brum.beds.ac.uk/10.3390/ijerph17020380 - 07 Jan 2020
Cited by 70 | Viewed by 6898
Abstract
The understanding of complex inhalation and transport processes of pollutant particles through the human respiratory system is important for investigations into dosimetry and respiratory health effects in various settings, such as environmental or occupational health. The studies over the last few decades for [...] Read more.
The understanding of complex inhalation and transport processes of pollutant particles through the human respiratory system is important for investigations into dosimetry and respiratory health effects in various settings, such as environmental or occupational health. The studies over the last few decades for micro- and nanoparticle transport and deposition have advanced the understanding of drug-aerosol impacts in the mouth-throat and the upper airways. However, most of the Lagrangian and Eulerian studies have utilized the non-realistic symmetric anatomical model for airflow and particle deposition predictions. Recent improvements to visualization techniques using high-resolution computed tomography (CT) data and the resultant development of three dimensional (3-D) anatomical models support the realistic representation of lung geometry. Yet, the selection of different modelling approaches to analyze the transitional flow behavior and the use of different inlet and outlet conditions provide a dissimilar prediction of particle deposition in the human lung. Moreover, incorporation of relevant physical and appropriate boundary conditions are important factors to consider for the more accurate prediction of transitional flow and particle transport in human lung. This review critically appraises currently available literature on airflow and particle transport mechanism in the lungs, as well as numerical simulations with the aim to explore processes involved. Numerical studies found that both the Euler–Lagrange (E-L) and Euler–Euler methods do not influence nanoparticle (particle diameter ≤50 nm) deposition patterns at a flow rate ≤25 L/min. Furthermore, numerical studies demonstrated that turbulence dispersion does not significantly affect nanoparticle deposition patterns. This critical review aims to develop the field and increase the state-of-the-art in human lung modelling. Full article
(This article belongs to the Special Issue Occupational Respiratory Health)
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