This proposed change would only impact filtering facepiece respirators (FFRs) and loose-fitting powered air-purifying respirators (PAPRs).
OSHA is proposing an update to the Respiratory Protection Standard to amend the medical evaluation requirements specified in paragraph (e) where an employee is required to wear either a filtering facepiece respirator (FFR) or loose-fitting powered air-purifying respirator (PAPR) and seeks comment on all aspects of this proposal. Using a respirator may place a physiological burden on employees that varies with the type of respirator worn, the job, and workplace conditions in which the respirator is used, and the medical status of the employee. OSHA has preliminarily determined this burden differs based on the type of respirator worn and therefore proposes an amendment to the medical evaluation requirements of the standard for FFRs and loose-fitting PAPRs.
In the 1998 final rule (63 FR 1210), OSHA determined that there existed “the potential for adverse health effects resulting from respirator use, even for healthy employees using respirators designed for low breathing resistance and used for short durations.” OSHA also found that “respirator use would impose a substantial risk of material impairment to the health of employees who have preexisting respiratory and cardiovascular impairments.” Based on the results of studies in the record as well as the comments received, OSHA determined “the use of any respirator requires a prior medical evaluation to determine fitness.”
OSHA now believes that the requirement for medical evaluations before the use of any type of respirator is too broad in practice, specifically with respect to the use of FFRs and loose-fitting PAPRs.
Lack of Data Showing Material Impairment Avoided by Medical Evaluations
i. Lack of large-scale epidemiological studies.
The use of medical evaluations in respiratory protection programs as a prospective measure to avoid adverse health outcomes remains a well-accepted best practice. However, the agency is not aware of any epidemiological studies that evaluate their efficacy for FFRs and loose-fitting PAPRs.
Many workers currently use FFRs and loose-fitting PAPRs without medical evaluations. For instance, NIOSH found that in the immediate wake of the publishing of the 1998 Respiratory Protection Standard 51.2% of an estimated 281,776 establishments may not have performed medical evaluations to determine fitness for wearing a respirator (Doney et al., 2005). A 2015 study (Brousseau et al., 2015) reported that 14% of hospital workers in Illinois and 23% in Minnesota did not receive a medical evaluation. Medical evaluations are likely far less prevalent in many industries with smaller and more dispersed workforces. For instance, workers in hog farms commonly wear respirators, predominantly N95s, when performing some tasks, but are generally not subject to the Respiratory Protection Standard and are likely not following it (Gibbs et al., 2020). The agency knows of no data related to these worker populations showing that the lack of medical evaluations is causing adverse health effects. OSHA requests comment on the extent to which medical evaluations are effective at preventing adverse health outcomes resulting from the use of FFRs and loose-fitting PAPRs.
ii. Despite large increases in respirator usage after the emergence of COVID-19, no evidence has surfaced illustrating the need for medical evaluations for FFR and PAPR usage.
FFR and PAPR usage increased immensely after the emergence of COVID-19. Workers across industries performing a wide variety of tasks were suddenly wearing these respirators, often for their entire shifts every work day. Despite this sudden increase and widespread usage of these respirators, often without a medical evaluation, the agency is not aware of any data identifying adverse outcomes from individuals with underlying medical conditions during the COVID-19 pandemic. OSHA requests comment on the extent to which workers have worn FFRs and loose-fitting PAPRs without medical evaluations since the emergence of COVID-19 in 2020.
With this lack of data about medical evaluation efficacy for FFRs and loose-fitting PAPRs, it is difficult to reaffirm that medical evaluations are either necessary or appropriate for preventing adverse health outcomes.
iii. Few workers are refused respirators.
As noted earlier, the data reported in the final rule for Respiratory Protection (29 CFR 1910.134) found that 2% or fewer workers did not pass the medical evaluation. That proportion appears to be fairly consistent with more recent studies. A 1999 study (Pappas et al.) found that out of 5,569 workers who had a medical evaluation only 1.3% had limitations placed upon their work and 0.2% were denied use. Pregnancy was the reason for denial and the researchers found that physical examination and spirometry added nothing to the analysis. A 2017 study (Desai et al.) found that only 1.48% of 337 subjects who passed the medical questionnaire evaluation failed the spirometry test under the American Thoracic Society criteria. In a survey of 35 clinics or clinic groups, Harber et al. (2025) found that nearly all workers were approved without restrictions and it was considered very unusual to decline approval.
In practice, few workers have their respirator use limited. Additionally, we currently have no ability to estimate, to the agency’s knowledge, how many adverse events are being avoided by restricting the use of FFRs and PAPRs by workers. As such, it is difficult to ascertain whether there is material impairment in these scenarios if a worker who should be restricted is permitted to use a respirator. OSHA requests comment on how many adverse events are being avoided by restricting the use of FFRs and PAPRs by workers.
iv. Workers are able to respond quickly when symptoms arise.
In the apparently rare circumstance that a worker develops symptoms from wearing an FFR or loose-fitting PAPR, these scenarios are not Immediately Dangerous to Life or Health (IDLH) situations. This is so because FFRs and loose fitting PAPRs are not permitted to protect employees in IDLH environments. Therefore, the worker should be able to seek safety with an exposure well below expected thresholds for adverse health outcomes. This is in contrast to other respirators—(
e.g., self-contained breathing apparatus (SCBA)— that would be required in more dangerous exposure environments.
v. Available data on effects largely shows minimal impact on health.
As noted in the original rule (63 FR 1152-1300), self-contained breathing apparatus (SCBA) respirators require a great deal of exertion given the weight of that apparatus. However, the body of literature does largely agree that any physiological effects from wearing much lighter FFRs and PAPRs are minimal during low to moderate exertion. In studies assessing cardiovascular parameters, FFRs and PAPRs did not significantly impact health in low to moderate exercise scenarios that would be typical of the vast majority of workplaces (Epstein et al., 2020; Anil et al., 2023). Similarly, Rothstein et al. studied 42 individuals who did not have a history of claustrophobia or metabolic disease and found that individuals who wore N-95 respirators displayed minor changes in respiratory and metabolic effects, but those “physiological parameters remained within normal ranges at rest and would not impact daily functioning” (Rothstein et al., 2025). A limitation on these studies is that they are performed on populations that screen out unhealthy individuals (e.g., smokers, known cardiovascular issues), but one would surmise that changes in physiological parameters would be observable even in healthy individuals and this does not seem to be the case. It is reasonable to assume that work that requires high exertion could impact the health of a wearer, but that high exertion work likely self-selects for individuals who would be medically fit to wear an FFR or a PAPR.
The 1998 final rule also noted some concern about non-physiological impacts, specifically noting claustrophobia. A more recent look into the evidence found that the notion of large numbers of workers experiencing claustrophobia is unfounded (Harber and Beckett, 2023). In a letter to the editor, McClellan (2020) found that full-shift work using an FFR could cause issues, such as psychological stresses, that result in the wearer feeling compelled to remove their respirator in potentially unsafe situations. While psychological stressors have been observed and can induce physiological impairment, the agency is unable to adequately qualify the degree to which this occurs in the affected workplaces. And, as noted above, if a worker wearing an FFR or loose fitting PAPR had to remove their respirator due to psychological distress, the worker would necessarily not be exposed to an IDLH atmosphere but would rather be able to seek safety with an exposure well below expected thresholds for adverse health outcomes.
Conclusion
The agency preliminarily concludes that there is not sufficient evidence to conclude that wearing FFRs and loose fitting PAPRs without a prior medical evaluation can result in unavoidable adverse outcomes, and that the assumption that medical evaluation effectively detects risk for adverse effects from the occupational use of FFRs and loose fitting PAPRs is unproven.