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APPENDIX H MEDICAL ASPECTS OF WEARING RESPIRATORS* In recommending medical evaluation criteria for respirator use, one should apply rigorous decision-making principles [Halperin et al. 1986];* tests used should be chosen for operating characteristics such as sensitivity, specificity, and predictive value. Unfortunately, many knowledge gaps exist in this area. The problem is complicated by the large variety of respirators, their conditions of use, and individual differences in the physiologic and psychologic responses to them. The following guidelines are intended primarily to assist the physician in developing medical evaluation criteria for respirator use. H.1 BACKGROUND INFORMATION Brief descriptions of the health effects associated with wearing respirators are summarized below. More detailed analyses of the data are available in recent reviews by James [1977] and Raven et al. [1979]. H.1.1 Pulmonary Effects In general, the added inspiratory and expiratory resistances and dead space of most respirators cause an increase in tidal volume and a decrease in respiratory rate and ventilation (including a small decrease in alveolar ventilation). These respirator effects have usually been small both among healthy individuals and, in limited studies, among individuals with impaired lung function [Gee et al. 1968; Altose et al. 1977; Raven et al. 1981; Hodous et al. 1983; Hodous et al. 1986]. This generalization is applicable to most respirators when resistances (particularly expiratory resistance) are low [Bentley et al. 1973; Love et al. 1977]. Although most studies report minimal physiologic effects during submaximal exercise, the resistances commonly lead to reduced endurance and reduced maximal exercise perform ance [Craig et al. 1970; Raven et al. 1977; Stemler and Craig 1977; Myhre et al. 1979; Deno et al. 1981]. The dead space of a respirator (reflecting the amount of expired air that must be rebreathed before fresh air is obtained) tends to cause increased ventilation. At least one study has shown substantially increased ventilation with a full-face respirator, a type that can have a large effective dead space [James et al. 1984]. However, the net effect of a respirator's added resistances and dead space is usually a small decrease in ventilation [Craig Adapted from NIOSH Respiratory Decision Logic [NIOSH 1987b]. ^References for Appendix H are at the end of this Appendix. 251 EGME, EGEE, and Their Acetates et al. 1970; Hermansen et al. 1972; Raven et al. 1977; Stemler and Craig 1977; Deno et al. 1981; Hodous et al. 1983]. The potential for adverse effects, particularly decreased cardiac output, from the positive pressure feature of some respirators has been reported [Meyer et al. 1975]. However, several recent studies suggest that this is not a practical concern, at least not in healthy individuals [Bjurstedt et al. 1979; Arborelius et al. 1983; Dahlbackand Balldin 1984]. Theoretically, the increased fluctuations in thoracic pressure caused by breathing with a respirator might constitute an increased risk to subjects with a history of spontaneous pneumothorax. Few data are available in this area. While an individual is using a negative-pressure respirator with relatively high resistance during very heavy exercise, the usual maximal-peak negative oral pressure during inhalation is about 15 to 17 cm of water [Dahlback and Balldin 1984]. Similarly, the usual maximal-peak positive oral pressure during exhalation is about 15 to 17 cm of water, which might occur with a respirator in a positive-pressure mode, again during very heavy exercise [Dahlback and Balldin 1984]. By comparison, maximal positive pressures such as those during a vigorous cough can generate 200 cm of water pressure [Black and Hyatt 1969]. The normal maximal negative pleural pressure at full inspiration is -40 cm of water [Bates et al. 1971], and normal subjects can generate -80 to -160 cm of negative water pressure [Black and Hyatt 1969]. Thus vigorous exercise with a respirator does alter pleural pressures, but the risk of barotrauma is substantially less with exercise than with coughing. In some asthmatics, an asthmatic attack may be exacerbated or induced by a variety of factors including exercise, cold air, and stress, all of which may be associated with wearing a respirator. Although most asthmatics who are able to control their condition should not have problems with respirators, a physician's judgment and a field trial may be needed in selected cases. H.1.2 Cardiac Effects The added work of breathing from respirators is small and could not be detected in several studies [Gee et al. 1968; Hodous et al. 1983]. A typical respirator might double the work of breathing (from 3% to 6% of the total oxygen consumption), but this is probably not of clinical significance [Gee et al. 1968]. In concordance with this view, several other studies indicated that at the same workloads heart rate does not change with the wearing of a respirator [Raven et al. 1982; Harber et al. 1982; Hodous et al. 1983; Arborelius et al. 1983; Petsonk et al. 1983]. In contrast, the added cardiac stress due to the weight of a heavy respirator may be considerable. A self-contained breathing apparatus (SCBA) may weigh up to 35 lb. Heavier respirators can reduce maximum external workloads by 20% and similarly increase heart rate at a given submaximal workload [Raven et al. 1977], In addition, it should be noted that many uses of SCBA (e.g., for firefighting and hazardous waste site work) also necessitate the wearing of 10 to 25 lb of protective clothing. Raven et al. [1982] found 252 Appendix H statistically significant higher systolic and/or diastolic blood pressures during exercise for persons wearing respirators. Arborelius et al. [1983] did not find significant differences for persons wearing respirators during exercise. H.1.3 Body Temperature Effects Proper regulation of body temperature is primarily of concern with the closed circuit SCBA that produces oxygen via an exothermic chemical reaction. Inspired air within these respirators may reach 120F (49C), thus depriving the wearer ofa minor cooling mechanism and causing discomfort. Obviously this can be more of a problem with heavy exercise and when ambient conditions and/or protective clothing further reduce the body's ability to lose heat. The increase in heart rate because of increasing temperature represents an additional cardiac stress. Closed-circuit breathing units of any type have the potential for causing heat stress since warm expired gases (after exothermic carbon dioxide removal with or without oxygen addition) are rebreathed. Respirators with large dead spaces also have this potential problem, again because of partial rebreathing of warmed expired air [James et al. 1984]. H. 1.4 Sensory Effects Respirators may reduce visual fields, decrease voice clarity and loudness, and decrease hearing ability. Besides the potential for reduced productivity, these effects may result in reduced industrial safety. These factors may also contribute to a general feeling of stress [Morgan 1983a], H.1.5 Psychologic Effects This important topic is discussed in recent reviews by Morgan [Morgan 1983a, 1983b]. There is little doubt that virtually everyone suffers some discomfort when wearing a respirator. The large variability and the subjective nature of the psychophysiologic aspects of wearing a respirator, however, make studies and specific recommendations difficult. Fit testing obviously serves an important additional function by providing a trial to determine if the wearer can psychologically tolerate the respirator. The great majority of workers can tolerate respirators, and experience in wearing them aids in this tolerance [Morgan 1983b]. However, some individuals are likely to remain psychologi cally unfit for wearing respirators. H.1.6 Local Irritation Effects Allergic skin reactions may occur occasionally from wearing a respirator, and skin occlusion may cause irritation or exacerbation of preexisting conditions such as pseudofolliculitis barbae. Facial discomfort from the pressure of the mask may occur, particularly when the fit is unsatisfactory. 253 EGME, EGEE, and Their Acetates H.1.7 Miscellaneous Health Effects In addition to the health effects (described above) associated with wearing respirators, specific groups of respirator wearers may be affected by the following factors: a. Perforated tympanic membrane Although inhalation of toxic materials through a perforated tympanic membrane (ear drum) is possible, recent evidence indicates that the airflow would be minimal and rarely if ever of clinical importance [Cantekin et al. 1979; Ronk and White 1985]. In highly toxic or unknown atmospheres, use of positive pressure respirators should ensure adequate protection [Ronk and White 1985]. b. Contact lenses Contact lenses are generally not recommended for use with respirators, although little documented evidence exists to support this viewpoint [daRoza and Weaver 1985]. Several possible reasons for this recommendation are noted below: (1) Corneal irritation or abrasion Corneal irritation or abrasion might occur with the exposure. This would, of course, be a problem primarily with quarter- and half-face masks, especially with particulate exposures. However, exposures could occur with full-face respirators because of leaks or inadvisable removal of the respirator for any reason. Although corneal irritation or abrasion might also occur without contact lenses, their presence is known to substantially increase this risk. (2) Loss or misplacement of a contact lens The loss or misplacement of a contact lens by an individual wearing a respirator might prompt the wearer to remove the respirator, thereby resulting in exposure to the hazard as well as to the potential problems noted above. (3) Eye irritation from respirator airflow The constant airflow of some respirators, such as powered air-purifying respirators (PAPR's) or continuous flow air-line respirators, might irritate the eyes of a contact lens wearer. H.2 SUGGESTED MEDICAL EVALUATION AND CRITERIA FOR RESPIRATOR USE The following NIOSH recommendations allow latitude for the physician in determining a medical evaluation for a specific situation. More specific guidelines may become available as knowledge increases regarding human stresses from the complex interactions of worker 254 Appendix H health status, respirator usage, and job tasks. Although some of the following recommen dations should be part of any medical evaluation of workers who wear respirators, others are applicable for specific situations. A physician should determine fitness to wear a respirator by considering the worker's health, the type of respirator, and the conditions of respirator use. The recommendation above leaves the final decision of an individual's fitness to wear a respirator to the person who is best qualified to evaluate the multiple clinical and other variables. Much of the clinical and other data could be gathered by other personnel. It should be emphasized that the clinical examination alone is only one part of the fitness determination. Collaboration with foremen, industrial hygienists, and others may often be needed to better assess the work conditions and other factors that affect an individual's fitness to wear a respirator. A medical history and at least a limited physical examination are recommended. The medical history and physical examination should emphasize the evaluation of the cardiopulmonary system and should elicit any history of respirator use. The history is ah important tool in medical diagnosis and can be used to detect most problems that might require further evaluation. Objectives of the physical examination should be to confirm the clinical impression based on the history and to detect important medical conditions (such as hypertension) that may be essentially asymptomatic. Although chest X-ray and/or spirometry may be medically indicated in some fitness determinations, these should not be routinely performed. In most cases, the hazardous situations requiring the wearing ofrespirators will also mandate periodic chest X-rays and/or spirometry for exposed workers. When such information is available, it should be used in the determination of fitness to wear respirators. Data from routine chest X-rays and spirometry are not recommended solely for determining if a respirator should be worn. In most cases, with an essentially normal clinical examination (history and physical), these data are unlikely to influence the respirator fitness determina tion; additionally, the X-ray would be an unnecessary source of radiation exposure to the worker. Chest X-rays in general do not accurately reflect a person's cardiopulmonary physiologic status, and limited studies suggest that mild to moderate impairment detected by spirometry would not preclude the wearing of respirators in most cases. Thus it is recommended that chest X-rays and/or spirometry be done only when clinically indicated. The recommended periodicity of medical fitness determinations varies according to several factors but could be as infrequent as every 5 years. Federal or other applicable regulations shall be followed regarding the frequency of respirator fitness determinations. The guidelines for most work conditions for which respirators are required are shown in Table H-l. 255 EGME, EGEE, and Their Acetates Table H-l.--Suggested frequency of medical fitness determinations Type of working conditions Worker age (yr) <35 35 to 45 >45 Most work conditions requiring respirators Strenuous working conditions with a SCBA* Every 5 yr Every 3 yr Every 2 yr Every 18 mo 1-2 yr Annually *Interim testing would be needed if changes in health status occur. *SCBA - self-contained breathing apparatus. These guidelines are similar to those recommended by ANSI, which recommends annual determinations after age 45 [ANSI 1984]. The more frequent examinations with advancing age relate to the increased prevalence of most diseases in older people. More frequent examinations are recommended for individuals performing strenuous work involving the use of a SCBA. These guidelines are based on clinical judgment and, like the other recommendations in this section, should be adjusted as clinically indicated. The respirator wearer should be observed during a trial period to evaluate potential physiological problems. In addition to considering the physical effects of wearing respirators, the physician should determine if wearing a given respirator would cause extreme anxiety or claustrophobic reaction in the individual. This could be done during training while the worker is wearing the respirator and is engaged in some exercise that approximates the actual work situation. Present OSHA regulations state that a worker should be provided the opportunity to wear the respirator "in normal air for a long familiarity period ..[29 CFR* 1910.134(e)(5)]. This trial period should also be used to evaluate the ability and tolerance of the worker to wear the respirator [Harber 1984]. This trial period need not be associated with respirator fit testing and should not compromise the effectiveness of the vital fit testing procedure. Examining physicians should realize that the main stress of heavy exercise while using a respirator is usually on the cardiovascular system and that heavy respirators (e.g., SCBA) can substantially increase this stress. Accordingly, physicians may want to consider exercise stress tests with electrocardiographic monitoring when heavy respirators are used, when cardiovascular risk factors are present, or when extremely stressful conditions are expected. ir Code of Federal Regulations. See CFR in references. 256 Appendix H Some respirators may weigh up to 35 lb and may increase workloads by 20%. Although a lower activity level could compensate for this added stress [Manning and Griggs 1983], a lower activity level might not always be possible. Physicians should also be aware of other added stresses, such as heavy protective clothing and intense ambient heat, that would increase the worker's cardiac demand. As an extreme example, fire fighters who use a SCBA inside burning buildings may work at maximal exercise levels under life-threatening conditions. In such cases, the detection of occult cardiac disease, which might manifest itself during heavy stress, may be important. Some authors have either recommended stress testing [Kilbom 1980] or at least its consideration in the fitness determination [ANSI 1984]. Kilbom [1980] has recommended stress testing at 5-yr intervals for fire fighters below age 40 who use SCBA and at 2-yr intervals for those aged 40 to 50. He further suggested that firemen over age 50 not be allowed to wear SCBA. Exercise stress testing has not been recommended for medical screening for coronary artery disease in the general population [Weiner et al. 1979; Epstein 1979]. It has an estimated sensitivity and specificity of 78% and 69%, respectively, when the disease is defined by coronary angiography [Weiner et al. 1979; Nicklin and Balaban 1984]. In a recent 6-yr prospective study, stress testing to determine the potential for heart attacks indicated a positive predictive value of 27% when the prevalence of disease was 3.5% [Giagnoni et al. 1983; Folli 1984]. Although stress testing has limited effectiveness in medical screening, it could detect individuals who may not be able to complete the heavy exercise required in some jobs. A definitive recommendation regarding exercise stress testing cannot be made at this time. Further research may determine whether this is a useful tool in selected circumstances. An important concept is that "general work limitations and restrictions identified for other work activities also shall apply for respirator use" [ANSI 1984]. In many cases, if a worker is physically able to do an assigned job while not wearing a respirator, the worker will in most situations not be at increased risk when performing the same job while wearing a respirator. Because of the variability in the types of respirators, work conditions, and workers' health status, many employers may wish to designate categories of fitness to wear respirators, thereby excluding some workers from strenuous work situations in volving the wearing of respirators. Depending on the various circumstances, several permissible categories of respirator usage are possible. One conceivable scheme would consist of three overall categories: full respirator use, no respirator use, and limited respirator use including "escape only" respirators. The latter category excludes heavy respirators and strenuous work conditions. Before identifying the conditions that would be used to classify workers into various categories, it is critical that the physician be aware that these conditions have not been validated and are presented only for consideration. The physician should modify the use of these conditions based on actual experience, further research, and individual worker sensitivities. He may 257 EGME, EGEE, and Their Acetates also wish to consider the following conditions in selecting or permitting the use of respirators: History of spontaneous pneumothorax Claustrophobia/anxiety reaction Use of contact lenses (for some respirators) Moderate or severe pulmonary disease Angina pectoris, significant arrhythmias, recent myocardial infarction Symptomatic or uncontrolled hypertension, and Advanced age Wearing a respirator would probably not play a significant role in causing lung damage such as pneumothorax. However, without good evidence that wearing a respirator would not cause such lung damage, the physician would be prudent to prohibit the individual with a history of spontaneous pneumothorax from wearing a respirator. Moderate lung disease is defined by the Intermountain Thoracic Society [Kanner and Morris 1975] as being present when the following conditions exist--a forced expiratory volume in 1 sec (FEVj) divided by the forced vital capacity (FVC) (i.e., FEV^/FVC) of 0.45 to 0.60, or an FVC of 51 % to 65 % of the predicted FVC value. Similar arbitrary limits could be set for age and hypertension. It would seem more reasonable, however, to combine several risk factors into an overall estimate of fitness to wear respirators under certain conditions. Here the judgment and clinical experience of the physician are needed. Many impaired workers would even be able to work safely while wearing respirators if they could control their own work pace, including having sufficient time to rest. H.3 CONCLUSION Individual judgment is needed to determine the factors affecting an individual's fitness to wear a respirator. Although many of the preceding guidelines are based on limited evidence, they should provide a useful starting point for a respirator fitness screening program. Further research is needed to validate these and other recommendations currently in use. Of particular interest would be laboratory studies involving physiologically impaired in dividuals and field studies conducted under actual day-to-day work conditions. H.4 REFERENCES Altose MD, McCauley WC, Kelsen SG, Chemiack NS [1977]. Effects of hypercapnia and inspiratory flow-resistive loading on respiratory activity in chronic airways obstruction. J Clin Invest 59:500-507. 258 Appendix H ANSI [1984]. American national standard for respirator protection-respirator use-physical qualifications for personnel, ANSI Z88.6-1984. New York, NY: American National Standards Institute, Inc., pp. 7-15. Arborelius M, Dahlback GO, Data P-G [1983]. Cardiac output and gas exchange during heavy exercise with a positive pressure respiratory protective apparatus. Scand J Work Environ Health 9:471-477. Bates DV, Macklem PT, Christie RV [1971]. Respiratory function in disease: an intro duction to the integrated study of the lung. 2nd ed. Philadelphia, PA: W.B. Saunders Co., p. 43. Bentley RA, Griffin OG, Love RG, Muir DCF, Sweetland KF [1973]. Acceptable levels for breathing resistance of respiratory apparatus. Arch Environ Health 27:273-280. Bjurstedt H, Rosenhamer G, Lindborg B, Hesser CM [1979]. Respiratory and circulatory responses to sustained positive-pressure breathing and exercise in man. Acta Physiol Scand 105:204-214. Black LF, Hyatt RE [1969]. Maximal respiratory pressures: normal values and relationship to age and sex. Am Rev Respir Dis 99:696-702. i* Cantekin El, Bluestone CD, Saez CA, Bern SA [1979]. Airflow through the eustachian tube. Ann Otol 88:603-612. CFR. Code of Federal Regulations. Washington, DC: U.S. Government Printing Office, Office of the Federal Register. Craig FN, Blevins WV, Cummings G [1970]. Exhausting work limited by external resistance and inhalation of carbon dioxide. J Appl Physiol 29(6):847-851. Dahlback GO, Balldin UI [1984]. Physiological effects of pressure demand masks during heavy exercise. Am Ind Hyg Assoc J 45(3):177-181. daRoza RA, Weaver C [1985]. Is it safe to wear contact lenses with a full-facepiece respirator? Lawrence Livermore National Laboratory manuscript UCRL-53653, pp. 1-3. Deno NS, Kamon E, Kiser DM [1981]. Physiological responses to resistance breathing during short and prolonged exercise. Am Ind Hyg Assoc J 42(8) :616-623. Epstein SE [1979]. Limitations of electrocardiographic exercise testing [editorial]. N Engl J Med 30I(5):264-265. Folli G [1984]. Exercise EKG in asymptomatic normotensive subjects [reply to letter to the editor]. N Engl J Med 310{13):852-853. Gee JBL, Burton G, Vassallo C, Gregg J [1968], Effects of external airway obstruction on work capacity and pulmonary gas exchange. Am Rev Respir Dis 98:1003-1012. 259 EGME, EGEE, and Their Acetates Giagnoni E, Secchi MB, Wu SC, Morabito A, Oltrona L, et al. [1983]. Prognostic value of exercise EKG testing in asymptomatic normotensive subjects. N Engl J Med 509(18): 1085 1089. Halperin WE, Ratcliffe JM, Frazier TM, Becker SP, Schulte PA [1986]. Medical screening in the workplace: proposed principles. J Occup Med 28{8):547-552. Harber P, Tamimie RJ, Bhattacharya A, Barber M [1982]. Physiologic effects of respirator dead space and resistance loading. J Occup Med 24(9):681-684. Harber P [1984]. Medical evaluation for respirator use. J Occup Med 26(7):496-502. Hermansen L, Vokac Z, Lereim P [1972]. Respiratory and circulatory response to added air flow resistance during exercise. Ergonomics 75(1): 15-24. Hodous TK, Petsonk L, Boyles C, Hankinson J, Amandus H [1983]. Effects of added resistance to breathing during exercise in obstructive lung disease. Am Rev Respir Dis 128:943-948. Hodous TK, Boyles C, Hankinson J [1986]. Effects of industrial respirator wear during exercise in subjects with restrictive lung disease. Am Ind Hyg Assoc J 47:176-180. James RH [1977]. Breathing resistance and dead space in respiratory protective devices. Cincinnati, OH: U.S. Department of Health, Education, and Welfare, Public Health Service, Center for Disease Control, National Institute for Occupational Safety and Health, DHEW (NIOSH) Publication No. 77-161. James R, Dukes-Dobos F, Smith R [1984]. Effects of respirators under heat/work condi tions. Am Ind Hyg Assoc J 45(6):399-404. Kanner RE, Morris AH, ed. [1975]. Clinical pulmonary function testing: a manual of uniform laboratory procedures for the intermountain area. 1st ed. Salt Lake City, UT: Intermountain Thoracic Society. Kilbom A [1980]. Physical work capacity of firemen. Scand J Work Environ Health 6:48-57. 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Nicklin D, Balaban DJ [1984]. Exercise EKG in asymptomatic normotensive subjects [letter to the editor]. N Engl J Med 310(13):852. NIOSH [1987]. NIOSH respirator decision logic. Cincinnati, OH: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 87-108. Petsonk EL, Hancock J, Boyles C [1983]. Physiologic effects of a self-contained self-rescuer. Am Ind Hyg Assoc J 44(5):368-373. Raven PB, Davis TO, Shafer CL, Linnebur AC [1977]. Maximal stress test performance while wearing a self-contained breathing apparatus. J Occup Med I9(12):802-806. Raven PB, Dodson AT, Davis TO [1979]. The physiological consequences of wearing industrial respirators: a review. Am Ind Hyg Assoc J 40(6):517-534. Raven PB, Jackson AW, Page K, et al. [1981]. The physiological responses of mild pulmonary impaired subjects while using a "demand" respirator during rest and work. 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