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      Running with Face Masks or Respirators Can Be Detrimental to the Respiratory and Cardiovascular Systems

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            Abstract

            Since the first cases of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were reported at the end of 2019, this infection has spread around the globe, becoming a pandemic. The use of face masks and respirators is an important public health measure to reduce or prevent transmission of SARS-CoV-2. Here we discuss the hypothetical mechanisms by which exercise with face masks or respirators can induce detrimental effects on the cardiovascular system, potentially explaining adverse events such as cardiac arrhythmias and spontaneous pneumothorax. Although sudden death associated with the wearing of a face mask during running is a rare event, the risk is higher especially in those with existing cardiac comorbidities. In such cases, a mask designed specifically for runners with no or few side effects of oxygen deficiency should be considered instead.

            Main article text

            Since the first cases of coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were reported in Wuhan, China, at the end of 2019, this infection has spread around the globe, becoming a pandemic. The use of face masks and respirators is an important public health measure to reduce or prevent transmission of SARS-CoV-2 [1, 2]. Because of people’s arduous efforts in coordinating control of the epidemic, the situation in China and other regions is improving. Medium-risk regions are promoting resumption of production, work, and schools in an orderly manner. When students returned to school, unfortunately, some tragic events have been reported in China. Over the past few months, several students without documented cardiac issues experienced sudden death when they were running in physical training classes with surgical masks or N95 respirators. Although there is no conclusive evidence such as an autopsy result that demonstrates face masks and respirators are the cause of such adverse outcomes, it is potentially dangerous to run or exercise outdoors with a face mask or a respirator.

            There are several potentially harmful side effects of wearing face masks or respirators when running and exercising outdoors. Face masks and respirators lead to less air being inhaled and subsequent breathlessness. Some studies show increases of 120% in inspiratory and expiratory flow resistances when N95 respirators are used, and the air exchange volume was reduced by an average of more than 30% [3]. The mean carbon dioxide levels rise and the mean oxygen levels drop in the breathing space inside face masks and respirators [4]. Furthermore, the exhaled carbon dioxide can accumulate, and can subsequently be inhaled during each respiratory cycle. This increases the frequency and depth of breathing, leading to oxygen deficiency, hypoventilation, and hypoxemia. This process contributes to glucose breakdown and a dangerous rise in lactic acid levels, predisposing individuals, especially runners breathing at a higher rate and needing much more air, to a high risk of sudden death. In addition, it is difficult for individuals to breathe because of high breathing flow resistances and insufficient oxygen. The sympathetic nervous system is stimulated by the shortage of oxygen and the heart rate increases. The interaction between respiration and heart rate variability induces respiratory sinus arrhythmia, which has been used to evaluate the function of the vagus nerve and can affect the prognosis of the cardiovascular system [5]. Although experts argue that such extreme symptoms are unlikely for most people, however, in subsets of individuals with underlying cardiovascular and respiratory disease, or with particularly tightly fitted masks and respirators, the side effects may be exacerbated during exercise such as running [6]. In a study of more than 200 paramedics, approximately 30% reported experiencing headaches when they wore face masks or respirators [7]. N95 and surgical masks can produce unsuitable temperature and humidity in a small space and have an additional effect on the respiratory and circulatory systems; this is also one of the causes of discomfort. Besides, the greater effort of breathing through face masks or respirators during exercise such as running will lead to an elevation of blood pressure, which is associated with an increase in cardiovascular mortality [8].

            In addition, as individuals run, hands are often used to adjust face masks and respirators, which may lead to inadvertent touching and contamination by respiratory droplets. This may increase the transmission of SARS-CoV-2, especially when social distancing measures are being relaxed and the individuals may be asymptomatic carriers of COVID-19.

            Although sudden death associated with wearing of a facemask during running is a rare event, the risk is higher especially in those with existing cardiac comorbidities. In such cases, a mask designed specifically for runners with no or less side effects of oxygen deficiency should be considered instead [9].

            Conflicts of Interest

            The authors declare that they have no competing interests.

            References

            1. , , , , , . Rational use of face masks in the COVID-19 pandemic. Lancet Respir Med 2020;8(5):434–6.

            2. World Health Organization. Coronavirus disease (COVID-19) advice for the public: When and how to use masks. 2020. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/when-and-how-to-use-masks .

            3. , . Objective Assessment of increase in breathing resistance of N95 respirators on human subjects. Ann Occup Hyg 2011;55(8):917–21.

            4. , . Physiologic effects and measurement of carbon dioxide and oxygen levels during qualitative respirator fit testing. J Chem Health Saf 2006;13(5):22–8.

            5. , , , . Gain and coherence estimates between respiration and heart-rate: differences between inspiration and expiration. Auton Neurosci 2013;178(1–2):89–95.

            6. , , , , . Risks of N95 face mask use in subjects with COPD. Respir Care 2020;65(5):658–64.

            7. , , , , , . Headaches and the N95 face-mask amongst healthcare providers. Acta Neurol Scand 2006;113(3):199–202.

            8. , , , , , , et al. Reducing personal exposure to particulate air pollution improves cardiovascular health in patients with coronary heart disease. Environ Health Perspect 2012;120(3):367–72.

            9. , , , . COVID-19: Electrophysiological mechanisms underlying sudden cardiac death during exercise with facemasks. Med Hypotheses. 2020;144:110177. [Cross Ref].

            Author and article information

            Journal
            CVIA
            Cardiovascular Innovations and Applications
            CVIA
            Compuscript (Ireland )
            2009-8782
            2009-8618
            September 2021
            September 2021
            : 6
            : 1
            : 63-65
            Affiliations
            [1] 1Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, 277 Yanta West Road, Xi’an, 710061 Shaanxi, China
            [2] 2Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, China
            Author notes
            Correspondence: Dr. Guoliang Li, Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, 277 Yanta West Road, Xi’an, 710061 Shaanxi, China, E-mail: liguoliang_med@ 123456163.com
            Article
            cvia.2021.0010
            10.15212/CVIA.2021.0010
            26d4c7c1-f353-45fe-af51-a056aa49c9fa
            Copyright © 2021 Cardiovascular Innovations and Applications

            This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 Unported License (CC BY-NC 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc/4.0/.

            History
            : 17 October 2020
            : 14 January 2021
            : 16 February 2021
            Categories
            Short Report

            General medicine,Medicine,Geriatric medicine,Transplantation,Cardiovascular Medicine,Anesthesiology & Pain management
            Running,Face masks,Respiratory system,COVID-19

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