Surgical Mask Placement Over N95 Filtering Facepiece Respirators: Physiological Effects on Healthcare Workers

Respirology. 2010 Apr;15(3):516-21. doi: 10.1111/j.1440-1843.2010.01713.x. Epub 2010 Mar 11.


Background and objective: Filtering facepiece respirators ('N95 Masks') may be in short supply during large-scale infectious outbreaks. Suggestions have been made to extend their useful life by using a surgical mask as an outer barrier, but the physiological impact of this added barrier upon the wearer has not been studied.

Methods: A surgical mask was worn over an N95 filtering facepiece respirator by 10 healthcare workers for 1 h at each of two work rates. Heart rate, respiratory rate, tidal volume, minute volume, oxygen saturation, transcutaneous carbon dioxide levels and respirator dead space gases were monitored and compared with controls (N95 filtering facepiece respirator without a surgical mask). Subjective perceptions of exertion and comfort were assessed by numerical rating scales.

Results: There were no significant differences in physiological variables between those who used surgical masks and controls. Surgical masks decreased dead space oxygen concentrations of the filtering facepiece respirators at the lesser work rate (P = 0.03) and for filtering facepiece respirators with an exhalation valve at the higher work rate (P = 0.003). Respirator dead space oxygen and carbon dioxide levels were not harmonious with Occupational Safety and Health Administration workplace ambient atmosphere standards. Exertion and comfort scores were not significantly impacted by the surgical mask.

Conclusions: Use of a surgical mask as an outer barrier over N95 filtering facepiece respirators does not significantly impact the physiological burden or perceptions of comfort and exertion by the wearer over that experienced without use of a surgical mask.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Carbon Dioxide / metabolism
  • Case-Control Studies
  • Environmental Health
  • Female
  • Health Personnel*
  • Heart Rate / physiology*
  • Humans
  • Male
  • Masks*
  • Occupational Health
  • Oxygen / metabolism
  • Physical Exertion / physiology
  • Respiratory Mechanics / physiology*
  • Respiratory Protective Devices*
  • Tidal Volume / physiology


  • Carbon Dioxide
  • Oxygen