Respiratory Disease

A suitable case for treatment

The symptoms

The fumes from the acid pickling bath begin to burn the lining of your throat and lungs, and you wonder whether the respirator you are wearing has been selected and maintained correctly.

The runaway chemical reaction floods the plant with hydrogen sulphide, and you attempt to learn how to put on the emergency escape respirator.

You fight for breath in the grip of an asthma attack, and wonder whether that air supply to your visor was high enough.

Your unconscious body is dragged from the confined space, and others try to establish how your air supply could become connected to a nitrogen purging line.

You leave the doctor’s surgery after the bombshell diagnosis that you have incurable lung cancer, and you begin to wonder whether the respiratory protection you used all those years ago was really as good as you believed.

These are nightmare scenarios, but they are all too real. And they are all avoidable. The root cause is usually the systems surrounding the respiratory protective equipment (RPE), and not the equipment itself. There is plenty of good advice and guidance available to those who must choose, provide and use RPE, but these examples, taken from direct experience of our activities in investigating incidents and ill health associated with respiratory hazards, demonstrate that the message doesn’t seem to be getting through. This is particularly true for smaller companies and the self-employed, who lack the resources to employ their own in-house health and safety specialists, but major industry players are not immune either.

The disease

Health and safety enforcement authorities the world over know that RPE is badly selected and applied by most users. With limited resource available to them, and in the prevailing climate of “self-regulation”, reliance is placed on legislation, backed up by written guidance on how to comply. Table 1 provides a not unrealistic summary of the ideal and actual situations as they apply to how RPE is selected and used. Bear in mind that the entries in the “What’s supposed to happen” column are enforceable legal requirements.

The bottom line on “What usually happens” is that people get ill, or possibly die, usually leading to legal proceedings against those deemed responsible.

Clearly, the advice and guidance which is available from enforcement authorities, equipment manufacturers, standardsmaking bodies, trade associations and the like is not as effective as we would wish. Looking at much of this information from the point of view of a non-specialist, non-technical potential user, this is perhaps not surprising. Guidance is wordy, turgid, full of confusing acronyms and concepts, and the route through it is often difficult to follow. The next section describes two major steps which can be taken towards curing this disease.

The treatment

Revised guidance – Guidance and advice to potential users of RPE must be made more accessible, understandable and easier to follow. In the UK, the Health and Safety Executive (HSE) is undertaking a complete rewrite of its main RPE guidance publication, HSG 53(1). Language is being simplified, and a fundamental rethink of the mechanics of the initial RPE selection process has been undertaken.

The main reason for using RPE in the first place is to protect against exposure to hazardous substances – in the UK the principal regulations on this subject are the Control of Substances Hazardous to Health (COSHH(2)) Regulations;

specific regulations for asbestos, lead and ionising radiation follow similar principles to COSHH. The first step in complying with COSHH is to carry out a risk assessment, followed by development of a control strategy. To help non-specialists work their way through the process, HSE has developed COSHH Essentials(3). This leads the user through a simplified “riskbanding” approach and identifies common control strategies for a range of tasks which should cover the majority of situations. If an assessment strays outside the simple boundaries, this is flagged up and the user is alerted to the need for specialist advice.

A similar simplified approach to the selection of adequate and suitable RPE for specific applications is being incorporated by HSE in the revision of HSG 53. This too should cover the majority of situations. For the remainder, those too complex for the simple approach, users are again referred to specialist advice; there is no safe alternative. The schematic diagram above outlines the main steps in this simplified process.

Note that the “Make final RPE selection” box is NOT the end of the process, but merely a pause in an ongoing cycle of reassessment.

In the revised guidance, introductory information on why RPE must be carefully selected and used is provided first. The user is then guided through the decision and selection process with the aid of a checklist, to first justify the use of RPE, and then to identify the types of RPE that can adequately protect against their specific respiratory hazards. HSE are again suggesting a risk-banding approach (similar to that in COSHH Essentials) to the identification of which types of equipment are capable of adequately controlling exposure.

The checklist then prompts the user with questions, the answers to which determine whether a particular type of adequate RPE is potentially suitable for their application; this decision can be made by:

• the users themselves, guided by the more detailed information on individual RPE types contained in HSG 53
• taking the completed form to their RPE supplier, who helps them to choose the most appropriate type
• employing a health and safety professional to make the final selection for them

Factors which influence this decision include the length of time the equipment will have to be worn, how hard the wearer will have to work, any need for high mobility, other equipment and tools used at the same time, and finally the physical attributes of the individual wearer. For each of these aspects, guidance notes are provided alongside the checklist. For each class of commonly available RPE, more detailed information is provided in a consistent and easily comparable format, together with essential pointers related to use in the shape of “Do’s and Don’ts”. The different types have been categorised under the headings called up by the checklist, to aid selection of the best RPE for each application and individual wearer – protection, workrate and wear duration.

Completed checklists are able to serve as written records of the initial RPE risk assessment and selection process for each wearer. The remainder of the guidance sets out the basic requirements for the supporting activities which are necessary (see the “What’s supposed to happen” column in Table 1). This revised guidance (HSG 53) is scheduled for publication in the second half of 2003.

Fit testing

It is one of the major shortcomings of all types of RPE that good protection is dependent on every relevant factor and component working correctly. Keeping RPE providing its peak protection is like balancing a ball on a mountain top – the only way it will stay on top is for all the forces acting on it to remain perfectly balanced. Any imbalance will inevitably make the ball roll downhill – in RPE terms, the level of protection provided will always decrease.

Fundamental to the entire process of establishing the suitability for individuals of many forms of RPE is demonstration of their ability to achieve a satisfactory fit. This specifically applies to any form of RPE which includes a mask (half masks, filtering facepieces, full facemasks). The recent revision of the UK COSHH Approved Code of Practice(2) recognises this, and brings COSHH into line with the situation which has existed in our asbestos regulations for some years.

Because fit is so crucial to good performance, wherever RPE masks are used there must be a robust assessment of whether the wearer is able to achieve an acceptable fit. This will partly be determined by the relative physical dimensions of the mask and the wearer’s face, and partly by their skill in donning it correctly. The problem is that while peoples’ faces come in an infinite variety of shapes and sizes, masks don’t. The realisation is dawning that gender and ethnic differences in the working population are not well catered for by existing masks, historically developed to accommodate a typical adult male Caucasian. Experience has shown that a significant proportion of the population cannot achieve a satisfactory fit with any mask, and this proportion is higher for females and/or some ethnic groups.

Let’s be clear here. Fit testing doesn’t guarantee you’ll get optimum protection every time you put the mask on. What it does do is clearly demonstrate that the wearer is capable of achieving an acceptable level of fit using a given type, size and material of mask, and donning procedure. This is an implicit prerequisite of being able to apply published performance criteria for selecting mask-based RPE, whether these are from the UK Health and Safety Executive, the US National Institute of Occupational Safety and Health, the Commité Européen de Normalisation, or wherever. More importantly, a properly conducted fit test identifies when such a fit can’t be achieved, and ensures that these bad mask/wearer combinations don’t go into hazardous areas. In addition, a well fitting mask is often a more comfortable mask, and stands a much better chance of being used correctly, and for longer.

So when and how do you carry out fit testing? As part of the selection procedure in the final assessment of suitability for individual wearers is the answer. There are a number of approaches possible, depending on the type of RPE mask needed (see Table 2). All have limitations, advantages and disadvantages, but there is an appropriate test method for every form of mask. Details of the methods, and a lot more background information on fit testing in general, is available on the HSE website(4).

Whichever approach is used, the test must be conducted according to defined protocols, by people with the required competence, otherwise test results can be dangerously misleading. Ask yourself how many mask styles and sizes of RPE you provide to your employees. Too often the answer to this question is “one”. You wouldn’t expect one size of shoes or trousers to fit everyone, so why expect it of a mask? Availability of different sizes has improved in recent years, partly in response to the increased application of fit testing, but also through the globalisation of the RPE market. Perhaps it is time to revisit the range of RPE available to your workforce.

The prognosis

The patient is sick, and the treatment may be unpalatable to some, but consider for a moment the consequences of not undertaking the cure. Refer back to the opening examples – then imagine the costs, financial and otherwise, of imperfect RPE systems.

Prospects for significant improvement have to be good, given that in many sectors we are starting from such a low base level. Doing something – anything – in this area has to be better than nothing. However, simply developing the treatment is not enough; it has to be administered.

COSHH Essentials and such simplified approaches go some way to improving accessibility to the lay public, but in the 21st century more can be done. On-line interactive guidance brings information dissemination bang up to date, and this is already available for COSHH(5). The new structure of HSE’s RPE guidance lends itself to a similar approach, and consideration will be given to developing it in this form. I hesitate to suggest the probably very effective, if somewhat radical, step of providing published hard-copy guidance free of charge.

Further afield, European and International Standards organisations are also developing guidance for users. The emerging structure of the new ISO RPE standards is adopting similar classification categories to HSE for performance and use protection level; work rate; wear time. This seems to be becoming an agreed format for the foreseeable future, and one aimed specifically at making RPE selection easier and more relevant.

Side effects

The principles described here don’t stop being valid at the factory gate. They apply equally to any situation where RPE may be needed. Outside of employment, this is most likely during DIY activities, and most topically during public disquiet over the threat of SARS or chemical/biological terrorism.

In situations like these, any hope of a rational and structured approach to correct selection and use of RPE is very slim indeed. Quite simply it takes the “What actually happens” column of Table 1 to its worst extent. Selection is driven by what can be easily found on the DIY superstore shelves, with a pinch of peer pressure, and possibly a good dash of panic thrown in. Once the army surplus stores have run out of time-expired gas masks, this almost exclusively ends in use of a particle filtering facepiece, or something that looks like one. Instruction and use is almost invariably on a “learn by example” basis. Given that the most obvious demonstrations of RPE use available to the majority of the population are through the mass media, example is a very poor teacher.

Take the current surfeit of home makeover and DIY programmes on our TV screens. In the recent past, these have, albeit unwittingly, advocated: o use of dust respirators against solvent vapour hazards

• use of non-protective “comfort masks” to provide respiratory protection

They have also preached appalling practice in putting on and wearing masks:

• ot using all, or in a few cases any, of the headstraps on a facepiece
• not shaping nose bridge formers to fit
• removing masks while working to talk
• using half-mask devices, which leave the eyes exposed, against substances which are both respiratory hazards and eye irritants
• gross incompatibility between masks and goggles such that neither can provide the intended protection
• no consideration of sizing or matching the RPE to the wearer

Similarly, recent news coverage of mass panic over SARS provides yet more examples of the way in which bad practice self-perpetuates. The media has been full of pictures of people wearing medical facemasks, and wearing them badly at that. It is not apparent that such masks are not intended to protect the wearer from infection, but primarily to protect the patient from the wearer, and that they have been proven to be about 5 times less effective than the most basic respirator. Again, “comfort masks” have been shown worn for protection; masks worn over the mouth only, with the nose still exposed; masks worn one on top of the other, and by people with full bushy beards.

With prime-time indoctrination like this, is it surprising that bad practice is the norm, and people follow each other like sheep to the slaughter? There is a very real concern that this bad practice spills over into the workplace. All these people are receiving far less protection than they think, if any. Short of a massive 1940s style public education campaign (“What’s that you are wearing Mr Cholmondly-Warner?” “Why, it’s a high efficiency particle filtering respirator Mr Grayson.”), chances of improving the situation quickly are not good. But some small steps could start us off pushing the ball up the long road to this particular mountain top:

• Given their lack of any practical value, and their huge potential for misuse, comfort masks could be removed from the market. In several European countries, manufacturers have voluntarily stopped marketing such masks in response to these concerns. In the UK, HSE is pressing for a similar voluntary withdrawal(6), and one major manufacturer has already announced plans to do so
• Where they have control, TV companies could pay a little more attention to how they depict the use of RPE (and PPE in general). The words “duty of care” come to mind. They could go one step further, and include an instructive storyline in a popular drama series

If TV companies need suggestions on either front, they can call me. Seriously.

References

(1) Current version is “The selection, use and maintenance of respiratory protective equipment – a practical guide”. (HSG 53), HSE Books, ISBN 0-7176-1537-5. To be replaced later this year by an updated and revised version. (2) The Control of Substances Hazardous to Health Regulations 2002, Approved Code of Practice and Guidance, 4th Edition. (L 5), HSE Books, ISBN 0-7176-2534-6 (3) COSHH Essentials: Easy steps to control chemicals. (HSG 193), HSE Books, ISBN 0-7176-2421-8 (4) http://www.hse.gov.uk/pubns/asbestos.pdf (5) www.coshh-essentials.org.uk (6) HSE News Release E003:03, 16 January 2003. “HSE warns against nuisance dust masks”. © Crown Copyright 2003

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Published: 10th Jul 2003 in Health and Safety International