FAA Office of Aerospace Medicine 
Civil Aerospace Medical Institute

Report No: DOT/FAA/AM-24/08

Title and Subtitle: Safety Implication of Respiratory Protection Mask Wear

Report Date: May 9, 2024

Authors: Wigdan Farah, MBBS, MPH, Michael Wolf, MD, Mohamed F. Abusalih, MD, Bashar Hasan, M.D, Elizabeth H. Lees, D.O, Farah Fleti, M.D, Wiaam Y. Elkhatib, M.D, Bruce D. Johnson, PhD, Gary Toups, MD, M. Hassan Murad, MD, MPH

Abstract: Background: Widespread use of respiratory protection masks has become a critical component of public health interventions. This systematic review explores the acute physiological, cognitive, and psychological impacts associated with different types of masks.

Methods: A comprehensive search from 2000 to 2023 was conducted across multiple databases (MEDLINE, EMBASE, Cochrane databases, Scopus, and PubMed). An umbrella systematic overview was conducted for physiological outcomes, utilizing published systematic reviews. De novo systematic reviews were conducted for cognitive and psychological outcomes. Pairs of independent reviewers determined eligibility, extracted data, and assessed risk of bias. Certainty at an outcome level was appraised using the GRADE approach.

Results: The search resulted in 13,370 potential citations, leading to the inclusion of nine systematic reviews for physiological outcomes (87 primary studies) and 10 primary studies for cognitive and psychological outcomes (3,815 participants). Studies evaluating physiological outcomes demonstrated that various types of masks did not significantly impact heart rate, stroke volume, cardiac output, blood pressure, or respiratory rate during rest or exercise (low certainty for most outcomes). Mask use may be associated with modest but statistically significant changes in minute ventilation, tidal volume, oxygen saturation, maximal oxygen consumption (VO2max), carbon dioxide partial pressure, lactate levels, and exercise performance (low certainty for most outcomes). Studies evaluating cognitive outcomes showed mixed results. Some studies reported reduced mental workload, while others showed no significant effect or decreased performance. The impact on attention, errors, and reaction time was variable. These studies were small and at moderate to high risk of bias. Evidence was insufficient to estimate an effect of mask use on psychological outcomes (claustrophobia, depression, and anxiety) as these studies were small, non-longitudinal, and at high risk of bias.

Conclusion: This comprehensive overview provides insight into the multifaceted impact of respiratory protection mask use. The limited certainty in evidence warrants further research since mask use is crucial for public health recommendations and policy decisions related to respiratory protection measures.

Key Words: Respiratory protection, Face mask, Physiological impact, Cognitive impact, Psychological outcomes, Systematic review

No. of Pages: 43