OBJECTIVE Inhalation of a cotton-based particulates has previously been associated with respiratory symptoms and impaired lung function. This study investigates the respiratory health of Nepalese textile workers in relation to dust and endotoxin exposure. METHODS A total of 938 individuals from four sectors (garment, carpet, weaving and recycling) of the textile industry in Kathmandu, Nepal completed a health questionnaire and performed spirometry. A subset (n=384) performed cross-shift spirometry. Personal exposure to inhalable dust and airborne endotoxin was measured during a full shift for 114 workers. RESULTS The overall prevalence of persistent cough, persistent phlegm, wheeze ever, breathlessness ever and chest tightness ever was 8.5%, 12.5%, 3.2%, 6.5% and 12.3%, respectively. Symptoms were most common among recyclers and least common among garment workers. Exposure to inhalable dust significantly predicted persistent cough and chest tightness. Exposure to endotoxin did not have any independent predictive effect. Significant cross-shift reduction in forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) were found (p<0.001 for both) being largest for FEV1 in the recyclers (-143 mL), and least in the garment workers (-38 mL; p=0.012). Exposure to inhalable dust predicted a cross-shift reduction in FEV1. CONCLUSIONS This study is the first to investigate the respiratory health of Nepalese cotton workers. The measured association between inhalable dust exposure and reporting of respiratory symptoms and across-shift decrement in FEV1 and FVC indicates that improved dust control measures should be instituted, particularly in the recycling and carpet sectors. The possible role of other biologically active agents of cotton dust beyond endotoxin should be further explored.