Respiratory Protection: Balancing Effectiveness and Comfort for Compliance


According to the Institute of Medicine of the National Academies, “Personal protective equipment (PPE) is one of the vital components of a system of safety controls and preventive measures used in healthcare facilities. The recent heightened awareness of patient safety issues has opened up opportunities to improve worker safety with the potential to benefit workers, patients, family members, and others who interact in the healthcare setting.”

Having worked through a difficult influenza season which saw the persistence of both H1N1 influenza and seasonal influenza, healthcare professionals are well versed in the challenges of complying with PPE requirements. According to the National Academy, “Because PPE works by acting as a barrier to hazardous agents, healthcare workers face challenges in wearing PPE that include difficulties in verbal communications and interactions with patients and family members, maintaining tactile sensitivity through gloves, and physiological burdens such as difficulties in breathing due to respirators. For healthcare workers this may affect their work and the quality of interpersonal relationships with patients and family members. As manufacturers continue to develop PPE that can reduce the job-related constraints, healthcare institutions and individual healthcare workers need to improve their adherence to appropriate PPE use. Healthcare employers need to provide a work environment that values worker safety, including provision of PPE that is effective against the hazards faced in the healthcare workplace. In turn, healthcare workers need to take responsibility to properly use PPE, and managers should ensure that the staff members they supervise also make proper use of PPE.”

Last year, the Occupational Safety and Health Administration (OSHA) and the Centers for Disease Prevention and Control (CDC) spelled out more stringent requirements for PPE use in general and facemask and respirator use in particular, especially when aerosol-generating procedures would be conducted or when interacting with patients who have airborne diseases such as active tuberculosis infection. According to OSHA’s respiratory protection standard 29 CFR 1910.134, respirators must be used as part of a comprehensive respiratory protection plan.

It is important for healthcare professionals to know when to don respirators; wearing one improperly generates a false sense of security and can lead to the contraction of a serious illness. N95 mask respirators remain the standard of care for respiratory protection, even though new design powered air-purifying respirators (PAPRs) -- recommended for high-risk situations -- are gaining in popularity for the level of comfort provided. To be an effective respirator, an N95 must provide an air-tight seal, which can cause pressure against the face. N95s can also cause heat buildup, resistance to normal breathing, fogging of protective eyewear, fatigue and headache -- which can cause healthcare workers to not wear respiratory protection when they must. Newer designs of PAPRs that are more comfortable are now available; some are considerably lighter than a motorcycle helmet, yet roomier and non-claustrophobic. And by eliminating the cumbersome air tube and bulky blower mounted at the waist, it doesn’t interfere with maneuverability. The laminar air flow down the front of the face eliminates integrated lens fogging and provides a gently cooling effect for wearers. More comfort and convenience, plus increased safety (higher filtration efficiency without requiring fit-testing) can lead to better compliance in respirator use; better compliance can improve healthcare worker safety and reduce overall costs of infection prevention.

The Occupational Safety and Health Administration (OSHA) has developed two new videos for healthcare workers that feature training and guidance on respirator safety. The videos also explain how workers can perform a user seal check to test whether a respirator is worn properly and will provide the expected level of protection. Viewers may watch these by visiting OSHA’s Respiratory Protection page or the U.S. Department of Labor’s YouTube site.

Despite expert recommendations and high-risk conditions, healthcare workers exhibit low rates of PPE use, according to the National Academies, which notes, “ Although the use of PPE is often examined by observational studies or survey questionnaires of individual workers, assessments of the explanations for noncompliance and the solutions to these issues need to focus beyond the individual and address the institutional issues that prevent, allow, or even favor noncompliance ... The lack of adherence to appropriate use of respirators and protective eyewear is especially prevalent throughout the literature; on the other hand, healthcare workers frequently wear gloves, with adherence often well above 90 percent. However, rates of adherence to hand hygiene best practices are often low; for example, in an observational study, Pittet and colleagues (2004) found 57 percent overall adherence to hand hygiene protocols among 163 physicians. Given the poor use of PPE, particularly respiratory PPE, and the high risk of exposure of healthcare workers to bloodborne and airborne pathogens and other hazardous materials, it is crucial to develop and implement strategies to improve the rates of adherence to PPE protocols and to mitigate risk.”

According to a National Academies report, “Lack of time is the most common reason healthcare workers give for not adhering to safety regulations.” Researchers note that job hindrance, or the perception that using PPE interferes with healthcare workers’ ability to perform their jobs, has also been cited as a major reason for noncompliance. Improving worker safety necessitates an organization-wide dedication to the creation, implementation, evaluation, and maintenance of effective and current safety practices—a culture of safety. An organization that has a functional and healthy safety culture is one in which all employees show a concern for safety issues within the infrastructure and act to maintain or update safety standards. Further, the organizational commitment to safety is evidenced by the organization’s policies, procedures, management support, and resources dedicated to safety, which include access to effective, appropriate and state-of-the-art safety equipment and PPE.


Baig AS, et al. Healthcare workers’ views about respirator use and features that should be included in the next generation of respirators. AJIC. 38(1):18-25. February 2010.

Lewis J. Radonovich LJ, et al. Respirator tolerance in healthcare workers. JAMA. 2009;301(1):36-38.

National Academies Press. Preparing for an Influenza Pandemic: Personal Protective Equipment for Healthcare Workers. 2008.

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