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      Physiologic and other effects and compliance with long-term respirator use among medical intensive care unit nurses


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          Long-term use of respiratory protection may be necessary, but compliance may be low, and physiologic effects have not been well evaluated.


          Ten nurses participated; physiologic effects, subjective symptoms, and compliance with wearing an N95 alone or with a surgical mask overlay were assessed. Longitudinal analysis based on multivariate linear regression models assessed changes in outcome variables (CO 2, O 2, heart rate, perceived comfort items, compliance measures, and others). Analyses compared changes over time, and compared wearing only an N95 to wearing an N95 with a surgical mask overlay.


          Most nurses (90%, n = 9) tolerated wearing respiratory protection for two 12-hour shifts. CO 2 levels increased significantly compared with baseline measures, especially when comparing an N95 with a surgical mask to only an N95, but changes were not clinically relevant. Perceived exertion; perceived shortness of air; and complaints of headache, lightheadedness, and difficulty communicating also increased over time. Almost one-quarter (22%) of respirator removals were due to reported discomfort. N95 adjustments increased over time, but other compliance measures did not vary by time. Compliance increased on day 2, except for adjustments, touching under the N95, and eye touches.


          Long-term use of respiratory protection did not result in any clinically relevant physiologic burden for health care personnel, although many subjective symptoms were reported. N95 compliance was fairly high.

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          Most cited references12

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          Headaches and the N95 face‐mask amongst healthcare providers

          Background:  During the 2003 severe acute respiratory distress syndrome epidemic, healthcare workers mandatorily wore the protective N95 face‐mask. Methods:  We administered a survey to healthcare workers to determine risk factors associated with development of headaches (frequency, headache subtypes and duration of face‐mask wear) and the impact of headaches (sick days, headache frequency and use of abortive/preventive headache medications). Results:  In the survey, 212 (47 male, 165 female) healthcare workers of mean age 31 years (range, 21–58) participated. Of the 79 (37.3%) respondents who reported face‐mask‐associated headaches, 26 (32.9%) reported headache frequency exceeding six times per month. Six (7.6%) had taken sick leave from March 2003 to June 2004 (mean 2 days; range 1–4 days) and 47 (59.5%) required use of abortive analgesics because of headache. Four (2.1%) took preventive medications for headaches during this period. Multivariate logistic regression showed that pre‐existing headaches [P = 0.041, OR = 1.97 (95% CI 1.03–3.77)] and continuous use of the N95 face‐mask exceeding 4 h [P = 0.053, OR = 1.85 (95% CI 0.99–3.43)] were associated with development of headaches. Conclusions:  Healthcare providers may develop headaches following the use of the N95 face‐mask. Shorter duration of face‐mask wear may reduce the frequency and severity of these headaches.
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            Physiological impact of the N95 filtering facepiece respirator on healthcare workers.

            To assess the physiological impact of the N95 filtering facepiece respirator (FFR) on healthcare workers. Ten healthcare workers each conducted multiple 1-hour treadmill walking sessions, at 1.7 miles/h, and at 2.5 miles/h, while wearing FFR with exhalation valve, FFR without exhalation valve, and without FFR (control session). We monitored heart rate, respiratory rate, tidal volume, minute volume, blood oxygen saturation, and transcutaneously measured P(CO2). We also measured user comfort and exertion, FFR moisture retention, and the carbon dioxide and oxygen concentrations in the FFR's dead space. There were no significant differences between FFR and control in the physiological variables, exertion scores, or comfort scores. There was no significant difference in moisture retention between FFR with and without exhalation valve. Two subjects had peak P(CO2) > or = 50 mm Hg. The FFR with exhalation valve offered no benefit in physiological burden over the FFR without valve. The FFR dead-space oxygen and carbon dioxide levels did not meet the Occupational Safety and Health Administration's ambient workplace standards. In healthy healthcare workers, FFR did not impose any important physiological burden during 1 hour of use, at realistic clinical work rates, but the FFR dead-space carbon dioxide and oxygen levels were significantly above and below, respectively, the ambient workplace standards, and elevated P(CO2) is a possibility. Exhalation valve did not significantly ameliorate the FFR's P(CO2) impact.
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              Surgical mask placement over N95 filtering facepiece respirators: physiological effects on healthcare workers.

              Filtering facepiece respirators ('N95 Masks') may be in short supply during large-scale infectious outbreaks. Suggestions have been made to extend their useful life by using a surgical mask as an outer barrier, but the physiological impact of this added barrier upon the wearer has not been studied. A surgical mask was worn over an N95 filtering facepiece respirator by 10 healthcare workers for 1 h at each of two work rates. Heart rate, respiratory rate, tidal volume, minute volume, oxygen saturation, transcutaneous carbon dioxide levels and respirator dead space gases were monitored and compared with controls (N95 filtering facepiece respirator without a surgical mask). Subjective perceptions of exertion and comfort were assessed by numerical rating scales. There were no significant differences in physiological variables between those who used surgical masks and controls. Surgical masks decreased dead space oxygen concentrations of the filtering facepiece respirators at the lesser work rate (P = 0.03) and for filtering facepiece respirators with an exhalation valve at the higher work rate (P = 0.003). Respirator dead space oxygen and carbon dioxide levels were not harmonious with Occupational Safety and Health Administration workplace ambient atmosphere standards. Exertion and comfort scores were not significantly impacted by the surgical mask. Use of a surgical mask as an outer barrier over N95 filtering facepiece respirators does not significantly impact the physiological burden or perceptions of comfort and exertion by the wearer over that experienced without use of a surgical mask.

                Author and article information

                Am J Infect Control
                Am J Infect Control
                American Journal of Infection Control
                Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc.
                12 June 2013
                December 2013
                12 June 2013
                : 41
                : 12
                : 1218-1223
                [a ]Institute of Biosecurity, Saint Louis University, School of Public Health, St Louis, MO
                [b ]School of Medicine, University of Louisville, Louisville, KY
                [c ]Department of Biostatistics, Saint Louis University School of Public Health, St Louis, MO
                Author notes
                []Address correspondence to Terri Rebmann, PhD, RN, CIC, Associate Professor, Institute for Biosecurity, Saint Louis University School of Public Health, 3545 Lafayette Avenue, Room 463, Saint Louis, MO 63104. rebmannt@ 123456slu.edu
                Copyright © 2013 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.


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