Respiratory Protection in Long Term Care

Regulations; OSHA

In last week’s article, Personal Protective Equipment, Hazard Assessment Standard, and the Hierarchy of Controls (, we discussed Personal Protective Equipment (PPE) and hazard assessments for PPE. Respirators are a specific and more advanced type of PPE and come with a host of regulatory requirements over and above those requirements that apply to other PPE. Most long term care (LTC) centers had no need for respirators before the pandemic because any patients with airborne infectious diseases were transferred and cared for in appropriate and capable alternate facilities. Moving forward, however, respirators and the compliance obligations that come with them are now part of the expected infection control and employee safety programs in most LTC centers. Importantly, OSHA has an entire standard devoted to respirators, the Respiratory Protection Standard (29 CFR 1910.134). While the OSHA standard can be complicated and is highly dependent on the type of hazard and respirator used, the following highlights the basic requirements that affect most LTC centers. 

What is a Respirator? 
Respirators are a broad category of devices worn by an individual to remove contaminates and pathogens from the air inhaled by that individual. They include anything from filtering facepieces, like NIOSH approved N95s, to self-contained breathing apparatus (SCBAs).  

Respirators are different from face masks. Face masks are loose fitting. Although they offer some protection to the wearer from large droplets and splashes, facemasks do not filter small airborne contaminants. Facemasks are also used as source control (protecting residents and co-workers from the user). In contrast, the primary function of a respirator is personal protection (protecting the user from their environment).  

The most commonly used respirator in LTC is a disposable NIOSH approved N95. N95s are tight fitting filtering facepiece respirators. Other types of respirators used in health care settings include reusable elastomeric respirators, which filter through cartridges attached to a rubberized mask, and powered air purifying respirators (PAPRs), which are loose fitting hoods that push filtered air into the hood. 

Who is NIOSH?
OSHA requires all respirators to be certified by the National Institute of Occupational Safety and Health (NIOSH). If a respirator is not NIOSH certified, it is not in compliance with the OSHA standard. NIOSH provides a list of all approved N95 respirator brands and models. “KN95” masks are common in healthcare settings. However, KN95 masks are not certified by NIOSH and do not meet the OSHA standard for respirators. 

Elements of an Effective Respiratory Protection Plan 

Medical Clearance (Questionnaire)  – If an employer requires, or may require, an employee to wear a respirator, that employee’s medical history must first be reviewed by a Physician or other Licensed Healthcare Professional (PLHCP) to determine whether they are medically able to wear that type of respirator. An evaluation can be an examination by the PLHCP, but the most common evaluation method is the PLHCP’s review of OSHA's Appendix C Respirator Medical Evaluation Questionnaire. The PLHCP reviews the questionnaire and makes a determination based on the employee’s answers. This determination is often recorded on a “medical clearance form,” which tells the employer the results of the medical evaluation without the PLHCP disclosing any of the employee’s health information.  

OSHA only requires a single medical clearance before the employee wears the respirator—there is not an annual requirement for medical clearance. But the health care professional evaluating the employee may determine that an annual evaluation is needed. Re-evaluation is also required for employees who have experienced significant changes in health. 

Training – Employees should be trained before wearing a respirator and at least annually thereafter. Training should include the following elements: 
  • General requirements of the OSHA standard 
  • Why a respirator is necessary 
  • Selected Respirator type and limitations 
  • Medical Evaluations 
  • Fit Testing 
  • Proper use 
  • Inspection and care 
  • Emergency use 
  • Medical symptoms that could limit effective use 
  • Donning, doffing, and user seal check 
  • Voluntary use 

Fit Testing – The final step before an employee wears a respirator is the fit test. If there is a break in the seal of the user’s respirator, it will not work, and their protection is compromised. The purpose of a fit test is to “test the fit” of tight-fitting respirators like N95s on the individual’s face to ensure it will function without any break in the seal. There are two basic methods to fit testing, qualitative and quantitative. In qualitative fit testing, the fit tested individual wears a hood and goes through movement exercises to ensure the respirator they’ve selected does not move or break the seal during activity. Qualitative fit testing relies on the respirator user’s sense of taste or smell to detect leakages. A quantitative fit test utilizes a machine that calculates the exact amount of leakage coming from the user’s respirator. Here are the OSHA’s accepted procedures for fit testing Appendix A - Fit Testing Procedures. LTCs commonly use the qualitative Bitrex (Bitter tasting) solution test or the Saccharin (sweet tasting) solution test. Like training, a fit test must be conducted initially and annually thereafter. Employees must also be re-fit tested if they change their respirator model.  

Adherence to the Program (Proper use) – OSHA’s standard also requires employees to properly don, doff, store, and dispose of the respirator. Employees should always perform a user seal check when putting on a respirator. The standard contains separate requirements for when the respirator is used voluntarily, rather than as a required element of the facility’s safety protocol. 

Recordkeeping – Finally, similar to other OSHA requirements, the Respiratory Protection Standard includes requirements to retain written records of medical clearance, training, and fit testing.  

LTC providers should expect respirators and the elements of OSHA’s Respiratory Protection Standard to remain part of the regulatory environment for years to come. Please keep in mind that there are many variables that will affect your respiratory protection plans, including the types of hazard and respirators used, that are not covered by the elements above. It is recommended that LTC operators utilize OSHA’s resources and consider consulting with a competent person or resource to implement and maintain a comprehensive respiratory protection plan in your building.