DI 34123.005 Respiratory Listings from 10/07/93 to 05/23/02
3.00 Respiratory System
A. Introduction The listings in this section describe impairments resulting from respiratory disorders
based on symptoms, physical signs, laboratory test abnormalities, and response to
a regimen of treatment prescribed by a treating source. Respiratory disorders along
with any associated impairment(s) must be established by medical evidence. Evidence
must be provided in sufficient detail to permit an independent reviewer to evaluate
the severity of the impairment.
Many individuals, especially those who have listing-level impairments, will have received
the benefit of medically prescribed treatment. Whenever there is evidence of such
treatment, the longitudinal clinical record must include a description of the treatment
prescribed by the treating source and response in addition to information about the
nature and severity of the impairment. It is important to document any prescribed
treatment and response, because this medical management may have improved the individual's
functional status. The longitudinal record should provide information regarding functional
recovery, if any.
Some individuals will not have received ongoing treatment or have an ongoing relationship
with the medical community, despite the existence of a severe impairment(s). An individual
who does not receive treatment may or may not be able to show the existence of an
impairment that meets the criteria of these listings. Even if an individual does not
show that his or her impairment meets the criteria of these listings, the individual
may have an impairment(s) equivalent in severity to one of the listed impairments
or be disabled because of a limited residual functional capacity. Unless the claim
can be decided favorably on the basis of the current evidence, a longitudinal record
is still important because it will provide information about such things as the ongoing
medical severity of the impairment, the level of the individual's functioning, and
the frequency, severity, and duration of symptoms. Also, the asthma listing specifically
includes a requirement for continuing signs and symptoms despite a regimen of prescribed
treatment.
Impairments caused by chronic disorders of the respiratory system generally produce
irreversible loss of pulmonary function due to ventilatory impairments, gas exchange
abnormalities, or a combination of both. The most common symptoms attributable to
these disorders are dyspnea on exertion, cough, wheezing, sputum production, hemoptysis,
and chest pain. Because these symptoms are common to many other diseases, a thorough
medical history, physical examination, and chest x-ray or other appropriate imaging
technique are required to establish chronic pulmonary disease. Pulmonary function
testing is required to assess the severity of the respiratory impairment once a disease
process is established by appropriate clinical and laboratory findings.
Alterations of pulmonary function can be due to obstructive airway disease (e.g.,
emphysema, chronic bronchitis, asthma), restrictive pulmonary disorders with primary
loss of lung volume (e.g., pulmonary resection, thoracoplasty, chest cage deformity
as in kyphoscoliosis or obesity), or infiltrative interstitial disorders (e.g., diffuse
pulmonary fibrosis). Gas exchange abnormalities without significant airway obstruction
can be produced by interstitial disorders. Disorders involving the pulmonary circulation
(e.g., primary pulmonary hypertension, recurrent thromboembolic disease, primary or
secondary pulmonary vasculitis) can produce pulmonary vascular hypertension and, eventually,
pulmonary heart disease (cor pulmonale) and right heart failure. Persistent hypoxemia
produced by any chronic pulmonary disorder also can result in chronic pulmonary hypertension
and right heart failure. Chronic infection, caused most frequently by mycobacterial
or mycotic organisms, can produce extensive and progressive lung destruction resulting
in marked loss of pulmonary function. Some disorders, such as bronchiectasis, cystic
fibrosis, and asthma, can be associated with intermittent exacerbations of such frequency
and intensity that they produce a disabling impairment, even when pulmonary function
during periods of relative clinical stability is relatively well-maintained.
Respiratory impairments usually can be evaluated under these listings on the basis
of a complete medical history, physical examination, a chest x-ray or other appropriate
imaging techniques, and spirometric pulmonary function tests. In some situations,
most typically with a diagnosis of diffuse interstitial fibrosis or clinical findings
suggesting cor pulmonale, such as cyanosis or secondary polycythemia, an impairment
may be underestimated on the basis of spirometry alone. More sophisticated pulmonary
function testing may then be necessary to determine if gas exchange abnormalities
contribute to the severity of a respiratory impairment. Additional testing might include
measurement of diffusing capacity of the lungs for carbon monoxide or resting arterial
blood gases. Measurement of arterial blood gases during exercise is required infrequently.
In disorders of the pulmonary circulation, right heart catheterization with angiography
and/or direct measurement of pulmonary artery pressure may have been done to establish
a diagnosis and evaluate severity. When performed, the results of the procedure should
be obtained. Cardiac catheterization will not be purchased.
These listings are examples of common respiratory disorders that are severe enough
to prevent a person from engaging in any gainful activity. When an individual has
a medically determinable impairment that is not listed, an impairment which does not
meet a listing, or a combination of impairments no one of which meets a listing, we
will consider whether the individual's impairment or combination of impairments is
medically equivalent in severity to a listed impairment. Individuals who have an impairment(s)
with a level of severity which does not meet or equal the criteria of the listings
may or may not have the residual functional capacity (RFC) which would enable them
to engage in substantial gainful activity. Evaluation of the impairment(s) of these
individuals will proceed through the final steps of the sequential evaluation process.
B. Mycobacterial, mycotic, and other chronic persistent infections of the lung. These disorders are evaluated on the basis of the resulting limitations in pulmonary
function. Evidence of chronic infections, such as active mycobacterial diseases or
mycoses with positive cultures, drug resistance, enlarging parenchymal lesions, or
cavitation, is not, by itself, a basis for determining that an individual has a disabling
impairment expected to last 12 months. In those unusual cases of pulmonary infection
that persist for a period approaching 12 consecutive months, the clinical findings,
complications, therapeutic considerations, and prognosis must be carefully assessed
to determine whether, despite relatively well-maintained pulmonary function, the individual
nevertheless has an impairment that is expected to last for at least 12 consecutive
months and prevent gainful activity.
C. Episodic respiratory disease When a respiratory impairment is episodic in nature, as can occur with exacerbations
of asthma, cystic fibrosis, bronchiectasis, or chronic asthmatic bronchitis, the frequency
and intensity of episodes that occur despite prescribed treatment are often the major
criteria for determining the level of impairment. Documentation for these exacerbations
should include available hospital, emergency facility and /or physician records indicating
the dates of treatment; clinical and laboratory findings on presentation, such as
the results of spirometry and arterial blood gas studies (ABGS); the treatment administered;
the time period required for treatment; and the clinical response. Attacks of asthma,
episodes of bronchitis or pneumonia or hemoptysis (more than blood-streaked sputum),
or respiratory failure as referred to in paragraph B of 3.03, 3.04, and 3.07, are
defined as prolonged symptomatic episodes lasting one or more days and requiring intensive
treatment, such as intravenous bronchodilator or antibiotic administration or prolonged
inhalational bronchodilator therapy in a hospital, emergency room or equivalent setting.
Hospital admissions are defined as inpatient hospitalizations for longer than 24 hours.
The medical evidence must also include information documenting adherence to a prescribed
regimen of treatment as well as a description of physical signs. For asthma, the medical
evidence should include spirometric results obtained between attacks that document
the presence of baseline airflow obstruction.
D. Cystic fibrosis is a disorder that affects either the respiratory or digestive body systems or both
and is responsible for a wide and variable spectrum of clinical manifestations and
complications. Confirmation of the diagnosis is based upon an elevated sweat sodium
concentration or chloride concentration accompanied by one or more of the following:
the presence of chronic obstructive pulmonary disease, insufficiency of exocrine pancreatic
function, meconium ileus, or a positive family history. The quantitative pilocarpine
iontophoresis procedure for collection of sweat content must be utilized. Two methods
are acceptable: the "Procedure for the Quantitative Iontophoretic Sweat Test for Cystic
Fibrosis" published by the Cystic Fibrosis Foundation and contained in, "A Test for
Concentration of Electrolytes in Sweat in Cystic Fibrosis of the Pancreas Utilizing
Pilocarpine Iontophoresis," Gibson, I.E., and Cooke, R.E., Pediatrics , Vol. 23: 545, 1959; or the "Wescor Macroduct System." To establish the diagnosis
of cystic fibrosis, the sweat sodium or chloride content must be analyzed quantitatively
using an acceptable laboratory technique. Another diagnostic test is the "CF gene
mutation analysis" for homozygosity of the cystic fibrosis gene. The pulmonary manifestations
of this disorder should be evaluated under 3.04. The nonpulmonary aspects of cystic
fibrosis should be evaluated under the digestive body system (5.00). Because cystic
fibrosis may involve the respiratory and digestive body systems, the combined effects
of the involvement of these body systems must be considered in case adjudication.
E. Documentation of pulmonary function testing The results of spirometry that are used for adjudication under paragraphs A and B
of 3.02 should be expressed in liters (L), body temperature and pressure saturated
with water vapor (BTPS). The reported one-second forced expiratory volume (FEV 1 ) and forced vital capacity (FVC) should represent the largest of at least three
satisfactory forced expiratory maneuvers. Two of the satisfactory spirograms should
be reproducible for both pre-bronchodilator tests and, if indicated, post-bronchodilator
tests. A value is considered reproducible if it does not differ from the largest value
by more than 5 percent or 0.1 L, whichever is greater. The highest values of the FEV1 and FVC, whether from the same or different tracings, should be used to assess the
severity of the respiratory impairment. Peak flow should be achieved early in expiration,
and the spirogram should have a smooth contour with gradually decreasing flow throughout
expiration. The zero time for measurement of the FEV1 and FVC, if not distinct, should be derived by linear back-extrapolation of peak
flow to zero volume. A spirogram is satisfactory for measurement of the FEV1 if the expiratory volume at the back-extrapolated zero time is less than 5 percent
of the FVC or 0.1 L, whichever is greater. The spirogram is satisfactory for measurement
of the FVC if maximal expiratory effort continues for at least 6 seconds, or if there
is a plateau in the volume-time curve with no detectable change in expired volume
(VE) during the last 2 seconds of maximal expiratory effort.
Spirometry should be repeated after administration of an aerosolized bronchodilator
under supervision of the testing personnel if the pre-bronchodilator FEV1 value is less than 70 percent of the predicted normal value. Pulmonary function studies
should not be performed unless the clinical status is stable (e.g., the individual
is not having an asthmatic attack or suffering from an acute respiratory infection
or other chronic illness). Wheezing is common in asthma, chronic bronchitis, or chronic
obstructive pulmonary disease and does not preclude testing. The effect of the administered
bronchodilator in relieving bronchospasm and improving ventilatory function is assessed
by spirometry. If a bronchodilator is not administered, the reason should be clearly
stated in the report. Pulmonary function studies performed to assess airflow obstruction
without testing after bronchodilators cannot be used to assess levels of impairment
in the range that prevents any gainful work activity, unless the use of bronchodilators
is contraindicated. Post-bronchodilator testing should be performed 10 minutes after
bronchodilator administration. The dose and name of the bronchodilator administered
should be specified. The values in paragraphs A and B of 3.02 must only be used as
criteria for the level of ventilatory impairment that exists during the individual's
most stable state of health (i.e., any period in time except during or shortly after
an exacerbation).
The appropriately labeled spirometric tracing, showing the claimant's name, date of
testing, distance per second on the abscissa and distance per liter (L) on the ordinate,
must be incorporated into the file. The manufacturer and model number of the device
used to measure and record the spirogram should be stated. The testing device must
accurately measure both time and volume, the latter to within 1 percent of a 3 L calibrating
volume. If the spirogram was generated by any means other than direct pen linkage
to a mechanical displacement-type spirometer, the spirometric tracing must show a
recorded calibration of volume units using a mechanical volume input such as a 3 L
syringe.
If the spirometer directly measures flow, and volume is derived by electronic integration,
the linearity of the device must be documented by recording volume calibrations at
three different flow rates of approximately 30 L/min (3 L/6 sec), 60 L/min (3 L/3
sec), and 180 L/min (3 L/ sec). The volume calibrations should agree to within 1 percent
of a 3 L calibrating volume. The proximity of the flow sensor to the individual should
be noted, and it should be stated whether or not a BTPS correction factor was used
for the calibration recordings and for the individual's actual spirograms.
The spirogram must be recorded at a speed of at least 20 mm/sec, and the recording
device must provide a volume excursion of at least 10 mm/L. If reproductions of the
original spirometric tracings are submitted, they must be legible and have a time
scale of at least 20 mm/sec and a volume scale of at least 10 mm/L to permit independent
measurements. Calculation of FEV1 from a flow-volume tracing is not acceptable, i.e., the spirogram and calibrations
must be presented in a volume-time format at a speed of at least 20 mm/sec and a volume
excursion of at least 10 mm/L to permit independent evaluation.
A statement should be made in the pulmonary function test report of the individual's
ability to understand directions as well as his or her effort and cooperation in performing
the pulmonary function tests.
The pulmonary function tables in 3.02 are based on measurement of standing height
without shoes. If an individual has marked spinal deformities (e.g., kyphoscoliosis),
the measured span between the fingertips with the upper extremities abducted 90 degrees
should be substituted for height when this measurement is greater than the standing
height without shoes.
F. Documentation of chronic impairment of gas exchange
1. Diffusing capacity of the lungs for carbon monoxide (DLCO) A diffusing capacity of the lungs for carbon monoxide study should be purchased in
cases in which there is documentation of chronic pulmonary disease, but the existing
evidence, including properly performed spirometry, is not adequate to establish the
level of functional impairment. Before purchasing DLCO measurements, the medical history,
physical examination, reports of chest x-ray or other appropriate imaging techniques,
and spirometric test results must be obtained and reviewed because favorable decisions
can often be made based on available evidence without the need for DLCO studies. Purchase
of a DLCO study may be appropriate when there is a question of whether an impairment
meets or is equivalent in severity to a listing, and the claim cannot otherwise be
favorably decided.
The DLCO should be measured by the single breath technique with the individual relaxed
and seated. At sea level, the inspired gas mixture should contain approximately 0.3
percent carbon monoxide (CO), 10 percent helium (He), 21 percent oxygen (O2 ), and the balance nitrogen. At altitudes above sea level, the inspired O2 concentration may be raised to provide an inspired O2 tension of approximately 150 mm Hg. Alternatively, the sea level mixture may be employed
at altitude and the measured DLCO corrected for ambient barometric pressure. Helium
may be replaced by another inert gas at an appropriate concentration. The inspired
volume (VI) during the DLCO maneuver should be at least 90 percent of the previously
determined vital capacity (VC). The inspiratory time for the VI should be less than
2 seconds, and the breath-hold time should be between 9 and 11 seconds. The washout
volume should be between 0.75 and 1.00 L, unless the VC is less than 2 L. In this
case, the washout volume may be reduced to 0.50 L; any such change should be noted
in the report. The alveolar sample volume should be between 0.5 and 1.0 L and be collected
in less than 3 seconds. At least 4 minutes should be allowed for gas washout between
repeat studies.
A DLCO should be reported in units of ml CO, standard temperature, pressure, dry (STPD)/min/mm
Hg uncorrected for hemoglobin concentration and be based on a single-breath alveolar
volume determination. Abnormal hemoglobin or hematocrit values, and/or carboxyhemoglobin
levels should be reported along with diffusing capacity.
The DLCO value used for adjudication should represent the mean of at least two acceptable
measurements, as defined above. In addition, two acceptable tests should be within
10 percent of each other or 3 ml CO(STPD)/ min/mm Hg, whichever is larger. The percent
difference should be calculated as 100 x (test 1 - test 2)/average DLCO.
The ability of the individual to follow directions and perform the test properly should
be described in the written report. The report should include tracings of the VI,
breath-hold maneuver, and VE appropriately labeled with the name of the individual
and the date of the test. The time axis should be at least 20 mm/sec and the volume
axis at least 10 mm/L. The percentage concentrations of inspired O2 , and inspired and expired CO and He for each of the maneuvers should be provided,
and the algorithm used to calculate test results noted. Sufficient data must be provided
to permit independent calculation of results (and, if necessary, calculation of corrections
for anemia and/or carboxyhemoglobin).
2. Arterial blood gas studies (ABGS) An ABGS performed at rest (while breathing room air, awake and sitting or standing)
or during exercise should be analyzed in a laboratory certified by a State or Federal
agency. If the laboratory is not certified, it must submit evidence of participation
in a national proficiency testing program as well as acceptable quality control at
the time of testing. The report should include the altitude of the facility and the
barometric pressure on the date of analysis.
Purchase of resting ABGS may be appropriate when there is a question of whether an
impairment meets or is equivalent in severity to a listing, and the claim cannot otherwise
be favorably decided. If the results of a DLCO study are greater than 40 percent of
predicted normal but less than 60 percent of predicted normal, purchase of resting
ABGS should be considered. Before purchasing resting ABGS, a program physician, preferably
one experienced in the care of patients with pulmonary disease, must review all clinical
and laboratory data short of this procedure, including spirometry, to determine whether
obtaining the test would present a significant risk to the individual.
3. Exercise testing Exercise testing with measurement of arterial blood gases during exercise may be
appropriate in cases in which there is documentation of chronic pulmonary disease,
but full development, short of exercise testing, is not adequate to establish if the
impairment meets or is equivalent in severity to a listing, and the claim cannot otherwise
be favorably decided. In this context, "full development" means that results from
spirometry and measurement of DLCO and resting ABGS have been obtained from treating
sources or through purchase. Exercise arterial blood gas measurements will be required
infrequently and should be purchased only after careful review of the medical history,
physical examination, chest x-ray or other appropriate imaging techniques, spirometry,
DLCO, electrocardiogram (ECG), hematocrit or hemoglobin, and resting blood gas results
by a program physician, preferably one experienced in the care of patients with pulmonary
disease, to determine whether obtaining the test would present a significant risk
to the individual. Oximetry and capillary blood gas analysis are not acceptable substitutes
for the measurement of arterial blood gases. Arterial blood gas samples obtained after
the completion of exercise are not acceptable for establishing an individual's functional
capacity.
Generally, individuals with a DLCO greater than 60 percent of predicted normal would
not be considered for exercise testing with measurement of blood gas studies. The
exercise test facility must be provided with the claimant's clinical records, reports
of chest x-ray or other appropriate imaging techniques, and any spirometry, DLCO,
and resting blood gas results obtained as evidence of record. The testing facility
must determine whether exercise testing present a significant risk to the individual;
if it does, the reason for not performing the test must be reported in writing.
4. Methodology Individuals considered for exercise testing first should have resting arterial blood
partial pressure of oxygen (PO2 ), resting arterial blood partial pressure of carbon dioxide (PCO2 ) and negative log of hydrogen ion concentration (pH) determinations by the testing
facility. The sample should be obtained in either the sitting or standing position.
The individual should then perform exercise under steady state conditions, preferably
on a treadmill, breathing room air, for a period of 4 to 6 minutes at a speed and
grade providing an oxygen consumption of approximately 17.5 ml/kg/min (5 METs). If
a bicycle ergometer is used, an exercise equivalent of 5 METs (e.g., 450 kpm/min,
or 75 watts, for a 176 pound (80 kilogram) person) should be used. If the individual
is able to complete this level of exercise without achieving listing-level hypoxemia,
then he or she should be exercised at higher workloads to determine exercise capacity.
A warm-up period of treadmill walking or cycling may be performed to acquaint the
individual with the exercise procedure. If during the warm-up period the individual
cannot achieve an exercise level of 5 METs, a lower workload may be selected in keeping
with the estimate of exercise capacity. The individual should be monitored by ECG
throughout the exercise and in the immediate post-exercise period. Blood pressure
and an ECG should be recorded during each minute of exercise. During the final 2 minutes
of a specific level of steady state exercise, an arterial blood sample should be drawn
and analyzed for oxygen pressure (or tension) (PO2 ), carbon dioxide pressure (or tension) (PCO2 ), and pH. At the discretion of the testing facility, the sample may be obtained
either from an indwelling arterial catheter or by direct arterial puncture. If possible,
in order to evaluate exercise capacity more accurately, a test site should be selected
that has the capability to measure minute ventilation, O2 consumption, and carbon dioxide (CO2 ) production. If the claimant fails to complete 4 to 6 minutes of steady state exercise,
the testing laboratory should comment on the reason and report the actual duration
and levels of exercise performed. This comment is necessary to determine if the individual's
test performance was limited by lack of effort or other impairment (e.g., cardiac,
peripheral vascular, musculoskeletal, neurological).
The exercise test report should contain representative ECG strips taken before, during
and after exercise; resting and exercise arterial blood gas values; treadmill speed
and grade settings, or, if a bicycle ergometer was used, exercise levels expressed
in watts or kpm/min; and the duration of exercise. Body weight also should be recorded.
If measured, O2 consumption (STPD), minute ventilation (BTPS), and CO2 production (STPD) also should be reported. The altitude of the test site, its normal
range of blood gas values, and the barometric pressure on the test date must be noted.
G. Chronic cor pulmonale and pulmonary vascular disease
The establishment of an impairment attributable to irreversible cor pulmonale secondary
to chronic pulmonary hypertension requires documentation by signs and laboratory findings
of right ventricular overload or failure (e.g., an early diastolic right-sided gallop
on auscultation, neck vein distension, hepatomegaly, peripheral edema, right ventricular
outflow tract enlargement on x-ray or other appropriate imaging techniques, right
ventricular hypertrophy on ECG, and increased pulmonary artery pressure measured by
right heart catheterization available from treating sources). Cardiac catheterization
will not be purchased. Because hypoxemia may accompany heart failure and is also a
cause of pulmonary hypertension, and may be associated with hypoventilation and respiratory
acidosis, arterial blood gases may demonstrate hypoxemia (decreased PO2 ), CO2 retention (increased PCO2 ), and acidosis (decreased pH). Polycythemia with an elevated red blood cell count
and hematocrit may be found in the presence of chronic hypoxemia.
P-pulmonale on the ECG does not establish chronic pulmonary hypertension or chronic
cor pulmonale. Evidence of florid right heart failure need not be present at the time
of adjudication for a listing (e.g., 3.09) to be satisfied, but the medical evidence
of record should establish that cor pulmonale is chronic and irreversible.
H. Sleep-related breathing disorders
Sleep-related breathing disorders (sleep apneas) are caused by periodic cessation
of respiration associated with hypoxemia and frequent arousals from sleep. Although
many individuals with one of these disorders will respond to prescribed treatment,
in some, the disturbed sleep pattern and associated chronic nocturnal hypoxemia cause
daytime sleepiness with chronic pulmonary hypertension and/or disturbances in cognitive
function. Because daytime sleepiness can affect memory, orientation, and personality,
a longitudinal treatment record may be needed to evaluate mental functioning. Not
all individuals with sleep apnea develop a functional impairment that affects work
activity. When any gainful work is precluded, the physiologic basis for the impairment
may be chronic cor pulmonale. Chronic hypoxemia due to episodic apnea may cause pulmonary
hypertension (see 3.00G and 3.09). Daytime somnolence may be associated with disturbance
in cognitive vigilance. Impairment of cognitive function may be evaluated under organic
mental disorders (12.02). If the disorder is associated with gross obesity, it should
be evaluated under the applicable obesity listings.
3.01 Category of Impairments, Respiratory System.
3.02 Chronic pulmonary insufficiency.
A. Chronic obstructive pulmonary disease, due to any cause, with the FEV 1 equal to or less than the values specified in table I corresponding to the person's
height without shoes. (In cases of marked spinal deformity, see 3.00E.);
TABLE I
Height without shoes (Centimeters)
|
Height without shoes (Inches)
|
FEV1 equal to or less than (L, BTPS)
|
154 or less
|
60 or less
|
1.05
|
155 -160
|
61-63
|
1.15
|
161 - 165
|
64-65
|
1.25
|
166 - 170
|
66-67
|
1.35
|
171 - 175
|
68-69
|
1.45
|
176 - 180
|
70-71
|
1.55
|
181 or more
|
72 or more
|
1.65
|
OR
B. Chronic restrictive ventilatory disease, due to any cause, with the FVC equal to
or less than the values specified in Table II corresponding to the person's height
without shoes. (In cases of marked spinal deformity, see 3.00E.);
TABLE II
Height without shoes (Centimeters)
|
Height without shoes (Inches)
|
FVC equal to or less than (L, BTPS)
|
154 or less
|
60 or less
|
1.25
|
155 - 160
|
61-63
|
1.35
|
161 - 165
|
64-65
|
1.45
|
166 - 170
|
66-67
|
1.55
|
171 - 175
|
68-69
|
1.65
|
176 - 180
|
70-71
|
1.75
|
181 or more
|
72 or more
|
1.85
|
OR
C. Chronic impairment of gas exchange due to clinically documented pulmonary disease.
With:
1. Single breath DLCO (see 3.00F1) less than 10.5 ml/min/mm Hg or less than 40 percent
of the predicted normal value. (Predicted values must either be based on data obtained
at the test site or published values from a laboratory using the same technique as
the test site. The source of the predicted values should be reported. If they are
not published, they should be submitted in the form of a table or nomogram); or
2. Arterial blood gas values of PO2 and simultaneously determined PCO 2 measured while at rest (breathing room air, awake and sitting or standing) in a clinically
stable condition on at least two occasions, three or more weeks apart within a 6-month
period, equal to or less than the values specified in the applicable table III-A or
III-B or III-C:
TABLE III A
(Applicable at test sites less than 3,000 feet above sea level)
Arterial PCO2 (mm. Hg) AND
|
Arterial PO2 equal to or less than (mm. Hg)
|
30 or below
|
65
|
31
|
64
|
32
|
63
|
33
|
62
|
34
|
61
|
35
|
60
|
36
|
59
|
37
|
58
|
38
|
57
|
39
|
56
|
40 or above
|
55
|
TABLE III B
(Applicable at test sites 3,000 - 6,000 feet above sea level)
Arterial PCO2 (mm. Hg) AND
|
Arterial PO2 equal to or less than (mm. Hg)
|
30 or below
|
60
|
31
|
59
|
32
|
58
|
33
|
57
|
34
|
56
|
35
|
55
|
36
|
54
|
37
|
53
|
38
|
52
|
39
|
51
|
40 or above
|
50
|
TABLE III C
(Applicable at test sites over 6,000 feet above sea level)
Arterial PCO2 (mm. Hg) AND
|
Arterial PO2 equal to or less than (mm. Hg)
|
30 or below
|
55
|
31
|
54
|
32
|
53
|
33
|
52
|
34
|
51
|
35
|
50
|
36
|
49
|
37
|
48
|
38
|
47
|
39
|
46
|
40 or above
|
45
|
OR
3. Arterial blood gas values of PO2 and simultaneously determined PCO 2 during steady state exercise breathing room air (level of exercise equivalent to
or less than 17.5 ml O2 consumption/kg/min or 5 METs) equal to or less than the values specified in the applicable
table III-A or III-B or III-C in 3.02C2.
3.03 Asthma. With:
A. Chronic asthmatic bronchitis. Evaluate under the criteria for chronic obstructive
pulmonary disease in 3.02A;
OR
B. Attacks (as defined in 3.00C), in spite of prescribed treatment and requiring physician
intervention, occurring at least once every 2 months or at least six times a year.
Each in-patient hospitalization for longer than 24 hours for control of asthma counts
as two attacks, and an evaluation period of at least 12 consecutive months must be
used to determine the frequency of attacks.
3.04 Cystic fibrosis. With:
A. An FEV1 equal to or less than the appropriate value specified in table IV corresponding to
the individual's height without shoes. (In cases of marked spinal deformity, see 3.00E.);
OR
B. Episodes of bronchitis or pneumonia or hemoptysis (more than blood-streaked sputum)
or respiratory failure (documented according to 3.00C), requiring physician intervention,
occurring at least once every 2 months or at least six times a year. Each inpatient
hospitalization for longer than 24 hours for treatment counts as two episodes, and
an evaluation period of at least 12 consecutive months must be used to determine the
frequency of episodes;
OR
C. Persistent pulmonary infection accompanied by superimposed, recurrent, symptomatic
episodes of increased bacterial infection occurring at least once every 6 months and
requiring intravenous or nebulization antimicrobial therapy.
TABLE IV
(Applicable only for evaluation under 3.04A - cystic fibrosis)
Height without shoes (Centimeters)
|
Height without shoes (Inches)
|
FEV1 equal to or less than (L, BTPS)
|
154 or less
|
60 or less
|
1.45
|
155 - 159
|
61-62
|
1.55
|
160 - 164
|
63-64
|
1.65
|
165 - 169
|
65-66
|
1.75
|
170 - 174
|
67-68
|
1.85
|
175 - 179
|
69-70
|
1.95
|
180 or more
|
71 or more
|
2.05
|
3.05 (Reserved)
3.06 Pneumoconiosis (demonstrated by appropriate imaging techniques). Evaluate under the appropriate criteria
in 3.02.
3.07 Bronchiectasis (demonstrated by appropriate imaging techniques). With:
A. Impairment of pulmonary function due to extensive disease. Evaluate under the appropriate
criteria in 3.02;
OR
B. Episodes of bronchitis or pneumonia or hemoptysis (more than blood-streaked sputum)
or respiratory failure (documented according to 3.00C), requiring physician intervention,
occurring at least once every 2 months or at least six times a year. Each in-patient
hospitalization for longer than 24 hours for treatment counts as two episodes, and
an evaluation of at least 12 consecutive months must be used to determine the frequency
of episodes.
3.08 Mycobacterial, mycotic, and other chronic persistent infections of the lung (see 3.00B). Evaluate under the appropriate criteria in 3.02.
3.09 Cor pulmonale secondary to chronic pulmonary vascular hypertension. Clinical evidence of cor pulmonale (documented according to 3.00G) with:
A. Mean pulmonary artery pressure greater than 40 mm Hg;
OR
B. Arterial hypoxemia. Evaluate under the criteria in 3.02C2;
OR
C. Evaluate under the applicable criteria in 4.02.
3.10 Sleep-related breathing disorders. Evaluate under 3.09 (chronic cor pulmonale), 9.09 (obesity), or 12.02 (organic mental
disorders).