The Air That You Breathe

     Just as I leaned in close to better hear my soft-spoken patient's answer to my question, he coughed, forcefully. A mist of sputum launched from his mouth and coated the side of my face and neck. His complaint was sudden onset of fever, weakness, chills, congestion and productive cough. Whatever he had, I could now feel it, smell it or taste it.

     Personal safety is always the EMS provider's first priority. This article reviews the Occupational Safety and Health Administration (OSHA) standard for respiratory protection. It also explores occupational exposure to tuberculosis.

     When respirators are provided by an EMS employer to protect the health of an employee, the employer must comply with the provisions of the OSHA Respiratory Protection Standard. According to standard 1910.134, "Respirators shall be provided by the employer when such equipment is necessary to protect the health of the employee. The employer shall be responsible for the establishment and maintenance of a respiratory protection program."

     Additionally, employees must have access to a local respiratory protection program administrator to answer questions about respiratory protection, perform medical evaluations and administer respirator fit tests. For questions about any of the content in this article or your organization's respiratory protection plan, contact your respiratory protection program administrator or designee.

WHY A RESPIRATORY PROTECTION PROGRAM?
      The purpose of a respiratory protection program is to minimize the risk to EMS providers from respiratory hazards, such as tuberculosis, during the performance of their regular job duties. The standard outlines these elements for a respiratory protection program:

• Respirator selection;
• Medical evaluation;
• Fit testing;
• Respirator use, maintenance, storage, care and disposal;
• Breathing air quality and use;
• Respiratory hazards training;
• Program evaluation.

     The standard requires employers to develop and implement written respiratory protection programs with required worksite-specific procedures and elements for required respirator use. Programs must be administered by trained administrators. The standard requires the employer provide effective training to employees who are required to use respirators. Employees who complete the training must demonstrate knowledge of respirator need and how improper fit, usage and maintenance can compromise its protective effect; its capabilities and limitations; use in emergency situations; respirator inspection; maintenance and storage; and recognition of medical signs and symptoms that may make the respirator ineffective.

     Training, respirators and medical evaluations must be provided to employees during work hours at no cost. Training is provided at the time of job assignment—before the employee has to wear a respirator in the workplace and at least annually thereafter, or when tasks are added or modified. Retraining is required annually and when:

• Changes in the workplace or the type of respirator render previous training obsolete;
• Inadequacies in the employee's knowledge or use of the respirator indicate that the employee has not retained the training;
• Any other situation arises in which retraining appears necessary to ensure safe respirator use.

     The standard requires employers to ensure that the written respiratory protection program is properly implemented, and to consult employees to ensure they are using the respirators properly. Factors to be assessed include:

• Respirator fit, including employee ability to use a respirator without interfering with effective work performance;
• Appropriate respirator selection for the hazards to which the employee is exposed;
• Proper respirator use under the workplace conditions the employee encounters;
• Proper respirator maintenance.

TUBERCULOSIS
     For EMS providers, the primary need for respiratory protection—in the form of N95 respirator face masks—is protection from tuberculosis (TB). TB is an infectious disease caused by the Mycobacterium tuberculosis bacteria. TB is spread from person to person through the air.¹ It usually affects the lungs and causes inflammation, fibrosis, abscesses and necrosis of lung tissue. TB can also affect other parts of the body, such as the brain, kidneys and spine.² It was once the leading cause of death in the United States, but by 2005 incidences were at a historic low, with just more than 14,000 cases reported.^2,3 Patients with TB who receive no treatment have a 90% mortality rate within 3–5 years of infection.

     Populations at the greatest risk of TB infection include the medically underserved, low-income populations, homeless persons, and residents and staff of prisons, nursing homes and drug treatment centers. Others at high risk include persons with HIV, persons in close contact with TB patients (including healthcare providers), persons who inject drugs, persons receiving immunosuppressive or corticosteroid therapy, and persons who are Type 1 diabetics.

     TB is spread by airborne dispersion of droplets, 1–5 microns in diameter, when a person with TB of the lungs or throat coughs, sneezes, speaks, spits or sings. The tiny droplets can stay airborne in a bedroom, bus shelter, prison cell or ambulance for several hours. Persons who breathe air containing these TB germs can become infected.

     The Mantoux tuberculin skin test, which you likely received during your pre-employment screening or annual health assessment, is used to detect TB infection. A positive result indicates infection; additional tests are used to confirm the disease.

     People with TB are sick from active TB germs that are multiplying and destroying tissue in their body.1 Patients with TB of the lungs or throat are capable of spreading germs to others. People with latent TB infection have TB germs in their bodies, but are not sick because the germs are not active.¹ Patients with latent TB infection don't have symptoms and cannot spread the germs to others. However, they may develop TB disease months, years or decades in the future. TB symptoms are classified as general or specific (see TB Symptoms).¹

     TB transmission is preventable. If your patient has signs of TB, protect yourself with an N95 respirator face mask. If you learn during your patient history that a patient is taking isoniazid (INH) and rifampin, assume they are being treated for TB and do the same. TB can be treated by taking several drugs for 6–12 months.1 It is important that people who have TB finish the medicine and take the drugs exactly as prescribed. If they stop taking the drugs too soon, they can become sick again. If they do not take the drugs correctly, the germs that are still alive may become resistant to those drugs.

     TB skin tests are offered by employers in covered workplaces at no cost to the employees, at a time and location convenient to workers. The TB skin test is administered to all potentially TB-exposed employees and all new employees. Depending on the worker category of risk, TB skin testing is conducted every three, six or 12 months. Follow-up and treatment evaluations are also to be offered at no cost to the workers. A TB skin test is an intradermal injection of tuberculin antigen with subsequent measurement of the induration by trained personnel 48–72 hours after the injection. For testing information, check with your program administrator.

     Patients with TB are often treated in negative-pressure respiratory isolation rooms, or airborne infection isolation (AII) rooms, as they're now known. Warning signs must be posted on AII rooms. These must state specifically the precautions required to interact with patients. If you are unsure, ask the nurse on duty about appropriate personal protective equipment before entering the patient's room.

Respirator Performance, Wearer Examinations and Fit Testing
      Engineering controls, like airborne infection isolation (AII) rooms and N95 disposable mask respirators, are the primary means to protect healthcare providers from respiratory pathogens. The minimum acceptable performance criteria for respirators for exposure to TB include the ability to:

• Filter one-micron particles with an efficiency of 95% or greater;
• Be qualitatively or quantitatively fit-tested in a reliable way to obtain a face-seal leakage of 10% or less;
• Fit different facial sizes and characteristics;
• Self-check face piece fit each time a respirator is used.

     Based upon these criteria, the minimally acceptable level of respiratory protection for EMS personnel from TB is a Type 95 or N95 particulate respirator. The Type 95 respirator is a non-powered air-purifying respirator. Type 99 or 100 respirators have a slightly higher efficiency than Type 95 respirators.

     Part of the respirator protection program is medical evaluations of any EMS providers who may be required to use respirators. Using respirators may place a physiological burden on employees that varies with the type of respirator worn, the job and workplace conditions in which the respirator is used, and the medical status of the employee.

     The medical examination or questionnaire must be administered confidentially, during the employee's normal working hours or at a time and place convenient to the employee, and the content must be understandable. Additionally, the employee needs to have an opportunity to discuss the questionnaire and examination results with a physician or other licensed healthcare professional. The standard outlines examination or questionnaire items that require follow-up.

     Fit testing determines the quality of the respirator seal against the face. Qualitative or quantitative fit testing is done with the same make, model, style and size of respirator that will be used in the workplace, and is performed before initial use of the respirator. During your fit test you should be fitted with a respirator that fits correctly and is acceptable to you. Assess for comfort based on the position of the mask on the nose, room for eye protection, room to talk, and the position of the mask on the face and cheeks. During the fit test, the adequacy of the fit is determined by checking for proper chin placement; adequate strap tension; fit across the nose bridge; respirator distance from nose to chin; and tendency of the respirator to slip. As the user, observe respirator fit and position with a mirror. During the fit test you will be asked to move your head side to side and up and down, breathe deeply, breathe normally, smile and frown, talk out loud slowly and possibly jog in place or reach for your toes.

     Fit tests are performed at least annually. Additional tests are needed whenever respirator design or facial changes occur that could affect proper fit.

What to Do With a Tuberculosis Patient
     

     A TB exposure incident is defined as exposure to the exhaled air of an individual with suspected or confirmed pulmonary TB disease, or exposure without appropriate respiratory protection to a high-hazard procedure performed on an individual with suspected or confirmed infectious TB disease. High-hazard procedures which have the potential to generate infectious airborne droplets include aerosolized medication administration, airway suctioning and endotracheal intubation.

     If you suspect your patient has latent TB infection, TB disease, TB symptoms or meningitis, do the following:

• Don appropriate personal protective equipment (gloves, eye protection, N95-type respirator mask) immediately;
• If the patient has adequate oxygen saturation, fit him/her with a surgical mask until placement in a negative-pressure room at the hospital;
• If the patient has inadequate oxygenation, administer oxygen using a non-rebreather mask with high-flow oxygen;
• Regardless of the patient's oxygenation, wear an N95 or better respirator during patient contact, transport and ambulance decontamination;
• Ensure the ambulance air system is non-recirculating and air is flowing through the ambulance from front to back;⁴
• Advise the emergency department staff of any patient with a known or suspected respiratory pathogen while en route to the hospital;
• After transfer of care, ask for a follow-up report of a patient diagnosis;
• Notify your supervisor immediately and follow the reporting, testing and monitoring guidelines in your department's respiratory protection program plan.

     A respirator is only effective if it fits properly and is continually worn during patient contact.5 EMS providers must wear a National Institute for Occupational Safety and Health (NIOSH)-certified N95 or better respirator in the following situations:

• Entering a room housing a patient with suspected or confirmed TB disease;
• Transporting in a closed vehicle an individual with suspected or confirmed TB disease;
• Performing a high-hazard procedure on a patient with suspected or confirmed TB disease.

     To don a respirator, first cup the respirator in your hand while holding the metal nosepiece in your fingertips. Allow the straps to hang freely below your hand. Next, place the respirator under your chin with the nosepiece up. Hold the respirator in place with one hand and bring the top strap over the top of your head with your other hand. Hold the respirator in place and bring the bottom strap over your head and position it around your neck, below your ears. The straps should be crossed but not twisted. For an optimal fit position the respirator low on your nose. Finally, mold the nosepiece to the shape of your nose. To mold the nosepiece, use two hands and at least two fingers on each side. Pinching the nosepiece with one hand may result in improper fit and less-effective performance.

     Each time you use your respirator, you must ensure a proper seal. To check the seal, cup both hands over the respirator, covering as much of it as possible, and exhale sharply. If air is felt over the nose area, readjust the respirator. If air is felt at the edges, adjust the straps. After adjustments are made, repeat the seal check. To remove a respirator, cup the respirator with one hand. Bring the bottom strap up and overhead, then the upper strap.

     Employers should provide employees with respirators that are clean, sanitary and in good working order. Before use, protect Type 95 respirators from damage or contamination. Respirator reuse by the same person is permitted as long as the respirator maintains its structural and functional integrity. Dispose of a Type 95 respirator if the filter material is physically damaged or soiled, or if it becomes wet, misshapen, damaged or difficult to breathe through.

CONCLUSION
      The OSHA Respiratory Protection Standard aims to minimize risk to workers from airborne pathogens, including tuberculosis and meningitis. EMS providers should use an employer-supplied Type 95 disposable respirator when assessing, treating or transporting patients with suspected or confirmed TB. For questions about the content in this article or your organization's respiratory protection plan, contact your respiratory protection program administrator or designee.

ONLINE RESOURCES

• To learn more about preventing TB transmission and how to reduce the threat to healthcare workers, view the Centers for Disease Control and Prevention's Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, available through www.cdc.gov.
• In addition to an online lesson on respiratory protection, RapidCE.com users can select from more than a dozen workplace safety lessons including bloodborne pathogens, lifting and back safety, hazard communication, hearing conservation and eye protection.

References

1. Division of Tuberculosis Elimination, CDC. Tuberculosis: General Information, www.cdc.gov/tb/pubs/tbfactsheets/tb.htm.
2. Division of Tuberculosis Elimination, CDC. Questions and Answers About TB 2007, www.cdc.gov/tb/faqs/qa_introduction.htm.
3. Taylor Z, Nolan CM, Blumberg HM. Controlling Tuberculosis in the United States: Recommendations from the American Thoracic Society, CDC, and the Infectious Diseases Society of America, www.cdc.gov/mmwr/preview/mmwrhtml/rr5412a1.htm.
4. Division of Tuberculosis Elimination, CDC. Guidelines for Preventing the Transmission of M. tuberculosis in Health-Care Settings, 2005, www.cdc.gov/tb/pubs/slidesets/InfectionGuidelines/slides.ppt.
5. St. Michael's Hospital Ministry Health Care. Respirator Protection Program: Care of Tuberculosis Patients Self Study Packet, 2005.

Greg Friese, MS, NREMT-P, WEMT, is president of Emergency Preparedness Systems LLC. EPS helps clients create, design, distribute and facilitate rapid e-learning for emergency responders. Greg is a paramedic, Wilderness Medical Associates lead instructor, outdoor enthusiast, conference speaker and author. Contact him at gfriese@eps411.com.

Erin Boness, BA, is a research and production assistant for Emergency Preparedness Systems LLC. Erin's interests include online education for emergency responders, literacy education for working adults, and workplace education and communications.