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“You can leave your mask on”: effects on cardiopulmonary parameters of different airway protection masks at rest and during maximal exercise
Abstract
Background
During the COVID-19 pandemic, the use of protection masks is essential to reduce contagions. However, public opinion reports an associated subjective shortness of breath. We evaluated cardiorespiratory parameters at rest and during maximal exertion to highlight any differences with the use of protection masks.
Methods
Twelve healthy subjects underwent three cardiopulmonary exercise tests: without wearing protection mask, with surgical and with FFP2 mask. Dyspnea was assessed by Borg Scale. Standard pulmonary function tests were also performed.
Results
All the subjects (40.8±12.4 years; 6 males) completed the protocol with no adverse event. At spirometry, from no mask to surgical to FFP2, a progressive reduction of FEV 1 and FVC was observed (3.94±0.91 l, 3.23±0.81 l, 2.94±0.98 l and 4.70±1.21 l, 3.77±1.02 l, 3.52±1.21 l, respectively, p<0.001). Rest ventilation, O 2 uptake (V̇O 2 ) and CO 2 production (VCO 2 ) were progressively lower with a reduction of respiratory rate. At peak exercise, subjects revealed a progressively higher Borg scale when wearing surgical and FFP2. Accordingly, at peak exercise, V̇O 2 (31.0±23.4, 27.5±6.9, 28.2±8.8 ml/kg/min, p=0.001), ventilation (92±26, 76±22, 72±21 l, p=0.003), respiratory rate (42±8, 38±5, 37±4, p=0.04) and tidal volume (2.28±0.72, 2.05±0.60, 1.96±0.65 l, p=0.001) were gradually lower. We did not observed a significant difference in oxygen saturation.
Conclusions
Protection masks are associated with significant but modest worsening of spirometry and cardiorespiratory parameters at rest and peak exercise. The effect is driven by a ventilation reduction due to an increased airflow resistance. However, since exercise ventilatory limitation is far from being reached, their use is safe even during maximal exercise, with a slight reduction in performance.
... In most studies, during cardiopulmonary exercise test (CPET), the face mask was worn underneath the silicone mask required for CPET, which has been discussed as influencing factor [4][5][6][7]13 . Additionally, measurements were predominantly performed on young, well-trained people 10,14,[20][21][22] and none of the preceding studies was blinded with respect to the type of mask to be worn by the subjects or focused on breathing physiology or breathing mechanics. ...
... The study participants covered a wide a range of age, fitness, and some common diseases. Subjects in other studies were younger and, in general, only well-trained subjects were examined 14,[20][21][22] . The PWC 130 in our study was similar for both sex, reflecting moderate to well-trained subjects 36 . ...
... Table 4. www.nature.com/scientificreports/ recreational sport activities with sometimes very high workloads 14,[20][21][22] . As a result, the biological variability of our measurement data was reduced. ...
The use of face masks became mandatory during SARS-CoV-2 pandemic. Wearing masks may lead to complaints about laboured breathing and stress. The influence of different masks on cardiopulmonary performance was investigated in a partially double-blinded randomized cross-over design. Forty subjects (19–65 years) underwent body plethysmography, ergometry, cardiopulmonary exercise test and a 4-h wearing period without a mask, with a surgical mask (SM), a community mask (CM), and an FFP2 respirator (FFP2). Cardiopulmonary, physical, capnometric, and blood gas related parameters were recorded. Breathing resistance and work of breathing were significantly increased while wearing a mask. During exercise the increase in minute ventilation tended to be lower and breathing time was significantly longer with mask than without mask. Wearing a mask caused significant minimal decreases in blood oxygen pressure, oxygen saturation, an initial increase in blood and inspiratory carbon dioxide pressure, and a higher perceived physical exertion and temperature and humidity behind the mask under very heavy exercise. All effects were stronger when wearing an FFP2. Wearing face masks at rest and under exercise, changed breathing patterns in the sense of physiological compensation without representing a health risk. Wearing a mask for 4-h during light work had no effect on blood gases.
... increase in breathing resistance (53,59,66,67,83 changes in microbial metabolism (lower gut and oral) (26,77). ...
... The effect size for O 2 uptake disturbance (as per SpO 2 outcome) is relatively smaller but highly significant (p = 0.0004; Figures 2A, B, 9A). Such respiratory gas-exchange discrepancy can be attributed to the constantly increased dead space ventilation volume (14,60,65,103,104) (i.e., continuous rebreathing from the masks dead space volume) and breathing resistance (14,53,59,66,67,83). Continuous CO 2 rebreathing causes the right-shift of hemoglobin-O 2 saturation curve. ...
... increase in heart rate(26,52, 56,57,60,61,67,68, 72,81,83,94,100,101).decrease in cardiopulmonary capacity(53,59,62).changes in respiratory rate(52-54, 56, 59, 60, 62, 68, 79, 81, 100).shortness of breath and difficulty breathing(47, 52-54, 58, 68, 69, 73, 79, 81, 83, 86, 87, 92, 94). headache (54, 63, 73, 78, 82, 84, 89, 92-95). ...
Background: As face masks became mandatory in most countries during the COVID-19 pandemic, adverse effects require substantiated investigation.
Methods: A systematic review of 2168 studies on adverse medical mask effects yielded 54 publications for synthesis and 37 studies for meta-analysis (on n=8641, m=2482, f=6159, age=34.8±12.5). The median trial duration was only 18 min (IQR=50) for our comprehensive evaluation of mask induced physio-metabolic and clinical outcomes.
Results: We found significant effects in both medical surgical and N95 masks, with a greater impact of the second. These effects included decreased SpO2 (overall Standard Mean Difference, SMD= -0.24, 95%CI= -0.38 to -0.11, p<0.001) and minute ventilation (SMD= -0.72, 95%CI=- 0.99 to -0.46, p<0.001), simultaneous increased in blood-CO2 (SMD= +0.64, 95%CI= 0.31–0.96, p<0.001), heart rate (N95: SMD= +0.22, 95%CI= 0.03–0.41, p=0.02), systolic blood pressure (surgical: SMD= +0.21, 95%CI= 0.03–0.39, p=0.02), skin temperature (overall SMD= +0.80 95%CI 0.23–1.38, p=0.006) and humidity (SMD +2.24, 95%CI= 1.32–3.17, p<0.001). Effects on exertion (overall SMD= +0.9, surgical= +0.63, N95=+1.19), discomfort (SMD= +1.16), dyspnoea (SMD= +1.46), heat (SMD= +0.70) and humidity (SMD= +0.9) were significant in n=373 with a robust relationship to mask wearing (p<0.006 to p<0.001). Pooled symptom prevalence (n=8128) was significant for: headache (62%, p<0.001), acne (38%, p<0.001), skin irritation (36%, p<0.001), dyspnoea (33%, p<0.001), heat (26%, p<0.001), itching (26%, p<0.001), voice disorder (23%, p<0.03) and dizziness (5%, p=0.01).
Discussion: Masks interfered with O2-uptake and CO2-release and compromised respiratory compensation. Though evaluated wearing durations are shorter than daily/prolonged use, outcomes independently validate mask-induced exhaustion-syndrome (MIES) and down-stream physio-metabolic disfunctions. MIES can have long-term clinical consequences, especially for vulnerable groups. So far, several mask related symptoms may have been misinterpreted as long COVID-19 symptoms. In any case, the possible MIES contrasts with the WHO definition of health.
Conclusion: Face mask side-effects must be assessed (risk-benefit) against the available evidence of their effectiveness against viral transmissions. In the absence of strong empirical evidence of effectiveness, mask wearing should not be mandated let alone enforced by law.
... In total, significant changes (p<0.05) could be found in most of the evaluated studies that measured body CO2 content during mask use [64,[76][77][78][79][80][81][82][83][84][85][86][87][88][89][90][91] (Table 2). Experiments with relatively short evaluation times [92] and pitfalls in their designs, e.g. ...
... A look at Table 3 shows that the results of the FDA (1979) [106] and Howard experiments (2012) [58,107] on toxic CO2 levels may explain the increase in the incidence of stillbirths found in the above studies. Moreover, wearing N95 masks that are linked to a higher carbon dioxide re-breathing (Table 2) [78,79,88] is significantly more associated with higher gestational age than surgical masks (stronger N95 use than surgical mask) [128]. ...
... A significant rise in carbon dioxide occurring while wearing a mask is scientifically proven in many studies [48,[64][65][66][67][68][69][70][71]73,[77][78][79][80][81][82][83][84][86][87][88][89][90][91], especially for N95-masks (Table 2) [66,[69][70][71]73,[77][78][79][80]82,[84][85][86]88,90,91] due to their higher deadspace and breathing resistance [48]. ...
Introduction: During the SARS-CoV2-pandemic, face masks have become one of the most important ubiquitous factors affecting human breathing. It increases the resistance and dead space volume leading to a re-breathing of CO2. So far, this phenomenon and possible implications on early life has not been evaluated in depth.
Method: As part of a scoping review, literature was systematically reviewed regarding CO2 exposure and facemask use.
Results: Fresh air has around 0.04% CO2, while wearing masks more than 5 minutes bears a possible chronic exposure to carbon dioxide of 1.41% to 3.2% of the inhaled air. Although the buildup is
usually within the short-term exposure limits, long-term exceedances and consequences must be considered due to experimental data. US Navy toxicity experts set the exposure limits for submarines carrying a female crew to 0.8% CO2 based on animal studies which indicated an increased risk for stillbirths. Additionally, mammals who were chronically exposed to 0.3% CO2 the experimental data demonstrate a teratogenicity with irreversible neuron damage in the offspring, reduced spatial
learning caused by brainstem neuron apoptosis and reduced circulating levels of the insulin-like growth factor-1. With significant impact on three readout parameters (morphological, functional, marker) this chronic 0.3% CO2 exposure has to be defined as being toxic. Additional data exists on the exposure of chronic 0.3% CO2 in adolescent mammals causing neuron destruction, which includes less activity, increased anxiety and impaired learning and memory. There is also data indicating testicular toxicity in adolescents at CO2 inhalation concentrations above 0.5%.
Discussion: There is a possible negative impact risk by imposing extended mask mandates especially for vulnerable subgroups. Circumstantial evidence exists that extended mask use may be related to current observations of stillbirths and to reduced verbal motor and overall cognitive performance in children born during the pandemic. A need exists to reconsider mask mandates.
... Vigorous intensity activity makes one breathe harder and faster; working at this level, the participants cannot say more than a few words without pausing for breath [16]. Research evidence exists that "wearing a face mask during vigorous exercise had no discernable detrimental effect on blood or muscle oxygenation" [16] and exercise performance in young, healthy participants [17][18][19][20][21][22][23][24]. Though the biophysical parameters were not affected, many participants still complained of discomfort wearing face masks while exercising. ...
... Common complaints regarding discomfort were decreased ease of breath and unpleasant odors from the face mask during moderate to vigorous exercises indoors. There are very few studies [17][18][19][20][21][22][23][24] investigating the users' perceived discomfort with significant findings. Three studies [21][22][23][24] reported that wearing a face mask when engaging in exercises produced a feeling of discomfort, while four other studies [17][18][19][20] concluded no significant difference in perceived discomfort during exercises and regular activities. ...
... There are very few studies [17][18][19][20][21][22][23][24] investigating the users' perceived discomfort with significant findings. Three studies [21][22][23][24] reported that wearing a face mask when engaging in exercises produced a feeling of discomfort, while four other studies [17][18][19][20] concluded no significant difference in perceived discomfort during exercises and regular activities. These studies included a small sample size, only 6-23 healthy candidates [17][18][19][20][21][22][23][24]. ...
Transmission of COVID-19 occurs predominantly through respired droplets and aerosols containing the SARS-CoV-2 virus. As a solution, face masks have been used to protect against infection. Wearing face masks during indoor exercises is essential to prevent the spread of virus-containing respiratory droplets and aerosols. However, previous studies have not investigated all elements, including the users’ perceived breathability (PB) and perceived air quality (PAQ) when wearing a face mask during indoor exercises. The current study aimed to assess users’ perceived comfort (PC) of face masks based on assessment criteria of PB and PAQ during moderate to vigorous exercises, and compare them with those during normal daily activities. Data on PC, PB, and PAQ were collected from an online questionnaire survey from 104 participants doing regular moderate to vigorous exercises. Within-subjects comparison with self-controlled case series design was performed to compare PC, PB, and PAQ between wearing face masks during exercises and daily activities. Results showed that the degree of dissatisfaction with PC, PB, and PAQ while wearing face masks and performing indoor exercises is higher than when performing daily activities (p < 0.05). The significance of the study implies that masks comfortable for daily activities may not remain the same during moderate to vigorous exercises, especially during indoor exercises.
... (6,(16)(17)(18)(19) Interventions varied greatly among the studies, and some used different devices and methods to measure the study variables. Interventions included walking, (5,20) treadmill walking, (18,19) medium-to highintensity interval exercise on a cycle ergometer, (6,12,16,21) and going up and down stairs. (22) ...
... Only 8 of the 10 studies included in this review provided sufficient data to analyze BP, HR, RR, and SpO 2 in the face of aerobic interventions with and without N95/FFP2 masks. (6,12,16,18,19,(21)(22)(23) Therefore, only the aforementioned 8 were included in our meta-analysis, totaling a sample of 166 volunteers. The standardized mean difference ranged from −0.32 to 0.17 for BP, −0.27 to 0.13 for SpO 2 , −0.10 to 0.27 for HR, and −0.16 to 0.28 for RR with the use of a fixed-effects model and with no statistically significant changes for any of the variables. ...
... As can be seen in Figure 3, the use of N95/FFP2 masks during aerobic exercise had no significant effect on SpO 2 , as evidenced by the diamond crossing the vertical line of null effect. Although Mapelli et al. (21) showed that the use of N95/FFP2 masks had a significant The influence of N95 and FFP2 masks on cardiorespiratory variables in healthy individuals during aerobic exercise: a systematic review and meta-analysis effect on SpO 2 , their findings did not affect the overall result, because the study sample was small. ...
Objective:
In view of the current COVID-19 pandemic, the objective of this study was to determine, through a systematic review and meta-analysis, whether the use of N95/FFP2 masks during aerobic exercise has a significant impact on HR, RR, SpO2, and blood pressure (BP) in healthy individuals.
Methods:
We searched the MEDLINE database for studies published in English between 2005 and 2021. To reduce bias and increase reliability, only randomized controlled trials and randomized crossover clinical trials were considered for inclusion. The selected outcomes included HR, RR, SpO2, and BP, with perceived exertion being evaluated by means of the Borg scale.
Results:
Eight controlled trials were included in the meta-analysis. Seven evaluated HR (p > 0.05), five evaluated RR (p > 0.05), five evaluated SpO2 and BP (p > 0.05 for both), and six evaluated perceived exertion, presenting controversial results such as risk ratios that were grouped for each variable.
Conclusions:
This study suggests that N95 and FFP2 masks do not have significant effects on HR, RR, SpO2, and BP during aerobic exercise in healthy individuals.
... Several studies have examined the impact of N95 respirators and surgical masks [5][6][7][8][9][10][11][12] . It has been noted that wearing a surgical mask or N95 respirator during exercise may increase discomfort and decrease exercise tolerance [7][8][9] . ...
... Several studies have examined the impact of N95 respirators and surgical masks [5][6][7][8][9][10][11][12] . It has been noted that wearing a surgical mask or N95 respirator during exercise may increase discomfort and decrease exercise tolerance [7][8][9] . Conversely, some studies reported that wearing a surgical mask had no effect on dyspnea, pulmonary gas exchange, or exercise performance [10][11][12] . ...
... Inadequate hyperventilation during intensive exercise can lead to decreased arterial oxy-hemoglobin saturation (SaO 2 ) 15 . Two studies have reported a decrease in the maximal oxygen uptake (Vo 2max ) with the use of surgical masks, thereby decreasing exercise tolerance 6,8 . ...
We aimed to determine the effects of wearing a cloth face mask on cardiorespiratory response, peak oxygen uptake (Vo2), respiratory muscle effort, and exercise tolerance during incremental exercise. The study had a randomized crossover design: 11 apparently healthy young men performed the Bruce protocol treadmill test in two conditions, wearing a cloth face mask (CFM) and without CFM (CON), in random order. Minute ventilation and oxygen uptake were measured using a mass spectrometry metabolic analyzer; cardiac output (CO) was measured using an impedance CO monitor; and mouth pressure (Pm) was measured and calculated as an integral Pm to assess respiratory muscle effort. Maximal minute ventilation was 13.4 ± 10.7% lower in the CFM condition than in the CON condition (P < 0.001). The peak Vo2 (52.4 ± 5.6 and 55.0 ± 5.1 mL/kg/min in CFM and CON, respectively) and CO were not significantly different between the two conditions. However, the integral value of Pm was significantly higher (P = 0.02), and the running time to exhaustion was 2.6 ± 3.2% lower (P = 0.02) in the CFM condition than in the CON condition. Our results suggest that wearing a cloth face mask increased respiratory muscle effort and decreased ventilatory volume in healthy young men; however, Vo2 remained unchanged. Exercise tolerance also decreased slightly.
... The initial search identified 4,587 studies in all combined databases. In the full-text stage, 69 studies were eligible, and in the end, 34 studies (Zimmerman et al., 1991;Roberge et al., 2010;Roberge et al., 2012a;Roberge et al., 2012b;Chen et al., 2016;Kim et al., 2016;Person et al., 2018;Fikenzer et al., 2020;Lässing et al., 2020;Morris et al., 2020;Wong et al., 2020;Ade et al., 2021;Bar-On et al., 2021;Dantas et al., 2021;Doherty et al., 2021;Driver et al., 2021;Egger et al., 2021;Epstein et al., 2021;Fukushi et al., 2021;Kampert et al., 2021;Mapelli et al., 2021;Modena et al., 2021;Reychler et al., Frontiers in Physiology frontiersin.org 04 2021;Rojo-Tirado et al., 2021;Ryu and Jong-Geun, 2021;Slimani et al., 2021;Tornero-Aguilera et al., 2021;Yoshihara et al., 2021;Zhang et al., 2021;Cabanillas-Barea et al., 2022;Jesus et al., 2022;Ng et al., 2022;Rosa et al., 2022;Steinhilber et al., 2022) met all the eligibility criteria and were included in the review. ...
... All studies presented a control condition (i.e., no face mask wearing). The samples were composed mostly by healthy (Zimmerman et al., 1991; Roberge et al., 2012a;Roberge et al., 2012b;Chen et al., 2016;Kim et al., 2016;Person et al., 2018;Lässing et al., 2020;Morris et al., 2020;Bar-On et al., 2021;Doherty et al., 2021;Driver et al., 2021;Fukushi et al., 2021;Mapelli et al., 2021;Reychler et al., 2021;Ryu and Jong-Geun, 2021;Slimani et al., 2021;Zhang et al., 2021;Cabanillas-Barea et al., 2022;Jesus et al., 2022;Steinhilber et al., 2022), healthy physically active Shaw et al., 2020;Wong et al., 2020;Ade et al., 2021;Epstein et al., 2021;Kampert et al., 2021;Yoshihara et al., 2021), healthy trained (Rojo-Tirado et al., 2021;Ng et al., 2022) resistance-trained (Rosa et al., 2022), and healthy sedentary (Otsuka et al., 2022) adults; athletes (Dantas et al., 2021;Egger et al., 2021;Tornero-Aguilera et al., 2021) and amateur soccer players (Modena et al., 2021). The sample size varied from six (Otsuka et al., 2022) to 72 (Tornero-Aguilera et al., 2021) participants per condition. ...
... 10 et al., 2021;Rojo-Tirado et al., 2021;Ryu and Jong-Geun, 2021;Yoshihara et al., 2021;Cabanillas-Barea et al., 2022;Rosa et al., 2022), and FFP2/N95 + EV (n = 5) (Roberge et al., 2010;Roberge et al., 2012a;Chen et al., 2016;Kim et al., 2016;Steinhilber et al., 2022). The effects of face mask wearing during exercise on affective/psychological parameters were assessed by some studies (n = 33) (Roberge et al., 2010;Roberge et al., 2012a;Roberge et al., 2012b;Chen et al., 2016;Kim et al., 2016;Person et al., 2018;Fikenzer et al., 2020;Lässing et al., 2020;Morris et al., 2020;Shaw et al., 2020;Wong et al., 2020;Ade et al., 2021;Bar-On et al., 2021;Dantas et al., 2021;Doherty et al., 2021;Driver et al., 2021;Egger et al., 2021;Epstein et al., 2021;Fukushi et al., 2021;Kampert et al., 2021;Mapelli et al., 2021;Modena et al., 2021;Reychler et al., 2021;Rojo-Tirado et al., 2021;Slimani et al., 2021;Tornero-Aguilera et al., 2021;Yoshihara et al., 2021;Zhang et al., 2021;Cabanillas-Barea et al., 2022;Ng et al., 2022;Otsuka et al., 2022;Rosa et al., 2022;Steinhilber et al., 2022), while others (n = 21) (Zimmerman et al., 1991;Person et al., 2018;Fikenzer et al., 2020;Ade et al., 2021;Dantas et al., 2021;Driver et al., 2021;Egger et al., 2021;Epstein et al., 2021;Kampert et al., 2021;Mapelli et al., 2021;Modena et al., 2021;Reychler et al., 2021;Rojo-Tirado et al., 2021;Ryu and Jong-Geun, 2021;Tornero-Aguilera et al., 2021;Zhang et al., 2021;Cabanillas-Barea et al., 2022;Jesus et al., 2022;Ng et al., 2022;Rosa et al., 2022;Steinhilber et al., 2022) assessed its effects on exercise performance responses. ...
Background: Face masks are widely used during the COVID-19 pandemic as one of the protective measures against the viral infection risk. Some evidence suggests that face mask prolonged use can be uncomfortable, and discomfort can be exacerbated during exercise. However, the acute responses of mask-wearing during exercise on affective/psychological and exercise performance responses is still a topic of debate.
Purpose: To perform a systematic review with meta-analysis of the acute effects of mask-wearing during exercise on affective/psychological and exercise performance responses in healthy adults of different/diverse training status.
Methods: This review (CRD42021249569) was performed according to Cochrane’s recommendations, with searches performed in electronic (PubMed, Web of Science, Embase, SportDiscus, and PsychInfo) and pre-print databases (MedRxiv, SportRxiv, PsyArXiv, and Preprint.Org ). Syntheses of included studies’ data were performed, and the RoB-2 tool was used to assess the studies’ methodological quality. Assessed outcomes were affective/psychological (discomfort, stress and affective responses, fatigue, anxiety, dyspnea, and perceived exertion) and exercise performance time-to-exhaustion (TTE), maximal power output (PO MAX ), and muscle force production] parameters. Available data were pooled through meta-analyses.
Results: Initially 4,587 studies were identified, 36 clinical trials (all crossover designs) were included. A total of 749 (39% women) healthy adults were evaluated across all studies. The face mask types found were clothing (CM), surgical (SM), FFP2/N95, and exhalation valved FFP2/N95, while the most common exercises were treadmill and cycle ergometer incremental tests, beyond outdoor running, resistance exercises and functional tests. Mask-wearing during exercise lead to increased overall discomfort (SMD: 0.87; 95% CI 0.25–1.5; p = 0.01; I ² = 0%), dyspnea (SMD: 0.40; 95% CI 0.09–0.71; p = 0.01; I ² = 68%), and perceived exertion (SMD: 0.38; 95% CI 0.18–0.58; p < 0.001; I ² = 46%); decreases on the TTE (SMD: −0.29; 95% CI −0.10 to −0.48; p < 0.001; I ² = 0%); without effects on PO MAX and walking/running distance traveled ( p > 0.05).
Conclusion: Face mask wearing during exercise increases discomfort (large effect), dyspnea (moderate effect), and perceived exertion (small effect), and reduces the TTE (small effect), without effects on cycle ergometer PO MAX and distance traveled in walking and running functional tests. However, some aspects may be dependent on the face mask type, such as dyspnea and perceived exertion.
Systematic Review Registration : [ https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021249569 ], identifier [CRD42021249569].
... As exhaled air can also be trapped in the dead space created between the mask and the face depending on how well the mask fits on an individual, this fraction of air when inhaled again may contribute to the increase in ECO 2 as well as decreased FeO 2 (14.52%). [10] A significant decrease (P = 0.001) in the expired oxygen FeO 2 at 30 and 45 min in the SM + N95 and N95 + V groups was recorded. ...
... [8,9] The pulse oximetry findings at no time were clinically decreased over the course of 45 min in any of the groups, the range being 96%-100% which is well within the normal physiological limits in concordance with several researchers. [9,10,16,17] The statistically significant value (P = 0.02) in the N95 + SM + V group was clinically irrelevant as the mean SpO 2 values ranged from 99% to 99.29%. Significant decreases in SPO 2 were seen in volunteers doing maximal exercise, and these studies documented mean saturation of 97.7% ± 0.5% and 95.1% ± 3.1%, respectively, which was again well within the acceptable normal range. ...
... Significant decreases in SPO 2 were seen in volunteers doing maximal exercise, and these studies documented mean saturation of 97.7% ± 0.5% and 95.1% ± 3.1%, respectively, which was again well within the acceptable normal range. [10,16] The use of SM over an N95 respirator also did not reflect any significant impact on the physiological variables which has been verified by previous studies. [2,18,19] It has to be remembered that N95 has to be discarded when it is damp, contaminated with body fluids, or when there is cross-contamination. ...
Background and aim:
The COVID pandemic necessitated the use of masks to reduce the propagation of coronavirus by airborne transmission. This research was conducted in healthy volunteers to assess the changes in noninvasive measurable physiological variables over 45 min at rest.
Methods:
This was a prospective randomized controlled crossover trial. Twenty-one healthy volunteers were monitored for pulse rate (PR), peripheral oxygen saturation (SpO2), systolic blood pressure (SBP), diastolic blood pressure (DBP), respiratory rate (RR), inspired carbon dioxide and expired carbon dioxide (ECO2), inspired (FiO2) and expired oxygen (FeO2), every 15 min for 45 minute (min) with N95 respirator, N95 respirator with surgical mask (SM), N95 with SM and visor (V), SM with N95, and N95 respirator with visor.
Results:
Repeated measures analysis of variance (ANOVA) of PR, RR, SpO2, SBP, and DBP over time within the group and intragroup was calculated and found statistically insignificant. P value for comparison of mean value within the group was calculated by paired t-test with Bonferroni correction. There was a significant rise in ECO2 in the N95 group over time, and repeated measures ANOVA showed P = 0.04 at 30 min between the N95 + V group and the N95 + SM + V group. Inspired CO2 was statistically significant over time in the N95 + SM + V with P = 0.02.
Conclusion:
N95 alone or in combination with a SM and visor does not cause any clinically significant measurable physiological derangements. The inspired CO2 may be implicated in the symptoms manifested by individuals.
... Taken together, the data from fikenzer et al., 15 Shaw et al., 17 epstein et al., 38 li et al., 33 Mapelli et al., 34 ade et al., 37 Ng et al., 35 cheshier et al., 36 and Wells et al. 25 reveal few changes in hemodynamic parameters or exercise performance outcomes with surgical mask use in healthy adults. however, while driver et al. 26 found no difference in SBp (p=0.68), ...
... 17 fikenzer et al. 15 also reported a decrease in the test duration (-52±45 seconds; p=0.005) when an incremental exercise test was performed with a N95 mask compared to a no-mask control, and no difference in exercise duration (-29±40 seconds; p=0.07) with surgical mask use compared to a nomask control. in a similar study to fikenzer et al., 15 li et al. 33 found a similar decrease in hr with surgical mask use during cycling exercise. In disagreement to the findings by fikenzer et al. 15 and li et al.; 33 Shaw et al., 17 Mapelli et al., 34 Ng et al., 35 cheshier et al., 36 ade et al., 37 and epstein et al. 38 found no differences when comparing hr between mask conditions during an incremental exercise test protocol at maximal effort using a cycle ergometer. ...
... 11 This suggests that there are negligible effects on ventilatory variables with N95 or surgical mask use during lower intensity exercise. however, there seems to be a drop in Ve 15, 33, 34 and TV 33,34 with surgical mask use observed with progressive exercise tests to volitional maximal exertion. Since these incremental exercise tests that end with volitional fatigue are most often reserved for use in a laboratory or clinical settings. ...
The use of masks in public settings and when around people has been recommended to limit the spread of Coronavirus disease 2019 (COVID-19) by major public health agencies. Several different types of masks classified as either medical- or non-medical grade are commonly used among the public. However, concerns with difficulty breathing, re-breathing exhaled carbon dioxide, a decrease in arterial oxygen saturation, and a decrease in exercise performance have been raised regarding the use of mask during exercise. We review the current knowledge related to the effect of different masks during exercise on cardiorespiratory, metabolic, thermoregulatory, and perceptual responses. As such, the current literature seems to suggest that there are minimal changes to cardiovascular, metabolic, and no changes to thermoregulatory parameters with facemask use. However, differences in ventilatory parameters have been reported with submaximal and maximal intensity exercise to volitional fatigue. Literature on perceptual responses to exercise indicate an impact on ratings of perceived exertion, dyspnea, and overall discomfort dependent on mask use as well as exercise intensity. In conclusion, data from the current literature suggests a minimal impact on physiological, perceptual, and thermoregulatory responses dependent on the type of mask used during exercise.
... Respiratory problems from prolonged use of respirators were discussed in many studies, which show varied results. One study by Mapelli et al. reported that using respirators was safe, with no significant differences in oxygen saturation even during high-intensity exercise [4]. In contrast, a study by Pimenta et al. showed a significant drop in oxygen saturation and warned of the cardiorespiratory impact of using respirators [5], but these might be only statistically significant, since arterial hypoxemia can be induced by exercise without any clinical significance [6]. ...
... Abbreviations: CI, confidence interval; SD, standard deviation; SpO2, oxygen saturation level; Std. mean diff., standard mean difference[4,5,[10][11][12][13]. ...
... Abbreviations: CI, confidence interval; SD, standard deviation; SpO 2 , oxygen saturation level; Std. mean diff., standard mean difference[4,5,[10][11][12][13]. ...
During the COVID-19 pandemic, N95 respirators were commonly used in many situations. Respiratory problems from prolonged use of respirators were discussed in many studies, which show varied results. From the inconclusive results, the current systematic review and meta-analysis discerned the effects of the N95 respirator by assessing the oxygen and carbon dioxide changes in both high- and low-to-moderate-intensity physical activities in a healthy population. Thirteen studies were identified for inclusion in the study. In high-intensity physical activities, our meta-analysis showed borderline lower oxygen saturation and higher carbon dioxide partial pressure, but oxygen saturation did not change in low-to-moderate physical activity. The use of N95 respirators could statistically affect the physiologic changes of carbon dioxide and oxygen in high-intensity physical activity among healthy participants, but this may not be clinically significant. Some users who have certain health conditions, such as respiratory problems, should be informed of the clinical symptoms related to hypercarbia and hypoxia for the early detection of adverse effects of N95 respirators.
... Studies have been carried out showing safety, limited effects on health, reduced or no impact on performance in moderate to light exercise, 15,34,47 and even intense activity. 35 Other studies have reported clear changes and deterioration in the cardiopulmonary, respiratory, physiological, and perceived variables, 16,22,29,55 and even suggest adapting the intensity of the physical exercise or task undertaken. 16,55 These adjustments are not considered sufficiently significant to present a health risk, according to other authors, even at maximum output, though they do produce a reduction in performance. ...
... 16,55 These adjustments are not considered sufficiently significant to present a health risk, according to other authors, even at maximum output, though they do produce a reduction in performance. 29 They even state that prolonged use of a facemask could improve the muscle function of the respiratory system. 18 We also examined studies carried out on children and youths 17,27 and on adults and the elderly with pathologies such as chronic obstructive pulmonary disease (COPD) 21,43 and sarcopenia. ...
... A total of 49 studies underwent a full text selection and, after applying the exclusion and inclusion criteria, 5 articles were finally chosen and included in the revision. 15,29,34,47,55 Furthermore, a total of 6 articles were identified using other methods from the citation search, out of which 3 were included in the review. 6,22,35 In total, 8 articles with 105 participants (79 men and 26 women) complied with our inclusion criteria. ...
Context
Use of facemasks in sport has been a particularly complex issue during the COVID-19 pandemic.
Objectives
A systematic review to examine the physiological effects the different types of masks have on healthy adults when doing physical exercise.
Data sources
PubMed, SPORTDiscus, Scopus, and Litcovid were searched up to March 20, 2021, following the PRISMA model. Articles published in the last 5 years with healthy adults.
Study Selection
A total of 633 studies related to the use of masks during physical exercise were found, of which 8 articles met the criteria to be included.
Study Design
Systematic review.
Level of Evidence
Level 2.
Data Extraction
The search process and the review of the articles were carried out by independent expert researchers. The risk of bias and the methodological quality of the different studies included in the systematic review were calculated following the Cochrane criteria using an adaptation for random cross-studies. Once the information was properly structured, the results were extracted, and the findings of the study analyzed.
Results
There were significant changes in the following physiological variables when engaging in physical exercise using masks: 25% in the heart rate and dyspnea, 37.5% in the rating of perceived exertion, 50% in the pulmonary variables, and 37.5% in discomfort. The oxygen saturation, blood pressure, systolic blood pressure, diastolic blood pressure, and the concentration of blood lactate did not present any significant effect in this study.
Conclusions
The usage of masks by a healthy adult population during the performance of physical exercise has shown minimal effects with regard to physiological, cardiorespiratory, and perceived responses. Some symptoms can be dyspnea, effort perceived, or discomfort, among others. These findings indicate that the use of masks is not harmful to individuals’ health. It does not present any significant detrimental effect on physical performance or risk to their well-being. However, further experiments are required to corroborate the findings of this review.
... However, the protection masks are associated with a significant worsening of spirometry measurements due to an increase in airflow resistance. 15 Therefore, it is important to ensure their safe use during Data are presented as mean ± SD. *Missing datapoint(s) due to pulse oximeter with heart rate monitoring malfunction. Abbreviations: bpm; breathes or beats per minute; HR, hearth rate; RR, respiratory rate; SpO 2 , pulse oxygen saturation; STST, 1-min sit-to-stand test; T 0 : before the STST; T 2 : 60-s post-STST; T 3 : 120-s post-STST rehabilitation in patients with respiratory diseases. ...
... 18 It is only at high intensity exercise that the masks reduce exercise performance. 15,19,20 A recent study found that the intensity of the 1-min sit-to-stand test was not sufficiently high to elicit an increase in dyspnoea sensation with the surgical mask in young healthy adults. 21 A clinically relevant increase in dyspnoea was only noted at the end of the sit-to-stand test with the cloth mask, probably because this mask opposed more resistance to airflow than the surgical mask. ...
... The dyspnoea sensation with the surgical mask was heightened during the effort, which is likely the reflect of a greater airflow resistance associated to higher ventilation demand while exercising. 15 Surprisingly, although dyspnoea at recovery was higher than dyspnoea before the test, the difference between the masked and unmasked conditions was no longer significant. Dyspnoea is a complex sensation involving sensory and affective dimensions which are closely intertwined. ...
Background:
Wearing a surgical mask in hospitalized patients has become recommended during care, including rehabilitation, to mitigate coronavirus disease 2019 (COVID-19) transmission. However, the mask may increase dyspnoea and raise concerns in promoting rehabilitation activities in post-acute COVID-19 patients.
Objective:
To evaluate the impact of the surgical mask on dyspnoea, exercise performance and cardiorespiratory response during a 1-min sit-to-stand test in hospitalized COVID-19 patients close to discharge.
Methods:
COVID-19 patients whose hospital discharge has been planned the following day performed in randomized order two sit-to-stand tests with or without a surgical mask. Outcome measures were recorded before, at the end, and after two minutes of recovery of each test. Dyspnoea (modified Borg scale), cardiorespiratory parameters and sit-to-stand repetitions were measured.
Results:
Twenty-eight patients aged 52 ± 10 years were recruited. Compared to unmasked condition, dyspnoea was significantly higher with the mask before and at the end of the sit-to-stand test (mean difference[95%CI]: 1.0 [0.6, 1.4] and 1.7 [0.8, 2.6], respectively). The difference was not significant after the recovery period. The mask had no impact on cardiorespiratory parameters nor the number of sit-to-stand repetitions.
Conclusion:
In post-acute COVID-19 patients near hospital discharge, the surgical mask increased dyspnoea at rest and during a submaximal exercise test but had no impact on cardiorespiratory response or exercise performance. Patients recovering from COVID-19 should be reassured that wearing a surgical facemask during physical or rehabilitation activities is safe. These data may also mitigate fears to refer these patients in rehabilitation centres where mask-wearing has become mandatory.
... The results regarding differences in RR between no mask and N95 FFRs were conflicting-Epstein et al. 18 reported no significant difference and Fikenzer et al. 10 reported a significant reduction of RR associated with wearing N95 FFRs. Two of the studies included in the systematic review examined the effect of N95 FFRs on SpO 2 during high-intensity exercises 18,25 . Neither reported significant differences between the mask and no-mask conditions. ...
... Content courtesy of Springer Nature, terms of use apply. Rights reserved 25 and Fikenzer et al. 10 reported a significant reduction in tidal volume when wearing N95 FFRs (both studies) and a surgical mask (only Mapelli et al. 25 ). We have obtained only two studies examining cloth masks. ...
... Content courtesy of Springer Nature, terms of use apply. Rights reserved 25 and Fikenzer et al. 10 reported a significant reduction in tidal volume when wearing N95 FFRs (both studies) and a surgical mask (only Mapelli et al. 25 ). We have obtained only two studies examining cloth masks. ...
Several concerns regarding the safety of face masks use have been propounded in public opinion. The objective of this review is to examine if these concerns find support in the literature by providing a comprehensive overview of physiological responses to the use of face masks. We have performed a systematic review, pairwise and network meta-analyses to investigate physiological responses to the use of face masks. The study has been registered with PROSPERO (C RD42020224791). Obtained results were screened using our exclusion and inclusion criteria. Meta-analyses were performed using the GeMTC and meta R packages. We have identified 26 studies meeting our inclusion and exclusion criteria, encompassing 751 participants. The use of face masks was not associated with significant changes in pulsoxymetrically measured oxygen saturation, even during maximal-effort exercises. The only significant physiological responses to the use of face masks during low-intensity activities were a slight increase in heart rate, mildly elevated partial pressure of carbon dioxide (not meeting criteria for hypercarbia), increased temperature of facial skin covered by the mask, and subsequent increase of the score in the rating of heat perception, with N95 filtering facepiece respirators having a greater effect than surgical masks. In high-intensity conditions, the use of face masks was associated with decreased oxygen uptake, ventilation, and RR. Face masks are safe to use and do not cause significant alterations in human physiology. The increase in heart rate stems most likely from increased respiratory work required to overcome breathing resistance. The increase in carbon dioxide is too small to be clinically relevant. An increased rating of heat perception when using face masks results from higher temperature of facial skin covered by the mask.
... While being recommended as protective against COVID-19 transmission, masks are inducing variable side-effects on our cardiorespiratory physiology [9][10][11], bronchopulmonary gas-exchange [12] and in vivo metabolic processes [13,14]. Studies have shown effects of surgical masks on cardiopulmonary parameters, oxygen (O 2 )-carbon dioxide (CO 2 ) homeostasis, blood pH and thermoregulation [15]. ...
... A recent pilot observation of mask-driven cardiopulmonary effects in 12 healthy subjects (age 40.8±12.4 years) at rest and during exercise are interpreted as significant, but modest [11]. ...
... Real-time breathomics has revealed a deeper insight into the physiometabolic side-effects of face mask wearing. Based on more recent pilot observations of cardiopulmonary parameters during exercise and rest in 12 healthy adults [11], researchers have generally recommended the continuous mask use. Within our setup, we have investigated the respiratory, haemodynamic and downstream metabolic changes in young to middle-aged and older adults for a longer period of time. ...
Background: While assumed to protect against coronavirus transmission, face masks may have effects on respiratory–haemodynamic parameters. Within this pilot study, we investigated immediate and progressive effects of FFP2 and surgical masks on exhaled breath constituents and physiological attributes in 30 adults
at rest.
Methods: We continuously monitored exhaled breath profiles within mask space in older (age 60–80 years) and young to middle-aged (age 20–59 years) adults over the period of 15 and 30 min by high-resolution
real-time mass-spectrometry. Peripheral oxygen saturation (SpO2) and respiratory and haemodynamic parameters were measured (noninvasively) simultaneously.
Results: Profound, consistent and significant (p⩽0.001) changes in SpO2 (⩾60_FFP2-15 min: 5.8±1.3%↓, ⩾60_surgical-15 min: 3.6±0.9%↓, <60_FFP2-30 min: 1.9±1.0%↓, <60_surgical-30 min: 0.9±0.6%↓) and end-tidal carbon dioxide tension (PETCO2) (⩾60_FFP2-15 min: 19.1±8.0%↑, ⩾60_surgical-15 min: 11.6±7.6%↑, <60_FFP2- 30 min: 12.1±4.5%↑, <60_surgical- 30 min: 9.3±4.1%↑) indicate ascending deoxygenation and hypercarbia. Secondary changes (p⩽0.005) to haemodynamic parameters (e.g. mean arterial pressure (MAP) ⩾60_FFP2-15 min: 9.8±10.4%↑) were found. Exhalation of bloodborne volatile metabolites, e.g. aldehydes, hemiterpene, organosulfur, short-chain fatty acids, alcohols, ketone, aromatics, nitrile and monoterpene mirrored behaviour of cardiac output, MAP, SpO2, respiratory rate and PETCO2. Exhaled humidity (e.g. ⩾60_FFP2-15 min: 7.1±5.8%↑) and exhaled oxygen (e.g. ⩾60_FFP2-15 min: 6.1±10.0%↓) changed significantly (p⩽0.005) over time.
Conclusions: Breathomics allows unique physiometabolic insights into immediate and transient effects of face mask wearing. Physiological parameters and breath profiles of endogenous and/or exogenous volatile
metabolites indicated putative cross-talk between transient hypoxaemia, oxidative stress, hypercarbia, vasoconstriction, altered systemic microbial activity, energy homeostasis, compartmental storage and
washout. FFP2 masks had a more pronounced effect than surgical masks. Older adults were more vulnerable to FFP2 mask-induced hypercarbia, arterial oxygen decline, blood pressure fluctuations and concomitant physiological and metabolic effects.
... It has been demonstrated that wearing PFM during aerobic exercise increases breathing resistance, decreases arterial oxygen saturation, and could lead to respiratory discomfort 5,10,[12][13][14] . ...
... Furthermore, recent studies showed differences in cardiovascular response wearing PFM during endurance exercise 5,13,16 . However, several investigations reported that the use of PFM caused no differences in hemodynamic parameters (i.e., heart rate, blood pressure), exercise tolerance, respiratory rate, and rating of perceived exertion (RPE) 14,[17][18][19] . ...
... Considering the relevance of the subject regarding the use of PFM after the advent of the COVID-19 pandemic, several studies have been recently conducted with the purpose of elucidating its physiological effects on the wearer 5,6,[35][36][37][38][39]13,14,[16][17][18][19]33,34 . Interestingly, when assessing the effects of surgical and FFP2/N95 masks in cardiorespiratory capacity, the FFP2/N95 ...
Protective face mask (PFM) has been widely used for safety purposes and, after the advent of the COVID-19 pandemic, its use is growing steadily, not only among healthcare personnel but also the general population. While PFM is important to preserve the wearer from contaminating agents present in the airflow, they are well known to increase the subjective perception of breathing difficulty. Although some studies demonstrated that PFM use worsens exercise tolerance, there are several studies stating that there is no such limitation with the use of PFM. Moreover, no serious adverse effects during physical exercise have been found in the literature. Physical exercise represents a significant challenge to the human body through a series of integrated changes in function that involve most of its physiologic systems. In this respect, cardiovascular and respiratory systems provide the capacity to sustain physical tasks over extended periods. Within this scenario, both convective oxygen (O2 ) transport (product of arterial O2 content x blood flow) to the working locomotor muscles and O2 diffusive transport from muscle capillaries to mitochondria are of paramount importance to endurance performance. Interestingly, the effects of PFM on cardiorespiratory response during aerobic exercise depends on the type of mask and exercise (i.e., walking, running, or cycling), including decrease in ventilatory demands, arterial oxygen levels, maximal oxygen consumption, and endurance performance. The purpose of this review was to elucidate the effect of protective face mask-wearing on 1) cardiorespiratory responses during aerobic exercise and 2) endurance performance.
... In a recent scoping review numerous important studies which provide statistically significant evidence for such CO 2 retention under the mouth-nose protection have been presented [11] and we have found additional studies that reveal scientific evidence of a carbon dioxide increase in the blood when masks are used. In total, significant changes (p<0.05) could be found in most of the evaluated studies that measured body CO 2 content during mask use [18,[29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44] (Table 2). Experiments with relatively short evaluation times [45] or questionable study design [46,47] showed no effects caused by masks. ...
... As a rise in carbon dioxide when wearing a mask is scientifically proven (Tables 1 and 2) [18][19][20][21][22][23][24][25][26][27][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44], further information about the phenomenon of the toxicological influence of elevated carbon dioxide of inhaled air on male fertility needs to be discussed. The toxic effects of low level carbon dioxide exposure on male fertility have been studied extensively in animal experiments. ...
... A look at Table 3 shows that the results of the FDA (1979) [58] and Howard experiments (2012) [59,60] on toxic CO 2 levels may explain the increase in the incidence of stillbirths found in the above studies. Moreover, wearing N95 masks that are linked to a higher carbon dioxide re-breathing (Table 2) [31,32,41] is significantly more associated with higher gestational age than surgical masks [107]. ...
Literature was systematically reviewed regarding CO exposure and facemask use. Observational and experimental data are helpful for a risk-benefit assessment for masks as a popular non-pharmaceutical intervention against SARS-CoV2 in the populace. Masks impede breathing by increasing the resistance and dead space volume leading to a re-breathing of CO with every breath taken. Fresh air has around 0.04% CO, while wearing masks more than 5 minutes bears a possible chronic exposure to carbon dioxide of 1.41% to 3.2% of the inhaled air. Although the buildup is usually within the short-term exposure limits, long-term consequences must be considered due to experimental data. US Navy toxicity experts set the exposure limits for submarines carrying female crews to 0.8% CO based on animal studies indicating an increased risk for stillbirths. Additionally, in mammals chronically exposed to 0.3% CO experimental data demonstrates teratogenicity with irreversible damage of neurons and reduced spatial learning caused by brainstem neuron apoptosis and a reduced blood level of the insulin-like growth factor 1. With significant impact on three readout parameters (morphological, functional, marker) this chronic 0.3% CO exposure has to be defined as being toxic. Additional data exists on the exposure of chronic 0.3% CO in adolescent mammals causing neuron destruction, which includes less activity, increased anxiety and impaired learning and memory. There is a possible negative impact risk by imposing extended mask mandates especially for vulnerable subgroups. Circumstantial evidence exists that extended mask use may be related to current observations of stillbirths and to reduced verbal motor and overall cognitive performance in children born during the pandemic. Extended masking in pregnant women, children and adolescents has not been thoroughly tested and studied. As a result of the animal experimental data available, a risk-benefit analysis is urgent and a need exists to rethink mask mandates, which provide appropriate warnings.
... Studies in adults have shown that it is safe to wear facemasks even during intense physical exercise [3][4][5][6], but data for children are lacking. The few paediatric studies included healthy children observed at rest or during mild physical exercise. ...
... [8] During the first 60 minutes of evaluation, there was no significant change in SpO2 and partial pressure of end tidal carbon dioxide (PETCO2). Studies conducted in adults found that wearing of masks could reduce performance, but did not affect gas exchange in healthy individuals undergoing moderate to vigorous exercise [3,4,6] or in patients with severe lung impairment after a 6-minute walk test. [5] Our data do not allow us to state whether the wearing of facemasks can lead to breathing difficulties or exacerbate breathing problems. ...
... It is thought that masks can increase airflow resistance with subsequent increased breathing effort, resulting in a feeling of discomfort frequently associated with their use. [4,6,7] Further limitations of our study include the small sample size, the short period of exercise, the assessment of surgical masks only and the absence of a control group without facemasks. However, it was not feasible to conduct a controlled study as it was recommended at that time to perform EIA tests with a mask to minimise the risk of SARS-CoV-2 transmission. ...
No episodes of oxygen desaturation or carbon dioxide retention were observed in this cross-sectional study assessing children with exercise-induced symptoms wearing a surgical facemask during a submaximal treadmill exercise test https://bit.ly/3GuxhvO.
... A significant number of the studies (e.g. Fikenzer et al 2020, Lässing et al 2020, Li et al 2021and Mapelli et al 2021 investigating the influence of protective face masks on human physiology use respiratory measurement masks (RM). In these studies, cardio-pulmonary function is assessed by open-circuit spirometry, which requires a RM to be placed over the protective face mask. ...
... The two articles we cited from Shaw et al (2021) are, of course, only to be understood as examples for studies using a RM. In fact, Shaw et al included two other publications with this methodological approach into their review, the studies by Li et al (2021) and Mapelli et al (2021). Regarding all four studies, Shaw et al summarized: 'This may affect the normal function of a face mask during exercise (e.g. ...
Marek and colleagues have written a commentary on our paper (Seibt et al 2023) in which they point out some methodological inconsistencies and flaws. In our response, we first address the objective of our study so that the specific responses to Marek’s criticism are placed in the proper context. In Seibt et al (2023) we investigated whether additional respiratory measurement masks used to evaluate protective face masks influence the outcomes. The physiological effect of protective masks was not the target in our study, neither at rest nor during exercise. Subsequently, we address the criticisms of Marek et al point by point. With our study and this detailed response to Marek et al (2023)), we hope to support researchers in choosing the adequate methodological approach for evaluating the effects of protective face masks on human physiology.
... Several studies evaluated the short-term influence of surgical masks and FFP masks on gas exchange or respiratory work [5][6][7][8][9]. In the largest study performed thus far, Medrzycka-Dabrowska et al. evaluated capillary blood gas analysis in 110 nurses and paramedics before and after wearing PPE for 4 hours [7]. ...
... Similarly, an increase in CO2 levels in inhaled air was reported in children wearing either surgical masks or FFP2 masks [11]. Mapelli et al. investigated the influence of masks on cardiorespiratory parameters at rest and during exercise in 12 healthy volunteers [8]. The authors showed a moderate but significant decrease of spirometric and cardiorespiratory parameters. ...
Background
The COVID-19 pandemic has changed worldwide hygiene practices. In particular, the use of filtering face piece (FFP) masks markedly increased. Concerns have been raised regarding possible negative respiratory effects of wearing FFP masks. Aim of this study was to investigate gas exchange and subjective breathing effort in hospital personnel wearing FFP2 or FFP3 masks.
Methods
In this prospective, single-centre, crossover study, 200 hospital workers were assigned to alternately wear FFP2 or FFP3 masks for one hour during routine activities. Capillary blood gas analysis was performed to evaluate gas exchange while wearing the FFP masks. The primary endpoint was the change in capillary partial pressure of carbon dioxide (PcCO2). In addition, PcO2, respiratory rate, and subjective breathing effort were assessed at the end of each hour. Changes between time points and study groups were estimated using univariate and multivariate models.
Results
PcCO2 increased from 36.8±3.5 to 37.2±3.3 (p=0.047) and 37.4±3.2 (p=0.003) mmHg in individuals wearing FFP2 or FFP3 masks, respectively. Age (p=0.021) and male gender (p<0.001) were significantly associated with increased PcCO2. Similarly, the PcO2 increased from 70.7±8.4 to 73.4±8.8 (p<0.001) and 72.8±8.5 (p=0.004) mmHg in individuals wearing FFP2 or FFP3 masks, respectively. Respiratory rate and subjective breathing effort increased significantly while wearing FFP2 and FFP3 masks (p<0.001 for all analyses). The order of wearing FFP2 or FFP3 masks did not significantly affect the results.
Conclusions
An hour of wearing FFP2 or FFP3 masks increased PcCO2 values, respiratory rate, and subjective breathing effort in healthcare personnel performing routine activities.
... This was also demonstrated in other studies conducted in adults during an exercise of mild to moderate intensity (9,16,18,19). This feeling was demonstrated to progressively increase proportionally to the exercise intensity in adults [24]. This higher perceived exertion at elevated exercise intensity is probably related to the increase in inspiratory and expiratory resistances that were previously highlighted [24,25]. ...
... This feeling was demonstrated to progressively increase proportionally to the exercise intensity in adults [24]. This higher perceived exertion at elevated exercise intensity is probably related to the increase in inspiratory and expiratory resistances that were previously highlighted [24,25]. Similarly, there was a significant reduction in running time with facemasks in trained children, at the maximum performance level [26]. ...
Only a few data associated to wearability of facemask during exercise are available in children. The aim of the study was to evaluate the effect of wearing a facemask on perceived exertion (primary aim), dyspnea, physical performance, and cardiorespiratory response during a submaximal exercise test in children aged between 8 and 12 years. This study was performed in 2021 in healthy volunteer children from 8 to 12 years. They performed prospectively two 1-min sit-to-stand tests (STST), with or without a surgical facemask. The perceived exertion (modified Borg scale), dyspnea (Dalhousie scale), heart rate, and pulsed oxygen saturation were recorded before and after STST. The STST measured the submaximal performance. Thirty-eight healthy children were recruited (8–9 years: n = 19 and 10–11 years: n = 19). After the STST, the perceived exertion increased with or without a facemask (8–9 years group: + 1 [0.6; 1.4] and + 1.6 [1.0; 2.1] — 10–11 years group: + 1.3 [0.7; 1.8] and + 1.9 [1.3; 2.6]) and it was higher with the facemask. The difference between the two conditions in perceived exertion was not clinically relevant in any group (mBorgf: 0.56 pts and 0.68 pts, respectively). The different domains of dyspnea assessed with Dalhousie scale were not influenced by the facemask. The submaximal performance measured by the STST was not changed by the mask whatever the age group. The cardio-respiratory demand was not clinically modified.Conclusion: The surgical facemask had no impact on dyspnea, cardiorespiratory parameters, and exercise performance during a short submaximal exercise in healthy children.
What is Known:
• The use of facemask has been associated with breathing difficulties during physical activities in adults.
• Before the COVID-19 pandemic, the facemasks were not recommended during exercise in children and the consequences have been poorly investigated.
What is New:
• The different domains of dyspnea assessed with Dalhousie scale, the cardiac demand, and the submaximal performance measured by the STST were not changed by the facemask whatever the age group in children.
... Goh et al. examined end-tidal pCO 2, and oxygen saturation in 106 children aged 7-14 at rest and on exertion, finding no relevant hypoxemia or hypercapnia [3]. The same was demonstrated in three other studies showing that during physical exertion, all masks are safe and have only minimal impact on performance and physiological variables [4][5][6]. However, during high-intensity exercise, wearing a face mask can have a relevant influence [7]. ...
... 1,A,2,B,3,C, etc.). Outcome parameters were reaction time (RT) for processing numbers (items 2-26), RT for processing letters (items 2-13), and switch costs (switch costs = switch RT [items 2-26]-numbers RT [items 2-26]-(letters RT [items 2-13]-numbers RT [items [2][3][4][5][6][7][8][9][10][11][12][13]). Negative switch costs indicating inadequate responses (at least one of the trials was not completed on time) were regarded as implausible and excluded from the analysis. ...
In the current SARS-CoV-2 pandemic, wearing a face mask is mandatory again during school lessons. There are no controlled studies in children to date indicating an effect on cognitive performance from wearing face masks. In a randomized controlled trial, we analysed the influence of face masks on cognitive performance of pupils during regular school lessons. Pupils (n = 133, fifth to seventh grade) were randomized by alternating allocation into control (with masks, n = 65) and intervention groups (without mask, n = 68). After two school lessons with (control) and without (intervention) face masks in class, all pupils performed digital tests for cognitive performance regarding attention and executive functions (switch, Corsi block-tapping, 2-back and flanker task). Overall, there were no significant differences in cognitive performance between both groups, masks vs. no masks. Wearing face masks has no significant influence on attention and executive functions of pupils and can still be recommended during school lessons.
... Mask use in public settings is recommended to limit the spread of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) that causes the disease known as COVID-19 1,2 and endorsed by the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). Wearing a mask during exercise may have implications for recreational exercisers and athletes that train and compete at a high exercise intensities as it has been shown to limit ventilation (VE) and increase end-tidal CO 2 compared to a nomask control [3][4][5][6] . For example, N95 masks are designed to fit more tightly around the nose and mouth than other types of masks 7 and have been shown to reduce markers of maximal exercise performance compared to a no-mask control for individuals performing an incremental ramp protocol on a cycle ergometer 3,5 . ...
... Wearing a mask during exercise may have implications for recreational exercisers and athletes that train and compete at a high exercise intensities as it has been shown to limit ventilation (VE) and increase end-tidal CO 2 compared to a nomask control [3][4][5][6] . For example, N95 masks are designed to fit more tightly around the nose and mouth than other types of masks 7 and have been shown to reduce markers of maximal exercise performance compared to a no-mask control for individuals performing an incremental ramp protocol on a cycle ergometer 3,5 . ...
Objective:
The purpose of this study was to investigate the effects of surgical mask use during high intensity interval exercise (HIIE) on physiological and perceptual responses in hot and temperate environments.
Methods:
In a randomized fashion, 10 healthy participants completed two HIIE sessions in a 36°C hot (HUE-HOT) and two HIIE sessions in a 23°C temperate environment (HIIE-TEMP) while wearing (MASK) and not wearing a surgical mask (CON).
Results:
No differences in physiological variables were found between MASK and CON during HIIE. An increase in perceived dyspnea and average RPE was found comparing MASK and CON. Interaction effects showed the greatest changes in perceived dyspnea and average RPE occurred in the HIIE-HOT/MASK condition.
Conclusion:
Wearing a surgical mask during HIIE increases the perception of dyspnea and exertion with the greatest effect occurring in hot environments.
... Blinding seems to be particularly important in the case of subjective assessments as it is well known that blinding makes it difficult to bias results intentionally or unintentionally and so helps ensure the credibility of study conclusions 29,30 . To our knowledge, blinding was only attempted in one previous study 14 , where subjects' perceived exertion was recorded using the Borg scale during physical exertion with masks (SM and FFP2). For single blinding of the no mask situation, a large piece of material was cut out centrally from a SM and worn underneath the silicone CPET mask. ...
To quantify the subjective and cognitive impairment caused by wearing face masks at work, 20 men and 20 women (median age 47 years, range 19–65) were tested under different ergometer workloads while wearing surgical mask, community mask, FFP2 respirator or no mask in a randomized and partially double-blinded design. Masks were worn also at the workplace for four hours. Subjective impairment was recorded by questionnaires. Cognitive performance was tested before and after the workplace examination. Subjective feeling of heat, humidity, and difficult breathing increased with rising physical exertion and wearing time for all three mask types, most notably for FFP2. Even when blinded, participants with FFP2 reported difficult breathing already at rest. During physical exertion, individuals with low tolerance to discomfort reported significantly stronger impairment (OR 1.14, 95% CI 1.02–1.27). Regarding light work, older subjects (OR 0.95, 95% CI 0.92–0.98) and women (OR 0.84, 95% CI 0.72–0.99) showed significantly lower and atopic subjects stronger impairment (OR 1.16, 95% CI 1.06–1.27). No significant influence of mask wearing was detected on cognitive performance. Wearing a mask had no effect on cognitive performance, but led to discomfort which increased with physical exertion and wearing time. Individuals who tolerate discomfort poorly felt more impaired by wearing a mask during physical exertion.
... As expected, such breathing resistance-induced reduction in SpO 2 did not appear during low-to moderate-intensity exercise [3][4][5] while elevated CO 2 retention and/or end-tidal CO 2 were frequently noted [3][4][5]10]. Interestingly, two previous studies that utilized strenuous exercise while wearing facemasks reported no changes in SpO 2 [11,25]. However, significant reductions in SpO 2 coinciding with reduced VO 2max were also observed in other studies [9,16] that controlled mask sealing for air leakage during exercise, similar to the present study, implicating that facemask fit affects airflow limitation and could variably influence cardiopulmonary function [3,4,17]. ...
Protective masks impose variable breathing resistance (BR) on the wearer and may adversely affect exercise performance, yet existing literature shows inconsistent results under different types of masks and metabolic demands. The present study was undertaken to determine whether added BR impairs cardiopulmonary function and aerobic performance during exercise. Sixteen young healthy men completed a graded exercise test on a cycle ergometer under the four conditions of BR using a customized breathing resistor at no breathing resistance (CON), 18.9 (BR1), 22.2 (BR2), and 29.9 Pa (BR3). The results showed that BR significantly elevates respiratory pressure (p < 0.001) and impairs ventilatory response to graded exercise (reduced V E ; p < 0.001) at a greater degree with an increased level of BR which caused mild to moderate exercise-induced hypoxemia (final mean SpO 2 : CON = 95.6%, BR1 = 94.4%, BR2 = 91.6%, and BR3 = 90.6%; p < 0.001). Especially, such a marked reduction in SpO 2 was significantly correlated with maximal oxygen consumption at the volitional fatigue (r = 0.98, p < 0.001) together with exaggerated exertion and breathing discomfort (p < 0.001). In conclusion, added BR commonly experienced when wearing tight-fitting facemasks and/or respirators could significantly impair cardiopulmonary function and aerobic performance at a greater degree with an increasing level of BR.
... A first explication for this is the use of face masks due to the COVID-19 pandemic. Mask use can indeed lead to mild respiratory discomfort at rest and increased airflow resistance (Mapelli et al., 2021). Another possible reason is related to respiration awareness. ...
We supposed that past contradictory findings on the efficiencies of emotion regulation strategies might comefrom temporal resolution limitations and we proposed the use of a difference index to gain sensitivity for signaldifferences. 102 participants reappraised, suppressed, or just watched positive or negative images, while experience, expressivity, and physiological arousal were recorded. Reappraisal regulated efficiently negative but notpositive experience. Suppression presented opposite results in terms of experience, but was markedly more efficient than reappraisal on expressivity. Dynamic changes were found for physiological arousal. The differenceindex may be then an effective method for measuring the emotion unfolding and studying regulation dynamics.
... However, these could not be meta-analysed due to the low number of comparable studies on those particular complaints. In the included literature additional reported mask related symptoms were: rhinitis 80 , disabilities to think and to concentrate 58,61,68,78 , drowsiness 78 , communication disorder 61,88,89 , depression and mood swings 72,88,90,91 , anger 72 , perceived discomfort 41,45,52,73 , anxiety 72,88,91 , and an overall perceived fatigue and exhaustion 44,45,47,48,52,53,55,56,[61][62][63][64]66,69,70,86 . ...
Background: As face masks are a mandatory public health intervention during the COVID-19 pandemic, adverse effects require substantiated investigation.
Methods: A systematic review of 2168 studies yielded 54 publications for synthesis and 37 studies for meta-analysis (on n=8641, m=2482, f=6159, age=34.8±12.5). The median trial duration was only 18 min (IQR=50) for our comprehensive evaluation of mask induced physio-metabolic and clinical outcomes.
Results: We found significant effects in both medical masks with a greater impact regarding the N95. These effects included decreased SpO2 (overall SMD=-0.24, 95%CI=-0.38 to -0.11, p=0.0004) and minute ventilation (SMD=-0.72, 95%CI=-0.99 to -0.46, p<0.00001), simultaneously increased blood-CO2 (SMD=+0.64, 95%CI=0.31–0.96, p=0.0001), heart rate (N95: SMD=+0.22, 95%CI=0.03–0.41, p=0.02), systolic blood pressure (surgical: SMD=+0.21, 95%CI=0.03–0.39, p=0.02), skin temperature (overall SMD=+0.80 95%CI 0.23–1.38, p=0.006) and humidity (SMD +2.24, 95%CI=1.32–3.17, p<0.00001). Effects on exertion (overall SMD=+0.9, surgical=+0.63, N95=+1.19), discomfort (SMD=+1.16), dyspnoea (SMD=+1.46), heat (SMD=+0.70) and humidity (SMD=+0.9) were significant in 373 cases with a robust relationship to mask wearing (p<0.006 to p<0.00001). Pooled symptom prevalence was significant in users (n=8128) for: headache (62%, p<0.00001), acne (38%, p<0.00001), skin irritation (36%, p<0.00001), dyspnoea (33%, p<0.00001), heat (26%, p<0.00001), itching (26%, p<0.00001), voice disorder (23%, p<0.03) and dizziness (5%, p=0.01).
Discussion: Masks interfered with O2-uptake and CO2-release and compromised respiratory compensation. Though evaluated wearing durations do not represent daily/prolonged use, outcomes independently validate mask-induced exhaustion-syndrome (MIES). MIES can have long-term clinical consequences, especially for vulnerable groups.
Conclusion: Face mask side-effects must be assessed (risk-benefit) against the available evidence of their effectiveness against viral transmissions.
... All participants were able to perform HIE with the surgical mask with subjective discomfort but with no objective deterioration in the work rate achieved. Other recent studies have also suggested that standard surgical face masks have minimal impact on performance during HIE [33][34][35]. In part, this is probably consistent with the idea that inhaled and exhaled air finds pathways around the mask. ...
Background and Aim
COVID-19 can be transmitted through aerosolised respiratory particles. The degree to which exercise enhances aerosol production has not been previously assessed. We aimed to quantify the size and concentration of aerosol particles and evaluate the impact of physical distance and surgical mask wearing during high intensity exercise (HIE).
Methods
Using a prospective observational crossover study, three healthy volunteers performed high intensity cardiopulmonary exercise testing at 80% of peak capacity in repeated 5-minute bouts on a cycle ergometer. Aerosol size and concentration was measured at 35, 150 and 300 cm from the participants in an anterior and lateral direction, with and without a surgical face mask, using an Aerodynamic Particle Sizer (APS) and a Mini Wide Range Aerosol Spectrometer (MiniWRAS), with over 10,000 sample points.
Results
High intensity exercise generates aerosol in the 0.2–1 micrometre range. Increasing distance from the rider reduces aerosol concentrations measured by both MiniWRAS (p=0.003 for interaction) and APS (p=0.041). However, aerosol concentrations remained significantly increased above baseline measures at 300 cm from the rider. A surgical face mask reduced submicron aerosol concentrations measured anteriorly to the rider (p=0.031 for interaction) but not when measured laterally (p=0.64 for interaction).
Conclusions
High intensity exercise is an aerosol generating activity. Significant concentrations of aerosol particles are measurable well beyond the commonly recommended 150 cm of physical distancing. A surgical face mask reduces aerosol concentration anteriorly but not laterally to an exercising individual. Measures for safer exercise should emphasise distance and airflow and not rely solely on mask wearing.
... Additionally, our results found that perceived exertion statistically significantly increased in those wearing surgical masks compared to no masks. This change occurred because masks induced airflow resistance, increased facial temperature, and trapped heat or moisture from inhaled air, leading to increased dyspnea [22][23][24]. Previous studies found that 6MWT distances in healthy participants with masks were similar with those with no masks [16,25]. ...
Background: This study aims to investigate the impacts of surgical mask wearing on cardiopulmonary fitness using a six-minute walk test (6MWT) among older adults with hypertension.
Methods: The 45 older adults with hypertension volunteers were recruited and randomized into a no mask wearing condition and a surgical mask wearing condition. All volunteers were investigated through submaximal exercise testing using a 6MWT. Cardiopulmonary parameters were measured before and after performing a 6MWT.
Results: The results indicate post performance on the 6MWT for both the with and without surgical mask conditions significantly increased systolic blood pressure, heart rate, respiratory rate, and oxygen saturation (SpO2) when compared to before performing a 6MWT. However, surgical masks resulted in no differences to systolic blood pressure, diastolic blood pressure, heart rate, respiratory rate, SpO2, and 6MWT distance when compared to no masks. In contrast, the surgical mask condition significantly increased perceived exertion when compared with the no mask condition (p < 0.05).
Conclusion: This study indicates that surgical masks did not have an impact on cardiopulmonary fitness in older adults with hypertension.
... VCO 2 was examined in five studies [26,30,42,43,48], and a reduction in VCO 2 was observed among those wearing surgical masks and in terms of the total effect ( Fig. 4a) (SMD − 0.74 and SMD − 0.77, respectively). Additionally, 13 studies reported PetCO 2 [13-15, 29, 37, 39, 43, 48, 52, 55, 56, 58, 59]. ...
Background
Wearing face masks in public is an effective strategy for preventing the spread of viruses; however, it may negatively affect exercise responses. Therefore, this review aimed to explore the effects of wearing different types of face masks during exercise on various physiological and psychological outcomes in healthy individuals.MethodsA literature search was conducted using relevant electronic databases, including Medline, PubMed, Embase, SPORTDiscus, Web of Science, and Cochrane Central Register of Controlled Trials on April 05, 2022. Studies examining the effect of mask wearing (surgical mask, cloth mask, and FFP2/N95 respirator) during exercise on various physiological and psychological parameters in apparently healthy individuals were included. For meta-analysis, a random effects model was used. Mean difference (MD) or standardized MD (SMD) with 95% confidence intervals (CI) were calculated to analyze the total effect and the effect in subgroups classified based on face mask and exercise types. The quality of included studies was examined using the revised Cochrane risk-of-bias tool.ResultsForty-five studies with 1264 participants (708 men) were included in the systematic review. Face masks had significant effects on gas exchange when worn during exercise; this included differences in oxygen uptake (SMD − 0.66, 95% CI − 0.87 to − 0.45), end-tidal partial pressure of oxygen (MD − 3.79 mmHg, 95% CI − 5.46 to − 2.12), carbon dioxide production (SMD − 0.77, 95% CI − 1.15 to − 0.39), and end-tidal partial pressure of carbon dioxide (MD 2.93 mmHg, 95% CI 2.01–3.86). While oxygen saturation (MD − 0.48%, 95% CI − 0.71 to − 0.26) decreased slightly, heart rate was not affected. Mask wearing led to higher degrees of rating of perceived exertion, dyspnea, fatigue, and thermal sensation. Moreover, a small effect on exercise performance was observed in individuals wearing FFP2/N95 respirators (SMD − 0.42, 95% CI − 0.76 to − 0.08) and total effect (SMD − 0.23, 95% CI − 0.41 to − 0.04).Conclusion
Wearing face masks during exercise modestly affected both physiological and psychological parameters, including gas exchange, pulmonary function, and subjective discomfort in healthy individuals, although the overall effect on exercise performance appeared to be small. This review provides updated information on optimizing exercise recommendations for the public during the COVID-19 pandemic.Systematic Review Registration NumberThis study was registered in the International Prospective Register of Systematic Review (PROSPERO) database (registration number: CRD42021287278).
... This effect is attributed to reduced ventilation and increased resistance to airflow during inhalation. Despite the observed reduction in respiratory efficiency during exercise while wearing a mask, the differences were small enough that wearing a mask was considered safe even during maximal efforts [4]. ...
... Lässing et al. [26] examined the changes in lung function when wearing a SM at rest. Respiratory resistance was almost twice as high with SM than without mask Mapelli et al. [27] showed a reduction in static and dynamic lung function parameters (FVC/FEV 1 ) when wearing SM or N95. ...
At workplaces, many additional conditions and influences must be considered when choosing adequate personal protection equipment, including masks to protect from SARS-CoV-2 infection and transmission to other workmates. Conditions like type,
proximity and duration of contact with colleagues, duration of mask wear, virus load, heat, humidity must be included for the risk analysis and decision if a mask is needed and if yes, what kind of mask is the best choice. A good scientific knowledge on the efficiency and burden of protection against SARS-CoV-2 by wearing masks is useful as an additional fundamental prerequisite for this decision. Depending on the type of mask, respiratory masks can be effective for both self-protection and protection of others (Asadi et al. [1], Chu et al. [2], Leung et al. [3], Liang et al. [4]). Jefferson and colleagues presented the state of knowledge on the effectiveness of masks in preventing the transmission of respiratory viruses until 2020 in a comprehensive literature review. The knowledge gained in the meantime (01.01.2022) will be briefly supplemented here. However, the main concern of this overview is the evaluation of the current scientific data on possible objective and subjective strains and stresses caused by wearing masks at rest and under different working (exercising) conditions.
... Generally, effects of mask wearing during maximal efforts such as graded exercise tests until volitional exhaustion are well described 3,9,[11][12][13][14] . On contrary, the effects of mask wearing during steady state exercise, mirroring situations of daily living (exercise training, physical labour and leisure time activities), are rare. ...
Mask induced airway resistance and carbon dioxide rebreathing is discussed to impact gas exchange and to induce discomfort and impairments in cognitive performance. N = 23 healthy humans (13 females, 10 males; 23.5 ± 2.1 years) participated in this randomized crossover trial (3 arms, 48-h washout periods). During interventions participants wore either a surgical face mask (SM), a filtering face piece (FFP2) or no mask (NM). Interventions included a 20-min siting period and 20 min steady state cycling on an ergometer at 77% of the maximal heart rate (HR). Hemodynamic data (HR, blood pressure), metabolic outcomes (pulse derived oxygen saturation, capillary carbon dioxide (pCO2), and oxygen partial pressure (pO2), lactate, pH, base excess), subjective response (ability to concentrate, arousal, perceived exertion) and cognitive performance (Stroop Test) were assessed. Compared to NM, both masks increased pCO2 (NM 31.9 ± 3.3 mmHg, SM = 35.2 ± 4.0 mmHg, FFP2 = 34.5 ± 3.8 mmHg, F = 12.670, p < 0.001) and decreased pH (NM = 7.42 ± 0.03, SM = 7.39 ± 0.03, FFP2 = 7.39 ± 0.04, F = 11.4, p < 0.001) during exercise. The FFP2 increased blood pressure during exercise (NM = 158 ± 15 mmHg, SM = 159 ± 16 mmHg, FFP2 = 162 ± 17 mmHg, F = 3.21, p = 0.050), the SM increased HR during sitting (NM = 70 ± 8 bpm, SM = 74 ± 8 bpm, FFP2 = 73 ± 8 bpm, F = 4.70, p = 0.014). No mask showed any comparative effect on other hemodynamic, metabolic, subjective, or cognitive outcomes. Mask wearing leads to slightly increased cardiovascular stress and elevated carbon dioxide levels during exercise but did not affect cognitive performance or wellbeing.
... In contrast, our results found that wearing cloth masks and surgical masks statistically significantly increased perceived exertion when compared with no mask. The face masks increased airflow resistance, facial skin temperature and moisture or heat of the inhaled air, resulting in increased dyspnea [26][27][28]. Previous studies reported that healthy subjects wearing face masks recorded similar distances walked during the 6MWT compared to no mask [17,25,29], while changes after the 6MWT were found in heart failure or chronic lung disease patients [30,31]. ...
The effects of wearing cloth masks and surgical masks were investigated on respiratory rate, heart rate, blood pressure, oxygen saturation and perceived exertion at rest and after performing a six-minute walk test (6MWT) in older adults. Forty older adults were recruited and randomized into six groups including wearing no mask, cloth masks and surgical masks, at rest and during the 6MWT. At rest, all subjects sat quietly wearing no mask, a cloth mask or a surgical mask. All subjects performed a 6MWT by walking as fast as possible without running while wearing no mask, a cloth mask or a surgical mask. Respiratory rate, heart rate, blood pressure, oxygen saturation and perceived exertion were assessed before and after the rest and the 6MWT. Results showed that cloth masks and surgical masks did not impact cardiorespiratory parameters at rest or after performing a 6MWT, while an increase in perceived exertion was apparent in the groups wearing surgical masks and cloth masks after performing the 6MWT (p < 0.01). Cloth masks and surgical masks did not have an impact on cardiorespiratory fitness at rest and after performing the 6MWT in older adults.
... [8]. However, Shaw et al and Mapelli et al showed that wearing face masks did not affect performance (time to exhaustion and peak power) [4,9]. Similarly, Epstein et al found that heart rate, respiratory rate, blood pressure, oxygen saturation, and time to exhaustion did not differ significantly [10]. ...
Background
Face masks have become an important part of the COVID-19 prevention approach. This study aimed to explore the effect of wearing masks on exercise ability and ventilatory anaerobic threshold (VAT).
Material/Methods
Thirty-four young, healthy volunteers were included in this study, consisting of 18 men and 16 women. The subjects were randomized to perform 2 cardiopulmonary exercise tests (CPET) on a cycle ergometer with gas exchange analysis, one with and another without wearing a face mask (cross-over design). The general data for all subjects and indicators from the 2 exercise tests performed with and without wearing a face mask were collected.
Results
In cardiopulmonary exercise tests, wearing a mask significantly (P<0.05) decreased peak indexes (eg, work rate (WR), oxygen consumption per kg body weight (VO2/kg), heart rate (HR), ventilation per minute (VE) and carbon dioxide ventilation equivalent (VE/VCO2)) and anaerobic threshold indexes (eg, WR, HR, VE, breath frequency (BF), dead space ratio (VD/VT), and VE/VCO2). However, the PETCO2 at peak was significantly higher. There was a positive linear correlation between WR difference and VO2 difference at VAT (abbreviated as δWR@VAT and δVO2@VAT, respectively) (r=0.495, P=0.003). Subgroup analysis of the VAT indexes showed that WR, VO2/kg, and VE were significantly decreased in the advanced VAT group with mask compared with the stable VAT group with mask (P<0.05). Logistic regression showed that δVE, δBF, and δVE/VCO2 had independent influences on VAT.
Conclusions
Wearing masks advances VAT in healthy young subjects during CPET. The advanced VAT was associated with changes in VE, BF, and VE/VCO2 while wearing masks.
... Fikenzer et al. 24 found no differences in tidal volume and VE at rest while wearing SM or N95 compared to NM. Mapelli et al. 25 found that the tidal volume was not different, but VE was reduced at rest, while wearing an SM or an N95, and only VO 2 was reduced while wearing an N95 compared to NM. However, we found that tidal volume, VE, VO 2 , and VO 2 /HR were decreased both at rest and warm-up, regardless of whether an SM or an N95 was worn. ...
Background: During the COVID-19 pandemic, studies of the physiological effects of masking during exercise have been rare.
Methods: Twelve healthcare workers performed a cardiopulmonary exercise test while wearing a surgical mask, an N95 mask, or no mask. Variables were collected at rest, warm-up, anaerobic threshold, and maximal exercise.
Results: From rest to maximal exercise, both the surgical and N95 masks decreased inspiratory flow, minute ventilation, and prolonged inspiratory time compared to the no mask condition. Oxygen uptake (VO2) and oxygen pulse (VO2/HR) decreased at rest, warm-up, and maximal exercise in both the surgical and N95 mask conditions (vs. no mask). At the anaerobic threshold, the surgical mask also led to a reduction of oxygen uptake and oxygen pulse compared to no mask. The maximal oxygen uptake (VO2% predicted) also decreased in both the surgical and N95 mask conditions. In addition, the severity of dyspnea increased, and exercise time decreased for both surgical and N95 masks. Compared to no mask, wearing an N95 mask led to lower breathing frequency and lower ventilation efficacy (assessed by VE/VCO2 and VE/VO2) from rest to maximal exercise (all p < 0.05 for trend). Wearing an N95 also led to retention of carbon dioxide (p < 0.05 for trend).
Conclusions: Wearing a surgical mask leads to a somewhat negative impact on cardiopulmonary function, and this effect is more serious with an N95 mask. Attention should be paid to exercise while wearing surgical or N95 masks.
... Several studies indicated that mask-wearing could induce increased airway resistance. Mapelli and their colleagues reported a significant worsening of cardiorespiratory parameters (forced expiratory volume in one second, forced vital capacity, oxygen uptake, carbon dioxide production) when wearing face masks at rest [24]. Lässing et al. also reported an increase in airway resistance when wearing surgical masks [25]. ...
Background:
Since the onset of the COVID-19 pandemic, there have been many reported cases showing the consequences-or the collateral damages-of COVID-19 on patients with non-COVID-related diseases. This study aimed to compare the clinical manifestations and treatment results of non-COVID-related pneumothorax patients before and during the pandemic.
Methods:
We retrospectively reviewed non-COVID-related pneumothorax patients who visited our hospital before the onset of the pandemic and during the pandemic. The primary outcome was the difference in the amount of pneumothorax between the two periods, and the secondary outcome was the difference in the treatment results between them. Multivariable logistic regression was conducted to find risk factors related to massive pneumothorax.
Results:
There were 122 and 88 patients in the pre-pandemic and pandemic groups, respectively. There was no significant difference between the two groups with respect to the preoperative demographic variables. However, the median amount of pneumothorax was significantly higher in the pandemic group (pre-pandemic: 34.75% [interquartile range (IQR) 18.30-62.95] vs. pandemic: 53.55% [IQR 33.58-88.80], p < 0.0001) and massive pneumothorax were more frequent in the pandemic group (52.3% vs. 30.3%, p = 0.002). Furthermore, more patients experienced re-expansion pulmonary edema after treatments during the pandemic (p = 0.0366). In multivariable analysis, the pandemic (OR: 2.70 [95% CI 1.49-4.90], p = 0.0011) was related to the occurrence of massive pneumothorax.
Conclusion:
During the pandemic, patients presented with a larger size of pneumothorax and had more re-expansion pulmonary edema, even in a country that handled the COVID-19 pandemic relatively well.
... This year, Mapelli et al. evaluated the cardiorespiratory effects of facemasks via exercise tests on 12 healthy subjects. They found that subjects had higher mean ETCO 2 values with FFP2 respirators ( 19 ). Özdemir et al. also noted a significant increase in ETCO 2 with FFP respirators in their study in which 12 healthy male HCWs' physiological variables were monitored for 30 min in resting position ( 18 ). ...
Background
International COVID-19 guidelines recommend that health care workers (HCWs) wear filtering facepiece (FFP) respirators to reduce exposure risk. However, there are concerns about FFP respirators causing hypercapnia via rebreathing carbon dioxide (CO2). Most previous studies measured the physiological effects of FFP respirators on treadmills or while resting, and such measurements may not reflect the physiological changes of HCWs working in the emergency department (ED).
Objective
Our aim was to evaluate the physiological and clinical impacts of FFP type II (FFP2) respirators on HCWs during 2 h of their day shift in the ED.
Methods
We included emergency HCWs in this prospective cohort study. We measured end-tidal CO2 (ETCO2), mean arterial pressure (MAP), respiratory rate (RR), and heart rate values and dyspnea scores of subjects at two time points. The first measurements were carried out with medical masks while resting. Subjects then began their day shift in the ED with medical mask plus FFP2 respirator. We called subjects after 2 h for the second measurement.
Results
The median age of 153 healthy volunteers was 24.0 years (interquartile range 24.0–25.0 years). Subjects’ MAP, RR, and ETCO2 values and dyspnea scores were significantly higher after 2 h. Median ETCO2 values increased from 36.4 to 38.8 mm Hg. None of the subjects had hypercapnia symptoms, hypoxia, or other adverse effects.
Conclusion
We did not observe any clinical reflection of these changes in physiological values. Thus, we evaluated these changes to be clinically insignificant. We found that it is safe for healthy HCWs to wear medical masks plus FFP2 respirators during a 2-h working shift in the ED.
... Goh et al. examined End-Tidal pCO2, and oxygen saturation in 106 children aged 7-14 at rest and on exertion finding no relevant hypoxemia or hypercapnia [3]. The same was demonstrated in three other studies showing that during physical exertion, all masks are safe and have only minimal impact on performance and physiological variables [4][5][6]. However, during high-intensity exercise, wearing a face mask can have a relevant influence [7]. ...
In the current Sars-CoV-2 pandemic, wearing a face mask was mandatory and is still desired during school lessons. There are no controlled studies in children to date indicating an effect on cognitive performance wearing face masks. In a randomized controlled trial, we analysed the influence of face masks on cognitive performance of pupils during regular school lessons. Pupils (n=133, 5th to 7th grade) were randomized by alternating allocation into control (with masks, n=65) and intervention groups (without mask, n=68). After two school lessons with (control) and without (intervention) face masks in class all pupils performed digital tests for cognitive performance regarding attention and executive functions (Switch, CORSI block tapping, 2-back and flanker task). Overall, there were no significant differences in cognitive performance between both groups, masks vs. no masks. Wearing face masks has no significant influence on attention and executive functions of pupils and can still be recommended during school lessons.
Esse é o volume 4 de uma coletânea produzida pelo projeto de extensão Prazer em Conhecer: Temas da Atualidade – COVID-19, do NUPEM/UFRJ. É composta por um conjunto de infográficos preparados para esclarecer algumas questões acerca da pandemia de COVID-19. O objetivo é facilitar o acesso a conhecimentos sobre o vírus, a doença e seus meios de prevenção. Esses conhecimentos vêm sendo publicados em abundância e extrema velocidade por artigos científicos. Buscamos apresentar alguns deles de forma mais clara, rápida e acessível. Em virtude da rápida atualização de pesquisas sobre a COVID-19, as informações aqui contidas podem passar por modificações em edições futuras.
Filtering facepiece respirators (FFR's) such as N95s have become widely used in appropriate settings for personal respiratory protection and are increasingly used beyond workplace settings. Concerns about possible adverse effects have appeared in many publications, particularly since the COVID‐19 pandemic led to much more widespread use. This paper synthesizes known effects based upon review of publications in PubMed since 1995, addressing effects other than pulmonary and cardiovascular (reviewed elsewhere). Findings: (1) Subjective discomfort is very frequently reported; this includes general discomfort or organ‐system‐specific complaints such as respiratory, headache, dermatologic, and heat. Research methods are widely divergent, and we propose a taxonomy to classify such studies by methodology, study population (subjects, experimental vs. observational methodology, comparator, specificity, and timeframe) to facilitate synthesis. (2) Objective measures of increased heat and humidity within the mask are well documented. (3) Frequency and characteristics of dermatologic effects have been insufficiently evaluated. (4) Physical mask designs are varied, making generalizations challenging. (5) More studies of impact on work performance and communication are needed. (6) Studies of effect of FFR design and accompanying training materials on ease and consistency of use are needed.
Introduction
Face masks are used to reduce the spread of respiratory diseases. Physical exertion increases distance traveled by expelled particles, so masking while exercising is recommended to help prevent disease transmission. However, there is limited literature assessing masking during higher-intensity exercise.
Purpose
This study aimed to compare the impact of surgical masks on physiological and subjective measures during 45 min of a progressive exercise protocol as compared with unmasked exercise.
Methods
Each subject completed two random 45-min exercise trials (15 min each at 40%, 60%, and 80% of their oxygen uptake reserve) with and without a surgical mask in random order. Heart rate, oxygen saturation, respiratory rate (RR), ratings of perceived exertion, and dyspnea (Dys) were measured at each intensity. Repeated-measures ANOVA was utilized, and significance was set at P < 0.05.
Results
Thirty subjects (age, 20.4 ± 1.2 yr; peak oxygen uptake, 40.12 ± 11.05 mL·kg ⁻¹ ·min ⁻¹ ; 57% female) completed the study. When comparing masked and unmasked trials at each exercise intensity, differences were found only in RR (40%: 17.6 ± 4.9 vs 15.8 ± 4.9, P < 0.02, d = 0.4; 60%: 23.7 ± 5.5 vs 21.3 ± 6.2, P < 0.01, d = 0.4; 80%: 35.8 ± 9.0 vs 30.1 ± 8.8, P < 0.01, d = 0.6). When comparing masked with unmasked trials across all intensities, a difference was found in Dys (3.5 ± 2.4 vs 2.9 ± 2.2, respectively; P < 0.001, d = 0.3).
Conclusions
The use of surgical masks seems to impact RR and one’s perception of Dys, but has minimal influences on heart rate, oxygen saturation, and rating of perceived exertion. Other than increasing one’s RR and perceptions of Dys, it seems that exercising with a mask at moderate and vigorous intensities is acceptable in healthy individuals.
Introduction
Face masks were recognized as one of the most effective ways for preventing the spread of the COVID-19-virus in adults, the benefits of wearing those were extended to children and adolescents and led to limited physical education (PE) lessons or cancellation of them. This further decreased the amount of physical activity available to children and adolescents during the pandemic. However, there is little published data on the potential adverse effects on wearing the most effective and partially mandatory FFP2/N95 face-masks during PE or physical activity (PA) in this age. Even though the pandemic has been declared as passed by the WHO, the rise of a new pandemic and thus the use of face-masks for limiting its spread is inevitable, so we need to be prepared in a better way for alternative options to lockdown and limitation of PA in such a scenario.
Material and Methods
20 healthy children aged 8–10 years performed two identical cardiopulmonary exercise tests as an incremental step test on a treadmill within an interval of two weeks, one time without wearing a protective mask and one time wearing a FFP2 mask. The cardiopulmonary exercise parameter and especially the endexpiratory gas exchange for oxygen and carbon dioxide (petO2 and petCO2) were documented for each step, at rest and 1 minute after reaching physical exhaustion.
Results
12 boys (mean age 8.5 ± 1.4 years) and 8 girls (mean age 8.8 ± 1.4 years) showed no adverse events until maximal exertion. The mean parameters measured at peak exercise did not differ significantly between both examinations (mean Peak VO2 = 42.7 ± 9.5 vs 47.8 ± 12.9 ml/min/kg, mean O2pulse 7.84 ± 1.9 ml/min vs. 6.89 ± 1.8, mean VE/VCO2slope 33.4 ± 5.9 vs. 34.0 ± 5.3). The most significant difference was the respiratory exchange rate (RER, 1.01 ± 0.08 vs 0.95 ± 0.08). The measured respiratory gases (end tidal O2 and CO2) decreased respectively increased significantly into nearly each step wearing an additional FFP2-mask without reaching levels of hypercapnia or hypoxia.
Conclusion
In this study, no significant differences of the cardiorespiratory function at peak exercise could be discerned when wearing a FFP2/N95 face mask. While the end-tidal values for CO2 increased significantly and the end-tidal values for O2 decreased significantly, these values did never reach pathological levels. Furthermore, the children terminated the exercise at a lower RER and heart rate (HR) suggesting a subconscious awareness of the higher strain. Since the detrimental effects of limiting sports during the pandemic are well documented, stopping PE lessons altogether because of the minor physiological effects wearing these masks instead of simply stopping pushing children to perform at their best seems premature and should be reconsidered in the future.
Background:
From 2020, most countries all over the world have implemented strategies aimed at limiting contagion of COVID-19. The pandemic caused a reduction in physical activity (PA) and sports at all levels. The aim of the present study was to analyze and quantify the related impact of imposed PA restrictions on functional capacity in young athletes.
Methods:
This observational cohort study evaluated annually the exercise capacity of a sample of young athletes (N.=344) referred for the pre-participation screening at our Sports and Exercise Medicine Division (2017-2021). Standardized maximal exercise testing was performed on treadmill and linear mixed models analyzed metabolic equivalent of tasks (METs) and exercise time as dependent variables.
Results:
METs and exercise time showed a reduction in the year 2020 and a subsequent increase in 2021, with males revealing a faster recovery in exercise capacity. Athletes who maintained >250 annual training hours were less affected by the pandemic.
Conclusions:
These data suggest a significant impact of forced physical inactivity on a cohort of apparently healthy young athletes. The COVID-19-related experience should lead to strategies to avoid negative effects and long-term consequences of containment measures.
Wearing a cloth face mask has been shown to impair exercise performance; it is essential to understand the impact wearing a cloth face mask may have on cognitive performance. Participants completed two maximal cardiopulmonary exercise tests on a cycle ergometer (with and without a cloth face mask) with a concurrent cognitive task. Blood pressure, heart rate, oxygen saturation, perceived exertion, shortness of breath, accuracy, and reaction time were measured at rest, during each exercise stage, and following a 4-minute recovery period. The final sample included 35 adults (age = 26.1 ± 5.8 years; 12 female/23 male). Wearing a cloth face mask was associated with significant decreases in exercise duration (−2:00 ± 3:40 min, P = 0.003), peak measures of maximal oxygen uptake (−818.9 ± 473.3 mL/min, −19.0 ± 48 mL·min⁻¹·kg⁻¹, P < 0.001), respiratory exchange ratio (−0.04 ± 0.08, P = 0.005), minute ventilation (−36.9 ± 18 L/min), oxygen pulse (−3.9 ± 2.3, P < 0.001), heart rate (−7.9 ± 12.6 bpm, P < 0.001), oxygen saturation (−1.5 ± 2.8%, P = 0.004), and blood lactate (−1.7 ± 2.5 mmol/L, P < 0.001). While wearing a cloth face mask significantly impaired exercise performance during maximal exercise testing, cognitive performance was unaffected in this selected group of young, active adults.
Objectives
Physical exertion is a high-risk activity for aerosol emission of respiratory pathogens. We aimed to determine the safety and tolerability of healthy young adults wearing different types of face mask during moderate-to-high intensity exercise.
Design
Cross-over randomised controlled study, completed between June 2021 and January 2022.
Participants
Volunteers aged 18–35 years, who exercised regularly and had no significant pre-existing health conditions.
Interventions
Comparison of wearing a surgical, cloth and filtering face piece (FFP3) mask to no mask during 4×15 min bouts of exercise. Exercise was running outdoors or indoor rowing at moderate-to-high intensity, with consistency of distance travelled between bouts confirmed using a smartphone application (Strava). Each participant completed each bout in random order.
Outcomes
The primary outcome was change in oxygen saturations. Secondary outcomes were change in heart rate, perceived impact of face mask wearing during exercise and willingness to wear a face mask for future exercise.
Results
All 72 volunteers (mean age 23.9) completed the study. Changes in oxygen saturations did not exceed the prespecified non-inferiority margin (2% difference) with any mask type compared with no mask. At the end of exercise, the estimated average difference in oxygen saturations for cloth mask was −0.07% (95% CI −0.39% to 0.25%), for surgical 0.28% (−0.04% to 0.60%) and for FFP3 −0.21% (−0.53% to 0.11%). The corresponding estimated average difference in heart rate for cloth mask was −1.20 bpm (95% CI −4.56 to 2.15), for surgical 0.36 bpm (95% CI −3.01 to 3.73) and for FFP3 0.52 bpm (95% CI −2.85 to 3.89). Wearing a face mask caused additional symptoms such as breathlessness (n=13, 18%) and dizziness (n=7, 10%). 33 participants broadly supported face mask wearing during exercise, particularly indoors, but 22 were opposed.
Conclusion
This study adds to previous findings (mostly from non-randomised studies) that exercising at moderate-to-high intensity wearing a face mask appears to be safe in healthy, young adults.
Trial registration number
NCT04932226
Background: As face masks are a mandatory public health intervention during the COVID-19 pandemic, adverse effects require substantiated investigation.
Methods: A systematic review of 2168 studies yielded 54 publications for synthesis and 37 studies for meta-analysis (on n=8641, m=2482, f=6159, age=34.8±12.5). The median trial duration was only 18 min (IQR=50) for our comprehensive evaluation of mask induced physio-metabolic and clinical outcomes.
Results: We found significant effects in both medical masks with a greater impact regarding the N95. These effects included decreased SpO2 (overall SMD=-0.24, 95%CI=-0.38 to -0.11, p=0.0004) and minute ventilation (SMD=-0.72, 95%CI=-0.99 to -0.46, p<0.00001), simultaneously increased blood-CO2 (SMD=+0.64, 95%CI=0.31–0.96, p=0.0001), heart rate (N95: SMD=+0.22, 95%CI=0.03–0.41, p=0.02), systolic blood pressure (surgical: SMD=+0.21, 95%CI=0.03–0.39, p=0.02), skin temperature (overall SMD=+0.80 95%CI 0.23–1.38, p=0.006) and humidity (SMD +2.24, 95%CI=1.32–3.17, p<0.00001). Effects on exertion (overall SMD=+0.9, surgical=+0.63, N95=+1.19), discomfort (SMD=+1.16), dyspnoea (SMD=+1.46), heat (SMD=+0.70) and humidity (SMD=+0.9) were significant in 373 cases with a robust relationship to mask wearing (p<0.006 to p<0.00001). Pooled symptom prevalence was significant in users (n=8128) for: headache (62%, p<0.00001), acne (38%, p<0.00001), skin irritation (36%, p<0.00001), dyspnoea (33%, p<0.00001), heat (26%, p<0.00001), itching (26%, p<0.00001), voice disorder (23%, p<0.03) and dizziness (5%, p=0.01).
Discussion: Masks interfered with O2-uptake and CO2-release and compromised respiratory compensation. Though evaluated wearing durations do not represent daily/prolonged use, outcomes independently validate mask-induced exhaustion-syndrome (MIES). MIES can have long-term clinical consequences, especially for vulnerable groups.
Conclusion: Face mask side-effects must be assessed (risk-benefit) against the available evidence of their effectiveness against viral transmissions.
Unlabelled:
Filtering facepiece respirators (FFRs) were introduced to protect the wearer by removing small particles from inspired air. FFRs are now also used to reduce spread of transmissible agents from the wearer and used outside traditional healthcare and other workplaces. The COVID-19 pandemic increased concerns about potential adverse effects on wearers.
Method:
A PUBMED query retrieved papers through June 2022. Abstracts and selected full text papers were systematically reviewed by the authors. This paper focuses upon cardiopulmonary physiologic effects (e.g., ventilation, CO2 elimination, oxygen uptake, and respiratory control) with emphasis upon current and potential research methods as well as summarizing results.
Results:
1985 records were identified, of which only 26% were published prior to 2020.
Conclusions:
Effects on CO2 elimination appear more likely to be potentially significant than effects on oxygenation or cardiovascular function. While FFRs appear well tolerated by healthy persons, more research is needed for those with pulmonary or cardiac disorders and for children. Many traditional pulmonary exercise study methods require special care when applied to filtering facepiece respirators. Studying additional parameters may explain the paradox of many subjective discomfort reports despite very limited physiologic effects. This article is protected by copyright. All rights reserved.
Zusammenfassung
Die Bedeutung der Aerosolübertragung für das Severe Acute Respiratory Syndrome Coronavirus Type 2 (SARS-CoV-2) wurde anfangs kontrovers diskutiert. Mit der Zeit haben sich zur Infektionsminderung jedoch neben Abstands- und Hygieneregeln auch aerosolphysikalisch begründete Maßnahmen wie das Tragen von Gesichtsmasken und Lüftung von Innenräumen als effektiv erwiesen. In einem interdisziplinären Workshop „Aerosol & SARS-CoV-2“ der Gesellschaft für Aerosolforschung (GAeF) in Kooperation mit der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin (DGP), dem Fachverband Allgemeine Lufttechnik im VDMA, der Gesellschaft für Virologie (GfV), der Gesundheitstechnischen Gesellschaft (GG) und der International Society for Aerosols in Medicine (ISAM) unter der Schirmherrschaft des Robert-Koch-Instituts (RKI) im März 2021 wurde der Forschungs- und Abstimmungsbedarf zu diesem Thema aufgegriffen. Wesentliche Grundlagen aus den verschiedenen Disziplinen sowie interdisziplinäre Perspektiven zur Aerosolübertragung von SARS-CoV-2 und zu infektionsmindernden Maßnahmen werden hier zusammengefasst. Abschließend werden offene Forschungsfragen und dringender Forschungsbedarf dargestellt.
Introduction: The 2019 Coronavirus Disease (COVID-19) pandemic causes public health protocols to be strictly enforced. This may disrupt the willingness to practice sports and/or exercises due to the requirement of masks, which may be uncomfortable and limiting for some people. However, masks are not an obstacle for someone to exercise. Moreover, some exercises, including respiratory-focused ones, are known to be particularly beneficial for one’s health. This study examined the effect of using masks on performing exercises, particularly respiratory exercises, in the era of COVID-19 pandemic.
Methods: A total of 24 people participated in this study using randomization and cross over techniques. The variables measured were respiratory rate, oxygen (O2) saturation, pulse rate, carbon monoxide (CO) levels, and fatigue scale using the Borg Breathless Score. Statistical test used independent t test, Wilcoxon, and Mann-Whitney U with a difference level of p < 0.05.
Results: There was no significant difference between the observed parameters (heart rate, respiratory rate, peripheral O2 saturation, CO levels, and Borg scale) in the groups using masks and not using masks.
Conclusion: The increase in pulse rate, respiratory rate, and Borg Scale in the aerobic phase of respiratory exercise is physiological and can improve significantly after the cooling phase.
Objective:
The aim of this study was to evaluate the effects of the use of both surgical masks and FFP2 respirators on the inspiratory muscle strength, metabolic parameters, heart rate, subjective perceived exertion, and dyspnea perception, before and during 30 min stable load exercise at "conversational level".
Methods:
A randomized cross-over study was carried out. Nineteen healthy adults completed 3 conditions (without a mask, with a surgical mask or an FFP2 respirator) during a 30-min steady-state test at the lactate threshold intensity. Inspiratory muscle strength was measured before and after the test, and metabolic parameters, heart rate, subjective perceived exertion, and dyspnea perception were collected at baseline, during, and after the test.
Results:
There was a significant reduction in inspiratory muscle strength after the 30-min test in all conditions (control: 6.26 mm Hg, p < 0.5; surgical mask: 8.55 mm Hg, p < 0.01; FFP2 respirator: 12.42 mm Hg, p < 0.001), but without significant differences between them (p = 0.283). Data showed a statistically significant effect for time, but did not show a statistically significant interaction between condition and time for heart rate (p = 0.674), oxygen saturation (p = 0.297), blood lactate level (p = 0.991), rating perceived exertion (p = 0.734) and dyspnea (p = 0.532) comparisons.
Conclusions:
The present study findings suggested that inspiratory muscle strength and physiological parameters during "conversational level" exercise were not impaired under wearing masks in healthy, nonsmoking young adults.
Wearing face masks reduce the maximum physical performance. Sports and occupational activities are often associated with submaximal constant intensities. This prospective crossover study examined the effects of medical face masks during constant-load exercise. Fourteen healthy men (age 25.7 ± 3.5 years; height 183.8 ± 8.4 cm; weight 83.6 ± 8.4 kg) performed a lactate minimum test and a body plethysmography with and without masks. They were randomly assigned to two constant load tests at maximal lactate steady state with and without masks. The cardiopulmonary and metabolic responses were monitored using impedance cardiography and ergo-spirometry. The airway resistance was twofold higher with the surgical mask (SM) than without the mask (SM 0.58 ± 0.16 kPa l −1 vs. control [Co] 0.32 ± 0.08 kPa l −1 ; p < 0.01). The constant load tests with masks compared with those without masks resulted in a significantly different ventilation (77.1 ± 9.3 l min −1 vs. 82.4 ± 10.7 l min −1 ; p < 0.01), oxygen uptake (33.1 ± 5 ml min −1 kg −1 vs. 34.5 ± 6 ml min −1 kg −1 ; p = 0.04), and heart rate (160.1 ± 11.2 bpm vs. 154.5 ± 11.4 bpm; p < 0.01). The mean cardiac output tended to be higher with a mask (28.6 ± 3.9 l min −1 vs. 25.9 ± 4.0 l min −1 ; p = 0.06). Similar blood pressure (177.2 ± 17.6 mmHg vs. 172.3 ± 15.8 mmHg; p = 0.33), delta lactate (4.7 ± 1.5 mmol l −1 vs. 4.3 ± 1.5 mmol l −1 ; p = 0.15), and rating of perceived exertion (6.9 ± 1.1 vs. 6.6 ± 1.1; p = 0.16) were observed with and without masks. Surgical face masks increase airway resistance and heart rate during steady state exercise in healthy volunteers. The perceived exertion and endurance performance were unchanged. These results may improve the assessment of wearing face masks during work and physical training.
To minimize transmission of SARS-CoV-2, the novel coronavirus responsible for COVID-19, the Center for Disease Control and World Health Organization recommend wearing facemasks in public. Some have expressed concern that these may affect the cardiopulmonary system by increasing the work of breathing (Wb), altering pulmonary gas exchange and increasing dyspnea, especially during physical activity. These concerns have been derived largely from studies evaluating devices intentionally designed to severely affect respiratory mechanics and gas exchange. We review the literature on the effects of various facemasks and respirators on the respiratory system during physical activity using data from several models: cloth face coverings and surgical masks, N95 respirators, industrial respirators and applied high resistive or high deadspace respiratory loads. Overall, the available data suggest that although dyspnea may be increased and alter perceived effort with activity, the effects on Wb, blood gases and other physiological parameters imposed by facemasks during physical activity are small, often too small to be detected, even during very heavy exercise. There is no current evidence to support sex-based or age-based differences in the physiological responses to exercise while wearing a facemask. While the available data suggest that negative effects of using cloth or surgical facemasks during physical activity in healthy individuals are negligible and unlikely to impact exercise tolerance significantly, for some individuals with severe cardiopulmonary disease, any added resistance and/or minor changes in blood gases may evoke considerably more dyspnea and, thus, affect exercise capacity.
COVID-19 outbreak has a profound impact on almost every aspect of life. Universal masking is recommended as a means of source control. Routinely exercising in a safe environment is an important strategy for healthy living during this crisis. As sports clubs and public spaces may serve a source of viral transmission, masking may become an integral part of physical activity. This study aimed to assess the physiological effects of wearing surgical masks and N95 respirators during short term strenuous workout. This was a multiple cross-over trial of healthy volunteers. Using a standard cycle ergometry ramp protocol, each subject performed a maximal exercise test without a mask, with a surgical mask, and with an N95 respirator. Physiological parameters and time to exhaustion were compared. Each subject served his own control. Sixteen male volunteers (mean age and BMI of 34 ±4 years and 28.72 ±3.78 kg/m2, respectively) completed the protocol. Heart rate, respiratory rate, blood pressure, oxygen saturation, and time to exhaustion did not differ significantly. Exercising with N95 mask was associated with a significant increase in end-tidal carbon-dioxide (EtCO2 ) levels. The differences were more prominent as the load increased, reaching 8mmHg at exhaustion (none vs. N95, p=0.001). In conclusion, in healthy subjects, short term moderate-strenuous aerobic physical activity with a mask is feasible, safe, and associated with only minor changes in physiological parameters, particularly a mild increase in EtCO2 . Subjects suffering from lung diseases should have a cautious evaluation before attempting physical activity with any mask.
Background
Due to the SARS-CoV2 pandemic, medical face masks are widely recommended for a large number of individuals and long durations. The effect of wearing a surgical and a FFP2/N95 face mask on cardiopulmonary exercise capacity has not been systematically reported.Methods
This prospective cross-over study quantitated the effects of wearing no mask (nm), a surgical mask (sm) and a FFP2/N95 mask (ffpm) in 12 healthy males (age 38.1 ± 6.2 years, BMI 24.5 ± 2.0 kg/m2). The 36 tests were performed in randomized order. The cardiopulmonary and metabolic responses were monitored by ergo-spirometry and impedance cardiography. Ten domains of comfort/discomfort of wearing a mask were assessed by questionnaire.ResultsThe pulmonary function parameters were significantly lower with mask (forced expiratory volume: 5.6 ± 1.0 vs 5.3 ± 0.8 vs 6.1 ± 1.0 l/s with sm, ffpm and nm, respectively; p = 0.001; peak expiratory flow: 8.7 ± 1.4 vs 7.5 ± 1.1 vs 9.7 ± 1.6 l/s; p < 0.001). The maximum power was 269 ± 45, 263 ± 42 and 277 ± 46 W with sm, ffpm and nm, respectively; p = 0.002; the ventilation was significantly reduced with both face masks (131 ± 28 vs 114 ± 23 vs 99 ± 19 l/m; p < 0.001). Peak blood lactate response was reduced with mask. Cardiac output was similar with and without mask. Participants reported consistent and marked discomfort wearing the masks, especially ffpm.Conclusion
Ventilation, cardiopulmonary exercise capacity and comfort are reduced by surgical masks and highly impaired by FFP2/N95 face masks in healthy individuals. These data are important for recommendations on wearing face masks at work or during physical exercise.
We identified seasonal human coronaviruses, influenza viruses and rhinoviruses in exhaled breath and coughs of children and adults with acute respiratory illness. Surgical face masks significantly reduced detection of influenza virus RNA in respiratory droplets and coronavirus RNA in aerosols, with a trend toward reduced detection of coronavirus RNA in respiratory droplets. Our results indicate that surgical face masks could prevent transmission of human coronaviruses and influenza viruses from symptomatic individuals.
During exercise, heart failure patients (HF) show an out-of-proportion ventilation increase, which in patients with COPD is blunted. When HF and COPD coexist, the ventilatory response to exercise is unpredictable.
We evaluated a human model of respiratory impairment in 10 COPD-free HF patients and in 10 healthy subjects, tested with a progressive workload exercise with different added dead space. We hypothesized that increased serial dead space upshifts the VE vs. VCO2 relationship and that the VE-axis intercept might be an index of dead space ventilation.
All participants performed a cardiopulmonary exercise test with 0, 250 and 500 mL of additional dead space. Since DS does not contribute to gas exchange, ventilation relative to dead space is ventilation at VCO2 = 0, i.e. VE-axis intercept. We compared dead space volume, estimated dividing VE-axis intercept by the intercept on respiratory rate axis of the respiratory rate vs. VCO2 relationship with standard method measured DS.
In HF, adding dead space increased VE-axis intercept (+0 mL = 4.98±1.63 L; +250 mL = 9.69±2.91 L; +500 mL = 13.26±3.18 L; p<0.001) and upshifted the VE vs.VCO2 relationship, with a minor slope rise (+0 mL = 27±4 L; +250 = 28±5; +500 = 29±4; p<0.05). In healthy, adding dead space increased VE-axis intercept (+0 mL = 4.9±1.4 L; +250 = 9.3±2.4; +500 = 13.1±3.04; p<0.001) without slope changes. Measured and estimated dead space volumes were similar both in HF and healthy subjects.
VE-axis intercept is related to dead space ventilation and dead space volume can be non-invasively estimated.
Spirometry and maximal respiratory pressures are pulmonary function parameters commonly used to evaluate respiratory function. Prediction values are available for conventional lung function devices using a standard tube or flanged type of mouthpiece connection. This equipment is not suitable for patients with facial or buccal muscle weakness, because of air leakage around the mouthpiece. A face mask was used for the portable lung function devices used in the neuromuscular department. The aim of this study was to compare the face mask and the conventional mouthpiece for the measurement of spirometry and of respiratory pressures in 22 healthy subjects. Values obtained with the conventional mouthpiece differed significantly from values obtained with the face mask. With the mask, forced vital capacity and forced expiratory volume in one second were 200 mL lower, and maximal expiratory pressure was 3.2 kPa lower than with the mouthpiece. Subsequently, new prediction values for face mask spirometry and maximal respiratory pressures were obtained from 252 other healthy subjects, from which new prediction equations were derived. It was concluded that the face mask connection to the lung function device is a valid alternative, is easy to use and is most useful to monitor changes in patients. This study confirms the importance of appropriate prediction equations, depending on subject-instrument interfaces.
Governments are preparing for a potential influenza pandemic. Therefore they need data to assess the possible impact of interventions. Face-masks worn by the general population could be an accessible and affordable intervention, if effective when worn under routine circumstances.
We assessed transmission reduction potential provided by personal respirators, surgical masks and home-made masks when worn during a variety of activities by healthy volunteers and a simulated patient.
All types of masks reduced aerosol exposure, relatively stable over time, unaffected by duration of wear or type of activity, but with a high degree of individual variation. Personal respirators were more efficient than surgical masks, which were more efficient than home-made masks. Regardless of mask type, children were less well protected. Outward protection (mask wearing by a mechanical head) was less effective than inward protection (mask wearing by healthy volunteers).
Any type of general mask use is likely to decrease viral exposure and infection risk on a population level, in spite of imperfect fit and imperfect adherence, personal respirators providing most protection. Masks worn by patients may not offer as great a degree of protection against aerosol transmission.
Background
Cardiopulmonary exercise test and 6-minute walking test are frequently used tools to evaluate physical performance in heart failure (HF), but they do neither represent activities of daily living (ADLs) nor fully reproduce patients’ symptoms. We assessed differences in task oxygen uptake, both as absolute value and as percentage of peak oxygen consumption (peakVO 2 ), ventilation efficiency (VE/VCO 2 ratio), and dyspnea intensity (Borg scale) in HF and healthy subjects during standard ADLs and other common physical actions.
Methods
Healthy and HF subjects (ejection fraction <45%, stable conditions) underwent cardiopulmonary exercise test. All of them, carrying a wearable metabolic cart, performed a 6-minute walking test, two 4-minute treadmill exercises (at 2 and 3 km/h), and ADLs: ADL1 (getting dressed), ADL2 (folding 8 towels), ADL3 (putting away 6 bottles), ADL4 (making a bed), ADL5 (sweeping the floor for 4 minutes), ADL6 (climbing 1 flight of stairs carrying a load).
Results
Sixty patients with HF (age 65.2±12.1 years; ejection fraction 30.4±6.7%, peakVO 2 14.2±4.0 mL/[min·kg]) and 40 healthy volunteers (58.9±8.2 years, peakVO 2 28.1±7.4 mL/[min·kg]) were enrolled. For each exercise, patients showed higher VE/VCO 2 ratio, percentage of peakVO 2 , and Borg scale value than controls, while absolute values of task oxygen uptake and exercise duration were lower and higher, respectively, in all activities, except for treadmill (fixed execution time and intensity). Differently from Borg Scale data, metabolic values and exercise time length changed in parallel with HF severity, except for ADL duration in very short (ADL3) and composite (ADL1) activities. Borg scale values correlated with percentage of peakVO 2 .
Conclusions
During ADLs, patients self-regulated activities in parallel with HF severity by decreasing intensity (VO 2 ) and prolonging the effort.
To date, the pandemic spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has involved over 100 countries in a matter of weeks, and Italy suffers from almost 1/3 of the dead cases worldwide.
In this report, we show the strategies adopted to face the emergency at Centro Cardiologico Monzino, a mono-specialist cardiology hospital sited in the region of Italy most affected by the pandemic, and specifically we describe how we have progressively modified in a few weeks the organization of our Heart Failure Unit in order to cope with the new COVID-19 outbreak. In fact, on the background of the pandemic, cardiovascular diseases still occur frequently in the general population, but we observed consistent reduction in hospital admissions for acute cardiovascular events and a dramatic increase of late presentation acute myocardial infarction. Despite a reduction of healthcare workers number, our ward has been rearranged in order to take care of both COVID-19 and cardiovascular patients. In particular according to a triple step procedure we divided admitted patients in confirmed, suspected and excluded cases (respectively allocated in “red”, “pink” and “green” separated areas).
Due to the absence of definite guidelines, our aim was to describe our strategy in facing the current emergency, in order to reorganize our hospital in a dynamic and proactive manner. To quote the famous Italian writer Alessandro Manzoni ‘It is less bad to be agitated in doubt than to rest in error.’
In the present practice review, we will explain how to perform and interpret a cardiopulmonary exercise test (CPET)in heart failure patients. Specifically, we will explain why cycle ergometer should be preferred to treadmill, the type of protocol needed, and the ideal exercise duration. Thereafter, we will discuss how to interpret CPET findings and determine the parameters that should be included. We will focus specifically on: peak VO 2 (absolute value and a percentage of its predicted value), exercise duration, respiratory exchange ratio, peak work rate, heart rate, O 2 pulse, end-tidal carbon dioxide pressure (PetCO 2 ), PetO 2 , and -if blood gas samples are obtained-dead space to tidal volume ratio. Moreover, we will discuss the physiological and clinical value of anaerobic threshold, respiratory compensation point, ventilation vs. VCO 2 and VO 2 vs. work relationships. Finally, attention will be dedicated to exercise-induced periodic breathing. We will also discuss when and why CPET should be integrated with other measurements in the so-called complex CPET. Specifically: a)when and how to use a complex non-invasive CPET, which integrates CPET measurements with non-invasive cardiac output determination, working muscle near-infrared spectroscopy, transthoracic echocardiography, thoracic ultrasound, and lung diffusion analysis; b)when and how to use a complex minimally invasive CPET, in which CPET is combined with esophageal balloon recordings or with serial arterial blood sampling for blood gas analysis; c)when and how to use a complex invasive CPET, which usually implies the presence of a Swan Ganz catheter in the pulmonary artery and an arterial line.
CO2 is generated when lactate is increased during exercise because its [H'] is buffered primarily by HCO: (22 ml for each meq of lactic acid). We developed a method to detect the anaerobic threshold (AT), using computerized regression analysis of the slopes of the CO, uptake (ko,) vs. 0, uptake (VO,) plot, which detects the beginning of the excess CO, output generated from the buffering of [H'], termed the V-slope method. From incremental exercise tests on 10 subjects, the point of excess CO, output (AT) predicted closely the lactate and HCO: thresholds. The mean gas exchange AT was found to correspond to a small increment of lactate above the mathematically defined lactate threshold [0.50 t 0.34 (SD) meq/l] and not to differ significantly from the estimated HCO: threshold. The mean VO, at AT computed by the V-slope analysis did not differ significantly from the mean value determined by a panel of six experienced reviewers using traditional visual methods, but the AT could be more reliably determined by the V-slope method. The respiratory compensation point, detected separately by examining the minute ventilation vs. VCO~ plot, was consistently higher than the AT (2.51 t 0.42 vs. 1.83 t 0.30 l/min of VOW). This method for determining the AT has significant advantages over others that depend on regular breathing pattern and respiratory chemosensitivity.
