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NIOSH Respiratory Diseases Research Program

Evidence Package for the National Academies' Review 2006-2007

NIOSH Programs > Respiratory Diseases > Evidence Package > 4. Airways Diseases > 4.2 Obstructive Airways Disease

4.2c) Prevention of COPD through Workplace Spirometric Monitoring and Intervention

previous 4.2b) Assess the Extent, Severity, and Burden of Work-Related COPD and Identify Industries, Occupations, and Occupational Exposures Associated with Potential High-Risk of COPD | 4.2d) Prevention and Reduction of Flavorings-Induced Bronchiolitis Obliterans next

Issue

A key goal of RDRP research on COPD is to develop detailed guidelines for implementation and execution of effective monitoring and intervention programs in the workplace. Pulmonary function monitoring of workers at risk of developing COPD has been recommended as a useful secondary prevention measure. Workplace monitoring for respiratory disease and pulmonary function decline was initiated in many workplaces during the late 1980s. However, clear guidelines on the interpretation of the longitudinal spirometry data that are based on scientific evidence have yet to be developed. Among organizations involved in occupational monitoring of lung function, some have expressed interest in collaborating with RDRP scientists to assess their data and to work towards the development of evidence-based guidelines.

Approach

Activities within RDRP are directed towards various critical aspects of worker lung function monitoring, including improvement in spirometric testing methods, evaluation and optimization of technician training and data quality control, development and evaluation of tools for interpretation of longitudinal declines, development of methods for identification of individuals with excessive decline in lung function, and evaluation of decision rules based on existing longitudinal data.

A specific project on pulmonary function monitoring at workplace was initiated in 2005 to facilitate research into procedures for worker medical monitoring using spirometry to measure lung function. The project is premised on the knowledge that systematic spirometry data collection is being done in many occupational venues and that RDRP has a role in developing guidelines on optimal collection and use of such data. RDRP scientists are collaborating with several external partners who collect periodic spirometry measurements. Several workplace spirometry monitoring databases are being analyzed with the objective of developing and applying practical methods for data evaluation and interpretation. Collaboration with RDRP external partners allows testing and evaluation of the impact of our proposed methods for prevention of respiratory disability.

RDRP also supports and develops NIOSH-approved spirometry testing course methodology.

Outputs and Transfer

With respect to outputs, RDRP has published extensively on longitudinal spirometry data analysis and interpretation in individuals, including assessing longitudinal data precision and identification of individuals with excessive rate of decline. With respect to direct transfer, RDRP is involved with spirometry technician training and mentoring in techniques of spirometry quality control.

Since 2000, five papers have been published (and two more have been recently submitted to journals) on optimal testing strategies, evaluation of lung function declines, and assessing and maintaining data quality. Of these, four papers are of particular importance. The first investigated variability in longitudinal spirometry data and provided guidance on designing more efficient longitudinal spirometry studies and screening programs (12, A4-67). A second paper looked at the magnitude of short-term pulmonary function decline to determine what should be considered abnormal in an individual. The results indicated that in healthy males tested according to American Thoracic Society standards, a yearly decline in FEV1 greater than eight percent or 330 ml should not be considered normal in a monitoring program for otherwise healthy workers, though the 15 percent American Thoracic Society criterion may be appropriate for evaluating diseased individuals in clinical settings (13, A4-68).

Data quality concerned a third noteworthy paper that proposed a new practical method for monitoring of longitudinal spirometry data precision in workplace monitoring. The publication was nominated for CDC’s Charles C. Shepard Science Award for 2006 (14, A4-69). The fourth important paper proposed a new statistical method for identification of individuals with an excessive decline in lung function based on the precision of existing longitudinal data. The method was shown to be more sensitive (while comparably specific) than an approach previously proposed by the American College of Occupational and Environmental Medicine for identifying individuals with excessive declines (15, A4-70).

Based on these above published methods, RDRP researchers have also developed computer software for Spirometry Longitudinal Data Analysis (SPIROLA). Stakeholders have showed great interest in this product, and collaborating partners are currently testing the product before making it available for general release (A4-71).

RDRP organized a workshop on “Interpretation of Longitudinal Spirometry Data in an Individual” for invited statistical, pulmonary and occupational medicine experts from throughout the U.S. The objective of this workshop, held on March 9-10, 2006, in Washington D.C., was to review the current statistical methods for longitudinal spirometry assessment in an individual and to specifically review the SPIROLA software (A4-72).

RDRP staff have developed and posted information on NIOSH-approved Spirometry Training Courses that is routinely updated and readily accessible (http://www.cdc.gov/niosh/topics/spirometry). This site has proved highly useful for course students, course sponsors, and course faculty, as well as for improving efficiencies of RDRP staff, which no longer need to respond to so many individual contacts for information on this program. 

RDRP staff taught the NIOSH-approved spirometry training course in Zambia in 2005, and they will be teaching it again in South Africa in 2006 and in Chile in 2007. Teaching these courses falls within the NIOSH global initiative on occupational disease prevention.

Intermediate Outcomes

The RDRP sub-program on monitoring individual declines in lung function is relatively new. Although substantial progress has been made in working with stakeholders and partners in exchanging information and developing collaborations, the program is in the stage of methods development and validation. As noted above, considerable interest has been evidenced by industry and other groups. This suggests that when the methods developed by this program reach the implementation and dissemination phase, they have the potential to be adopted by a broad range of groups outside of NIOSH.

Progress Towards End Outcomes

As noted for “Intermediate Outcomes,” RDRP’s COPD sub-program on spirometric monitoring of individual declines in lung function has only recently been developed. Owing to the length of time necessary for the development and reliable assessment of deleterious pulmonary function changes, evidence on the efficacy of the recommended practices will take time to be realized. However, this program, despite being in its early phases, has great potential.

What’s Ahead

Overall, this component of the COPD research program is moving from the developmental stage into a testing and evaluation stage. Substantial progress has been made on techniques and strategies for evaluating individual longitudinal declines—their magnitude, reliable assessment, and interpretation. The next stage is to work with stakeholders to evaluate the developed techniques and strategies, to determine their practical efficacy. Once this has been done, and any modifications made, the final task will be to develop guidance materials and disseminate recommendations.

Active plans are underway to share and test RDRP-developed concepts and tools in real-life settings. Towards this end, NIOSH signed an MOU with the Phoenix Fire Department for an intervention study involving spirometry monitoring on about 3,000 firefighters and also with a large construction company, CIANBRO, conducting spirometry monitoring in 6,203 construction workers employed in different companies across U.S. The aim is to develop model monitoring programs with central spirometry quality control and an automated statistical approach for monitoring of data precision, identification of individuals with excessive decline, and targeting preventive interventions.

Intermediate Goal and Objectives Moving Forward

The relevant RDRP intermediate goal is to prevent and reduce work-related COPD. Objectives to accomplish this are:

  • Monitor and evaluate the extent, severity, and characteristics of work-related COPD
  • Elucidate the nature and causes of work-related COPD
  • Develop better tools for identification, evaluation, and prevention of work-related COPD
  • Develop recommendations to prevent work-related COPD