One of the most common applications for the evaluation of respiratory diseases consists of the assessment of work disability.2 This process, which should be done by a pulmonologist, requires the previous diagnosis of a respiratory disease and the prescription and compliance with optimal treatment. Once these requirements are met, the assessment of work disability consists of successive processes3:

• •

  Evaluation of the degree of deterioration. This is done by measuring how the respiratory disease affects the lung function while at rest. To do so, it is usually necessary to perform spirometry, carbon monoxide diffusion capacity and arterial blood gas tests.

• •

  Evaluation of the disability. This step includes determining the degree of functional limitation (to exercise) that the disease produces. It is necessary to do a cardiorespiratory exercise test and determine peak oxygen consumption.

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  Definition of the handicap. This last step, which is usually done by labor inspection services, establishes whether the functional limitation that the patient presents stops him/her from carrying out occupational activities. A patient with a certain degree of disability is not able to do any work requiring a high level of energy (unloading a truck, for instance) but is able to do less physically demanding jobs (office work, for example).

The pertinent legislation in this area is included in the Royal Decree4 published in January 2000. It establishes the criteria for determining the degree of disability for each system of the organism. Within the occupational assessment, what pulmonologists are usually requested to do is to determine permanent disability.

In 1976, the WHO published the first International Classification of Impairments, Disabilities, and Handicaps (ICIDH), which has later been revised. The last revision is from the year 2000, with a Spanish translation being published in 2001.7 The aim of the ICIDH was to complement the International Statistical Classification of Diseases and Related Health Problems (commonly known as the ICD) to be able to establish a catalog of the consequences of the disease beyond the mere recompilation of what their causes are.

The ICIDH considers the following terms:

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  Impairment refers to abnormalities of the body structure and appearance, as well as that of the function of an organ or system, whatever the cause, although initially impairments represent disorders at the organ level. The ICIDH, in the context of health experience, has defined it as “any loss or abnormality of psychological, physiological or anatomical structure or function”.

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  Disability reflects the consequence of the impairment from the standpoint of functional performance and activity of the individual; disability therefore represents disabilities at the level of the individual. The ICIDH, in the context of health experience, has defined disability as “any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being.”

• •

  Handicap refers to the disadvantages experienced by the individual as a consequence of impairments and disabilities. Thus, handicap reflects an interaction and adaptation of the individual to his/her environment. The ICIDH, in the context of health experience, has defined it as “disadvantage for a given individual, resulting from impairment or a disability that limits or prevents the fulfillment of a role that is normal (depending on age, sex, and social and cultural factors) for that individual.”

With these definitions, it can be seen that the objective of the evaluation is to consider the individual within his/her personal and social situation.

The Spanish Ministry of Employment and Social Affairs (Ministerio de Trabajo y Asuntos Sociales), through the General Secretary of Social Affairs and the Institute for Seniors and Social Services (IMSERSO), published guidelines in the year 2000 which stipulated the procedures and determinations necessary for evaluating disabilities caused by permanent impairments. These guidelines were published in the Official State Bulletin (BOE) n. 22 of 26 January 2000/3355. There is an initial general section that is common for all the impairments, whose main points are the following:

• 1.

  The pathological process that produced the impairment, be it either congenital or acquired, needs to have been previously diagnosed by the competent organisms; the therapeutic measures indicated need to have been applied and should be documented.

• 2.

  The diagnosis of the disease is not an assessment criterion itself. The steps for evaluating disability that are established in the following chapters are based on the severity of the consequences of the disease, whatever it may be.

• 3.

  Permanent impairments are those organic or functional alterations that are not recoverable, meaning that there is no reasonable possibility of restitution or improvement of the structure or function of the affected organ.

• 4.

  Permanent impairments of the different organs or systems are evaluated, whenever possible, with objective parameters and are reflected in the corresponding chapters. However, the assessment is not based on the extent of the impairment but instead on the effect it has on the ability to perform ADL, meaning the degree of disability that the impairment has caused.

Impairments caused by diseases that run their course with exacerbations should be evaluated during intercritical periods. However, the frequency and the duration of the exacerbations are factors to keep in mind due to the interferences produced when performing ADL. In order to evaluate the consequences of this type of disease, the corresponding chapters include criteria for the frequency and duration of the acute phases.

The evaluation should respond to homogenous criteria. With this aim, the ADL as well as the degrees of disability are defined for their use by assessment teams; these are shown in Tables 1 and 2.

Both the degrees of disability and the ADL described constitute reference patterns for assigning the percentage of disability. This percentage is determined in agreement with the criteria and the types that are specified for each system, as the legislation considers them separately. Five general categories are established (Table 3).

When one person has two or more coexisting impairments— included in classes II–V —the percentages are combined by using a table of specific values (not merely a sum), as it is considered that the consequences of these impairments together can be stronger, producing greater interference in performing ADL and, therefore, a degree of disability higher than what is caused by each separately. The percentages obtained for impairments from different systems are combined, unless otherwise specified. When there are impairments that affect different organs of a same system, the criteria for determining under which circumstances the percentages should be combined are included in the corresponding chapters.

Most of the criteria described here have been adapted from the ATS criteria.8 We provide the criteria for assessing disabilities produced by respiratory tract impairments as considered from the standpoint of the alteration in lung function and, in most cases, quantifiable with objective tests.9

• 1.

  The only respiratory disease patients who will be assessed are those who have chronic diseases considered to be non-recoverable in function, with a clinical course of no less than 6 months since the diagnosis and start of treatment.

• 2.

  The assessment of the impairment is based on the result of objective lung function tests (spirometry, carbon monoxide diffusion capacity and exercise capacity), complemented with clinical criteria. Transitory functional alterations that are either spontaneously reversible or reversible with treatment should not be considered.

• 3.

  In clinical stages that, as a consequence of exacerbative phases, may experience an increase in respiratory dysfunction, a new evaluation should not be repeated until the situation has stabilized.

  When the respiratory disease runs its course with exacerbations, the evaluation of the disability that may be produced is done during intercritical periods. For the evaluation of these situations, a criterion of temporality has been introduced according to the frequency and duration of the episodes, and said episodes should be documented medically.

• 4.

  The rules and criteria for the assessment of persons who have diseases that, due to their characteristics, require being considered differently than other respiratory tract pathologies are contemplated in the section “Criteria for the assessment of specific situations”.

• 5.

  If the respiratory affectation is part of a pathologic entity with manifestations in other organs and systems, the disability percentages corresponding to all the affected parts are combined.

Table 4 demonstrates the criteria for assigning the percentage of disability depending on respiratory function limitations.

The actions that SEPAR may propose to include the following:

• 1.

  Diffusion among its members the legal criteria for disability as well as the way to assess them with initiatives such as workshops or courses to teach how to do functional assessments.

• 2.

  Propose the inclusion of a series of determinations that are not currently contemplated, which in interstitial diseases can be representative of the degree of affectation, such as imaging techniques, pulse-oximetry during exercise or the determination of static lung volumes.

• 3.

  Validate the spirometry cut-points with other global (multidimensional) parameters that are more representative and have a greater relationship with quality of life and mortality, probably by means of multicenter studies or data analyses from large cohorts of patients with COPD that are being carried out by the different SEPAR workgroups (COPD Area, etc.).

• 4.

  Include radiographic parameters that can be useful in cases of interstitial disease or emphysema that are not currently contemplated.

• 5.

  Attempt to define for each specific disease the best parameters that reflect the deterioration of a patient, separating COPD from the general group.