A Study of Strategies to Achieve Proper N95 Respirator Use by Regular N95 Respirator
Keywords:
N95 respirator, Quantitative Fit Tests, face sizes, health care workers, strategiesAbstract
Objective To explore different strategies for achieving proper use of N95 respirators by hospital staff, including viewing the donning process in a mirror, receiving assistance from a Buddy during donning, and using a bouffant cap to cover the hair after donning an N95 respirator. This study evaluated the fit factor, the time required for donning a respirator, and the practical usability of each strategy.
Methods This quasi-experimental study involved 60 healthcare workers. Demographic and medical information were collected using Occupational Safety and Health Administration (OSHA) compliant questionnaires. Facial dimensions were measured and classified into three face-size groups according to the NIOSH bivariate panel. Participants practiced one of four different N95 respirator donning strategies after watching a training video: using a mirror, receiving Buddy assistance, and using a bouffant cap. A quantitative fit test (QNFT) was conducted before and after practicing each strategy following a modified OSHA protocol. After completing each of the strategies, participants indicated their preferred donning method. They were subsequently randomly divided into three groups to further practice one of the strategies, with repeated QNFTs to ensure consistency.
Results Post video training, participants had a higher fit factor (FFs) (median, IQR) (113.50 [48.50, 200]) and an increased passing rate (61.67%) on the fit test compared to no training which had an FF of 65.50 [18.50, 118.50]) and a passing rate of 25.00%. Practice with the Buddy and Mirror strategies resulted in significantly higher FFs for small, medium, and large face sizes. The Bouffant cap strategy showed significantly higher FF than post video training alone for small face sizes: (102 [50.5, 143]) and (50 [18, 108]), respectively.
Conclusions The study found significant differences in FF for different facial sizes, with participants having medium and large face sizes achieving higher FFs compared to those with small face sizes. For individuals with small face sizes, FF improved significantly post video training using alternative strategies (Mirror, Buddy, and Bouffant cap) compared to no training. Using a mirror during donning allowed wearers to inspect the mask fit more effectively, while the Buddy strategy proved more efficient in identifying and addressing leaks compared to self-checking.
References
Centers for Disease Control and Prevention (CDC). Infection control: Transmission-based precautions [Internet]. 2024 [cited 2025 Apr 20]. Available from: https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html
World Health Organization (WHO). Significant milestone of ending TB: WHO announces Thailand is no longer listed in high-burden countries for drug resistant TB [Internet]. 2021 Jul 2 [cited 2023 Apr 18]. Available from: https://www.who.int/thailand/news/detail/02-07-2021-significant-milestone-of-ending-tb-who-announces-thailand-is-no-longer-listed-in-high-burden-countries-for-drug-resistant-tb
World Health Organization (WHO). WHO releases new global lists of high-burden countries for TB, HIV-associated TB and drug-resistant TB [Internet]. 2021 Jun 17 [cited 2023 Apr 18]. Available from: https://www.who.int/news/item/17-06-2021-who-releases-new-global-lists-of-high-burden-countries-for-tb-hiv-associated-tb-and-drug-resistant-tb
de Vries G, Šebek M, van Weezenbeek C. Healthcare workers with tuberculosis infected during work. Eur Respir J. 2006;28:1216-21.
Janpho P, Chaiear N, Kamsa-ard S. Factors associated with latent tuberculosis infection among hospital employees in a tertiary hospital of Northeastern Thailand. Int J Environ Res Public Health. 2020;17:6876. PubMed PMID: 32967073
World Health Organization (WHO). WHO guidelines on tuberculosis infection prevention and control: 2019 update [Internet]. 2019 [cited 2025 Jan 6]. Available from: https://iris.who.int/handle/10665/311259
Hon C, Danyluk Q, Bryce E, Janssen B, Neudorf M, et al. Comparison of qualitative and quantitative fit-testing results for three commonly used respirators in the healthcare sector. J Occup Environ Hyg. 2017;14:175-9.
Occupational Safety and Health Administration (OSHA). Major requirements of OSHA’s respiratory protection standard 29 CFR 1910.134 [Internet]. [cited 2023 Mar 16]. Available from: https://www.osha.gov/training/library/respiratory-protection/major-requirements
Wardhan R, Patel V, Neff A, Cook R, White J, et al. Qualitative fit test outcomes for N95 filtering facepiece respirators in health care workers. Am J Infect Control. 2023;51:194-8.
Lee M, Takaya S, Long R, Joffe A. Respirator-fit testing: Does it ensure the protection of healthcare workers against respirable particles carrying pathogens? Infect Control Hosp Epidemiol. 2008;29:1149-56.
Harber P, Boumis RJ, Su J, Barrett S, Alongi G. Component analysis of respirator user training. J Occup Environ Hyg. 2013;10:556–63.
Kim H, Lee J, Lee S, Oh J, Kang B, Lim TH, et al. Comparison of fit factors among healthcare providers working in the emergency department center before and after training with three types of N95 and higher filter respirators. Medicine (Baltimore). 2019;98:e14250. PubMed PMID: 30732139
Or P, Chung J, Wong T. Does training in performing a fit check enhance N95 respirator efficacy? Workplace Health Saf. 2012;60:511-5.
Crutchfield C, Fairbank E, Greenstein S. Effect of test exercises and mask donning on measured respirator fit. Appl Occup Environ Hyg. 1999;14:827-37.
Jankusol K, Chaiear N, Mitsungnern T. Different fit factors for the N95 respirator during endotracheal intubation: Comparing video laryngoscopy and direct laryngoscopy. Asia Pac J Sci Technol. 2023;28:APST-28-02-12.
Centers for Disease Control and Prevention (CDC). Proper N95 respirator use for respiratory protection preparedness [Internet]. 2020 Mar 16 [cited 2025 Jan 6]. Available from: https://blogs.cdc.gov/niosh-science-blog/2020/03/16/n95-preparedness/
3M Company. 3M respirators | 3M personal protective equipment [Internet]. [cited 2025 Apr 18]. Available from: https://www.3m.co.th/3M/th_TH/worker-health-safety-th/covid19/airlift/
Segal R, Bradley WP, Williams D, Nunes RC, Ng I. Remote Buddy monitoring of the donning and doffing of personal protective equipment. Med J Aust. 2021; 214:526-7
Oestenstad R, Dillion H, Perkins L. Distribution of faceseal leak sites on a half-mask respirator and their association with facial dimensions. Am Ind Hyg Assoc J. 1990;51:285-90.
Hasni NAK, Ismail R, Robat RM, Mohamad N, Suib FA, et al. The effect of N95 designs on respirator fit and its associations with gender and facial dimensions. PLoS One. 2023 Nov 29;18(11):e0288105. PubMed PMID: 38019763
Thapthim-On M, Chaiear N, Mitsungnern T. Which alternative well-fit masks can be used in medical procedures? J Infect Public Health. 2024;17:204-11.
Fakherpour A, Jahangiri M, Jansz J. A systematic review of passing fit testing of the masks and respirators used during the COVID-19 pandemic: Part 1-quantitative fit test procedures. PLoS One. 2023;18:e0293129. PubMed PMID: 37883443
Kraus S, Macherey R, Rimkus L, Tschudin-Sutter S, Marsch S, Sellmann T. Under Armour – Use of personal protective equipment for simulated CPR of COVID-19 patients: An observational study. Antimicrob Resist Infect Control. 2024;13:55. PubMed PMID: 38816876
Li Y, Wang Y, Li Y, Zhong M, Liu H, Wu C, et al. Comparison of repeated video display vs combined video display and live demonstration as training methods to healthcare providers for donning and doffing personal protective equipment: A randomized controlled trial. Risk Manag Healthc Policy. 2020;13:2325-35.
