The Impact of Ubiquitous Face Masks and Filtering Face Piece Application During Rest, Work and Exercise on Gas Exchange, Pulmonary Function and Physical Performance: A Systematic Review with Meta-analysis

Physiological effects and tolerance of wearing surgical and N95 masks during sleep in normal individuals and patients with mild-moderate obstructive sleep apnea: a randomized crossover trial

BACKGROUND

In certain situations, masks are worn during sleep to prevent respiratory infections. However, the effects of mask wearing on cardiopulmonary function during sleep are unknown. This study aimed to determine whether wearing masks during sleep has an impact on cardiopulmonary function, including in patients with obstructive sleep apnea.

METHODS

This was a prospective, randomized crossover-controlled trial. The effects of wearing surgical masks or N95 respirators on cardiopulmonary function were measured in healthy subjects and patients with mild-moderate obstructive sleep apnea. Sleep breathing parameters were monitored during nocturnal sleep using a sleep monitor, and subjective feelings about mask wearing were assessed using a questionnaire.

RESULTS

Wearing masks during sleep at night did not significantly impact sleep breathing parameters. Furthermore, there were no significant differences in heart rate, blood oxygenation, and blood pressure before and after wearing masks. However, masks wearing, especially wearing N95 mask, had an adverse impact on sleep quality and were subjectively uncomfortable.

CONCLUSIONS

Wearing masks during sleep at night does not adversely affect cardiopulmonary function but it's uncomfortable, especially N95 mask. Thus, in circumstances where wearing N95 masks during nocturnal sleep proves intolerable, we recommend the use of surgical masks as a more comfortable alternative.

Masks and respirators for prevention of respiratory infections: a state of the science review

SUMMARYThis narrative review and meta-analysis summarizes a broad evidence base on the benefits-and also the practicalities, disbenefits, harms and personal, sociocultural and environmental impacts-of masks and masking. Our synthesis of evidence from over 100 published reviews and selected primary studies, including re-analyzing contested meta-analyses of key clinical trials, produced seven key findings. First, there is strong and consistent evidence for airborne transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and other respiratory pathogens. Second, masks are, if correctly and consistently worn, effective in reducing transmission of respiratory diseases and show a dose-response effect. Third, respirators are significantly more effective than medical or cloth masks. Fourth, mask mandates are, overall, effective in reducing community transmission of respiratory pathogens. Fifth, masks are important sociocultural symbols; non-adherence to masking is sometimes linked to political and ideological beliefs and to widely circulated mis- or disinformation. Sixth, while there is much evidence that masks are not generally harmful to the general population, masking may be relatively contraindicated in individuals with certain medical conditions, who may require exemption. Furthermore, certain groups (notably D/deaf people) are disadvantaged when others are masked. Finally, there are risks to the environment from single-use masks and respirators. We propose an agenda for future research, including improved characterization of the situations in which masking should be recommended or mandated; attention to comfort and acceptability; generalized and disability-focused communication support in settings where masks are worn; and development and testing of novel materials and designs for improved filtration, breathability, and environmental impact.

Exploring factors affecting the unsafe behavior of health care workers' in using respiratory masks during COVID-19 pandemic in Iran: a qualitative study

BACKGROUND

The use of respiratory masks has been one of the most important measures to prevent the spread of COVID-19 among health care workers during the COVID-19 pandemic. Therefore, correct and safe use of breathing masks is vital. The purpose of this study was to exploring factors affecting the unsafe behavior of health care workers' in using respiratory masks during the COVID-19 pandemic in Iran.

METHODS

This study was carried out using the conventional qualitative content analysis. Participants were the number of 26 health care workers selected by purposive sampling method. Data collection was conducted through in-depth semi-structured interviews. Data analysis was done using the content analysis approach of Graneheim and Lundman. This study aligns with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist and was conducted between December 2021 and April 2022.

RESULTS

The factors affecting the unsafe behavior of health care workers while using respiratory masks were divided into 3 main categories and 8 sub-categories. Categories included discomfort and pain (four sub-categories of headache and dizziness, skin discomfort, respiratory discomfort, feeling hot and thirsty), negative effect on performance (four sub-categories of effect on physical function, effect on cognitive function, system function vision, and hearing), and a negative effect on the mental state (two subcategories of anxiety and depression).

CONCLUSION

The findings can help identify and analyze possible scenarios to reduce unsafe behaviors at the time of using breathing masks. The necessary therapeutic and preventive interventions regarding the complications of using masks, as well as planning to train personnel for the correct use of masks with minimal health effects are suggested.

Investigating effects of FFP2 wearing during physical activity on gas exchange, metabolism and affective state using a randomized controlled trial

Concerns are repeatedly raised about possible adverse respiratory effects of wearing filtering face pieces (FFP) during physical activity. This study compared the impact of FFP type 2 (NF95) on pulmonary function, blood gas values, metabolism and discomfort during light, moderate and vigorous physical activity. Healthy adults (n = 13; 6 females, 7 males; mean 31.3, SD 5.5 years) participated in this randomized two-armed (Ergometer cycling with a FFP type 2 vs. no mask) crossover trial. Baseline cardiopulmonary exercise testing and two interventions (masked and unmasked ergometer cycling 40%, 50% and 70% VO2max, 10 min each) were separated by 48 h washout periods. Spiroergometric data (End tidal carbon dioxide partial pressure PetCO2; breathing frequency; inspiration time), blood gas analysis outcomes (capillary carbon dioxide partial pressure, pCO2) and subjective response (Breathing effort and perceived exertion) were contrasted between conditions using ANOVAs. All participants completed the crossover trial, seven started with the FFP2 condition (No adverse events or side effects). FFP2 decreased breathing frequency, prolonged inspiration time, increased perceived breathing effort and PetCO2 (p < .05). Blood pCO2 in millimetres mercury increased during exercise with 50%VO2max (mean 36.67, SD 3.19 vs. mean 38.46, SD 2.57; p < .05) and 70%VO2max (35.04, 2.84 vs. 38.17, 3.43; p < .05) but not during exercise with 40%VO2max (36.55, 2.73 vs. 38.70). Perceived exertion was not affected (p > 0.05) by mask wearing. Conclusion: Mask-induced breathing resistance decreased respiratory performance and limited pulmonary gas exchange. While FFP2 affected subjective breathing effort per se, invasive diagnostics showed that statistically significant metabolic effects are induced from moderate intensity upwards. Trial registration: DRKS-ID: DRKS00030181, Date of registration: 05/09/2022 (German Register for Clinical Trials).

Sports despite masks: no negative effects of FFP2 face masks on cardiopulmonary exercise capacity in children

Face masks were recognized as one of the most effective ways to prevent the spread of the COVID-19 virus in adults. These benefits were extended to children and adolescents. However, the fear of negative consequences from wearing a face mask during physical exercise led to cancellations of physical education lessons. 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 of 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 better prepared for alternative options to lockdown and limitation of PA in such a scenario. Twenty healthy children aged 8-10 years performed two identical cardiopulmonary exercise tests as an incremental step test on a treadmill within an interval of 2 weeks, one time without wearing a protective mask and one time wearing an FFP2 mask. The cardiopulmonary exercise parameter and especially the end-expiratory gas exchange for oxygen and carbon dioxide (petO2 and petCO2) were documented for each step, at rest and 1 min after reaching physical exhaustion. Twelve 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, p = 0.097, mean O2pulse 7.84 ± 1.9 ml/min vs. 6.89 ± 1.8, p = 0.064, mean VE/VCO2slope 33.4 ± 5.9 vs. 34.0 ± 5.3, p = 0.689). The only significant difference was the respiratory exchange rate (RER, 1.01 ± 0.08 vs 0.95 ± 0.08, p = 0.004). The measured respiratory gases (end-tidal O2 and CO2) decreased and respectively increased significantly in almost every step when wearing an FFP2 mask. However, these levels were well below hypercapnia and above hypoxia.

CONCLUSION

 In this study, no significant differences in the cardiorespiratory function at peak exercise could be discerned when wearing an 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 levels of hypercapnia or hypoxia. 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 of wearing these masks instead of simply stopping pushing children to perform at their best seems premature and should be reconsidered in the future.

WHAT IS KNOWN

• Wearing a face mask has an influence on psychological, social, and physiological functions in adults. • Because of the observed effects of wearing face masks in adults, physical activity in children was limited during the pandemic.

WHAT IS NEW

• Wearing an FFP2/N95 mask during physical activity did not lead to hypercapnia or hypoxia in children in this study. • Even though end-tidal CO2 values were significantly higher and end-tidal O2 values significantly lower when wearing an FFP2/N95 face mask, no pathological values were reached.

Surgical masks and filtering facepiece class 2 respirators (FFP2) have no major physiological effects at rest and during moderate exercise at 3000-m altitude: a randomised controlled trial

BACKGROUND

During the COVID-19 pandemic, the use of face masks has been recommended or enforced in several situations; however, their effects on physiological parameters and cognitive performance at high altitude are unknown.

METHODS

Eight healthy participants (four females) rested and exercised (cycling, 1 W/kg) while wearing no mask, a surgical mask or a filtering facepiece class 2 respirator (FFP2), both in normoxia and hypobaric hypoxia corresponding to an altitude of 3000 m. Arterialised oxygen saturation (SaO2), partial pressure of oxygen (PaO2) and carbon dioxide (PaCO2), heart and respiratory rate, pulse oximetry (SpO2), cerebral oxygenation, visual analogue scales for dyspnoea and mask's discomfort were systematically investigated. Resting cognitive performance and exercising tympanic temperature were also assessed.

RESULTS

Mask use had a significant effect on PaCO2 (overall +1.2 ± 1.7 mmHg). There was no effect of mask use on all other investigated parameters except for dyspnoea and discomfort, which were highest with FFP2. Both masks were associated with a similar non-significant decrease in SaO2 during exercise in normoxia (-0.5 ± 0.4%) and, especially, in hypobaric hypoxia (-1.8 ± 1.5%), with similar trends for PaO2 and SpO2.

CONCLUSIONS

Although mask use was associated with higher rates of dyspnoea, it had no clinically relevant impact on gas exchange at 3000 m at rest and during moderate exercise, and no detectable effect on resting cognitive performance. Wearing a surgical mask or an FFP2 can be considered safe for healthy people living, working or spending their leisure time in mountains, high-altitude cities or other hypobaric environments (e.g. aircrafts) up to an altitude of 3000 m.

Comment on 'Limitations in evaluating COVID-19 protective face masks using open circuit spirometry systems: respiratory measurement mask introduces bias in breathing pressure and perceived respiratory effort'

We comment on the paper by Seibt and coworkers (Seibtet al2023) which investigates whether wearing an additional respiratory measurement mask during open-circuit spirometry assessments (respirometry mask) shows any effect on breathing pressure and perceived respiratory effort when wearing protective face masks commonly worn during the COVID-19 pandemic.

The Influence of COVID-19 in Endocrine Research: Critical Overview, Methodological Implications and a Guideline for Future Designs

The COVID-19 pandemic has changed many aspects of people's lives, including not only individual social behavior, healthcare procedures, and altered physiological and pathophysiological responses. As a result, some medical studies may be influenced by one or more hidden factors brought about by the COVID-19 pandemic. Using the literature review method, we are briefly discussing the studies that are confounded by COVID-19 and facemask-induced partiality and how these factors can be further complicated with other confounding variables. Facemask wearing has been reported to produce partiality in studies of ophthalmology (particularly dry eye and related ocular diseases), sleep studies, cognitive studies (such as emotion-recognition accuracy research, etc.), and gender-influenced studies, to mention a few. There is a possibility that some other COVID-19 related influences remain unrecognized in medical research. To account for heterogeneity, current and future studies need to consider the severity of the initial illness (such as diabetes, other endocrine disorders), and COVID-19 infection, the timing of analysis, or the presence of a control group. Face mask-induced influences may confound the results of diabetes studies in many ways.

Evaluation of Mask-Induced Cardiopulmonary Stress: A Randomized Crossover Trial

This randomized crossover trial evaluates the cardiopulmonary effects of extended use of the N95 mask during daily life.

Influence of face masks on the subjective impairment at different physical workloads

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.

Influence of Face Masks on Physiological and Subjective Response during 130 Min of Simulated Light and Medium Physical Manual Work-An Explorative Study

BACKGROUND

Undesirable side effects from wearing face masks during the ongoing COVID-19 pandemic continue to be discussed and pose a challenge to occupational health and safety when recommending safe application. Only few studies examined the effects of continuously wearing a face mask for more than one hour. Therefore, the influence of wearing a medical mask (MedMask) and a filtering facepiece class II respirator (FFP2) on the physiological and subjective outcomes in the course of 130 min of manual work was exploratively investigated. Physical work load and cardiorespiratory fitness levels were additionally considered as moderating factors.

METHODS

Twenty-four healthy subjects (12 females) from three different cardiorespiratory fitness levels each performed 130 min of simulated manual work with light and medium physical workload using either no mask, a MedMask or FFP2. Heart rate, transcutaneous oxygen and carbon dioxide partial pressure (P_tcO₂, P_tcCO₂) as well as perceived physical exertion and respiratory effort were assessed continuously at discrete time intervals. Wearing comfort of the masks were additionally rated after the working period.

RESULTS

There was no difference in time-dependent changes of physiological outcomes when using either a MedMask or a FFP2 compared to not wearing a mask. A stronger increase over time in perceived respiratory effort occurred when the face masks were worn, being more prominent for FFP2. Physical workload level and cardiorespiratory fitness level were no moderating factors and higher wearing comfort was rated for the MedMask.

CONCLUSION

Our results suggest that using face masks during light and medium physical manual work does not induce detrimental side effects. Prolonged wearing episodes appeared to increase respiratory effort, but without affecting human physiology in a clinically relevant way.

Effects of wearing different face masks on cardiopulmonary performance at rest and exercise in a partially double-blinded randomized cross-over study

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.

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 &lt; 0.001) and minute ventilation (SMD = −0.72, 95% CI = −0.99 to −0.46, p &lt; 0.001), simultaneous increased in blood-CO2 (SMD = +0.64, 95% CI = 0.31–0.96, p &lt; 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 &lt; 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 &lt; 0.006 to p &lt; 0.001). Pooled symptom prevalence (n = 8,128) was significant for: headache (62%, p &lt; 0.001), acne (38%, p &lt; 0.001), skin irritation (36%, p &lt; 0.001), dyspnoea (33%, p &lt; 0.001), heat (26%, p &lt; 0.001), itching (26%, p &lt; 0.001), voice disorder (23%, p &lt; 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.

The COVID-19 vaccine did not affect the basal immune response and menstruation in female athletes

The COVID-19 pandemic restricted the regular training and competition program of athletes. Vaccines against COVID-19 are known to be beneficial for the disease; however, the unknown side effects of vaccines and postvaccination reactions have made some athletes hesitant to get vaccinated. We investigated the changes in inflammatory responses and menstrual cycles of female athletes before and after vaccination. Twenty female athletes were enrolled in this study. Blood was collected from each subject before the first COVID-19 vaccination and after the first and second vaccinations. Laboratory data, including white blood cell, neutrophil, lymphocyte, and platelet counts, and inflammatory markers, including NLR (neutrophil-to-lymphocyte ratio), PLR (platelet lymphocyte ratio), RPR (red cell distribution width to platelet ratio), SII (systemic immune-inflammation index), and NeuPla (neutrophil-platelet ratio), were analyzed statistically. The menstrual changes before and after vaccination and the side effects were collected by questionnaires. No significant changes in the laboratory data were found after the first and second shots when compared to those at prevaccination: white blood cell, neutrophil, lymphocyte, platelet, NLR, PLR, SII, RPR, and NeuPla (p > 0.05). In addition, there were no significant changes in the menstruation cycle or days of the menstrual period (p > 0.05). All side effects after vaccination were mild and subsided in 2 days. The blood cell counts, inflammatory markers, and menstruation of female athletes were not affected by COVID-19 vaccines.

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.

Face masks while exercising trial (MERIT): a cross-over randomised controlled study

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.

Effects of Wearing a Mask During Exercise on Physiological and Psychological Outcomes in Healthy Individuals: A Systematic Review and Meta-Analysis

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.

METHODS

A 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.

RESULTS

Forty-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 NUMBER

This study was registered in the International Prospective Register of Systematic Review (PROSPERO) database (registration number: CRD42021287278).

Facial mask acute effects on affective/psychological and exercise performance responses during exercise: A meta-analytical review

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; I² = 0%), dyspnea (SMD: 0.40; 95% CI 0.09-0.71; p = 0.01; I² = 68%), and perceived exertion (SMD: 0.38; 95% CI 0.18-0.58; p < 0.001; I² = 46%); decreases on the TTE (SMD: -0.29; 95% CI -0.10 to -0.48; p < 0.001; I² = 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].

Blood gas levels, cardiovascular strain and cognitive performance during surgical mask and filtering face piece application

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.

Aerosol emission from playing wind instruments and related COVID-19 infection risk during music performance

The pandemic of COVID-19 led to restrictions in all kinds of music activities. Airborne transmission of SARS-CoV-2 requires risk assessment of wind instrument playing in various situations. Previous studies focused on short-range transmission, whereas long-range transmission risk has not been assessed. The latter requires knowledge of aerosol emission rates from wind instrument playing. We measured aerosol concentrations in a hermetically closed chamber of 20 m³ in an operating theatre as resulting from 20 min standardized wind instrument playing (19 flute, 11 oboe, 1 clarinet, 1 trumpet players). We calculated aerosol emission rates showing uniform distribution for both instrument groups. Aerosol emission from wind instrument playing ranged from 11 ± 288 particles/second (P/s) up to 2535 ± 195 P/s, expectation value ± uncertainty standard deviation. The analysis of aerosol particle size distributions shows that 70–80% of emitted particles had a size of 0.25–0.8 µm and thus are alveolar. Masking the bell with a surgical mask did not reduce aerosol emission. Aerosol emission rates were higher from wind instrument playing than from speaking or breathing. Differences between instrumental groups could not be found but high interindividual variance, as expressed by uniform distribution of aerosol emission rates. Our findings indicate that aerosol emission depends on physiological factors and playing techniques rather than on the type of instrument, in contrast to some previous studies. Based on our results, we present transmission risk calculations for long-range transmission of COVID-19 for three typical woodwind playing situations.