Respiratory System

• Author: Thomas E. Bush/David A. Morton III/David Traver/Sarah H. Bohr/Curtis J. Fisher/Kimberly V. Cheiken
• Pages: 134-213

3-134

Chapter 3

Respiratory System

Part I – Adults

§3.00 Respiratory System

§3.01 Category of Impairments, Respiratory System

§3.02 Chronic Pulmonary Insufficiency

§3.03 Asthma

§3.04 Cystic Fibrosis

§3.05 (Reserved)

§3.06 Pneumoconiosis

§3.07 Bronchiectasis

§3.08 Mycobacterial, Mycotic, and Other Chronic Persistent Infections of the Lung

§3.09 Cor Pulmonale

§3.10 Sleep-Related Breathing Disorders

§3.11 Lung Transplant

Part II – Children

§103.00 Respiratory System

§103.01 Category of Impairments, Respiratory System

§103.02 Chronic Pulmonary Insufficiency

§103.03 Asthma

§103.04 Cystic Fibrosis

§103.05 Lung Transplant

Part III – Forms

§3.02F Chronic Pulmonary Insufficiency

§3.03F Asthma

§3.04F Cystic Fibrosis

§3.07F Bronchiectasis

§3.08F Chronic Persistent Lung Infection

§3.09F Cor Pulmonale Secondary to Chronic Pulmonary Vascular Hypertension

§3.10F Sleep-Related Breathing Disorders

§3.11F Lung Transplant

Long Forms on Digital Access Only

§3.02F(L) Chronic Pulmonary Insufficiency

§3.03F(L) Asthma

§3.04F(L) Cystic Fibrosis

§3.07F(L) Bronchiectasis

§3.08F(L) Chronic Persistent Lung Infection

§3.09F(L) Cor Pulmonale Secondary to Chronic Pulmonary Vascular Hypertension

§3.10F(L) Sleep-Related Breathing Disorders

§3.11F(L) Lung Transplant

135 RESPIRATORY SYSTEM §3.00

Form Reference:

See Forms 3.02, 3.03, 3.04, 3.07, 3.08, 3.09, 3.10, 3.11 to solicit

treating source medical information relevant to the above adult and

corresponding child listings.

General Legal Text Cross-References:

Also see Bohr’s Social Security Issues Annotated (James Pub-

lishing), §318, regarding specific court cases involving respiratory

impairments.

Part I – Adults

§3.00 Respiratory System

[The applicable Listing of Impairments introduces each chapter

and is typeset in Helvetica. Author comments follow each Listing

subsection and are typeset in Times.]

SSA Listing of Impairments

A. Introduction. The listings in this section describe impairments re-

sulting from respiratory disorders based on symptoms, physical signs,

laboratory test abnormalities, and response to a regimen of treatment

prescribed by a treating source. Respiratory disorders along with any

associated impairment(s) must be established by medical evidence.

Evidence must be provided in sufficient detail to permit an indepen-

dent reviewer to evaluate the severity of the impairment.

Many individuals, especially those who have listing-level im-

pairments, will have received the benefit of medically prescribed

treatment. Whenever there is evidence of such treatment, the lon-

gitudinal clinical record must include a description of the treatment

prescribed by the treating source and response in addition to informa-

tion 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. Even if an indi-

vidual does not show that his or her impairment meets the criteria of

these listings, the individual may have an impairment(s) equivalent

in severity to one of the listed impairments or be disabled because

of a limited residual functional capacity. Unless the claim can be

decided favorably on the basis of the current evidence, a longitudinal

record is still important because it will provide information about

such things as the ongoing medical severity of the impairment, the

level of the individual’s functioning, and the frequency, severity, and

duration of symptoms. Also, the asthma listing specifically includes

a requirement for continuing signs and symptoms despite a regimen

of prescribed treatment.

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 exertion1, cough, wheezing, sputum

production, hemoptysis2, and chest pain. Because these symptoms

are common to many other diseases, a thorough medical history,

physical examination, and chest x-ray or other appropriate imag-

ing technique are required to establish chronic pulmonary disease.3

Pulmonary function testing is required to assess the severity of the

respiratory impairment once a disease process is established by ap-

propriate clinical and laboratory findings.

Alterations of pulmonary function can be due to obstructive

airway disease (e.g., emphysema, chronic bronchitis, asthma), re-

strictive pulmonary disorders with primary loss of lung volume (e.g.,

pulmonary resection4, thoracoplasty5, chest cage deformity as in ky-

phoscoliosis6 or obesity), or infiltrative interstitial disorders (e.g.,

diffuse pulmonary fibrosis). Gas exchange abnormalities without sig-

nificant airway obstruction can be produced by interstitial disorders.

Disorders involving the pulmonary circulation (e.g., primary pulmo-

nary hypertension7, recurrent thromboembolic disease8, primary or

secondary pulmonary vasculitis9) can produce pulmonary vascular

hypertension and, eventually, pulmonary heart disease (cor pulmo-

nale) and right heart failure.10 Persistent hypoxemia11 produced by

any chronic pulmonary disorder also can result in chronic pulmonary

hypertension and right heart failure. Chronic infection, caused most

frequently by mycobacterial12 or mycotic13 organisms, can produce

1 Dyspnea on exertion means shortness of breath on exertion. The abbreviation DOE is commonly seen on medical records.

2 Hemoptysis means coughing up blood.

3 Other appropriate techniques might be computerized tomographic (CT) scans, magnetic resonance imaging (MRI) scans, radionuclide scans, or ultrasonic

scans.

4 Pulmonary resection means surgical removal of lung tissue. A lobectomy is the most common form of pulmonary resection, and involves removal of a

major division (lobe) of the right or left lung. Pneumonectomy usually means removal of an entire right or left lung, but could be used to just mean the resection

of lung tissue in any amount. Some surgeons refer to a partial pneumonectomy for resection procedures that are less extensive than a total pneumonectomy.

5 Thoracoplasty refers to surgical reconstruction of part of the chest wall, which would usually involve removal of one or more ribs. An obsolete, pre-an-

tibiotic era, surgical procedure was rib thoracoplasty for the purposes of letting part of a tuberculous lung collapse in upon itself. One, more current use of rib

thoracoplasty involves removal of some ribs to correct a deforming rib bulge caused by scoliosis. (Scoliosis, a common abnormal sideways spinal curvature,

can cause distortion of the chest wall.) In other instances, thoracoplasty may be needed as a part of surgical procedures to resect cancer of the chest wall.

6 Kyphoscoliosis is a combination of kyphosis and scoliosis.

7 Pulmonary hypertension refers to high blood pressure in the vascular system of the lungs. If it is primary, the disorder originates in the pulmonary vascular

system itself. Secondary pulmonary hypertension results from other disorders, especially some forms of heart disease that overload the lung blood vessels with

abnormally increased blood flow.

8 Thrombi are blood clots. Formation of a thrombus is normal when it occurs as a response of the body’s coagulation system to stop bleeding. But clots that

form inside blood vessels are abnormal and almost always arise in the venous system, especially deep veins in the legs. An embolus means the movement of

any type of material in the bloodstream (e.g., air, fat, thrombi). Pulmonary thromboemboli are blood clots that move to the right side of the heart, usually from

the legs, then are pumped into the lung’s arterial system.

9 Vasculitis refers to arterial inflammation; it can occur as a result of autoimmune disorders, infections, or toxins. If the vasculitis arises in the pulmonary

arterial system, it is primary; if associated with some other disorder, it is secondary.

10 Cor pulmonale is heart disease caused by lung disease, and can result in heart failure when the right side of the heart cannot adequately pump blood

through the vascular system of the lungs.

11 Hypoxemia refers to a condition of decreased arterial blood oxygenation.

12 Mycobacterial infections are considered in listing 3.08.

13 Mycotic infections are considered in listing 3.08.

§3.00 SOCIAL SECURITY DISABILITY COLLECTION 136

extensive and progressive lung destruction resulting in marked loss

of pulmonary function. Some disorders, such as bronchiectasis14,

cystic fibrosis15, and asthma, can be associated with intermittent

exacerbations of such frequency and intensity that they produce a

disabling impairment, even when pulmonary function during periods

of relative clinical stability is relatively well-maintained.

Respiratory impairments usually can be evaluated under these

listings on the basis of a complete medical history, physical ex-

amination, 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 cyanosis16 or secondary

polycythemia17, an impairment may be underestimated on the basis

of spirometry alone. More sophisticated pulmonary function testing

may then be necessary to determine if gas exchange abnormalities

contribute to the severity of a respiratory impairment. Additional

testing might include measurement of diffusing capacity of the lungs

for carbon monoxide or resting arterial blood gases. Measurement

of arterial blood gases during exercise is required infrequently. In

disorders of the pulmonary circulation, right heart catheterization

with angiography and/or direct measurement of pulmonary artery

pressure may have been done to establish a diagnosis and evaluate

severity. When performed, the results of the procedure should be

obtained. Cardiac catheterization will not be purchased.

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 impair-

ment 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 combina-

tion of impairments is medically equivalent in severity to a listed

impairment. Individuals who have an impairment(s) with a level of

severity which does not meet or equal the criteria of the listings may

or may not have the residual functional capacity (RFC) which would

enable them to engage in substantial gainful activity. Evaluation of

the impairment(s) of these individuals will proceed through the final

steps of the sequential evaluation process.

B. Mycobacterial, mycotic, and other chronic persistent infec-

tions 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 lesions18,

or cavitation19, is not, by itself, a basis for determining that an in-

dividual has a disabling impairment expected to last 12 months. In

those unusual cases of pulmonary infection that persist for a period

approaching 12 consecutive months, the clinical findings, compli-

cations, therapeutic considerations, and prognosis must be carefully

assessed to determine whether, despite relatively well-maintained

pulmonary function, the individual nevertheless has an impairment

that is expected to last for at least 12 consecutive months and prevent

gainful activity.

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 frequen-

cy and intensity of episodes that occur despite prescribed treatment

are often the major criteria for determining the level of impairment.

Documentation for these exacerbations should include available hos-

pital, emergency facility and/or physician records indicating the dates

of treatment; clinical and laboratory findings on presentation, such

as the results of spirometry and arterial blood gas studies (ABGS);

the treatment administered; the time period required for treatment;

and the clinical response.20 Attacks of asthma, episodes of bronchitis

or pneumonia or hemoptysis (more than blood-streaked sputum), or

respiratory failure as referred to in paragraph B13621 of listings 3.03,

3.04, and 3.07, are defined as prolonged symptomatic episodes

lasting one or more days and requiring intensive treatment, such as

intravenous bronchodilator or antibiotic administration or prolonged

inhalational bronchodilator therapy in a hospital, emergency room or

equivalent setting. Hospital admissions are defined as inpatient hospi-

talizations for longer than 24 hours. The medical evidence must also

include information documenting adherence to a prescribed regimen

of treatment as well as a description of physical signs. For asthma, the

medical evidence should include spirometric results obtained between

attacks that document the presence of baseline airflow obstruction.22

D. Cystic fibrosis is a disorder that affects either the respirato-

ry 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 so-

dium concentration or chloride concentration accompanied by one

or more of the following: the presence of chronic obstructive pul-

monary disease, insufficiency of exocrine pancreatic function23,

meconium ileus24, or a positive family history. The quantitative pi-

locarpine iontophoresis procedure for collection of sweat content

14 Bronchiectasis is a chronic bronchial infection considered in listing 3.07.

15 Cystic fibrosis (CF) is a genetic disorder that results in a glandular secretory defect which can affect the mucous glands in the bronchi as well as pancreatic

enzyme secretions. Recurrent lung infection is a major problem. CF is considered in listing 3.04.

16 Cyanosis is a bluish discoloration of tissues, such as skin and mucous membranes of the mouth, resulting from inadequate arterial oxygenation.

17 Secondary polycythemia refers to an abnormal increase in red blood cell, as the body’s bone marrow attempts to compensate for hypoxemia by creating

more red cells to carry oxygen.

18 Reference is made here to abnormalities in the spongy part of the lung that allows oxygen to pass into the bloodstream, in contrast to the bronchi that carry air.

19 Some disorders, such as tuberculosis and fungal infections, can produce infected spaces where normal lung tissue has been destroyed. Even if the infection

is cured, the cavity will remain and that part of the lung will remain non-functional. Disability will depend on the size and number of cavities, whether there

is active infection, and the patient’s symptoms.

20 Arterial blood gas studies (ABGS) include measurement of the pressure of oxygen and carbon dioxide in arterial blood, as well as acidity.

21 The SSA calls the various parts of a listing “paragraphs.” Perhaps this decision was to avoid confusion with various parts of federal regulations, e.g., Parts 404, 416, etc.

However, in a book like this with its added and various explanatory text paragraphs, use of the word “paragraphs” for parts of listings would be worse in regard to potential

confusion. Therefore, this book uses the word “part” for the various parts of listings. However, where the source of text is federal, the word “paragraph” has been retained.

22 If a claimant has chronic obstructive pulmonary disease (see §3.02.1.a) secondary to asthma, then there should be a persistent abnormality in air flow that

is documented as present between episodes of exacerbation.

23 The exocrine glands of the pancreas secrete enzymes that are released into the small intestine for the digestion of food.

24 Meconium refers to material in the newborn’s intestine. Meconium is a greenish-black substance consisting of dead cells, secretions from the infant’s

intestine, and the fine hair (lanugo) that covers the developing embryo that is swallowed by the fetus along with amniotic fluid. Meconium is normal and

accumulates in the last part of the small intestine (ileum) because the developing fetus does not have the enzymes to digest it. Normally, the meconium will be

passed within two days after birth. In CF, about 10% of infants retain the meconium—a condition known as meconium ileus. Intestinal obstruction can then

result from inability to pass the meconium. Inability to pass the meconium in CF is related to the fact that the meconium tends to become inspissated (dried).

The meconium consequently obstructs the movement of normal digestive products after birth, and this causes distention (enlargement) of the abdomen and

vomiting. X rays characteristically show dilated loops of intestine with a “ground-glass” appearance.