Well, good afternoon, my name is Sally Foster Chang, I'm an Occupational Environmental Nurse Practitioner with about 30 years of experience. My presentation today will be Respirators, Medical Approvals, and FIT Testing. This is my financial disclosure statement, I hereby certify to the best of my knowledge I have no relevant financial relationships with ineligible companies and no aspect of my current personal or professional situation might reasonably be expected to affect significantly my views on the subject on which I am presenting. So these are the objectives of the presentation. At the end of this presentation, I'm hoping my learners will be able to describe the history of respiratory protection and the related regulations, review the legal requirements for respiratory protection mandated by 29 CFR 1910.134, develop a basic understanding of the types of respirators and the NIOSH respirator selection logic, outline the medical approval process for FIT testing and respirator use, and discuss some of the current guidelines related to cardiac and pulmonary assessment for respirator use. Starting with a brief history of respiratory protection, though Dr. Alice Hamilton and others had recognized various work-related issues, that is, cancer among young radium watch-style painters and lead poisoning, the emergence of the labor movement in the 1930s drew national attention to occupational health issues. In 1936, with the passage of the Walsh-Healy Public Contracts Act, the federal government required companies receiving federal contracts worth over $10,000 to comply with certain health and safety standards. But it was not until 1968 when the death of 78 miners in an explosion in Farmington, West Virginia was industrial health and safety placed on the national agenda. In 1969, the Coal Mine Health and Safety Act became federal law. Next came the establishment of the American National Safety Code, or ANSI 29, for head, eye, and respiratory protection, and the passage of the Occupational Safety and Health Act in 1970. The National Institute for Occupational Health and Safety, or NIOSH, was born in 1971. NIOSH established a respirator evaluation and certification program in collaboration with the Mine Safety and Health Administration. However, it was not until 1998 that 29 CFR 1910.134 became law, requiring companies to offer a comprehensive respiratory protection program to employees. Now Title 29 Code of Federal Regulations 1910.134 sets out the legal requirements for respiratory protection. These include a written program with worksite-specific procedures. A respiratory protection program administrator with the proper knowledge and qualifications must be identified. The company must provide proper respirators, provide medical evaluations and training at no cost to employees. The specific program elements are also outlined in this slide. The required elements are careful and appropriate selection of respirators, appropriate medical evaluations of employees who will be wearing respirators as part of their job, fit testing, continual monitoring of use practices, and specific training and education. Finally, the program must be evaluated on an ongoing basis. Now this slide depicts the various currently available types of respiratory protection. I'll talk about the respirators in the top row in the next couple of slides. Looking at the bottom row, supplied air respirators are connected to an outside air source that supplies clean, compressed air through a hose. Since these respirators are lightweight, they're appropriate for use when working long hours in environments unlikely to be immediately dangerous to life and health. Self-contained breathing apparatus, or SCBAs, are used for entry or escape from environments deemed immediately dangerous to life and health. They contain their own air supply. Combination respirators can either be a supplied air slash SCBA respirator or a supplied air purifying respirator. The supplied air, air purifying combo cannot be used in environments that are immediately dangerous to life and health. Now in general, there are two basic types of respirators, air filtering or air purifying respirators and air supplying respirators. Examples of air filtering or air purifying respirators are M95s, PAPRs, cartridge respirators with specific filtering cartridges for specific toxins, and elastomeric respirators, half-face and full-face. Examples of air supplying respirators are negative pressure respirators with the negative pressure created by breathing in, positive pressure respirators where clean air is added to the breathing zone, self-contained breathing apparatus respirators, or SCBAs, and escape respirators. Now I'm sure some of you have wondered what the N and the 95 in N95 stands for. An N95 mask filters at least 95% of airborne particles but is not resistant to oil. Likewise, an N99 filters at least 99% of particles and an N100 filters 99.97% of particles. By contrast, a respirator designated with an R is somewhat resistant to oil and filters designated with the P are strongly resistant to oil. A respirator designated HE has a high efficiency filter which filters at least 99.97% of airborne particles. High efficiency filters are used on PAPRs only. Now filtering facepiece respirators like the N95 are manufactured to be one-use and disposable. These masks cover the nose and mouth and filter out particles such as dust, mist, and fumes. They come in various flavors. That is, they might be from the N series and not resistant to oil. They could come from the R series and be somewhat resistant to oil or from the P series and be strongly resistant to oil. Now during the COVID-19 pandemic, there were various methods tested to extend the life of one-use N95s. Unfortunately, many of the methods resulted in reduced filtration and or ill-fitting masks after decontamination. Two of the most successful decontamination processes included moist heat and ultraviolet germicidal decontamination. Additional research into methods to extend the life of N95 masks included the use of melt-blown polypropylene filtration, 3D printing, and ceramics. The good news was if safe and effective N95 masks could be manufactured to be reusable, the amount of medical landfill trash would be greatly reduced. The bad news was that not all of these new respirators were able to obtain NIOSH certification. Another issue currently under review is whether filtering face piece respirators can be constructed in a way to provide adequate protection without completely hiding the face. Now, elastomeric respirators are made of both natural and synthetic rubber. Elastomeric respirators are made of natural and synthetic rubber, urethane, polyurea, and polymetric coatings, and they exhibit resilience. They can be stretched and still hold their shape. They're relatively flexible and do not melt at high temperatures. These are often reusable and have replaceable cartridges or filters. The full face piece elastomeric respirator covers both the face and eyes and therefore does not melt at high temperatures. The powered air purifying respirator, or PAPR, has a battery-powered blower that circulates air through filters, canisters, or cartridges. PAPRs provide protection against gases, vapors, or particles when they are equipped with the proper cartridges, canisters, or filters. You can also see that many of them are loose-fitting and therefore would not require fit testing. However, individuals wearing PAPRs are required to be medically cleared. Now, firefighting is an occupation where self-contained breathing apparatus, or SCBA respirators, are mandatory. The environment created by an active fire is full of toxins and is more often than not oxygen deficient. The burning of plastics can release a variety of potentially life-threatening toxins into the air. Self-contained breathing apparatus respirators are generally heavy because they require an adequate oxygen supply be carried into the oxygen deficient and hazardous situation. Firefighters often carry something that looks like a scuba tank on their backs in addition to full-body protective equipment. If you are approving someone to wear an SCBA respirator, you need to consider the extra metabolic stress of carrying a significant amount of extra weight. Now, the definitions on this slide are from the OSHA Respiratory Protection Standard and are important to be familiar with. A demand respirator is an atmosphere-supplying respirator that emits breathing air to the face piece only when a negative pressure is created inside the face piece when the individual inhales. An assigned protection factor is the workplace level of respiratory protection that a respirator or a class of respirators is expected to provide to employees. An end-of-service life indicator, or ESLI, is a system that warns the respirator user of the approach of the end of adequate respiratory protection. And finally, an escape-only respirator is a respirator intended to be used only for emergency exits. Now, if you're going to be directly responsible for choosing respirators for your worker population, I would recommend you be very familiar with the NIOSH respirator decision logic and algorithm. There is a link to this document on this slide. In the next few slides, we will briefly discuss some of the important components of the respirator selection process. The following three slides provide a brief introduction to the NIOSH respirator selection logic and algorithm. What you see on the following few slides was adapted from the NIOSH respirator selection logic and algorithm to illustrate some of the most important guidance. For now, I'll make a couple of salient points. For environments immediately dangerous to life and health, for example, what a firefighter might encounter, a self-contained breathing apparatus is the best and probably the only choice. If the toxin expected to be encountered is an eye irritant, a full face could or has a hood or helmet is the only option. If the environment is expected to be or even could become oxygen deficient, or if the worker might be exposed to a carcinogen, a self-contained breathing apparatus respirator is the only choice. Note, there's an error in the top of this slide. That is, I've referred to SCBAs as SCUBAs. SCUBAs are self-contained breathing tanks used for underwater. So the SCUBA at the top actually refers to self-contained underwater breathing apparatus. I apologize for the error, but I'm a NAWI certified diver and it was force of habit. Now, different types of respirators have different assigned protection factors. In general, if the contaminant has the potential to exceed the permissible exposure level, the respirator chosen should have an assigned protection factor greater than the minimum protection required. Some toxins have smells that can be detected at levels of contamination below what is considered dangerous. If this is the case, an employee may be able to smell a toxin and leave the area immediately. But keep in mind, there is something called olfactory fatigue. And after a certain amount of exposure to a noxious odor, human beings rapidly lose the ability to smell it. And this could be minutes. This is why most respirators today have an end of service life indicator, which alerts the user the filter, cartridge, or respirator needs to be replaced. Air supplying respirators may be powered or non-powered. Once again, if a toxin is an eye irritant, a full face helmet or hood is necessary. If the exposure is to a particulate only, and there's no associated eye irritation, and we are not dealing with a gas or vapor, an or a nasal respirator may be all that is required. Now, this slide outlines the process for medical approval for respirator fit testing and use. Every employee who will need a respirator to do their job, and those who choose to use one, must fill out the OSHA screening medical approval questionnaire, which is in Appendix C of 29 CFR 1910.134. All employees must be able to read and understand this questionnaire. The questionnaire may need to be translated into another language. If there are no significant yes answers to any of the questions one through nine, approvals may be done in some states by registered nurses without advanced practice licensure. If any yes answers are encountered in sections one through nine, or the full questionnaire is required, for example, for full face or SCBA respirators, medical approval must be done by a physician, a nurse practitioner, or a physician's assistant who is licensed to provide medical evaluation and diagnostic services. Medical approvals for FIT testing and respirator use may require further evaluations, including but not necessarily limited to an interview, a hands-on physical, spirometry, chest x-ray, EKG, exercise tolerance test, et cetera. Approvals may even require specialty consultation, for example, a cardiologist, a diabetologist, a pulmonologist, an oncologist, perhaps a psychiatrist, a neurologist, a dermatologist, et cetera, in certain circumstances. We'll discuss this further later in the presentation. Now according to McClellan and Schuster, 2000, any clinician performing respirator medical approvals must know certain information about the respirator the employee will be using and the conditions under which it will be used. This information includes the type and weight of the respirator selected for the employee, the duration and frequency of respirator use, including is it used for rescue or escape, the expected use type and weight of any additional personal protective or other equipment, the type, the duration, the expected level of physical work involved when using a respirator, the temperature and humidity likely to be encountered when using the respirator. And it also behooves the provider to have on hand a copy of their specific employer's written respiratory protection program and a copy of 29 CFR 1910.134. The provider should be well-informed about the toxin the employee is expected to encounter. The clinician should be aware of the physical, chemical, and toxological product properties of the toxin and the general use conditions. Other important information is the odor threshold level, the NIOSH recommended exposure limit or REL, the OSHA permissible exposure limit, or any other relevant exposure limit levels. The clinician needs to know if the toxin is immediately dangerous to life and health, and if so, at what concentration. And finally, any service life information available on the respirator and cartridges or canisters used. Another important factor the clinician must consider in approving an individual to use a respirator is the amount of work effort the employee will be required to exert. OSHA defines levels of physical work effort in 29 CFR 1910.134 Appendix C. Light physical work is defined as desk work, control room, or automated equipment operation where the individual is using less than 25% of their maximal oxygen uptake. Moderate physical work is defined as sitting with heavy arm motion, sweeping, light shoveling, machine fitting, manual cleaning of machinery, small container filling line duty, or driving heavy equipment where there is approximately 25 to 50% of maximal oxygen uptake. Heavy physical work is defined as lifting from floor to waist, heavy shoveling, mixer loading, fast walking, sawing wood, or heavy mechanical work where there is approximately 50 to 75% of maximal oxygen uptake. And finally, very heavy physical work is defined as climbing stairs or ladders, emergency response and rescue, fire and brigade duty, hazardous waste operations, confined space entry, or the use of fully encapsulated suits where there is approximately 75% of maximal oxygen uptake. Now if a physical examination is indicated prior to approval for fit testing and respirator use, what are the components of such an exam? Listed here are the main considerations. First, a comprehensive medical history including current medications and any known medical problems. The history will allow the examiner to zero in on any specific concerns. The physical exam should include, at a minimum, a basic cardiac assessment, a pulmonary assessment, an assessment of any diseases or conditions likely to cause sudden incapacitation or poor judgment in emergency situations, an assessment of the skin, an assessment of general agility and strength if it's indicated for the job they'll be doing, an assessment of any sensory deficits, visual, tactile, or auditory, and finally, an assessment of any potential fit issues. Do they have facial hair? Do they have irregular teeth? Do they have an unusual face shape, et cetera? At the end of this presentation, listed in the references, is a link to a YouTube video of a provider actually performing a respirator medical evaluation. Now this slide highlights potential red flags that might make respirator use hazardous. Any uncontrolled medical conditions that have the potential of resulting in a sudden loss of consciousness or the inability to function would be potentially disqualifying. Severe claustrophobia may interfere with respirator use, uncontrolled anxiety attacks, manic depressive illness, or similar affective psychological disorders could be problematic. Significant restrictive or obstructive pulmonary disorders might make respirator use ill-advised. Significant arrhythmias or other cardiac conditions that might result in disability or sudden death must be considered. Uncontrolled hypertension could disqualify an individual from respirator use, as use of a respirator can increase blood pressure in certain situations. Use of medications that lower the level of awareness, produce hallucinations or erratic behaviors might be dangerous to an individual wearing a respirator in a hazardous environment or even dangerous to that individual's coworkers. Use of medications that might require emergency removal of a respirator should not be allowed in work environments where removal of the respirator would subject the user to a toxic condition. Finally, facial hair or facial or dental deformities that would interfere with a good respirator seal would be problematic. Now the conditions on this slide might require further evaluation before approval for respirator use and are self-explanatory. They include conjunctivitis or blepharitis in a person using a full-face respirator. Visual deficiencies requiring correction that interferes with a face seal. Many respirators have inserts now that can be used to correct vision. If they have a history of heat stroke, if they have psychosis barbe or barber's itch, which could interfere with a good face seal, they could possibly have other dermatological conditions like eczema, psoriasis, rosacea, or severe acne, which might compromise a good face seal. If they had significant respiratory or cardiac disease, if they had an acute respiratory tract infection, do they have a history of neurologic disorders like epilepsy? Do they have significant hearing loss? Do they have significant psychiatric conditions that could interfere with use, judgment, or escape? Now the clinician, when considering the cardiac status of the potential respirator user, should do a basic risk factor assessment. Is there a family history of sudden cardiac death before 55 in a male or before 65 in a female? Is the patient over age 45 in male? Is the patient over 55 in female with early menopause? Is the blood pressure over 140, over 90 on two separate occasions? Does the patient have hypercholesterolemia, diabetes, or a sedentary lifestyle? If there is any question regarding an individual's fitness from a cardiac standpoint, possible cardiac diagnostic studies might include an EKG, a lipid panel, an exercise tolerance test, perhaps a full stress test, or an echo. Now use of the American Society of Cardiovascular Disease risk calculator or another similar risk calculator might be an appropriate approach. Values can be plugged in for age, height, weight, blood pressure, smoking, history, and cholesterol. The risk calculator will give you a percentage risk for a sudden cardiac event in the next 10 years. In general, a risk percentage over 10% should prompt further evaluation and possible referral to a cardiologist. It's recommended that advanced practice providers implement a well-defined protocol to determine the need for further evaluation and use this approach with each and every patient. In this way, it's possible to ensure any stepwise approach to diagnostic studies is consistent across your entire patient population. Note that a comprehensive cardiac assessment is indicated for someone who will be wearing an SCBA or hazmat equipment, or at least strongly recommend it. When completing a respiratory assessment, the first place to start is with the medical history. Does the worker have a history of pneumothorax, asthma, or even lung cancer? Is the individual a smoker or have a history of some other type of respiratory compromise or injury? Are the lungs clear without wheezing or ronchi? Are there any upper respiratory issues, deviated septum, seasonal allergies, surgical alteration of the nasal cavity or face? Are there currently any signs or symptoms of upper respiratory infection or olfactory dysfunction? For example, a case of olfactory compromise after COVID that's not resolved. Is the thorax a normal size and shape? Are there genetic malformations of the thorax which could interfere with respiratory function? Is the patient obese to the extent that it could interfere with respirator use? What is the patient's allergy profile? Are they allergic to the toxin? What medications are they on? Spirometry might be indicated if there is a question as to the health or integrity of the pulmonary system as a whole. Now spirometry is a diagnostic procedure and provides a sensitive measure of lung function and integrity. It identifies restrictive or obstructive lung disease. It can also delineate risk factors. For example, preoperatively, spirometry can both detect early lung dysfunction and monitor for lung function decline over time. On this slide is a flow volume graph that is part of the spirometry evaluation. The top red curve is normal, while the blue and yellow are not. Baseline and serial spirometry are specifically required to conform to 14 different OSHA standards. These are examples of the OSHA standards which require baseline and serial spirometry to monitor for any significant changes over time. If you work in heavy industry, your workers might potentially be exposed at levels that would require both respiratory protection and serial spirometry monitoring. Now there are contraindications to spirometry and several of them are listed here. Acute MI within one week should prompt a rescheduling of the procedure. Spirometry is contraindicated in systemic hypotension, with severe hypertension, with acute core pulmonol, unstable pulmonary embolism, or the potential presence of a pulmonary emboli, pneumothorax, or history of syncope related to forced expiration or cough. Spirometry should not be done in the presence of cerebral aneurysm. Spine surgery within the last four weeks, recent concussion with continuing symptoms, a sinus or middle ear surgery within a week, any abdominal surgery within a week, a transmissible respiratory infection, hemoptysis, significant secretions, oral lesions, or oral or nasal bleeding. Now the spirometry measures with physiological significance for respirator use are forced vital capacity, or FVC, and this is basically how much you can force out of your lungs. Forced expiratory volume in one second, and that's how much you can force out in the first second, and the FEV1 slash FVC ratio, that is how much a person can force out of his, her, or their lungs in one second divided by the total forced vital capacity. Spirometry data gathered must be compared to biological peers who are non-smokers and have disease-free lungs. Now healthy lung function is dependent on your age, on your sex, on your height, and your ethnicity or country of origin background. Using race in any medical evaluations has actually more or less gone out of style recently, but it isn't actually race that we need to properly interpret spirometry. It's actually the size and shape of the lungs of the worker, and this does vary among individuals with different genetic origins, but more about that later. There are currently major controversies about what spirometry reference values to use in what situations to interpret spirometry. Though I know in many places things have returned to business as usual in terms of infection control with spirometry and fit testing. However, during the COVID-19 pandemic, the American College of Occupational and Environmental Medicine recommended certain changes in the procedures for doing the spirometry as the hazard level for performing spirometry varies over time. As we are now heading into a fall-winter season where highly resistant new variants of the COVID-19 virus are circulating, they still recommend that all patients be screened for respiratory disease before performing spirometry or doing fit testing. If there is any doubt, defer testing until the patient is tested for COVID-19. The room where the spirometry is performed should have adequate ventilation and or a freestanding HEPA air filter if ventilation is not adequate. They also recommend air disinfection using ultraviolet germicidal irradiation if possible and room disinfection between patients. A dedicated test area is best or even using an outdoor space. All staff should be vaccinated against COVID-19 and should wear proper PPE. A dedicated technician is ideal and all staff should be adequately educated regarding how to avoid infection and to produce a high quality test. Now, spirometry interpretation guidelines are changing rapidly. Current guidelines recommend against using specific numbers to define normal for FEV1, FVC or FEV1 slash FVC. What is recommended is to use what is called the lowest level of normal or 1.65 standard deviation below the median for biological peers of the person being tested. Lowest level of normal is based on the names three reference values and these are the ones that should be used. For Asians, the white reference value should be multiplied by a scaling factor of 0.88 for FVC and FEV1. FEV1 over FVC is a ratio and does not need to be scaled in this manner. The highest test results should be used for interpretation and a change of more than 15% from year to year should be cause for concern. Always use self-reported race and gender assigned at birth for calculating the lower level of normal. So why should we use the names three reference values rather than the American Thoracic Society Global Lung Institute reference values? GOI reference values are not race neutral and are not based specifically on the North American population. GOI reference values are more likely to result in false positives and false negatives. GILI reference values over-diagnose impairment in blacks and under-diagnose impairment in whites. There is a very interesting article by Hankinson et al in 2010 if you would like more information on this issue. The American Thoracic Society is recommending the use of the Global Lung Institute reference values to ensure that we find lung dysfunction if it is there. But in occupational health in North America, it is currently recommended to use the names three reference values. Now, this is a bell-shaped curve and I apologize to those of you who don't love math. However, this graph shows the standard deviations from the median. The median is this line right in the center. Most groups will fall into a bell-shaped curve with a smaller number of outliers at the right and left edges. That is, some people have lung function significantly better than the median and will end up on this curve tending to the right tail and others may have lung function that falls below the median, that is, in the left tail. Lower level of normal is approximately 1.65 standard deviations below the median. Now, some of your spirometry reports will have Z-scores. I have placed along the bottom a guide to interpreting Z-scores. That is, how far results are away from the median. A standard deviation of negative 1.65 or a Z-score of minus 2.5 is still within the lower level of normal. If you have questions about this, there is a great article by Mary Townsend referenced at the end of this presentation on interpreting spirometry. But before we get more deeply into interpretation, let's look at a few spirometry curves. Now, this spirometry curve example is from the OSHA publication, Spirometry Testing in Occupational Health Programs, Best Practices for Healthcare Professionals. This is an example of an acceptable test. The worker blasts out the air during a forced expiration with a rapid increase in exhaled air and then continues to release air until the exhalation is complete. This is the first curve on your left at the top. The second curve, the flow volume curve, shows maximal speed of exhaled air achieved immediately followed by subsequent slowing. And these are normal curves. Now, in order to interpret spirometry, you need at a minimum an adequate calibration of the equipment, three acceptable tests, a difference between the tests of less than or equal to 15% or 0.15 liters. You need well-trained staff and you need to use an appropriate reference value or the proper correction factors. On the left of this slide, you see two spirometry trials superimposed on one another. As you can see, the darker line indicates a smaller volume overall, suggesting that the patient had an incomplete inspiration for the second test. The trial with the incomplete inspiration should be discarded and not be one of your three valid trials. On the right side of the slide, you see an interrupted flow volume graph. Note the divots in this one. This is where the tested individual was coughing. This spirometry attempt should also be discarded. On this slide, you see what happens to the flow volume graph when the individual did not start the flow of air with a strong blast. You do not see the characteristic mountain shape on the graph on the left of the volume flow graph and this spirometry attempt should also be discarded. Now, there are online applications that can assist you in interpreting spirometry. If you do not have ready access to a knowledgeable pulmonologist or a pulmonary function lab, several of these are listed here. There are apparently others. Some of them charge and some of them are free. I've also included a link to the NAMES III Spirometry Reference Values. These tables do include lower level of normal values for men, women, for white individuals, black individuals, and Mexican-American individuals and you must use the scaling factor for Asian individuals. If you work at a hospital, it's entirely possible they are using the Global Lung Institute Reference Values and you may need to reinterpret any spirometry you're doing for occupational health purposes to avoid over or under diagnosing lung dysfunction for work purposes. Make sure you know what reference values are being used to interpret spirometry on your employees and make sure they're appropriate. If you or your staff are not doing the spirometry evaluations or you are a consultant, how do you evaluate whether or not results you are receiving are valid? I'll discuss that in the next slide. First of all, the equipment must be calibrated before each use. All equipment must have a calibration tube that measures between one to six liters of airflow. This tube must be rechecked annually by the manufacturer. Before each use of the spirometry equipment, the tube is utilized to ensure subsequent results fall within 0.15 liters of each other. This should be done at low, medium, and high air volumes before the patient trial. The equipment should also be checked for air leaks. Your staff should be educated to calibrate the spirometry equipment before each patient encounter. If there are three or graded acceptable graphs with FVC and FEV1 reproducible to within 150 milliliters or 0.15 liters, this is a valid test. If not, it is invalid. So obstructive impairment exists when the FEV1 slash FVC falls below the lower level of normal. This is characterized by a reduction in airflow. If the FEV1 slash FVC is less than the lower level of normal and the FEV1 is greater than or equal to 100% of predicted, and the FEV1 is greater than or equal to the lower level of normal, one of two things could be going on. There might be borderline obstruction or a normal physiological variant is present. If you encounter this situation, it would make sense to consult a pulmonologist. If the FEV1 slash FVC is less than the lower level of normal and the FEV1 is less than or equal to the lower level of normal, there is obstructive impairment. Couple of examples of obstructive lung disease include COPD, asthma, and cystic fibrosis. If the forced vital capacity or FVC is greater than or equal to the lower level of normal, there is no restrictive lung disease. If the FVC is less than the lower level of normal, there is either a need for further evaluation or the patient has restrictive lung disease. Restrictive disease is due to a reduction in lung volume. Examples of restricted lung diseases are scleroderma, pleural effusions, systemic lupus erythematosus, rheumatoid arthritis, or sarcoidosis. Now, if you choose to do spirometry in your clinic, this is a step-by-step approach to doing quality spirometry evaluations. First of all, any staff performing the spirometry should be properly trained and certified. Your equipment and calibration tube must be serviced and maintained, the equipment calibrated before each patient, checking results at low lung volumes, medium lung volumes, and high lung volumes. Do not begin the interpretation process until you have three valid sets of spirometry results, and they shouldn't vary more than plus or minus 0.15 liters from one another. And the spirometry curves have to be reasonable. Use the highest result for interpretation. Is there a change of more than 15%? If so, further evaluation is indicated. Refer as appropriate to the appropriate specialist. Now, at the end of a respirator medical evaluation, the provider must produce a written opinion. The written opinion must contain employee name, job category, whether or not they're approved for any respirator, and if not, are there certain types of respirators the employee is approved to wear? Any appropriate limitation in respiratory use must be noted. A copy of such a written opinion must go to the employee, the employee's supervisor, and the company. No medical diagnoses should appear on this report. If the evaluation is pending, there should be an estimate as to when the evaluation will be complete, with both the supervisor and the employee informed. Loose-fitting respirators might be assigned in some situations. Any necessary medical accommodations should be as specific as possible. Any duty restrictions should be backed up by medical evidence or in accordance with the current standard of care. It is important to advise the employee that they will not lose their job if they cannot work with a respirator, but they could be assigned to another role. Listed here are a number of triggers for medical re-evaluation. If the employee reports anything, if the healthcare provider or supervisor informs the employer regarding the need for an evaluation, if information from the Respiratory Protection Program indicates a need for re-evaluation, maybe they're having problems fit testing, if work conditions change substantially, increasing the physiologic burden on the employee, if there are required condition-specific re-evaluations recommended by the healthcare provider, and if something comes up indicated by the brief medical questionnaire filled out at the time of the annual fit test. So why is fit testing required? Fit testing is done to verify the selected make, model, and size of the face piece adequately accommodates the individual's facial characteristics. Fit testing is also done to assure the individual can properly don and doff the face piece and to ensure a proper seal is possible to achieve appropriate protection. So how is fit testing done? The individual is placed in a hood with the respirator of choice. Fit testing can be qualitative or quantitative. Qualitative fit testing is done with Bittrex or Saccharin. It is sprayed into the hood with the respirator in place. The individual is to report whether or not they taste the Bittrex or the Saccharin. Special equipment is needed for quantitative fit testing. While in the hood, the individual must be able to turn the head, move the head up and down, talk, grimace, bend over, jog in place, and breathe normally without tasting or smelling the fit test solution. Education is a huge part of the fit testing process. Mandatory fit testing procedures are available from OSHA at the website listed in the references. So why is fit testing required annually? Studies have indicated that after three months, respirator users may not be using the respirators properly. Employees are not always forthcoming about new medical issues. Respirator education is one of the most important pieces of this process. High quality fit testing education should include at the very least what contaminants the respirator protects against, what locations and situations might result in exposure, what are the possible health effects of the contaminants, how the respirator works, under which condition the respirator should not be worn, how to properly don and remove the respirator, how and where should the respirator be stored, what to do if the respirator fails, and with a new medical evaluation, which each new medical evaluation, a fit test or respirator is indicated. These are the references I used for this presentation. Here is the website for the respirator selection logic and algorithm, and the Hankinson reference explains why NAMES 3's spirometry values should be used in the occupational health setting. Several more references, and still more. The NIOSH site on respiratory protection has answers to most of a provider's questions about respirators, and anything by Mary Townsend and Philip Harbour is valuable if you're doing spirometry in your occupational health office. I particularly recommend the 2020 article by Mary Townsend in the Journal of Occupational and Environmental Health. So I thank you for your attention, and if there are any questions, I'd be happy to entertain them now. And I just thought this picture of my granddaughter was rather appropriate for the end of this presentation.

respirators

medical approvals

fit testing

occupational environmental nurse practitioner

respiratory protection regulations

NIOSH certification

medical evaluation

spirometry testing

reference values