Transcript No Slide Title

EVALUATING
PULMONARY
IMPAIRMENTS
MURRAY J. GILMAN, M.D.
MEDICAL CONSULTANT
ATLANTA REGIONAL OFFICE
Nasal
Cavity
Nose
Respiratory Overview
Throat
(pharynx)
Mouth
Bronchus
Bronchiole
Windpipe
(Trachea)
Left lungs
Ribs
Alveolus
Diaphragm
MB
Alveoli and Bronchi Picture
Trachea
Bronchi Tubes
Bronchiole
Alveoli
MB
Alveoli Picture
Here is a close
up picture of
your Alveoli
and a Capillary
surrounding it.
Capillary
Wall of
the air
sac
Carbon
Dioxide is
dropped off
Oxygen is
picked up
Red Blood
Cell
MB
Diagram of Diaphragm
JH
This organ is what pumps
oxygen rich blood, nutrients,
hormones, and the other things
your body needs to maintain
your health, to your organs and
(Superior Vena Cava)
tissues.
From the Body
The Heart
Pulmonary Artery
(Aortic Artery) To the body
The pulmonary veins you see
on the right side of the diagram
come from your lungs, where
the blood cells collect oxygen.
It’s then pumped out to the rest
of the body through the Aorta
(Top).
All of the blue sections show
blood cells carrying waste,
(C02) moving back to the lungs
(where the C02 will be replaced
by oxygen) through the
Pulmonary Artery (Top, blue)
By The Way…
Pulmonary Veins
Valves: tricuspid valve, semilunar
(pulmonary) valve, bicuspid (mitral)
valve, and the semilunar (aortic) valve
(Inferior Vena Cava)
From the Body
Whenever the blood is pumped from
one section of the heart another a
valve closes behind it preventing the
blood from moving backwards.
Respiratory Diseases
COPD
Emphysema
Chronic Bronchitis
Asthma
Bronchiectasis
Interstitial Pulmonary Fibrosis
UIP NSIP RBILD DIP
Respiratory Diseases
Morbid Obesity
Pickwickian Syndrome
Obesity-Hypoventilation Syndrome
Cystic Fibrosis
Pulmonary Hypertension
Tuberculosis
mycobacterium tb
atypical
Respiratory Diseases
Pneumoconiosis
Asbestosis
Silicosis/CWP
Sarcoidosis
Neuromuscular Disorders
Muscular Dystrophy
Myasthenia Gravis
RESPIRATORY LISTINGS
3.02 CHRONIC PULMONARY
INSUFFICIENCY
3.03 ASTHMA
3.04 CYSTIC FIBROSIS
3.06 PNEUMOCONIOSIS
3.07 BRONCHIECTASIS
RESPIRATORY LISTINGS
3.08 MYCOBACTERIAL, MYCOTIC, &
OTHER CHRONIC PERSISTENT
INFECTIONS OF THE LUNG
3.09 COR PULMONALE SECONDARY
TO CHRONIC PULMONARY
VASCULAR HYPERTENSION
3.10 SLEEP-RELATED BREATHING
DISORDERS
Chronic Pulmonary Insufficiency
Listing 3.02
• 3.02A
obstructive\ ventilatory defect
• 3.02B
• 3.02C
restrictive ventilatory defect
impairment of gas exchange
1) diffusing capacity
2) arterial blood gas
3) exercise ABG
Listing 3.02A
Listing 3.02B
Listing 3.02C 1&2
• Single breath DLCO less than 10.5 or less
than 40% of predicted normal value
• ABG values of PO2 and PCO2 while at rest
on room air, clinically stable on at least two
occasions, three or more weeks apart within
a 6-month period equal to or less than the
values in Table III-A, III-B, or III-C.
Listing 3.02C2
FROM THE INTRODUCTION:
“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.”
PULMONARY FUNCTION
MEASURES
1. PULMONARY FUNCTION TESTS (PFT)
2. DIFFUSING CAPACITY OF LUNGS FOR
CARBON MONOXIDE (DLCO)
3. ARTERIAL BLOOD GAS
STUDIES (ABGS)
PULMONARY FUNCTION
MEASURES
4. PULSE OXIMETRY (SpO2)
5. CARDIAC CATHETERIZATION FOR
PULMONARY ARTERY PRESSURE
(IF ALREADY DONE - WILL
NOT BE PURCHASED)
When to Request PFS
• Clinical diagnosis of chronic bronchitis,
chronic asthmatic bronchitis, emphysema,
COPD, ILD
• A normal chest x-ray or a normal physical
exam does not exclude a significant
exertional impairment
• Listing level airflow obstruction can occur
with minimal findings on exam
• When in doubt, objective data necessary
Clinical Example
• 54 year old laborer with 30 pack/year
smoking history
• Complains of dyspnea on exertion
• No prior physician encounters
• CE cites COPD as a clinical diagnosis
• DDS assigns a light RFC based on available
medical evidence
Clinical Example
• 40 year old non-smoker with a history of
asthma
• Requires bronchodilator medications as
needed
• No ER visits or hospitalizations for asthma
• Alleges dyspnea on exertion but no other
medical evidence of COPD
Clinical Example
• Morbidly obese 40 year old male nonsmoker
• Alleges marked dyspnea on exertion
• Chest x-ray and lung exam normal
• DDS RFC sedentary
• No ABG’s or PFS in the record
THE MOST COMMON
ADJUDICATIVE PROBLEM
LACK OF VALID
PULMONARY
FUNCTION
STUDIES
THE WATER-SEALED
STEAD-WELLS SPIROMETER
JONES SPIROMETER
TIPS FOR ASSESSING
THE VALIDITY OF
PULMONARY
FUNCTION
TESTS
PULMONARY FUNCTION TEST
ACCEPTABILITY CRITERIA
1. GOOD START OF TEST
2. NO COUGHING, ESPECIALLY
DURING FIRST SECOND
3. NO VARIABLE FLOW
4. NO EARLY TERMINATION OF
EXPIRATION
5. GOOD REPRODUCIBILITY OF
CONSISTENCY OF EFFORTS
PULMONARY FUNCTION TEST
ACCEPTABILITY CRITERIA
1. GOOD START OF TEST
2. NO COUGHING, ESPECIALLY
DURING FIRST SECOND
3. NO VARIABLE FLOW
4. NO EARLY TERMINATION OF
EXPIRATION
5. GOOD REPRODUCIBILITY OF
CONSISTENCY OF EFFORTS
GOOD EFFORT
ACTUAL
CASE FILE
POOR START OF TEST
PULMONARY FUNCTION TEST
ACCEPTABILITY CRITERIA
1. GOOD START OF TEST
2. NO COUGHING, ESPECIALLY
DURING FIRST SECOND
3. NO VARIABLE FLOW
4. NO EARLY TERMINATION OF
EXPIRATION
5. GOOD REPRODUCIBILITY OF
CONSISTENCY OF EFFORTS
COUGHING
PULMONARY FUNCTION TEST
ACCEPTABILITY CRITERIA
1. GOOD START OF TEST
2. NO COUGHING, ESPECIALLY
DURING FIRST SECOND
3. NO VARIABLE FLOW
4. NO EARLY TERMINATION OF
EXPIRATION
5. GOOD REPRODUCIBILITY OF
CONSISTENCY OF EFFORTS
VARIABLE FLOW RATES
PULMONARY FUNCTION TEST
ACCEPTABILITY CRITERIA
1. GOOD START OF TEST
2. NO COUGHING, ESPECIALLY
DURING FIRST SECOND
3. NO VARIABLE FLOW
4. NO EARLY TERMINATION OF
EXPIRATION
5. GOOD REPRODUCIBILITY OF
CONSISTENCY OF EFFORTS
NOT ACCEPTABLE
EARLY TERMINATION
NO EARLY TERMINATION
EARLY TERMINATION
PULMONARY FUNCTION TEST
ACCEPTABILITY CRITERIA
1. GOOD START OF TEST
2. NO COUGHING, ESPECIALLY
DURING FIRST SECOND
3. NO VARIABLE FLOW
4. NO EARLY TERMINATION OF
EXPIRATION
5. GOOD REPRODUCIBILITY OF
CONSISTENCY OF EFFORTS
GOOD
REPRODUCIBILITY
POOR
REPRODUCIBILITY
FLOW-VOLUME LOOP
IF ON
CONTINUOUS
OXYGEN
PFS NOT NEEDED
Arterial Blood Gases
• Table III-A ( applicable up to 3,000 feet)
if PO2 at rest on room air is less than 55
meets 3.02C2
Similar to CMS guidelines for home O2
• Pulse oximetry is not considered an
“acceptable substitute”
• Exercise ABG’s with O2 consumption of
17.5 or 5 METS
Listing 3.02C2
MEDICAL SOURCE
OPINION EVIDENCE
A TREATING SOURCE
STATEMENT THAT
THE CLAIMANT NEEDS
CONTINUOUS OXYGEN
SHOULD BE VERIFIED
BY OBJECTIVE EVIDENCE
Diffusing Capacity
Impairment of gas exchange
• Tracings
• Verification of accuracy
• Non-invasive
Case A
55 yrs
Male
Diffusing Capacity
Diffusing Capacity
• Tracings are required as per 3.00F
• VI
• Breath-hold maneuver
Diffusing Capacity
• VI – should be at least 90% of the
previously determined vital capacity (VC)
• Inspiratory time for the VI should be less
than 2 seconds
• Breath-hold time should be between 9-11
seconds
Asthma
• Listing 3.03A – evaluate as per 3.02A
• Listing 3.03B
in spite of prescribed treatment and
requiring physician intervention
occurring at least once every 2 months
or at least 6 times per year
evaluation period of at least 12 months
Cystic Fibrosis
• Listing 3.04 A,B, or C
A) FEV1 parameters differ from 3.02A
B) frequency of exacerbations
C) persistent pulmonary infxn requiring
intravenous or nebulization antimicrobial
therapy
Listing 3.06 to 3.08
• Pneumoconiosis
• Bronchiectasis
• Mycobacterial Disease
Tuberculosis
Atypical (MAI)
Pulmonary Hypertension
• Listing 3.09 A or B
MEAN pulmonary artery pressure
>40 mmHG
arterial hypoxemia as per 3.02C2
Sleep-related Breathing
Disorders
• Listing 3.10
evaluate under 3.09 – chronic cor
pulmonale or
Listing 12.02
Lung Transplant
• Listing 3.11
consider disabled for 12 months
thereafter evaluate under the residual
impairment
Respiratory Case Study
• Explain the key findings
• Does the condition meet a respiratory
Listing
• What limitations in functioning might result
from this condition
• Would discontinuing smoking completely
have any effect
Respiratory Case Study
• Is there any other treatment that might
improve his functioning
• Will his limitations likely improve over
time
Childhood Respiratory Listings
•
•
•
•
Asthma
Congenital Lung Disease
Cystic Fibrosis
Neuromuscular Disorders
Listing 103.03
• FEV1 equal to or less than table 1 103.02A
• Attacks in spite of prescribed treatment and
requiring physical intervention, occurring at
least once every two months or at least six
times a year
• Evaluation period of at least 12 consecutive
months
Listing 103.03
• Persistent low grade wheezing between
acute attacks requiring daytime and
nocturnal use of sympathomimetic
bronchodilators with one of the following:
1. persistent prolonged expiration with
radiographic or other appropriate imaging of
pulmonary hyperinflation or peribronchial
disease or
Listing 103.03
2. Short courses of corticosteroids that
average more than 5 days per month for at
least 3 months during a 12 month period;
or
D. Growth impairment as described under
criteria in 100.00
Case Study
• Did the claimant MEET Listing 103.03C2?
• If not meet, did it EQUAL?
• Is Budenoside a corticosteroid? If so, would
the claimant’s daily use of budenoside alone
meet the criterial of Listing 103.03C2
• Is Budenoside prescribed in the form of an
inhaler or used as a nebulizer?
Case Study
• Would it make a difference if a
corticosteroid were administered in an
inhaler form or liquid form in a nebulizer in
terms of meeting Listing 103.03C2?
• What other brands of medications are
considered corticosteroids?