Medical fitness to wear respirators Allen Kraut, MD, FRCPC Oct 3, 2010 OEMAC Saskatoon, SK.
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Transcript of Medical fitness to wear respirators Allen Kraut, MD, FRCPC Oct 3, 2010 OEMAC Saskatoon, SK.
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Medical fitness to wear respirators
Allen Kraut, MD, FRCPCOct 3, 2010
OEMAC Saskatoon, SK
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Respirator program CSA Z94.9-02
Roles and responsibilities Hazard assessment Selection of appropriate respirator Health surveillance Respirator fit testing Training Maintenance and storage Program evaluation Record keeping
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Is the worker medically fit to use a respirator?
Detailed reports on respirator programs but no guidance on medical decisions.
OSHA similar approach to CSA
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What information is needed to make a decision?
Worker’s health status Type of respirator Type of work
Physical level Environments
IDLH Other protective equipment
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What health information influences decision? Physiologic conditions
Pulmonary conditions Cardiac conditions Symptoms
Psychological issues Safety issues
Environment - Immediately toxic or oxygen deficient atmospheres
Communication – Hearing, Vision Loss of consciousness
Seizure disorder, diabetic on insulin Past ability to tolerate a respirator
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What health information influences decision?
Seal issues Psychological -Claustrophobia Respiratory - cough Facial - deformities ? beard
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Physiologic effects of a respirator
-ve pressure air purifying Pulmonary
Increased resistance Increased tidal volume, decreased
breathing frequency, decreased alveolar ventilation
Submaximal workloads effects small Maximal workloads may be decreased
by 10%.
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How does using a –ve pressure respirator affect individuals with respiratory disorders?
Mild to moderate obstructive and restrictive respiratory defects Subtle effects Not sensitive or specific for
determining fitness to use a respirator
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PFT abnormalities 27 yo female geologist with cystic fibrosis
wishes to be hired by a mining company as a field tester. She has worked for a contractor doing similar work in the mine for the last three years with according to her, no problems. She reports using a half face mask cartridge respirator regularly in the past with no problems. Her FEV1 is 0.77 L 25% predicted and FVC is 0.92 L 54% predicted, the ratio of FEV1/FVC is 40%.
Is she fit to wear a half face mask cartridge respirator?
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PFT abnormalities 1. Fit to wear the suggested respirator 2. Fit with restrictions/conditions
What restrictions/conditions? 3. Fitness decision needs to deferred
until additional information is available. What information?
4. Unfit to wear the suggested respirator.
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Q1 PFTs
0
2
4
6
8
10
12
Fit
Restrictions/ conditionsDeferred more info
Unfit
N =22
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Restrictions/conditions 3 could do tasks 1 air powered, fresh air supply
Deferred 1 check pfts to follow decline 2 speak to respirologist 3 more info on job and person 1 blood gas, diffusion 2 trial of respirator 2 get out in emergency
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My answer #3
1. Verified that she could wear her respirator and do her work
2. Verified her sickness absences 3. Verified that she could exit the
mine.
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Q1 PFTs
0
2
4
6
8
10
12
14
16
Fit
Restrictions/ conditionsDeferred more info
Unfit
N =23
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After verification #2
Restrictions/conditions 1. Only fit for current job 2. Needed to report any significant
change in medical condition 3. Needs to provide a letter yearly
from her physician stating that her condition has not deteriorated
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What PFT measurement gives the best overall assessment of lung function?
FEV1 > 60% predicted - trial of respirator
Lower levels for light duties ATS guidelines
Am J Respir Crit Care Med 1996 154:1153-1165
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How often do PFTs help in the certification decision?
5,569 workers DOE facility 98.7% no restriction 71 (1.3%) restrictions 5 (0.1%) solely on basis of PFTs
Pappas et al AJIM, 1999;35:390-94
Can questionnaires screen out people who do not need further assessment? YES 49/413 abnormal PFTs only 1 case did it
influence decision Pappas et al, AJIM 1999;35:395-400
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Pregnancy 27 yo Female 16 week pregnant works in a
aircraft manufacturing facility. A variety of solvent based compounds are used and air measurements for all of them are < 2% of the TLV. Cartridge respirators are optional in this workplace. Alternative work is not available and she wishes to wear a cartridge respirator for about two hours a day when she feels her exposures would be greatest. Is she fit to wear a negative pressure respirator?
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Pregnancy 1. Fit to wear the suggested respirator 2. Fit with restrictions/conditions
What restrictions/conditions? 3. Fitness decision needs to deferred
until additional information is available. What information?
4. Unfit to wear the suggested respirator.
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Q2 Pregnancy
0
2
4
6
8
10
12
14
Fit
Restrictions/ conditionsDeferred more info
Unfit
N =22
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Restrictions/conditions 2 concerned about solvents 1 fit tested can change in pregnancy 1 personal monitoring and monthly assessment of
fitness Deferred
1 assess workload 2 more medical info past pregnancies 1 list exposures 1 pft 1 fit may change during pregnancy 1 concerned re solvents
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Q2 Pregnancy
0
2
4
6
8
10
12
14
16
18
Fit
Restrictions/ conditionsDeferred more info
Unfit
N =22
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My answer #1
Issues 1. Does pregnancy affect the ability to
wear a respirator? 2. Is the pregnant worker at risk if the
respirator fails?
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Does pregnancy affect the ability to wear a respirator?
Israeli study – Gulf War 48 pregnant women wearing gas
masks 24 during labour and delivery.
No decrease in maternal po2 Mild tachypnea No fetal heart rate abnormalities. Delivered babies did well Apgar > 8 at 1’
Can J. Anaesthesia 1992;39:895-96.
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Seizure disorder 28 yo male with a history of head trauma and residual seizure
disorder wishes to work in maintenance at a food processing plant. He has no other neurologic sequelae from his injury and is otherwise well. His work involves intermittently using a negative pressure cartridge respirator when exposed to irritants and six times per year using an SCBA to clean the inside of large vats. This is quite hard work. He supplies a note from his physician stating that he is compliant with his medication and that his drug levels are in the therapeutic range. His last seizure was 6 months prior when he was up all night due to travel arrangement complications during a trip. His last seizure prior to that was 18 months previous. He has had an aura prior to previous seizures. Is he fit to wear the respirators required for his job?
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Seizure
1. Fit to wear the suggested respirators 2. Fit with restrictions/conditions
What restrictions/conditions? 3. Fitness decision needs to deferred
until additional information is available. What information?
4. Unfit to wear the suggested respirators.
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Q3 Seizure
0
2
4
6
8
10
12
Fit
Restrictions/ conditionsDeferred more info
Unfit
N =22
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Restrictions/conditions 2 Needs longer seizure free period 1 yr , 2 yr 4 No SCBA 4 Can’t work alone
Deferred 1 consult neurologist 1 CV fitness, can’t work alone 1 Is this a unionized environment? If so he will have
to be approved as an arbitrator would declare him to be fit if tested at a hearing as it would be. The cost of an arbitration is usually $15,000, so to save the waste of that money he would be approved without further ado.
1 can he drive?
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Q2 Seizure Issue SCBA
0
2
4
6
8
10
12
Fit
Restrictions/ conditionsDeferred more info
Unfit
N =22
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Seizure free periods- after diagnosis of epilepsy
Private driver - 6 –12 months seizure free compliant patient on medication
Commercial driver- five years NFPA 5 years seizure free Safety sensitive jobs in railway – 5
years
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Seizure My answer #1
Frequency of seizures Compliance with treatment Precipitating circumstances Presence of warning symptoms
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Asthma 45 YO Male egg processing manager develops
occupational asthma secondary to exposure to egg proteins. At diagnosis he presented to ER. With appropriate treatment he is feeling well and has had no further hospital visits. Pre-bronchodilator spirometry shows mild obstruction which resolves with salbutamol. The man does not want to change careers because he feels he will not be able to replace his income. He is able to limit, but not eliminate his exposure to the egg proteins at work. Should be allowed to work wearing a negative pressure respirator while exposed to eggs?
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Asthma 1. Fit to wear the suggested respirator 2. Fit with restrictions/conditions
What restrictions/conditions? 3. Fitness decision needs to deferred
until additional information is available. What information?
4. Unfit to wear the suggested respirator.
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Q3 Asthma
0
1
2
3
4
5
6
7
8
9
10
Fit
Restrictions/ conditionsDeferred more info
Unfit
N =22
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Restrictions/conditions 4 medical follow up, spirometry, methacholine
challenge, symptoms 1 fit testing 3 concerned about exposure if sensitized should not
be exposed Deferred
1 on the job evaluation 1 pre post pfts 1review history no anaphylactic reactions 1 Need spirometry would follow post exposure 1 how long since diagnosis, PAPR
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Q2 Asthma
0
2
4
6
8
10
12
14
Fit
Restrictions/ conditionsDeferred more info
Unfit
N =22
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Occupational immunologic asthma
Ideally stop exposure Stopping exposure may be
associated with loss of income ? PPE
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Asthma –irritant or non occupational
Protects against exposure Harber (JOEM 2010)Asthmatics
may report more symptoms with cartridge respirators.
If the respirator is not used properly increased exposure to irritants ? Asthmatic attack.
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Asthma #2
Conditions –Needs medical follow up q 6 months for lung function testing and methacholine challenge while working with potential exposure.
Continued working for 15 years, no persistent decline in PFTs. Laid off, could not find permanent work.
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SCBA 45 yo male with history of Type II diabetes
on metformin, obesity (BMI 32), mild hypertension, smoking ½ ppd, normal cholesterol is referred for respirator certification. He works in a chemical plant and he needs to wear an SCBA for emergency circumstances in case there is a spill and he has to rescue a co-worker. He has no history of cardiac disease or symptoms suggestive of angina. His father had an MI at age 67. Is he fit to wear an SCBA respirator?
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Cardiac risk factors. 1. Fit to wear the suggested respirator 2. Fit with restrictions/conditions
What restrictions? 3. Fitness decision needs to deferred
until additional information is available. What information?
4. Unfit to wear the suggested respirator.
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Q3 Cardiac Risk
0
2
4
6
8
10
12
Fit
Restrictions/ conditionsDeferred more info
Unfit
N =22
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Restrictions/conditions Deferred
1 practical test 8 cardiac stress 2 more medical info 3 pfts 1 no facial hair
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Q3 Cardiac Risk
0
2
4
6
8
10
12
Fit
Restrictions/ conditionsDeferred more info
Unfit
N =22
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SCBA cardiac risk factors
Although likelihood of needing SCBA is low, needs to be able to use it.
Need further information Exercise test
If negative then ok.
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How should respirator certification decision be made?
No clear guidelines Tolerance more dependent on comfort
and psychological factors than physiologic measures
In general, if a worker is healthy enough to do the job without a –ve pressure respirator he/she should be able to perform the work with a respirator.
Past experience best guide.
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How should a decision be made?
Estimate the likelihood of an unacceptable adverse outcome.
If no clear contraindications, trial and observe
at work or in simulated situation
If a worker reports difficulties try a different type of respirator
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Conclusions
The vast majority of people who can work, can tolerate a –ve pressure air purifying resp.
Issue is usually fitness to work not fitness to wear respirator
Questionnaires can be used to screen people who require more intense evaluation
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Conclusions
PFTs useful only in workers with symptoms or history suggestive of lung disease. May be needed for surveillance purposes.
Worker’s should not be restricted from using –ve pressure respirators solely based on spirometry results.
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Conclusions IDLH environments, emergency workers,
SCBA users require more intense evaluation Cardiac Pulmonary Musculoskeletal Seal issues
Post certification follow up would be useful to identify if worker having problems with a respirator