Powered Air Purifying Respirator (PAPR) restores the N95 face mask induced cerebral hemodynamic alterations among Healthcare Workers during COVID-19 Outbreak

Primary Headache Attributed to External Compression or Traction to the Head: A Narrative Review

BACKGROUND

The aim of this review is to synthesize the existing knowledge regarding headaches attributed to external physical stimuli, as classified by the ICHD-3 (Group 4.6). Two forms can be distinguished in this group: (1) headache attributed to external compression and (2) headache attributed to external traction.

METHODS

A comprehensive literature review was conducted using the Medline (PubMed) database and other relevant academic sources. All English-language articles were subjected to a relevance assessment.

RESULTS

The prevalence of the two types of headache varies considerably, with a higher incidence observed in women or in the presence of predisposing factors (e.g., work with compulsory helmets or long hair). An external-compression headache is typically described as a pressing sensation, whereas an external-traction headache is characterized by a sensation of pulling. The headaches typically persist for less than an hour after the stimulus has ceased, and the intensity is typically reported as mild to moderate. Apart from avoiding the trigger, which is not always possible, effective therapies have not been established.

CONCLUSION

Both types of headaches are relatively common, yet they remain underrepresented in the scientific literature. Furthermore, there is a dearth of comprehensive overviews. If the triggering factor cannot be eliminated, both types of headaches can interfere with daily living and working.

Feasibility study of a low-cost powered air-purifying respirator (PAPR): A hospital-based simulation study to assess the perception of healthcare professionals

Background There is a need for affordable and effective air-filtering respirators, that provide the user protection against infection and are comfortable to wear. Among the various air-filtering respirators, powered air-purifying respirators (PAPR) that supply the user with filtered air through a powered system provide better protection than the commonly used N-95 masks, that directly filters the air that surrounds the user, with filtration efficiency of these procedures being up to 99.99% and up to 95%, respectively. However, in India, the PAPRs are imported, making them unaffordable. Engineers at our university developed a low-cost PAPR model. We investigated the feasibility of using this low-cost PAPR as a potential air-filtering respirator as part of personal protective equipment. Methods In a simulation study, 20 woman nurses wore an N-95 mask with face shield, or the low-cost PAPR in two separate sessions and performed routine nursing tasks. They then answered questionnaires to assess their perceived comfort and suitability for the tasks. Results The low-cost PAPR provided better breathing comfort and vision. However, the current N-95 mask system was perceived to be more suitable for tasks requiring high mobility. Discussion Our study demonstrated the feasibility of the low-cost PAPR model, particularly for low-mobility tasks.

The influence of N95 and surgical masks on carbon dioxide levels: A comprehensive systematic review and meta-analysis

Objectives

This study aimed to assess the impact of wearing N95 and surgical masks on carbon dioxide (CO2) concentrations during various activity levels, to understand the implications for mask use in different settings, especially in light of the COVID-19 pandemic.

Study design

Systematic Review and Meta-Analysis.

Methods

A systematic review was conducted, retrieving 6798 articles from PubMed, Web of Science, and Scopus databases. Twenty-nine articles met the inclusion criteria. Mask types were categorized into N95 and surgical masks, while activities were classified as low, medium, and high.

Results

The meta-analysis revealed CO2 concentrations (mmHg) for different scenarios: No mask (37.91, 95 % CI: 36.46, 39.35), N95-low (36.83, 95 % CI: 33.57, 40.10), N95-moderate (37.85, 95 % CI: 36.51, 39.20), N95-high (39.51, 95 % CI: 38.00, 41.02), N95 with exhalation valve (35.82, 95 % CI: 32.89, 38.75), N95 without exhalation valve (38.45, 95 % CI: 37.10, 39.81), surgical mask-low (38.31, 95 % CI: 34.48, 42.14), surgical mask-moderate (35.05, 95 % CI: 31.12, 38.97), surgical mask-high (36.07, 95 % CI: 34.18, 37.96).

Conclusions

Our findings indicate that N95 masks lead to higher CO2 accumulation during various activities compared to surgical masks. Moreover, surgical masks exhibit higher CO2 concentrations during low activity compared to moderate and high activities. Notably, CO2 concentrations are higher in N95 masks without an exhalation valve compared to those with a valve. No significant difference was observed between not wearing a mask and wearing either N95 or surgical masks in terms of CO2 accumulation. These results provide important insights for mask selection and usage recommendations in different scenarios.

Which Mask, N95 or Surgical Mask, Causes Hoarseness in Healthcare Workers?

OBJECTIVES

This study aimed to determine the impact of different types of masks on the voices of healthcare professionals who had to wear masks for an extended amount of time during the pandemic period and had a healthy voice.

METHODS

Our research included 41 healthcare workers. The participants were separated into two groups: surgical (n = 21) and N95 mask users (n = 20). Healthcare workers evaluated masks before and after wearing them for at least 8 hours throughout the workday. All subjects had a videolaryngoscopic examination; the Voice Handicap Index-10 (VHI-10), GRBAS, acoustic voice analysis (F0, jitter%, shimmer%, noise/harmonic ratio, relative average perturbation [RAP]), aerodynamic measures (maximum phonation time, MPT), and blood oxygen saturation were evaluated.

RESULTS

Although both groups' VHI-10 scores increased after using the mask, this rise was not statistically significant in our research. According to the GRBAS classification, voice quality deterioration was identified in 9.6% (mild-moderate) of the group using surgical masks and 15% (mild) of the group wearing N95. Only the jitter and RAP values of individuals wearing both surgical and N95 masks were determined to be statistically significant. There was no significant change in MPT following mask wear in either group. Both the surgical and N95 mask-using groups showed a substantial drop in blood oxygen saturation before and after mask usage.

CONCLUSION

There was no change in voice quality between healthcare workers wearing surgical and N95 masks. It has been noticed that voice perception and quality are affected by the mask's barrier effect rather than the kind of mask.

An antimicrobial zinc ion fiber for COVID-19 prevention in nonwoven face coverings for healthcare settings

The COVID-19 pandemic created an unprecedented increase in the usage of personal protective equipment (PPE) in the healthcare industry, especially in the form of face coverings. Subsequently, guidelines related to breathability and wear comfort were published by the Centers for Disease Control (CDC) as an influx of various new materials entered the PPE market. This study evaluated a proprietary, novel, zinc-ion embedded fiber with the ability to deactivate bacteria and viruses, including SARS-COV-2, for its wear comfort in a nonwoven disposable mask in comparison to a commercially available surgical face mask which served as the control. Ten healthy, full-time, career, firefighters participated in this study wearing both masks in a randomized fashion. A medical task simulation (MTS) protocol was developed to replicate nursing task metabolic rates, per the compendium of physical activities, via a graded treadmill walking exercise. Participant ratings including ease of mask fit, overall mask comfort, facial comfort, breathability, and facial temperature sensation were recorded before, during, and after the 50-minute protocol in a controlled environmental chamber. The 100% nylon, zinc ion mask was rated as slightly cooler at the beginning of the trial (at 0.8 vs. 1.3), than the commercially available polypropylene mask. The polypropylene mask also reached a perceived mask facial comfort (MFC) rating of 1.6 just 35 min into the protocol whereas the zinc ion mask did not reach a rating of slight discomfort until the end of the exercise. Findings indicate the novel zinc-ion embedded mask was as comfortable, if not more so, than the commercially available nonwoven mask with more favorable ratings for longer durations. Not only do the zinc properties provide enhanced protection, but they maintain, if not improve, wearer comfort.

Physiological effects of N95 respirators on rescuers during cardiopulmonary resuscitation

Objectives

There is a lack of evidence in the medical literature reporting the physiological stress imposed by the wearing of N95 respirators during cardiopulmonary resuscitation (CPR) in healthcare providers. The aim of this study is to monitor the changes in hemodynamics and blood gas profiles in rescuers during the performance of CPR while wearing N95 respirators.

Methods

Thirty-two healthy healthcare workers performed standard CPR on manikins, each participant conducted 2 min of chest compression followed by 2 min of rest for 3 cycles. A non-invasive blood gas measuring device via a fingertip detector was used to collect arterial blood gas and hemodynamic data. Student t-test was used for comparison of various physiologic parameters before and after each session of chest compression.

Results

There were no significant differences in arterial blood gas profiles including partial pressure of arterial carbon dioxide and partial pressure of arterial oxygen before and after each session of chest compression (p > 0.05 for all). Heart rate and cardiac output were significantly higher after CPR (p < 0.05 for all), but no significant changes were found on blood pressure.

Conclusions

Our data suggest that healthcare providers wearing N95 respirators during provision of CPR in a short period of time does not cause any significant abnormalities in blood gas profiles and blood pressure. This may provide evidence to reassure the safe use of N95 respirator during performance of CPR.

The impact of the COVID-19 pandemic era on children with primary headache: a questionnaire survey study and literature review

Background

The coronavirus disease (COVID-19) pandemic has resulted in individual isolation and secondary problems, especially in children. Research on the effect of the social isolation on children with primary headache is limited. This study aimed at exploring the effects of environmental changes caused by COVID-19 on headache in children.

Methods

This cross-sectional survey study enrolled school-aged children (age, 8-16 years) with headache who were able to complete the questionnaire from a Pediatric Headache Clinic between January 2021 and December 2022. Headache diaries for all patients were in their medical records and two questionnaire responses were requested at a 3-month interval. The questionnaires included headache type, frequency, previous medical conditions, family history, Pediatric Migraine Disability Assessment scores (PedMIDAS) scores, changes in daily life after COVID-19, and factors that aggravated headaches associated with social distancing.

Results

We identified 35 patients who were diagnosed with primary headache and continued to visit our outpatient clinic for at least 3 months. Among them, 33 (15 males and 18 females) patients responded to the first survey. The average age (±SD) of patients was 12.5 ± 1.9 years. PedMIDAS scores were not affected by the COVID-19 infection history. Prolonged use of masks and increased use of digital devices were reported as the most common factors that aggravated headache during the pandemic era.

Conclusion

COVID-19 did not affect in worsening primary headache in children. However, the pandemic can introduce various changes in daily life, which in turn can affect the management of headache. By gathering feedback regarding the thoughts of the patients on the impact of the current pandemic environment, patient counseling on the precautions and management can be conducted in advance in the case of repeated lockdown in the future.

Physiologic effects of surgical masking in children versus adults

Background

Surgical masks remain a focal part of the CDC guidelines to decrease COVID-19 transmission. Evidence refuting significant effects of masking on ventilation is mostly limited to small studies, with a paucity of studies on children, and none comparing children to adults.

Methods

A total of 119 subjects were enrolled (71 adults, 49 children) in a prospective interventional study with each subject serving as their own mask-free control. End tidal CO2 (ETCO2), inspired CO2 (ICO2), and respiratory rate were measured by nasal cannula attached to an anesthesia machine D-fend module. Pulse oximetry and heart rate were also followed. After the mask-free period, an ASTM Level 3 disposable surgical mask was donned and 15 min of mask-worn data were collected.

Results

A steady state was confirmed for ETCO2 and ICO2 over the masked period, and mean ICO2 levels rose significantly (p < 0.001) after masking in all age groups. The increase in ICO2 for the 2- to 7-year-old group of 4.11 mmHg (3.23-4.99), was significantly higher (p < 0.001) than the final ΔICO2 levels for both the 7- to 14-year-old group, 2.45 mmHg (1.79-3.12), and adults, 1.47 mmHg (1.18-1.76). For the pediatric group there was a negative, significant correlation between age and ΔICO2, r = -0.49, p < 0.001. Masking resulted in a statistically significant (p < 0.01) rise in ETCO2 levels of 1.30 mmHg in adults and 1.36 mmHg in children. The final respective ETCO2 levels, 34.35 (33.55-35.15) and 35.07 (34.13-36.01), remained within normal limits. Pulse oximetry, heart rate, and respiratory rate were not significantly affected.

Discussion

The physiology of mechanical dead space is discussed, including the inverse relationship of subject age vs ICO2. The methodology and results are compared to previously published studies which detracted from the physiologic safety of surgical masking.

Conclusions

The wearing of a surgical mask results in a statistically significant rise in ICO2 and a smaller rise in ETCO2. Because ETCO2 and other variables remain well within normal limits, these changes are clinically insignificant.

Physio-metabolic and clinical consequences of wearing face masks-Systematic review with meta-analysis and comprehensive evaluation

Background

As face masks became mandatory in most countries during the COVID-19 pandemic, adverse effects require substantiated investigation.

Methods

A systematic review of 2,168 studies on adverse medical mask effects yielded 54 publications for synthesis and 37 studies for meta-analysis (on n = 8,641, m = 2,482, f = 6,159, 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 = 8,128) 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.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021256694, identifier: PROSPERO 2021 CRD42021256694.

Possible toxicity of chronic carbon dioxide exposure associated with face mask use, particularly in pregnant women, children and adolescents - A scoping review

Introduction

During the SARS-CoV-2-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 min 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.

Human thermal physiological response of wearing personal protective equipment: An educational building semi-open space experimental investigation

With the outbreak and spread of the COVID-19 epidemic, HCWs are frequently required to wear personal protective equipment (PPE) for nucleic acid sample collection in semi-open transition spaces. Wearing PPE causes significant psychological and physical stress in HCWs. In this study, operative temperature (T_op) and wet-bulb globe temperature (WBGT) were used to assess thermal conditions through field experiments, while multiple physiological parameters were measured in the subjects. The results indicated that the subjects showed statistically significant differences in thermal perception and physiological parameters with and without PPE. Using observed increases in heart rate (HR), auditory canal temperature (T_ac), mean skin temperature (MST), and end-tidal CO₂ pressure, subjects were shown to have an increased metabolic rate and heat storage while wearing PPE. Additionally, a decrease in oxygen concentration was also observed, and this decrease may be linked to fatigue and cognitive impairment. Moreover, HR, MST, and T_ac showed a significant linear relationship, which increased with temperature and operative temperature, and the HR response was stronger with PPE than without PPE. The neutral, preferred, and acceptable temperatures were significantly lower with PPE than without PPE, and the deviations for neutral T_op/WBGT were 9.5/7.1 °C and preferred T_op/WBGT was 2.2/4.0 °C, respectively. Moreover, the upper limits of acceptable WBGT, 29.4 °C with PPE and 20.4 °C without PPE, differed significantly between the two phases. Furthermore, the recorded physiological parameter responses and thermal perception responses of the subjects while wearing PPE indicated that they were at risk of thermal stress. Overall, these results suggest that people who wear PPE should focus on their health and thermal stress. This study provides a reference for the development of strategies to counteract heat stress and improve thermal comfort.

Headache caused by the use of personal protective equipment in healthcare workers during the COVID-19 pandemic period

Objective

Coronavirus 2019 disease (COVID-19), the cause of the ongoing pandemic, is an acute respiratory tract infection, which has made it necessary for healthcare personnel to use protective equipment such as N95 masks, protective goggles and visors. External compression headaches caused by the compression of the pericranial soft tissues by wearing hats, helmets, or goggles (worn during swimming or diving) have been previously described. In our study, we aimed to evaluate the presence and characteristics of personal protective equipment-associated headaches in healthcare workers during the COVID-19 pandemic period and to determine the effects of such headaches.

Materials and methods

A face-to-face questionnaire was delivered to 300 male and female healthcare personnel between the ages of 18-56 working in healthcare units where COVID-19 patients were evaluated and treated. The data from 296 completed questionnaires was evaluated.

Results

We included 296 participants (166 females and 130 males) in our study; the mean age was 33.98 ± 8.52 years (range 18-56). One hundred ninety-six (66.22%) participants indicated that they had new onset personal protective equipment-associated headaches. Percentages of those with newly emergent headaches because of protective equipment were higher in the following participant groups: females (p = 0.045), those with COVID-19 disease history (p < 0.001), and those diagnosed with headaches before the pandemic (p = 0.001).

Conclusion

Our study showed the presence of new-onset headaches associated with personal protective equipment in healthcare workers during the COVID-19 pandemic. Personal protective equipment-related headaches were associated with the following factors: female sex, a history of COVID-19 disease, and the presence of primary headaches diagnosed before the pandemic.

The impact of wearing powered air purifying respirators or N95 masks on the olfactory function in healthcare workers: A randomized controlled trial

BACKGROUND

With the Coronavirus disease 2019 epidemic, wearing a mask has become routine to prevent and control the virus's spread, especially for healthcare workers. However, the impact of long-term mask wear on the human body has not been adequately investigated. This study aimed to investigate whether Powered Air Purifying Respirators and N95 masks impact the olfaction in healthcare workers.

METHODS

We recruited fifty-six healthcare workers and randomly divided them into 2 groups, wearing a powered air purifying respirator (PAPR) (experiment group, N = 28) and an N95 mask (control group, N = 28). Olfactory discrimination and threshold tests were performed before and after wearing the masks. SPSS 26.0 (SPSS Inc., Chicago, Illinois) software was used for the statistical analyses.

RESULTS

There was a statistical difference in the olfactory threshold test after wearing the mask in both PAPR Group (Z = -2.595, P = .009) and N95 Group (Z = -2.120, P = .034), with no significant difference between the 2 (χ2 = 0.29, P = .589). There was no statistical difference in the discrimination test scores in both 2 groups after wearing the masks.

CONCLUSION

Wearing a mask affects the healthcare workers' olfaction, especially odor sensitivity. Healthcare workers have a higher olfactory threshold after long-term mask wear, whether wearing PAPRs or N95 masks.

Health effects of filtering facepiece respirators: Systematic review of pulmonary and cardiovascular effects

Filtering facepiece respirators (FFRs) were introduced to protect the wearer by removing small particles from inspired air. FFRs are now also used to reduce the spread of transmissible agents from the wearer and are worn outside traditional healthcare and other workplaces. The COVID-19 pandemic increased concerns about potential adverse effects on wearers. A PUBMED query retrieved articles through June 2022. Abstracts and selected full-text articles were systematically reviewed by the authors. This article 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. 1985 records were identified, of which only 26% were published before 2020. FFR effects on CO₂ elimination appear more likely to be 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.

Effects of wearing personal protective equipment (PPE) and its role in affecting the work efficiency of dentists during the COVID-19 pandemic

BACKGROUND

The risk of exposure to COVID-19 infection through droplets/aerosol in dental clinics has renewed focus on the utility and possible adverse effects of using personal protective equipment (PPE) on dentists.

OBJECTIVE

To obtain information from a cross-section of dentists regarding their PPE usage and to evaluate the possible risk factors that can influence their work efficiency.

METHODS

A 31-item cross-sectional survey with a structured multiple-choice questionnaire was designed. Social media and emails were used to circulate the questionnaire among dental professionals worldwide. A total of 317 respondents returned the completed forms.

RESULTS

A total of 184 (55%) participants reported getting soaking wet while wearing PPE at the end of the working hours (approximately eight hours of working). Many respondents (n = 286, 90%) reported that the use of PPE resulted in reduced visibility of the operating field. The majority of respondents (84%) felt that their overall work efficiency had reduced after using PPE. Binary logistic regression had shown that two significant factors that were associated with reduced work efficiency included, pre-existing systemic illness and getting soaking wet from wearing a PPE.

CONCLUSION

Definite protocols should be introduced that mandate the doffing of PPE for every patient, in a separate well-ventilated area where the skin can recuperate from the heat and pressure points caused by the PPE. Dentists should take greater care in choosing the appropriate PPE to prevent exacerbation of pre-existing illnesses, which may reduce their work efficiency.

Thermophysiological and Perceptual Responses of Amateur Healthcare Workers: Impacts of Ambient Condition, Inner-Garment Insulation and Personal Cooling Strategy

While personal protective equipment (PPE) protects healthcare workers from viruses, it also increases the risk of heat stress. In this study, the effects of environmental heat stress, the insulation of the PPE inner-garment layer, and the personal cooling strategy on the physiological and perceptual responses of PPE-clad young college students were evaluated. Three levels of wet bulb globe temperatures (WBGT = 15 °C, 28 °C, and 32 °C) and two types of inner garments (0.37 clo and 0.75 clo) were chosen for this study. In an uncompensable heat stress environment (WBGT = 32 °C), the effects of two commercially available personal cooling systems, including a ventilation cooling system (VCS) and an ice pack cooling system (ICS) on the heat strain mitigation of PPE-clad participants were also assessed. At WBGT = 15 °C with 0.75 clo inner garments, mean skin temperatures were stabilized at 31.2 °C, H_skin was 60-65%, and HR was about 75.5 bpm, indicating that the working scenario was on the cooler side. At WBGT = 28 °C, T_skin plateaued at approximately 34.7 °C, and the participants reported "hot" thermal sensations. The insulation reduction in inner garments from 0.75 clo to 0.37 clo did not significantly improve the physiological thermal comfort of the participants. At WBGT = 32 °C, T_skin was maintained at 35.2-35.7 °C, H_skin was nearly 90% RH, T_core exceeded 37.1 °C, and the mean HR was 91.9 bpm. These conditions indicated that such a working scenario was uncompensable, and personal cooling to mitigate heat stress was required. Relative to that in NCS (no cooling), the mean skin temperatures in ICS and VCS were reduced by 0.61 °C and 0.22 °C, respectively, and the heart rates were decreased by 10.7 and 8.5 bpm, respectively. Perceptual responses in ICS and VCS improved significantly throughout the entire field trials, with VCS outperforming ICS in the individual cooling effect.

Perceived Workload Using Separate (Filtering Facepiece Respirator and Face Shield) and Powered Air-Purifying Respirator and Integrated Lightweight Protective Air-Purifying Respirator: Protocol for an International Multisite Human Factors Randomized Crossover Feasibility Study

BACKGROUND

The design of personal protective equipment (PPE) may affect well-being and clinical work. PPE as an integrated item may improve usability and increase adherence by healthcare professionals. Human factors design and safety may reduce occupational-acquired diseases. As an integrated PPE, a lightweight protective air-purifying respirator (L-PAPR) could be used during health procedures where healthcare professionals are exposed to airborne pathogens. The human factors affecting the implementation of alternative PPE such as L-PAPR have not been thoroughly studied. The population of interest is health care professionals, the intervention is the performance by PPE during tasks across the three PPE types 1.) N95 respirators and face shields, 2.)traditional powered air-purifying respirator(PAPR), and 3.) L-PAPR. The outcomes are user error, communications, safety, and end-user preferences.

OBJECTIVE

This study will assess whether the L-PAPR improves health care professionals' comfort in terms of perceived workload and physical and psychological burden during direct patient care when compared with the traditional PAPR or N95 and face shield. This study also aims to evaluate human factors during the comparison of the use of L-PAPR with a combination of N95 respirators plus face shields or the traditional PAPRs.

METHODS

This is an interventional randomized crossover quality improvement feasibility study consisting of a 3-site simulation phase with 10 participants per site and subsequent field testing in 2 sites with 30 participants at each site. The 3 types of respiratory PPE will be compared across medical tasks and while donning and doffing. We will evaluate the user's perceived workload, usability, usage errors, and heart rate. We will conduct semistructured interviews to identify barriers and enablers to implementation across each PPE type over a single continuous wear episode and observe interpersonal communications across conditions and PPE types.

RESULTS

We expect the research may highlight communication challenges and differences in usability and convenience across PPE types along with error frequency during PPE use across PPE types, tasks, and time.

CONCLUSIONS

The design of PPE may affect overall well-being and hinder or facilitate clinical work. Combining 2 pieces of PPE into a single integrated item may improve usability and reduce occupational-acquired diseases. The human factors affecting the implementation of an alternative PPE such as L-PAPR or PAPR have not been thoroughly studied.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/36549.

Personal protective equipment-associated headaches in health care workers during COVID-19: A systematic review and meta-analysis

Introduction

Health Care Workers (HCWs) use Personal Protective Equipment (PPE) during the COVID-19 pandemic to protect themselves and prevent the transmission of the disease. The use of PPE, especially respiratory masks, has adverse consequences, including headaches, which have been secondary and unusual. The aim of the present systematic review and meta-analysis study was to investigate the prevalence of PPE-associated headaches in HCWs during COVID-19 pandemic.

Methods

The present review study was performed based on the PRISMA guideline. The protocol of the present study was registered in PROSPERO with the code CRD42022304437. Valid data resources such as Scopus, PubMed, Web of Science, Science Direct, Google Scholar, Embase were used to identify and extract relevant studies. The searches were conducted between the beginning of 2020 and the end of January 2022. A random effects model was used for meta-analysis and I ² index was used to investigate between-study heterogeneity. Data were analyzed using STATA ver. 14.

Results

A total of 539 articles were first identified through initial search and finally 26 final studies were selected to undergo the meta-analysis phase. According to the results of meta-analysis, the prevalence of headache after and before the use of PPE was 48.27% (95% CI: 40.20-56.34, I ² = 99.3%, p = 0 < 001) and 30.47% (95% CI: 20.47-40.47, I ² = 97.3%, p = 0 < 001), respectively.

Conclusion

The results of the present study showed that the prevalence of PPE-associated headache in HCWs was relatively high, so, the use of PPE during COVID-19 pandemic can be considered as one of the causes of headache. Therefore, management strategies such as regular screening of HCWs for headaches and regular rest periods without the use of PPE can be effective in reducing the prevalence of headaches.

Health hazards related to using masks and/or personal protective equipment among physicians working in public hospitals in Dhaka: A cross-sectional study

Background

Wearing masks or personal protective equipment (PPE) has become an integral part of the occupational life of physicians due to the coronavirus disease 2019 (COVID-19) pandemic. Most physicians have been developing various health hazards related to the use of different protective gears. This study aimed to determine the burden and spectrum of various health hazards associated with using masks or PPE and their associated risk factors.

Methods

This cross-sectional survey was conducted in Dhaka Medical College from March 01–May 30, 2021, among physicians from different public hospitals in Dhaka, Bangladesh. We analyzed the responses of 506 physicians who completed case record forms through Google forms or hard copies.

Findings

The mean (SD) age of the respondents was 35.4 [7.7], and 69.4% were men. Approximately 40% were using full PPE, and 55% were using N-95 masks. A total of 489 (96.6%) patients experienced at least one health hazard. The reported severe health hazards were syncope, severe dyspnea, severe chest pain, and anaphylaxis. Headache, dizziness, mood irritation, chest pain, excessive sweating, panic attack, and permanent facial disfigurement were the minor health hazards reported. Extended periods of work in the COVID-19-unit, reuse of masks, diabetes, obesity, and mental stress were risk factors for dyspnea. The risk factors for headaches were female sex, diabetes, and previous primary headaches. Furthermore, female sex and reusing masks for an extended period (> 6 h) were risk factors for facial disfigurement. The risk factors for excessive sweating were female sex and additional evening office practice for an extended period.

Conclusions

Healthcare workers experienced several occupational hazards after using masks and PPE. Therefore, an appropriate policy is required to reduce such risks.

Inhaled CO2 Concentration While Wearing Face Masks: A Pilot Study Using Capnography

Background

Face masks are recommended based on the assumption that they protect against SARS-CoV-2 transmission, however studies on their potential side effects are still lacking. We aimed to evaluate the inhaled air carbon dioxide (CO2) concentration, when wearing masks.

Methods

We measured end-tidal CO2 using professional side-stream capnography, with water-removing tubing, (1) without masks, (2) wearing a surgical mask, and (3) wearing a FFP2 respirator (for 5 minutes each while seated after 10 minutes of rest), in 146 healthy volunteers aged 10 to 90 years, from the general population of Ferrara, Italy. The inhaled air CO2 concentration was computed as: ([mask volume × end-tidal CO2] + [tidal volume - mask volume] × ambient air CO2)/tidal volume.

Results

With surgical masks, the mean CO2 concentration was 7091 ± 2491 ppm in children, 4835 ± 869 in adults, and 4379 ± 978 in the elderly. With FFP2 respirators, this concentration was 13 665 ± 3655 in children, 8502 ± 1859 in adults, and 9027 ± 1882 in the elderly. The proportion showing a CO2 concentration higher than the 5000 ppm (8-hour average) acceptable threshold for workers was 41.1% with surgical masks, and 99.3% with FFP2 respirators. Adjusting for age, gender, BMI, and smoking, the inhaled air CO2 concentration significantly increased with increasing respiratory rate (mean 10 837 ±3712 ppm among participants ⩾18 breaths/minute, with FFP2 respirators), and among the minors.

Conclusion

If these results are confirmed, the current guidelines on mask-wearing should be reevaluated.

External nasal dilator decreases N95 respirator-related respiratory effort and symptoms in gastrointestinal endoscopy unit staff

Background and study aims  N95-filtering facepiece respirators (FFR) use is associated with physiological changes and symptoms due to impaired nasal airflow and increased breathing resistance. We prospectively studied the effect of using an external nasal dilator (END) in gastroenterology laboratory (gastrointestinal lab) staff using N95FFR. Patients and methods  N95FFR qualitative saccharine fit testing was performed on study participants with and without an END. Prospective data collection and comparisons included: 1) survey of perceived symptoms and difficulty of performing one day of gastrointestinal procedures with N95FFR and 1 day of gastrointestinal procedures with END plus N95FFR in random sequence; and 2) vitals and respiratory belt plethysmography in ten gastroenterologists performing simulated colonoscopy while wearing a surgical mask (SM), N95FFR plus SM, END plus N95FFR plus SM for 20 minutes each in random sequence and rapid succession. Results  Twenty-nine of 31 participants passed the N95FFR and the END plus N95FFR fit test. Twenty-two participants (12 physicians; 11 males; mean age 44.1 years, range 31-61) performed 1 day of gastrointestinal procedures with an N95FFR and 1 day of gastrointestinal procedures with an END plus N95FFR. Significantly less difficulty with nasal breathing and severity of symptoms including breathing difficulty, headache, fatigue and frustration, occurred while using an END plus N95FFR. Respiratory plethysmography peak-to-trough measurement showed an increase during the N95FFR stage compared to the END plus N95FFR stage and the SM stage. Conclusions  N95FFR related respiratory changes and symptom development may be mitigated by END use.

Physical problems of prolonged use of personal protective equipment during the COVID-19 pandemic: A scoping review

BACKGROUND

It is widely believed that using personal protective equipment (PPE) provides high levels of protection for healthcare workers (HCWs) in the fight against coronavirus disease (COVID-19). However, the long-term use of PPE is inconvenient for HCWs and may cause physical discomfort. These factors could result in poor compliance and disrupt the health and safety of HCWs, which may negatively affect the patient's safety.

OBJECTIVE

This study aimed to investigate the literature for the purpose of collecting convincing evidence of HCWs' physical problems associated with PPE use during the COVID-19 pandemic.

METHODS

This scoping review was conducted using PubMed, Embase, ProQuest, Science Direct, Springer, Biomed Central, and Google Scholar to identify the related literature.

RESULTS

HCWs have experienced various physical disorders including skin, respiratory, musculoskeletal, nervous, urinary, and circulatory system problems that are associated with PPE in various body systems. Among these, skin problems were the most frequent physical problems.

CONCLUSIONS

The literature demonstrated the adverse impacts of using PPE on HCWs. Therefore, healthcare policymakers should take the appropriate measures to improve the work environment during the COVID-19 pandemic, which could consequently prevent and mitigate the adverse effects of using PPE.

Carbon dioxide rises beyond acceptable safety levels in children under nose and mouth covering: Results of an experimental measurement study in healthy children

Nose and mouth covering (NMC) has been made compulsory for children in many countries during the Covid-19 pandemic. We wanted to determine the average CO₂ levels in inhaled air with NMC in children between age 6 and 17. We used short term measurements under surgical masks and FFP2 masks according to European norm EN 149, compared to baseline in an experimental, intra-individually controlled study over 25 min. CO₂ content was measured every 15 s using an automated dual-wavelength infrared CO₂ measurement device (G100, Geotech, Leamington Spa, UK) over 25 min in a short-term experimental setting, with children seated. After baseline measurement children were provided with two types of commonly worn NMC: surgical masks and FFP2--masks in randomized sequence for 3 min each. We kept ambient CO₂-levels below 1000 parts per million (ppm) through frequent ventilation. We measured breathing frequency and pulse as potential physiological moderator variables. Forty-five children, 25 boys, 20 girls, with a mean age of 10.7 years (standard deviation 2.6) were measured. We measured 13,100 ppm (SD 380) under surgical mask and 13,900 ppm (SD 370) under FFP2 mask in inhaled air. A linear model with age as a covariate showed a highly significant effect of the condition (p < 1*10^-9). We measured 2,700 ppm (SD 100) CO₂ at pre-baseline and 2,800 ppm (SD 100) at post-baseline, a non-significant small difference. Appropriate contrasts revealed that the change was due to the masks only and the difference between the two types of masks was small and not significant. Wearing of NMC (surgical masks or FFP2- -masks) raises CO₂ content in inhaled air quickly to a very high level in healthy children in a seated resting position that might be hazardous to children's health.

Psychological Responses of Health Care Workers Are Strongly Associated With Pandemic Management

Background

Globally, governments adopted protective measures to stabilize the worsening COVID-19 pandemic situation. These measures had a large impact on health care workers (HCWs) and could make the work environment more stressful for them. Therefore, we explored the associations of the psychological responses of HCWs and pandemic management among Slovak health care workers during the second wave of the pandemic.

Materials and Methods

We obtained data about psychological responses, COVID-19 experiences, information overload, non-adherence of the public, work stress and barriers and facilitators of health care provision from HCWs at the COVID-19-related departments of one hospital that mainly covered eastern Slovakia (215 health care professionals, 77.7% females, M/SD = 44.4). Data were analyzed using logistic regression models adjusted for gender.

Results

Pandemic management was most strongly associated with psychological responses, such as irritability, sadness, anxiety, dizziness, and back pain, in health care workers. The non-adherence of the public had the strongest associated psychological impact on HCWs, mostly affecting anxiety and irritability (odds ratios, ORs varying from 3.9 to 7.0). From the barriers and facilitators of health care provision, the use of personal protective equipment had the most impact psychologically, whereas efficient department management was most protective, with ORs around 0.3.

Conclusion

Pandemic management has a large impact on health care workers, and promoting resilience may seriously decrease job-related stress and associated psychological responses of HCWs.

Examination of the Effects of 4-Hour Nonvalved Filtering Facepiece Respirator Use on Blood Gas Values of Health Care Professionals: A Before and After Study

INTRODUCTION

The use of personal protective equipment increased rapidly during the COVID-19 pandemic that began in 2019. The purpose of this study was to examine the effects of uninterrupted 4-hour use of internationally certified nonvalved filtering facepiece respirators on venous blood gas in health care workers during the COVID-19 pandemic.

METHODS

A before-after design included venous blood gas analyses collected at the beginning of shifts before nonvalved filtering facepiece respirator had been put on and after 4-hour uninterrupted use of nonvalved filtering facepiece respirator.

RESULTS

In this study, 33 volunteer health care workers took part. In terms of blood gas values, mean pCO₂ values were 47.63 (SD = 5.16) before and 47.01 (SD = 5.07) after nonvalved filtering facepiece respirator use, mean HCO₃ values were 23.68 (SD = 1.10) in first blood gas analysis and 24.06 (SD = 1.31) in second blood gas analysis, and no significant difference was observed between before and after the use of nonvalved filtering facepiece respirator (t = 0.67, P = .50, t = -2.0, P = .054, respectively). The only significant difference in parameters investigated between the groups was in pH levels, at pH = 7.35 (SD = 0.29) before and pH = 7.36 (SD = 0.20) after nonvalved filtering facepiece respirator use (t = -2.26, P = .03).

CONCLUSION

Continuous nonvalved filtering facepiece respirator use for 4 hours was not associated with clinician impairment in blood gas and peripheral SpO₂ levels during nonexertional clinical ED work.

Headache related to personal protective equipment in healthcare workers during COVID-19 pandemic in Mexico: baseline and 6-month follow-up

Background and aim

Headaches related to the use of personal protective equipment (PPE) could affect performance at work in healthcare personnel. Our aim was to describe the prevalence and risk factors for headaches related to PPE, in the personnel of a specialized coronavirus disease 2019 (COVID-19) tertiary hospital.

Methods

In this cross-sectional survey study, we invited healthcare workers from COVID-19 referral center in Mexico (May 22–June 19, 2020) to answer a standardized structure questionnaire on characteristics of new-onset PPE-related headache or exacerbation of primary headache disorder. Participants were invited regardless of whether they had a current headache to avoid selection bias. This is the primary analysis of these data.

Results

Two hundred and sixty-eight subjects were analyzed, 181/268 (67.5%) women, 177/268 (66%) nurses, mean age 28 years. The prevalence of PPE-related headache was 210/268 (78.4%). Independent risk factors were occupation other than physician (OR 1.59, 95% CI 1.20–2.10), age > 30 years (OR 2.54, 95% CI 1.25–5.14), and female sex (OR 3.58, 95% CI 1.86–6.87). In the 6-month follow-up, 13.1% of subjects evolve to chronic headache, with stress as predictive risk factor.

Conclusion

The frequency of PPE-associated headache is high, and a subgroup could evolve to chronic headache. More studies are necessary to improve the knowledge about this condition.

Is it a challenging task to work with personal protective equipment in a COVID-19 ICU: Findings from a hospital-based cross-sectional study from north India

Introduction

Amidst the coronavirus disease 2019 (COVID-19) pandemic, the use of personal protective equipment (PPE) is mandatory for healthcare workers to remain protected against infection. The present study was undertaken to evaluate challenges faced by the healthcare workers while using level 3 PPE.

Methods

This hospital-based study was conducted among resident doctors selected by convenience sampling method using a pretested, semi-structured, self-administered questionnaire after getting informed consent from the participants to collect data on the somatic, psychological, and technical problems faced while working in PPE. Bivariate and multivariable logistic regression was done between outcome variables and other independent variables to check for the association.

Results

Of the total, 252 resident doctors completed the survey, their age ranged from 22 to 36 years with 140 (55.6%) males and 112 (44.4%) females. One-twenty-nine (51.2%) residents were trained to work in ICU, 73 (29%) participants used PPE ≤10 times and the rest 179 (71%) used PPE more than 10 times. The difficulties faced were as follows: visual impairment (n = 244, 96.8%), headache (n = 226, 89.6%), breathing difficulty (n = 216, 85.7%), hearing impairment (n = 201, 79.8%), sweating (n = 242, 96%), and fear of being infected (n = 156,61.9%). Two-thirty-six (93.6%) participants felt that overall work quality reduced due to PPE. Headache, hunger, urge to micturate, anxiety, sleep disturbances, and need to change the timing of medication or diet were higher with increased duration of work with PPE.

Conclusion

A longer duration of work is associated with headache, hunger, anxiety, and sleep disturbances. More research has to be done to improve the PPE to reduce problems like visual impairment, skin irritation, sweating, and breathing difficulty.

Assessment of the impact of N95 respirators or surgical masks use on the retinal microvasculature

PURPOSE

To determine the possible impact of wearing N95 respirator or surgical masks on retinal vessel diameters and choroidal thickness in healthy healthcare workers.

METHODS

Diameters of peripapillary retinal arteries and veins and choroidal thickness values at the foveal center and at 1000 μm distances from the foveal center in both nasal and temporal directions were measured before mask wearing using a spectral-domain optical coherence tomography. After four hours (h) of N95 or surgical mask wearing vessel diameter and choroidal thickness measurements were repeated.

RESULTS

A total of 52 eyes from 52 participants (28 F [53.8%]; 24 M [46.2%]) were enrolled in this study. The mean age of patients was 34.58 ± 5.24 years (25-44 years). The diameters of all measured arteries [inferior temporal artery (p = 0.003), superior temporal artery (p < 0.001), inferior nasal artery (p = 0.003), and superior nasal artery (p = 0.004)] and veins,with the exception of superior nasal vein, (inferior temporal vein (p = 0.031), superior temporal vein (p = 0.027), inferior nasal vein (p < 0.001), and superior nasal vein (p = 0.063)] increased significantly after four hour use of N95 respirators and surgical maskswhen compared to baseline. There was also a significant diameter increase of the superior temporal (p < 0.001), inferior nasal veins (p < 0.001), and superior temporal artery (p = 0.037) for N95 respirators and surgical masks use, respectively. The differences in central subfoveal, temporal, and nasal choroidal thickness between baseline and after 4 h use of N95 respirators were statistically significant (From 366.73 ± 70.81 μm to 381.23 ± 69.29μm,p < 0.001 for the subfoveal; from 324.00 ± 64.13μm to 335.40 ± 61.35 μm, p = 0.007 for the temporal; from 297.40 ± 68.18 μm to 308.23 ± 74.51μm, p = 0.002 for the nasal thicknesses). Choroidal thickness values were also increased with surgical mask use. But only the increase in central subfoveal thickness was statistically significant (From 366.78 ± 71.00 μm to 372.58 ± 76.56 μm, p = 0.031 for the central subfoveal; from 297.42 ± 68.35 μmto 302.79 ± 73.05 μm, p = 0.068 for the nasal; from 324.01 ± 64.21μm to 330.33 ± 65.84, p = 0.117 for the temporal thicknesses).

CONCLUSION

With four hours use of N95 respirators or surgical face masks, retinal vessel diameters and choroidal thicknesses showed an increase in comparison to baseline measurements. Hemodynamic changes seen secondary to hypercapnia due to prolonged use of N95 respirators or surgical masks may also be observed in the retinal and choroidal circulation. Furthermore, the use of face masks should be taken into account while assessing the retinal microvasculature.

Personal Interventions to Reduce Exposure to Outdoor Air Pollution

Unhealthy levels of air pollution are breathed by billions of people worldwide, and air pollution is the leading environmental cause of death and disability globally. Efforts to reduce air pollution at its many sources have had limited success, and in many areas of the world, poor air quality continues to worsen. Personal interventions to reduce exposure to air pollution include avoiding sources, staying indoors, filtering indoor air, using face masks, and limiting physical activity when and where air pollution levels are elevated. The effectiveness of these interventions varies widely with circumstances and conditions of use. Compared with upstream reduction or control of emissions, personal interventions place burdens and risk of adverse unintended consequences on individuals. We review evidence regarding the balance of benefits and potential harms of personal interventions for reducing exposure to outdoor air pollution, which merit careful consideration before making public health recommendations with regard to who should use personal interventions and where, when, and how they should be used.

The impacts of masks and disinfectants on migraine patients in the COVID-19 pandemic

Since the onset of the COVID-19 pandemic, the use of personal protective equipment (PPE) and disinfectants has become necessary to prevent transmission of the virus. However, the effects of such pandemic obligations on chronic diseases such as migraine have not been fully elucidated. We aimed to investigate the effects of the COVID-19 pandemic, as well as the use of masks and disinfectants, on migraine patients. A total of 310 migraine patients were included. Demographic data, migraine characteristics, and mask and disinfectant use were obtained through a face-to-face survey. Patients were grouped as worsening, stable, or improving according to pre-pandemic and pandemic migraine characteristics. Migraine worsening was found in 177 (57.1%) patients, stable course in 96 (31%) patients, and improvement in 37 (11.9%) patients. The use of scalp contact masks and double masks and daily mask duration were higher in the worsening group (p:0.005, p:0.005 and p:0.001). In addition, the frequency of personal disinfectant use was higher in this group (p:0.011). In regression analysis, mask type, daily mask duration, presence of allodynia, being a health worker, depression score, and odor were determined as independent risk factors for migraine worsening. We found a worsening of migraines in more than half of patients during the COVID-19 pandemic. We also demonstrated a relationship between migraine worsening and mask type, number of masks, and intensive disinfectant use. Migraine patients should be advised of optimal prevention methods based on individual social and working conditions rather than exaggerated preventative measures.

Safety and Efficacy of External Nasal Dilator Strips with N95 Respirator Masks by Emergency Department Personnel

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic has prompted increased use of personal protective equipment (PPE) to maintain the health and safety of caregivers. This study was conducted in 2020 to evaluate the safety and efficacy of external nasal dilator strips (ENDS) coupled with N95 respirators in a sample of community hospital emergency department personnel.

METHODS

After obtaining written consent, the authors tested participants' response to exercise (i.e., walking up 10 flights of stairs) while wearing an N95 respirator, both with and without an ENDS. The authors measured participants' heart rate and respiratory effort responses over four minutes following their exercise trial. A convenience sample of these personnel also repeated their respirator fit testing while wearing an ENDS with the N95 style they had previously been fitted for.

RESULTS

A total of N = 50 participants were enrolled. Peak heart rate while wearing an ENDS was 125 beats per minute (BPM) with the ENDS versus 130 BPM without (p = 0.21). The Borg Exertion Score while wearing an ENDS peaked at 13 with the ENDS versus 14 without (p = 0.08). However, when subjects were surveyed before and after the trial upon whether they would consider using an ENDS beneath their N95 using a scale of 1-5, their interest in this significantly increased (p = 0.004). Four of the 13 (31%) participants who completed repeated fit testing while wearing the ENDS beneath their N95 respirator failed the repeat testing.

CONCLUSIONS

These results first suggest that a sizable proportion of ED personnel may fail N95 fit testing while wearing an ENDS beneath the N95 mask for which they had been previously fitted. Although providers' subjective interest in use of ENDS increased, these results also demonstrate that use of an ENDS beneath an N95 respirator may not significantly increase exercise tolerance.

Headaches and the use of personal protective equipment in the general population during the COVID-19 pandemic

INTRODUCTION

Headaches associated with personal protective equipment were reported in health-care workers in previous epidemiological studies.

METHODS

National web-based survey advertised by the Portuguese Headache Society and National Headache and Migraine patient´s organization between September-December 2020 screening for personal protective equipment usage pattern, pre-existing and de novo headaches after the onset of the COVID-19 pandemic, and its relation to personal protective equipment use.

RESULTS

Of 5064 participants, 90.6% (4562/5034) were women, mean age was 37.2 ± 11 years. Most questions had a completion rate above 87% (non-completion rate ranging from 0-12.7%). Twenty percent were health-care professionals (993/5046). Surgical and cloth masks were the most common personal protective equipment type, whereas protective eyewear and FFP2/FFP3 masks were mostly used by health-care professionals. About 97% (1814/1870) of migraine and headache participants reported aggravation of pre-existing headaches with personal protective equipment use, and 56% (2476/4420) had de novo headaches. Participants with de novo headaches had a higher frequency of pre-existing migraine (1118/1226, 91.2% vs 1408/1600, 88%, P = .042), and wore personal protective equipment for longer periods of time (7 ± 2 h 42 vs 6 ± 2 h 54 min per day, P < .001). In multivariate analysis longer mean duration of personal protective equipment use (OR of 1.1, 95% CI 1-1.2) and previous migraine (OR of 1.2, 95% CI 1-1.4) were predictors of developing de novo headaches.

CONCLUSIONS

Almost all participants with pre-existing headache reported worsening of their headaches, and more than half of the study population developed de novo headaches following personal protective equipment use. Duration of personal protective equipment usage and pre-existing migraine were the strongest predictors of de novo headaches.

The Effects of Wearing a Medical Mask on the Masticatory and Neck Muscle Activity in Healthy Young Women

The objective of this study was to analyze the influence of wearing a medical mask on masticatory and neck muscle activity in healthy young women. We recruited 66 healthy women aged from 18 to 30 years (mean 23.6 ± 2.3 years). The temporalis anterior (TA), the superficial part of the masseter muscle (MM), the anterior bellies of the digastric muscle (DA), and the middle part of the sternocleidomastoid muscle (SCM) potentials were recorded at rest and during functional activity using an eight-channel device for surface electromyography—BioEMG III^TM. There was a statistically significant decrease in mean TA activity during medical mask measurement compared to no mask examination at rest (2.16 µV vs. 2.58 µV; p = 0.05; ES = 0.2). Significant decreases in resting RMS values were also observed during the medical mask phase in comparison to no mask examination concerning the left MM (1.75 µV vs. 2.17 µV; p = 0.01; ES = 0.3), and mean bioelectrical activity of the MM (1.81 µV vs. 2.15 µV; p = 0.02; ES = 0.2). The differences between the two conditions did not reach the assumed significance level (p > 0.05) in terms of other indices. Wearing a medical mask has a small effect on decreasing the resting potentials of the temporalis anterior and masseter muscles without changing the parameters of activity and asymmetry within the stomatognathic system.

Inhaled CO2 Concentration While Wearing Face Masks: A Pilot Study Using Capnography

BACKGROUND

Face masks are recommended based on the assumption that they protect against SARS-CoV-2 transmission, however studies on their potential side effects are still lacking. We aimed to evaluate the inhaled air carbon dioxide (CO₂) concentration, when wearing masks.

METHODS

We measured end-tidal CO₂ using professional side-stream capnography, with water-removing tubing, (1) without masks, (2) wearing a surgical mask, and (3) wearing a FFP2 respirator (for 5 minutes each while seated after 10 minutes of rest), in 146 healthy volunteers aged 10 to 90 years, from the general population of Ferrara, Italy. The inhaled air CO₂ concentration was computed as: ([mask volume × end-tidal CO₂] + [tidal volume - mask volume] × ambient air CO₂)/tidal volume.

RESULTS

With surgical masks, the mean CO₂ concentration was 7091 ± 2491 ppm in children, 4835 ± 869 in adults, and 4379 ± 978 in the elderly. With FFP2 respirators, this concentration was 13 665 ± 3655 in children, 8502 ± 1859 in adults, and 9027 ± 1882 in the elderly. The proportion showing a CO₂ concentration higher than the 5000 ppm (8-hour average) acceptable threshold for workers was 41.1% with surgical masks, and 99.3% with FFP2 respirators. Adjusting for age, gender, BMI, and smoking, the inhaled air CO₂ concentration significantly increased with increasing respiratory rate (mean 10 837 ±3712 ppm among participants ⩾18 breaths/minute, with FFP2 respirators), and among the minors.

CONCLUSION

If these results are confirmed, the current guidelines on mask-wearing should be reevaluated.

Spatio-Temporal Variation of Health Production Efficiency Considering Environmental Pollution in China Based on Modified EBM and Spatial Econometric Model

In order to strengthen the construction of China's health industry and improve the health of the people, based on the data of 31 provinces and cities in China from 2009 to 2019, the improved EBM model is used to measure the health production efficiency of each region, and Moran index is used to study the Spatio-temporal variation of health production efficiency of each province. Finally, the spatial econometric model is applied to study the influencing factors of the Spatio-temporal variation of health production efficiency. The results show that generally speaking, the average efficiency of 31 provinces and cities is above 0.7, and the average efficiency of some regions is above 1. From the perspective of time variation, the average efficiency value in the eastern region and the middle region increases from 0.816 to 0.882 and from 0.851 to 0.861, respectively. However, the average efficiency value in the western region and northeast region decreases from 0.861 to 0.83 and from 0.864 to 0.805, respectively. From the perspective of spatial distribution, HH agglomeration and LL agglomeration exist in most regions. By comparing Moran scatter plots in 2009 and 2019, it is found that the quadrants of most regions remain unchanged, and LL agglomeration is the main agglomeration type in local space. There is a significant spatial dependence among different regions. From the perspective of spatial empirical results, Pgdp, Med, and Pd have a positive effect on health production efficiency. The direct effect and indirect effect of Pgdp, Med, and Gov all pass the significance test of 1%, indicating that there are spatial spillover effects of the three indicators. Each region should reasonably deal with the spillover effect of surrounding regions, vigorously develop economic activities, carry out cooperation with surrounding regions and apply demonstration effect to accelerate the development of overall health production.

Comparison of Effects of N95 Respirators and Surgical Masks to Physiological and Psychological Health among Healthcare Workers: A Randomized Controlled Trial

Since the onset of the coronavirus disease 2019 pandemic, wearing facemasks has become more important for healthcare workers. This study aimed to investigate and compare the influence of wearing N95 respirators and surgical masks for 8 h on physiological and psychological health. Sixty-eight healthcare workers were randomly assigned to the N95 respirator or surgical mask groups. Physiological parameters of participants were measured by Tensor Tip MTX at baseline and at the 2nd, 4th, 6th and 8th h of wearing the facemasks. The symptoms after wearing facemasks were also determined via the questionnaire. There were no significant changes in physiological parameters at most time checkpoints in both groups. Significant differences were observed in terms of heart rate at the 8th h, time trends (adjusted difference of least squares means were −8.53 and −2.01), and interaction of time and mask type between the two groups (p-value for interaction was 0.0146). The values of these physiological parameters were within normal ranges. The N95 respirator group had significantly higher incidences of shortness of breath, headache, dizziness, difficulty talking and fatigue that spontaneously resolved. In conclusion, healthcare workers who wore either N95 respirators or surgical masks during an 8 h shift had no obvious harmful effects on physiological and psychological health. Additionally, the N95 respirator group did not show a higher risk than the surgical mask group.

What do masks mask? A study on transdermal CO2 monitoring

Medical professionals have complained of extreme discomfort and fatigue from continuous wearing of N95 respirators (N95) overlaid with surgical masks (SM) and face shields (FS) during COVID-19 pandemic. However, there are no reports on the effect of face coverings on transdermal CO₂ (TrCO₂) levels (a measure of blood CO₂) during moderate activity. In this study, real-time monitoring of TrCO₂, heart rate and skin surface temperature was conducted for six subjects aged 20-59 years with and without wearing personal protective equipment (PPE). We initially studied the effect of wearing PPE (N95+SM+FS) at rest. Then, the effect of moderate stepping/walking activity (120 steps per minute for 60 min) while wearing PPE was evaluated. In addition, we investigated the effect of exercising intensity with different masks. We observed a significant difference (p < 0.0001) in TrCO₂ levels between without and with PPE during moderate exercise, but not while resting. TrCO₂ levels were correlated to exercise intensity independently with masking condition and breathability of masks. For the first time, we present data showing that a properly fitting N95 worn along with SM and FS consistently leads to elevated TrCO₂ under moderate exertion, which could contribute to fatigue over long-term use.

Different reflections of the face mask: sleepiness, headache and psychological symptoms

Objectives. The COVID-19 pandemic has had significant physical and mental effects on healthcare workers. This study aims to evaluate the relationship between wearing face masks and headache, sleepiness, mood and anxiety symptoms in healthcare workers. Methods. A survey was administered to 365 healthcare workers working during the pandemic. The Beck depression inventory, the Beck anxiety inventory and the Epworth sleepiness scale were used to assess depressive symptoms, anxiety symptoms and daytime sleepiness, respectively. Participants were also asked about new-onset headaches. Results. Almost half of the participants (47.6%) reported new-onset headaches, and 23.2% reported excessive daytime sleepiness. The frequencies of depressive and anxiety symptoms were 43.7 and 59.2%, respectively. Sleepiness scores and new-onset headache frequency were higher in women and those using filtering facepiece respirators. A statistically significant positive correlation was found between mask-wearing duration, depressive and anxiety symptom scores, and sleepiness score. Conclusions. The present study has shown that many healthcare workers wearing face masks suffered from sleepiness, headaches and psychological symptoms during the COVID-19 pandemic. These findings indicate the importance of improving working conditions and planning psychological interventions for healthcare workers.

COVID-19 pandemic impact on headache in healthcare workers: a narrative review

Background: Pandemic of COVID-19, the potentially fatal disease caused by SARS-CoV-2, had caused intangible consequences on global health systems, economy, daily life, education, travel, leisure, work, and mental health. Its impact on mental and physical health, especially in health professionals, has been described. Objective: This study aimed to review and discuss the published evidence regarding the presence of headache on COVID-19 healthcare workers. Methods: In this review, we searched for all articles published in various data bases including PubMed / Medline, Scopus, and Web of Science and all original research studies, letters to editor, case reports, commentaries and reviews published in English, Portuguese or Spanish were searched. Two researchers independently analyzed published articles in order to include/exclude based on inclusion or exclusion criteria.  Results: Thirteen articles were included.  All studies included in this review were observational; eleven were cross-sectional studies, one was a prospective/cohort and one was a retrospective. Two studies evaluated psychological outcomes, mental health disorders and associated factors, one study investigated symptoms and causes of somatic symptom disorder and all other studies evaluated headaches associated with Personal Protective Equipment (PPI). Conclusions: The present review shows that COVID-19 pandemic has negative impact on physical and mental health in healthcare workers and headache has been associated to psychological stress and work overload during pandemic.  Further studies are necessary to better investigate COVID-19 pandemic effects on headaches and other neurological conditions.

Novel 3D printable powered air purifying respirator for emergency use during PPE shortage of the COVID-19 pandemic: a study protocol and device safety analysis

OBJECTIVES

To design a low-cost 3D printable powered air-purifying respirator (PAPR) that meets National Institute for Occupational Safety and Health (NIOSH) standard for flow rate and Occupational Safety and Health Administration (OSHA) standard for particle filtration for loose-fitting PAPRs and that can be made with a 3D printer and widely available materials.

DESIGN

Detailed description of components, assembly instructions and testing of a novel PAPR design in an academic laboratory following respective protocols. The assembled PAPR must meet NIOSH standards of flow rate, 170 L/min; OSHA fit factor for particle filtration, ≥250 and maintain positive pressure during regular and deep breathing.

MAIN OUTCOME MEASURES

The PAPR design was run through a series of tests: air flow (L/min), particle filtration (quantitative and qualitative) and positive pressure measured inside the helmet (mm Hg).

RESULTS

Flow rate was 443.32 L/min (NIOSH standard: minimum 170 L/min) and overall fit factor for particle filtration was 1362 (OSHA pass level: ≥500), n=1. The device passed qualitative particle filtration, n=2, and measured peak pressure of 6mm Hg (>0 mm Hg indicates positive pressure) in the helmet, n=1.

CONCLUSIONS

The Hygieia PAPR is a low-cost, easily accessible, just-in-time 3D printable PAPR design that meets minimum NIOSH and OSHA standards for flow-rate and particle filtration for loose-fitting PAPR devices to be made and used when industry-made designs are unavailable.

CHOROIDAL CHANGES DUE TO LONG-TERM USE OF N95 FACE MASKS

PURPOSE

We aimed to examine the changes in choroidal stroma and vascular system due to long-term use of N95 mask in healthcare workers.

METHOD

The healthcare workers included in the study were between the ages of 18-50, with best corrected visual acuity (BCVA) 10/10, spherical and cylindrical refractive errors less than 3 diopters, intraocular pressures (IOP) within normal limits, and axial lengths (AL) less than 25 mm. The choroid was imaged with enhanced depth imaging (EDI) techniques using SD-OCT. The choroidal vascularity index (CVI), total choroidal area (TA), luminal area (LA), and stromal area (SA) were measured in the subfoveal 2 mm area. Measurements were first made after wearing the N95 mask for at least 2 hours without removing it and repeated 1hour after removing, while doing office working.

RESULTS

The study included 62 eyes from 62 participants (32 women [%51.61]; 30 men [%48.39]). The mean age of patients was 33.81± 8.88 years (20-50 years). The differences in subfoveal TA, LA, SA between 2 hours of N95 mask use and 1 hour after removal of the mask were statistically significant (p<0.05 for each). However, the difference in CVI between the mask use and removal of the mask was not statically significant (p=0.537) CONCLUSION: Due to CO2 retention and hemodynamıc changes, choroidal vascular flow, the choroidal vascular area, and the choroidal stromal area may be affected by prolonged use of masks.

Headache Related to PPE Use during the COVID-19 Pandemic

PURPOSE OF REVIEW

Personal protection equipment (PPE)-associated headache is an unusual secondary headache disorder that predominantly occurs in healthcare workers as a consequence of the donning of protective respirators, face masks and/or eyewear. The appreciation of this entity is important given the significant ramifications upon the occupational health of healthcare workers and could additionally have an impact on persons living with pre-existing headache disorder(s).

RECENT FINDINGS

There has been a renewed interest and recognition of PPE-associated headaches amongst healthcare professionals, largely brought about by the ongoing COVID-19 pandemic which has besieged healthcare systems worldwide. De novo PPE-associated headaches may present with migrainous or tension-type features and can be viewed as a subtype of external compression headache. The prognosis of the disorder is generally favourable, given that most headaches are short-lived without long-term sequalae. Several aetiologies have been postulated to account for the development of these headaches. Notably, these headaches can affect the occupational health and work performance of healthcare workers. In this review, we discuss the epidemiology, clinical characteristics, probable etiopathogenesis, management and prognosis of PPE-associated headaches in the context of the COVID-19 pandemic. Future directions for research and PPE development are proposed.

Pyrolysis kinetic behaviour and TG-FTIR-GC-MS analysis of Coronavirus Face Masks

In the times of Covid-19, face masks are considered to be the main source of protection against the virus that reduces its spread. These masks are classified as single-use medical products with a very short service life, estimated at few days, hence millions of contaminated masks are generated daily in the form of hazardous materials, what requires to develop a safe method to dispose of them, especially since some of them are loaded with viruses. 3-ply face masks (3PFM) represent the major fraction of this waste and are composed mainly from polypropylene and melt blown filter with high content of volatile substances (96.6 wt.%), what makes pyrolysis treatment an emerging technology that could be used to dispose of face masks and convert them into energy products. In this context, this work aims to study pyrolysis kinetic behaviour and TG-FTIR-GC-MS analysis of 3PFM. The research started with analysis of 3PFM using elemental analysis, proximate analysis, and compositional analyses. Afterwards, TG-FTIR system was used to study the thermal and chemical decomposition of 3PFM analyzed at different heating rates: 5, 10, 15, 20, 25, and 30 °C/min. The GC/MS system was used to observe the synthesized volatile products at the maximum decomposition temperatures. After that, isoconversional methods, the advanced nonlinear integral isoconversional method, and the iterative linear integral isoconversional method were used to determine the activation energies of mask pyrolysis, while the distributed activation energy model and the independent parallel reactions kinetic model were used to fit TGA and DTG curves with deviations below <1. The TGA-DTG results showed that 3PFM can decompose in three different periods with a total weight loss of 95 % and maximum decomposition in the range 405-510 °C, while the FTIR spectra and GC-MS analysis exhibited that - C-H (aromatic and aliphatic) and 2,4-Dimethyl-1-heptene (28-43 % based on heating rate) represented the major compounds in the released volatile components. Finally, Vyazovkin and the iterative linear integral isoconversional methods gave activation energies almost similar to that obtained by the KAS isoconversional method.

The effect of N95 and surgical masks on mucociliary clearance function and sinonasal complaints

PURPOSE

The aim of this study was to reveal the effect of N95 and surgical masks on mucociliary clearance function and sinonasal complaints.

METHODS

Sixty participants were enrolled in this study, including 30 people in N95 mask group and 30 people in surgical mask group. Two interviews, three days apart, were performed with all participants. The participants were asked not to use any mask before the first interview while they were asked to use the determined mask just before the second interview for 8 h. In both interviews, the mucociliary clearance times (MCTs) were measured and participants were asked to score ten distinct sinonasal complaints using visual analog scale (VAS). Data obtained from first interview were named pre-mask data, data obtained from second interview were called after-mask data. In both groups, pre-mask MCTs and VAS scores were compared with after-mask MCTs and VAS scores.

RESULTS

After-mask MCTs (mean = 13.03 ± 6.05 min) were significantly longer than pre-mask MCTs (mean = 10.19 ± 4.21 min) in N95 mask group (p = 0.002). No significant difference was found between after-mask and pre-mask MCTs (mean = 12.05 ± 5.21 min, mean = 11.00 ± 5.44 min, respectively) in surgical mask group (p = 0.234). When after-mask VAS scores were compared with pre-mask VAS scores, it was found that N95 mask use increased nasal blockage and postnasal discharge, surgical mask usage increased nasal blockage.

CONCLUSION

While the use of N95 mask leads to nasal blockage and postnasal discharge, surgical mask use results in nasal blockage. N95 masks cause impairment in mucociliary clearance function. But all these effects are mild. Surgical masks have not been found to have any effect on mucociliary clearance function.

Is a Mask That Covers the Mouth and Nose Free from Undesirable Side Effects in Everyday Use and Free of Potential Hazards?

Many countries introduced the requirement to wear masks in public spaces for containing SARS-CoV-2 making it commonplace in 2020. Up until now, there has been no comprehensive investigation as to the adverse health effects masks can cause. The aim was to find, test, evaluate and compile scientifically proven related side effects of wearing masks. For a quantitative evaluation, 44 mostly experimental studies were referenced, and for a substantive evaluation, 65 publications were found. The literature revealed relevant adverse effects of masks in numerous disciplines. In this paper, we refer to the psychological and physical deterioration as well as multiple symptoms described because of their consistent, recurrent and uniform presentation from different disciplines as a Mask-Induced Exhaustion Syndrome (MIES). We objectified evaluation evidenced changes in respiratory physiology of mask wearers with significant correlation of O2 drop and fatigue (p < 0.05), a clustered co-occurrence of respiratory impairment and O2 drop (67%), N95 mask and CO2 rise (82%), N95 mask and O2 drop (72%), N95 mask and headache (60%), respiratory impairment and temperature rise (88%), but also temperature rise and moisture (100%) under the masks. Extended mask-wearing by the general population could lead to relevant effects and consequences in many medical fields.

Carbon dioxide increases with face masks but remains below short-term NIOSH limits

BACKGROUND AND PURPOSE

COVID-19 pandemic led to wide-spread use of face-masks, respirators and other personal protective equipment (PPE) by healthcare workers. Various symptoms attributed to the use of PPE are believed to be, at least in part, due to elevated carbon-dioxide (CO2) levels. We evaluated concentrations of CO2 under various PPE.

METHODS

In a prospective observational study on healthy volunteers, CO2 levels were measured during regular breathing while donning 1) no mask, 2) JustAir® powered air purifying respirator (PAPR), 3) KN95 respirator, and 4) valved-respirator. Serial CO2 measurements were taken with a nasal canula at a frequency of 1-Hz for 15-min for each PPE configuration to evaluate whether National Institute for Occupational Safety and Health (NIOSH) limits were breached.

RESULTS

The study included 11 healthy volunteers, median age 32 years (range 16-54) and 6 (55%) men. Percent mean (SD) changes in CO2 values for no mask, JustAir® PAPR, KN95 respirator and valve respirator were 0.26 (0.12), 0.59 (0.097), 2.6 (0.14) and 2.4 (0.59), respectively. Use of face masks (KN95 and valved-respirator) resulted in significant increases in CO2 concentrations, which exceeded the 8-h NIOSH exposure threshold limit value-weighted average (TLV-TWA). However, the increases in CO2 concentrations did not breach short-term (15-min) limits. Importantly, these levels were considerably lower than the long-term (8-h) NIOSH limits during donning JustAir® PAPR. There was a statistically significant difference between all pairs (p < 0.0001, except KN95 and valved-respirator (p = 0.25). However, whether increase in CO2 levels are clinically significant remains debatable.

CONCLUSION

Although, significant increase in CO2 concentrations are noted with routinely used face-masks, the levels still remain within the NIOSH limits for short-term use. Therefore, there should not be a concern in their regular day-to-day use for healthcare providers. The clinical implications of elevated CO2 levels with long-term use of face masks needs further studies. Use of PAPR prevents relative hypercapnoea. However, whether PAPR should be advocated for healthcare workers requiring PPE for extended hours needs to evaluated in further studies.