Skip to content Social Security Online |
Disability Programs |
![]() |
Professionals Home |
![]() Medical/Professional Relations |
|
Disability Evaluation Under Social Security
|
Section | 3.00 Respiratory System |
|
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. 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. 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. 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. These listings are examples
of common respiratory disorders that are severe enough to prevent
a person from engaging in a 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. 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. 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. 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.
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 appropriately labeled spirometric tracing, showing the claimant's name, date of testing, distance per second on the abscissa and the 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 testing device must have had a recorded calibration performed previously on the day of the spirometric measurement. 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 and 3.04 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. 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. 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. Sufficient data must be provided, including documentation of the source of the predicted equation, to permit verification that the test was performed adequately, and that, if necessary, corrections for anemia or carboxyhemoglobin were made appropriately. 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. 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 presents 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 (P02), resting arterial
blood partial pressure of carbon dioxide (PC02) 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 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). 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). 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. I. Effects of obesity. Obesity is a medically determinable impairment that is often associated with disturbance of the respiratory system, and disturbance of this system can be a major cause of disability in individuals with obesity. The combined effects of obesity with respiratory impairments can be greater than the effects of each of the impairments considered separately. Therefore, when determining whether an individual with obesity has a listing-level impairment or combination of impairments, and when assessing a claim at other steps of the sequential evaluation process, including when assessing an individual's residual functional capacity, adjudicators must consider any additional and cumulative effects of obesity. 3.01 Category of Impairments, Respiratory System 3.02 Chronic pulmonary insufficiency A. Chronic obstructive pulmonary disease due to any cause, with the FEV1 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
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
or C. Chronic impairment of gas exchange due to clinically documented pulmonary disease. With: 1. Single breath DLCO (see 3.00Fl) 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 PCO2 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 then 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
(Applicable at test sites 3,000 through 6,000 feet above sea level)
Table III-C (Applicable at test sites over 6,000 feet above sea level)
or 3. Arterial blood gas values of PO2 and simultaneously determined PCO2 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 3.02 C2. 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 bloodstreaked 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
3.06 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 bloodstreaked 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 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;
|
![]() |
Privacy Policy | Website
Policies & Other Important Information | Site
Map
Last reviewed or modified Thursday May 15, 2008 |