Comparative effects of wearing N95, surgical, cloth, and PM2.5 masks during six-minute walk test on dyspnea, breathing effort, oxygen saturation, and functional capacity in pre-aging individuals

Main Article Content

Kusalin Khamtue
Patraporn Sitilertpisan
Sauwaluk Dacha


Background: Wearing a face mask became a part of daily life due to the COVID-19 pandemic and fine particulate matter (PM2.5) air pollution in Thailand. However, performing activities while wearing different types of masks can cause different physiological effects, especially in the pre-aging population that still performs outdoor activities regularly.

Objectives: To compare the impacts of different types of the mask (no mask, N95, surgical, cloth, PM2.5 mask) on dyspnea, breathing effort, blood oxygen saturation (SpO2), and functional capacity (six-minute walk distance and estimated VO2max) during the six-minute walk test (6MWT) in pre-aging individuals.

Materials and methods: Twenty-four healthy pre-aging individuals (54±3 years) performed five trials of 6MWT wearing different types of masks. Pre-test and post-test of dyspnea, breathing effort, and blood oxygen saturation values were recorded. The estimated VO2max was calculated from 6MWT. The satisfaction for each type of mask was collected using questionnaires.

Results: SpO2, walking distance, and estimated VO2max were not significantly different (p>0.05) among all trials. Changes in dyspnea, breathing effort, and systolic blood pressure values were statistically different (p=0.026, p=0.031, and p=0.028, respectively). Despite post hoc analysis revealing a nonsignificant difference in delta changes in dyspnea between walking trials, there was a clinical difference in dyspnea while wearing N95 compared to no mask as well as surgical masks compared to other masks (MCID for Borg scale ≥1). Wearing an N95 or surgical mask resulted in higher dyspnea. Moreover, wearing an N95 mask also resulted in higher breathing effort and systolic blood pressure compared to wearing no mask.

Conclusion: Wearing various types of masks in the pre-aging population during moderate-intensity activity did not result in differences in oxygen saturation and functional capacity. Wearing an N95 resulted in higher levels of dyspnea, breathing effort and systolic blood pressure than wearing no mask. Wearing a surgical mask may have resulted in higher levels of dyspnea than wearing no mask, a cloth mask, or a PM2.5 mask.


Download data is not yet available.

Article Details

How to Cite
Khamtue, K., Sitilertpisan, P., & Dacha, S. (2023). Comparative effects of wearing N95, surgical, cloth, and PM2.5 masks during six-minute walk test on dyspnea, breathing effort, oxygen saturation, and functional capacity in pre-aging individuals. Journal of Associated Medical Sciences, 56(2), 8–17. Retrieved from
Research Articles


WHO coronavirus (COVID-19) dashboard [Internet]. Switzerland: World Health Organization; 2022 [updated 2022 Aug 1; cited 2022 Aug 12]. Available from:

How to protect yourself and others [Internet]. Atlanta GA: Center of Disease Control and Prevention; 2022 [updated 2022 Feb 25; cited 2022 Jul 30]. Available from: https://www.

Ponpiboon T, Jayasvasti I, Roongpisuthipong A. Disaster in the winter of particle matter (PM2.5). EAU Herit J. 2014; 8: 40-6 (in Thai).

Thangavel P, Park D, Lee Y-C. Recent insights into particulate matter (PM2.5)-mediated toxicity in humans: an overview. Int J Environ Res Public Health. 2022; 19: 7511. doi:10.3390/ijerph19127511.

Medical and public health operation manual for particulate matter with a size less than 2.5 microns in 2020 [Internet]. Thailand: Ministry of Public Health; 2020 [updated 2019 Dec; cited 2022 Jul 29]. Available from: http://envocc.ddc. PM2.5.pdf (in Thai).

Face mask crisis of another design [Internet]. Thailand: Thailand Development Research Institute; 2020 [updated 2020 May 27; cited 2022 Jul 29]. Available from: https:/

Harber P, Barnhart S, Boehlecke BA, Beckett WS, Gerrity T, McDiarmid MA, et al. Respiratory protection guidelines. this official statement of the American thoracic society was adopted by the ATS board of directors, March 1996. Am J Respir Crit Care Med. 1996; 154: 1153-65. doi: 10.1164/ ajrccm.154.4.8887621.

Adanur S, Jayswal A. Filtration mechanisms and manufacturing methods of face masks: an overview. J Ind Text. 2020; 51: 3683S-717S. doi: 10.1177/ 1528083720980169.

Sinkule EJ, Powell JB, Goss FL. Evaluation of N95 respirator use with a surgical mask cover: effects on breathing resistance and inhaled carbon dioxide. Ann Occup Hyg. 2013; 57: 384-98. doi: 10.1093/ annhyg/mes068.

Fikenzer S, Uhe T, Lavall D, Rudolph U, Falz R, Busse M, et al. Effects of surgical and FFP2/N95 face masks on cardiopulmonary exercise capacity. Clin Res cardiol. 2020; 109: 1522-30. doi: 10.1007/ s00392-020-01704-y.

Meechana P, Khansakorn N, Silawan T, Rawiworrakul T, Phijaisanit P. Readiness of pre-aging population for quality aging society in Nongyasai sub district, Nongyasai district, Suphanburi province. EAU Herit J. 2017; 11: 259-71 (in Thai).

Two-thirds of adults still plan to wear masks in shops and on public transport [internet]. United Kingdom: Office for National Statistics; 2021 [updated 2021 Jul 26; cited 2022 Aug 16]. Available from: community/healthandsocialcare/healthandwellbe ing/articles/twothirdsofadultsstillplantowearmask sinshopsandonpublictransport/2021-07-16.

Pringle E, Phillips C, Thijs L, Davidson C, Staessen JA, de Leeuw PW, et al. Systolic blood pressure variability as a risk factor for stroke and cardiovascular mortality in the elderly hypertensive population. J Hypertens. 2003; 21: 2251-7. doi: 10.1097/00004872-200312000- 00012.

Exercise attitudes and behaviors: a survey of adults age 50-79 [internet]. Washington D.C: American Association of Retired Persons; 2002 [updated 2002 May; cited 2020 Oct 29]. Available from: nlmuid-101168240-pdf.

Person E, Lemercier C, Royer A, Reychler G. [Effect of a surgical mask on six minute walking distance]. Rev Mal Respir. 2018; 35: 264-8. doi: 10.1016/j. rmr.2017.01.010.

Kyung SY, Kim Y, Hwang H, Park JW, Jeong SH. Risks of N95 face mask use in subjects with COPD. Respir Care. 2020; 65: 658-64. doi: 10.4187/ respcare.06713.

Cabanillas-Barea S, Rodríguez-Sanz J, Carrasco- Uribarren A, López-de-Celis C, González-Rueda V, Zegarra-Chávez D, et al. Effects of using the surgical mask and FFP2 during the 6-min walking test. a randomized controlled trial. Int J Environ Res Public Health. 2021; 18. doi: 10.3390/ijerph182312420.

Dacha S, Chuatrakoon B, Sornkaew K, Sutthakhun K, Weeranorapanich P. Effects of wearing different facial masks on respiratory symptoms, oxygen saturation,and functional capacity during six-minute walk test in healthy subjects. Can J Respir Ther. 2022; 58: 85-90. doi: 10.29390/.

Sperandio EF, Arantes RL, Matheus AC, Silva RP, Lauria VT, Romiti M, et al. Intensity and physiological responses to the 6-minute walk test in middle-aged and older adults: a comparison with cardiopulmonary exercise testing. Braz J Med Biol Res. 2015; 48: 349-53. doi: 10.1590/1414-431X 20144235.

Kendrick KR, Baxi SC, Smith RM. Usefulness of the modified 0-10 Borg scale in assessing the degree of dyspnea in patients with COPD and asthma. J Emerg Nurs. 2000; 26: 216-22. doi: 10.1016/ s0099-1767(00)90093-x.

Burr JF, Bredin SS, Faktor MD, Warburton DE. The 6-minute walk test as a predictor of objectively measured aerobic fitness in healthy working-aged adults. Phys Sportsmed. 2011; 39: 133-9. doi: 10.3810/psm.2011.05.1904.

ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002; 166: 111-7. doi: 10.1164/ajrccm.166.1.at1102.

Solano T, Shoele K. Investigation of the role of face shape on the flow dynamics and effectiveness of face masks. Fluids. 2022; 7: 209. doi: 10.3390/fluids 7060209.

Perel A. The physiological basis of arterial pressure variation during positive-pressure ventilation. Réanimation. 2005; 14. Doi: 10.1016/j.reaurg.2005. 02.002.

Ries AL. Minimally clinically important difference for the UCSD shortness of breath questionnaire, borg scale, and visual analog scale. COPD. 2005; 2: 105-10. doi: 10.1081/copd-200050655.

Shaw KA, Zello GA, Butcher SJ, Ko JB, Bertrand L, Chilibeck PD. The impact of face masks on performance and physiological outcomes during exercise: a systematic review and meta-analysis. Appl Physiol Nutr Metab. 2021; 46: 693-703. doi: 10.1139/apnm-2021-0143.

Martellucci CA, Flacco ME, Martellucci M, Violante FS, Manzoli L. Inhaled CO2 concentration while wearing face masks: a pilot study using capnography. Environ Health Insights. 2022: 2022.05.10.22274813. doi: 10.1101/2022.05.10.22274813.

3M™ health care particulate respirator and surgical masks [Internet]. U.S.A: 3M Company; 2020 [updated 2020 Feb 10; cited 2022 Jul 30]. Available from: 1387857O/health-care-brochure.pdf.

Parikh R, Mathai A, Parikh S, Sekhar GC, Thomas R. Understanding and using sensitivity, specificity, and predictive values. Indian journal of ophthalmology. 2008; 56(1): 45.

Face mask brackets for COVID-19: are they safe and effective? [Internet]. U.S.A: Huffpost; 2020 [updated 2020 Oct 5; cited 2022 Aug 13]. Available f ro m :htt ps :/ / w w w. h u ff p o st . co m /ent r y/ face-masks-covid-safe-effective_l_5f6cd969c¬5b653a2bcb1ae24.

Lane R, Adams L, Guz A. Is low-level respiratory resistive loading during exercise perceived as breathlessness?. Clin Sci (Lond). 1987; 73: 627-34. doi: 10.1042/cs0730627.

Jolley CJ, Moxham J. A physiological model of patient-reported breathlessness during daily activities in COPD. Eur Respir Rev. 2009; 18: 66-79. doi: 10.1183/09059180.00000809.

Mioxham J, Jolley C. Breathlessness, fatigue and the respiratory muscles. Clin Med (Lond). 2009; 9: 448-52. doi: 10.7861/clinmedicine.9-5-448.

Shingai K, Kanezaki M, Senjyu H. Distractive auditory stimuli alleviate the perception of dyspnea induced by low-intensity exercise in elderly subjects with COPD. Respir Care. 2015; 60: 689-94. doi: 10.4187/ respcare.03533.

O'Donnell DE, Milne KM, James MD, de Torres JP, Neder JA. Dyspnea in COPD: new mechanistic insights and management implications. Adv Ther. 2020; 37: 41-60. doi: 10.1007s12325-019-01128-9.

Cano Carrizal R, Casanova Rodríguez C. Surgical facemask: an ally of exercise stress echocardiographyduring the COVID-19 pandemic?. Rev Esp Cardiol (Engl Ed). 2021; 74: 472-4. doi: 10.1016/j.rec.2020.10.007.

Boron WF, Boulpaep EL. Medical physiology. 3rd ed. London: Elsevier Health Sciences; 2016.

Salles-Rojas A, Valderrábano C, Madrid W, González-Molina A, Silva-Cerón M, Rodriguez C, et al. Masking the 6 minutes-walking-test in the COVID-19 era. Ann Am Thorac Soc. 2020; 18: 1070-4. doi: 10.1513/AnnalsATS.202009-1088RL.

Mairbäurl H. Red blood cells in sports: effects of exercise and training on oxygen supply byred blood cells. Front Physiol. 2013; 4: 332. doi: 10.3389/ fphys.2013.00332.

Hopkins SR. Exercise induced arterial hypoxemia: the role of ventilation-perfusion inequality and pulmonary diffusion limitation. Adv Exp Med Biol. 2006; 588: 17-30. doi: 10.1007/978-0-387- 34817-9_3.

Lin Q, Cai Y, Yu C, Gu W, Tan Y, Wang L, et al. Effects of wearing face masks on exercise capacity and ventilatory anaerobic threshold in healthy subjects during the COVID-19 epidemic. Med Sci Monit. 2022; 28: e936069. doi: 10.12659/ msm.936069.

Driver S, Reynolds M, Brown K, Vingren JL, Hill DW, Bennett M, et al. Effects of wearing a cloth face mask on performance, physiological and perceptual responses during a graded treadmill running exercise test. Br J Sports Med. 2022; 56: 107-13. doi: 10.1136/bjsports-2020-103758.