What are the work clearance implications for an asymptomatic individual with borderline pulmonary function tests (PFTs) showing reversibility, working in corrections and using gas masks?

From the Guidelines

I strongly recommend a conditional work clearance for this individual with borderline pulmonary function tests (PFTs) showing reversibility who works in corrections and requires gas mask use, with specific accommodations to ensure their safety and monitor their lung function. The employee should be cleared for work with the following conditions: they should have their rescue bronchodilator (such as albuterol) available at all times, undergo a supervised gas mask fit test to ensure proper function, and have regular follow-up PFTs every 6-12 months to monitor lung function, as suggested by the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society 1. Additionally, they should be evaluated by a pulmonologist to optimize their asthma management with appropriate controller medications like inhaled corticosteroids (such as fluticasone 110-220 mcg twice daily) and possibly a long-acting bronchodilator, as recommended for symptomatic patients with FEV1 between 60% and 80% predicted 1. The reversibility on PFTs indicates some degree of bronchospasm that responds to medication, suggesting asthma that can be controlled with proper treatment. While the employee is currently asymptomatic, the borderline PFTs raise concern about potential respiratory compromise during physically demanding activities or in emergency situations requiring prolonged gas mask use, highlighting the importance of careful monitoring and management. A trial period with the gas mask under controlled conditions would be advisable to assess tolerance before full clearance. The employee should also be educated about reporting any new respiratory symptoms promptly, as early intervention can prevent worsening of their condition. Key considerations for this individual's work clearance include:

• Regular monitoring of lung function with PFTs every 6-12 months
• Availability of rescue bronchodilator at all times
• Supervised gas mask fit test to ensure proper function
• Evaluation by a pulmonologist to optimize asthma management
• Education on reporting new respiratory symptoms promptly.

From the Research

Work Clearance with Asymptomatic but Borderline PFT with Reversibility

• Working in corrections with gas masks requires careful consideration of an individual's pulmonary function, especially when borderline PFT results with reversibility are present 2, 3.
• The diagnosis of COPD is based on spirometric evidence of airways obstruction following bronchodilator administration, and a considerable proportion of patients exhibit clinically significant bronchodilator reversibility 3.
• Bronchodilator response is usually tested to establish reversibility of airflow obstruction, and a 15 percent increase in FEV1 or FVC and a 30 percent increase in isovolume FEF25-75% or FEF50% above baseline are acceptable criteria for bronchodilator response 2.

Relevance to Work Clearance

• The usefulness of acute reversibility to short-acting bronchodilators in predicting a patient's long-term response to bronchodilator maintenance therapy is unclear, although most studies suggest that a lack of acute response to short-acting bronchodilators does not preclude a beneficial long-term response to maintenance bronchodilator treatment 3.
• Inhaled albuterol powder may not be as effective as isoetharine aerosol in assessing for reversibility of airflow obstruction during routine pulmonary function testing 4.
• Nebulized bronchodilators, such as ipratropium bromide and albuterol, can be effective in the outpatient management of stable chronic obstructive pulmonary disease 5.

Pulmonary Function Testing

• The ratio of FEV1 to the vital capacity (VC) is universally accepted as the cornerstone of pulmonary function test (PFT) interpretation, but using the largest measured vital capacity (VCmax) instead of FVC can result in differences in PFT interpretation 6.
• Evaluating borderline or ambiguous PFTs using the VCmax may be informative in diagnosing obstruction and excluding restriction, especially when a positive bronchodilator response is present 6.