Physiological impact of surgical masks and N95 masks on obese operating room staff | Scientific Reports

Scientific Reports volume 15, Article number: 6533 (2025) Cite this article

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This study aimed to determine whether wearing N95 masks for 4 h significantly affected physiological indicators in obese operating room staff compared to surgical masks (SMs). In this randomized crossover trial, the physiological impacts of wearing SMs and N95 masks for 4 h was analysed among 20 obese operating room staff. The data were connected to a nasal sampling tube using the Capnostream 20p monitor. The primary outcome was the change in venous carbon dioxide partial pressure (PvCO2) levels at 4-hour intervention. Secondary outcomes included venous oxygen pressure (PvO2), bicarbonate (HCO3−), pH levels, end-tidal carbon dioxide partial pressure (PetCO2), peripheral oxygen saturation (SpO2), respiratory rate (RR), pulse rate (PR) and blood pressure after mask intervention. Dyspnoea, palpitations, headache were assessed with the visual analogue scale (VAS) score. N95 masks had a statistically significant rather than clinically significant impact on PvCO2 (mean [95% CI], 1.4 [0.8, 1.9], P < 0.001) and RR (0.6 [0.1, 1.1)], P = 0.023) changes compared with SM. The three subjective VAS scores of the N95 group showed significantly increased than SM group after 2 h. In conclusion, obese operating room staff continuously wearing SM or N95 masks 4 h showed almost no difference in physiological impacts.

Trial registration NCT05950256, 18/07/2023.

Obesity was identified as body mass index (BMI) of 30 kg/m2 or higher according to the World Health Organization criteria1. In recent years, obesity has become a serious public health threat because of its rising prevalence1,2. Due to the accumulation of adipose tissue in the abdomen and chest, obesity can cause expiratory flow limited, atelectasis, and possibly hypoxemia and hypercapnia3. Medical staff are more prone to obesity due to factors such as long working hours, shift schedules, changes in body regulation, metabolism, and stress4,5. To prevent surgical site infections in patients and protect medical staff from contaminated blood, body fluids, and most surgical smoke6,7, operating room staff are required to wear masks according to established guidelines and it is recommended to replace masks every 4 h8. However, it is not clear if wear masks affect respiratory function and comfort experience in obese medical staff.

Wearing masks by medical staff has been proven to be associated with various symptoms, including hypoxemia, physiological changes, as well as subjective discomfort such as breathing difficulties and headaches9,10. Early studies had found that surgical mask (SM) can reduce postoperative peripheral oxygen saturation (SpO2) and increase pulse rate (PR) for surgeons compared to preoperative conditions11. Our previous research revealed a significantly reduced SpO2 and increased respiratory rate (RR) in anaesthesiologists wearing SMs for more than 2 h12.

N95 masks exhibited better protective properties and particularly suitable for high-risk environments compared with SMs13,14. Notably, researches showed that N95 masks significantly increased end-tidal carbon dioxide pressure (PetCO2) of intensive care unit (ICU) nurses after wearing for 12 h15. In addition, medical staff within emergency departments wearing N95 masks for 4 h caused changes in gas exchange, including plasma pH, venous oxygen pressure (PvO2) decreased and PetCO2 increased16.

Both obesity and masks may contribute to increase the cardiopulmonary burden, but there is no evidence to show whether these two types of masks have a negative effect on the respiratory function of obese medical staff. Therefore, this study aims to compare the effects of wearing SM or N95 masks for 4 h on physiological indices among obese operating room medical staff. This can help medical staff to formulate strategies on optimizing medical protection.

This single-centre, prospective, randomized crossover trial was conducted in the operating room of Qilu Hospital, Shandong University, China, from July 2023 to October 2023. The study was carried out in accordance with the Declaration of Helsinki (2013 Edition) and approved by the Qilu Hospital of Shandong University Medical Ethics Committee (No. KYLL-202306-032) and registered before patient enrollment at ClinicalTrials.gov (NCT05950256, principal investigator: Shaozhong Yang, date of registration: 18/07/2023). Written informed consent was obtained from all participants. Study followed the Consolidated Standards of Reporting Trials (CONSORT) guideline (Fig. 1).

Study flowchart.

We recruited 20 obese participants aged 20–60 years, nonsmoking, with a body mass index (BMI) ≥ 30 kg/m2, and without chronic cardiopulmonary diseases from anaesthesiologists and nurses in the operating room. Regardless of sex, they voluntarily participated in this study. The exclusion criteria were recent acute or chronic respiratory disease; recent history of headache or dizziness; pregnancy or lactation; rhinitis; nasal polyps; respiratory distress; facial skin inflammation; or skin laxity. Each participant provided written informed consent before participating in this study.

An allocation and randomization list was generated by a computer program. Participants were randomly assigned to either SM-first group or N95 mask-first group in a 1:1 ratio, and completed data observation during the continuous wearing of SMs or N95 masks for 4 h. Trial outcomes adjudicators and statisticians were blinded to group allocation (study flowchart, Fig. 1). After a 24-hour washout period, the protocol was repeated.

To avoid using daily personal protective equipment familiar to participants, N95 masks and SMs were purchased from third-party suppliers outside Qilu Hospital of Shandong University and did not undergo compatibility testing. During the study period, each participant was required to correctly wear a disposable lace-up SM (Dongbei Medical Strap Style, China) or a disposable N95 mask (Dongbei Medical NST-9502, China).

Participants were required to avoid using masks for at least 10 min before the test started and to stay away from the clinical area to ensure that baseline measurements were obtained under normal breathing conditions. The subjects were seated and connected to a specialized nasal sampling tube (Microstream Advance Adult Oral-Nasal CO2 Filter Line, Medtronic, Minneapolis, Co.) using the Capnostream 20p monitor (Medtronic, Minneapolis, Co.) to collect respiratory data. The right index finger was connected to a pulse oximetry probe, while an electronic sphygmomanometer (Omron U724J, China, Omron Co., Ltd.) was used to measure blood pressure (BP). Baseline data (T0) were collected without the participant wearing a mask, and the participants were blinded to the monitoring and BP readings. Then, the participants were asked to use a nasal sampling tube and wear an SM or N95 mask continuously for 4 h during medical work. To ensure the airtightness of the mask, a sterile wound dressing was used to fix the sampling tube between the mask and skin, and participants underwent the mask seal check (positive and negative seal check, eSupplementary). After the first stage and a 24-hour washout period, the second stage began. If participants were unable to persist, they can immediately remove the mask and abandon the test. Researchers monitored these subjects until symptoms improved.

The baseline data included SpO2, the RR, the pulse rate (PR), PetCO2, BP, and subjective sensation scores for dyspnoea, palpitation and headache. Venous blood (1 ml) was collected from the cubital vein of the participants using a 1 ml syringe, and baseline values for the no-mask condition were measured using a blood gas analyser (Cobas b 123, Roche Diagnostics). The pH, PvO2, venous carbon dioxide partial pressure (PvCO2), and bicarbonate (HCO3−) levels were recorded. To reduce harm to the subjects, baseline venous blood gas analysis was performed only once. Subsequently, the abovementioned data were collected using the same method immediately after mask wearing (T1) (after three regular breaths) and after continuous mask wearing for 1 h (T2), 2 h (T3), 3 h (T4), and 4 h (T5). To minimize data variability, data were collected twice at each time point, after which the average value was calculated. After continuously wearing an SM or N95 mask for 4 h, 1 ml of venous blood was extracted for blood gas analysis. All subjective sensations (dyspnoea, palpitations and headache) were scored by means of a 10-point visual analogue scale (VAS) from 0 (no discomfort) to 10 (worst discomfort imaginable).

The primary outcome was the change in PvCO2 value after continuous SM and N95 mask wearing for 4 h. The secondary outcomes were PetCO2, SpO2, the PR, the RR, BP, and the VAS subjective sensation scores at 5 time points (T1, T2, T3, T4 and T5), as well as the pH, PvO2, and HCO3− of venous blood gas after 4 h of mask wear.

The sample size was calculated with Pass 15 (NCSS, LLC, Kaysville, UT, USA). In our preliminary experiment, six obese anaesthesiologists working in the operating room were included; after 4 h of the intervention, the difference in the PvCO2 between the SM and N95 mask groups was 1.5 (1.3) mmHg. With a two-sided test, an α of 5%, and a power of 90%, 18 participants were needed. Assuming a 10% dropout rate, we included a total of 20 participants.

Statistical analysis was performed using R software (version 4.3.1). Categorical data are represented as numbers or percentages. Continuous data were tested for normality using the Shapiro-Wilk test and are expressed as the mean (standard deviation) or median (interquartile range [IQR]). A linear mixed model (eSupplementary) was established the differences in physiological changes caused by N95 masks and SMs, as well as the differences in physiological changes caused by different intervention measures within subjects over time, while considering the internal correlations among subjects caused by cross design and repeated measurements. We modeled the cyclical and carryover effects, and used the FDR method for correction after multiple comparisons. A P value of < 0.05 was considered to indicate statistical significance.

Between July 2023 and October 2023, among 199 operating room medical staff, 33 obese medical staff were assessed for eligibility. As described in the flowchart (Fig. 1), 13 participants were excluded, and ultimately 20 obese participants were randomized, including 7 anesthesiologists, 5 anesthesia nurses and 8 operating room nurses.

Twenty obese participants in the operating room (mean [SD] age, 32.2 [6.0] years; 9 women [45%]) completed this study, with an average BMI of 32.8 (SD, 2.1) kg/m2. There were no significant differences in baseline values for age, height, weight, BMI, venous blood gas or physiological indicators between the SM-first group and the N95 mask-first group (Table 1).

Estimates of mean changes between baseline and 4 h of mask intervention obtained from the repeated measures analysis are reported in Table 2. There was a significant difference in the primary outcome measure (P < 0.001), changes in average PvCO2, between N95 masks (3.3 [2.2, 4.4]) and SM (1.9 ([0.9, 3.00]). Baseline venous blood gas was only collected once in both groups. Compared to continuously wearing SMs 4 h, N95 mask wear for 4 h significantly increased PvCO2 [49.0 (3.8) vs. 50.4 (4.0), P < 0.001] (Table S1). As shown in Fig. 2, the PvCO2 values of the N95 mask group were significantly higher in both stage 1 (Mean [95% CI], 1.6 [0.9, 2.3], P < 0.001) and stage 2 (Mean [95% CI], 1.1 [0.0, 2.2], P = 0.044), indicating that the N95 mask had a more significant treatment effect (Table S2).

Comparison of reported PvCO2, PvO2, pH and HCO3− among the two-stage SM and N95 mask wearing conditions.

The treatment effect, period effect, and carryover effect of secondary outcome measures in crossover study were validated (Table S2). Estimates of mean changes between baseline and 4 h for secondary outcome measures are presented in Table 2. After continuous masks wearing for 4 h, there was no significant difference in the changes in venous blood gas pH, PvO2, HCO3−, and physiological indices such as PetCO2, RR, PR, SpO2, and BP between the two groups. The pH, PvO2, HCO3− changes between the two groups in stage 1 and stage 2 were also not significant (Fig. 2). As shown in Fig. 3, Table S1 and Table S3, at each time point, intergroup comparisons were made between SM and N95 mask interventions, and the results showed that there were no significant differences in PetCO2, RR, SpO2, SBP, and DBP. Both groups showed a significant increase in PetCO2 (P < 0.001) immediately after donning an SM or N95 mask (T1). After continuous wearing of masks for 4 h (T5), the estimated mean change in PR between baseline and N95 mask group was significantly increased than that of the SM group (Mean [95% CI], 0.6 [0.1, 1.1], P = 0.023).

Estimated mean changes in physiological indices and VAS scores for subjective sensations during 4-hour intervention with SMs and N95 masks.

At each time point, the mean estimated changes in VAS scores for dyspnoea, headache and palpitations were compared between the N95 mask and SM groups at baseline and that time point (Fig. 3). With prolonged SM and N95 mask wear, the VAS scores of the obese operating room staff for dyspnoea, palpitations and headache gradually increased (Table S1 and Fig. 3). Intergroup comparisons revealed significant differences (P < 0.001) in the VAS scores for the three subjective sensations between the two mask interventions at 2, 3, and 4 h (Table 2; Fig. 3). With increasing mask use duration, the subjective VAS scores of participants in the N95 mask group increased more significantly than did those of participants in the SM group, but the scores remained tolerable (mean VAS score, < 3).

Obesity and mask use may both increase the cardiopulmonary burden3,12,13,14. This study investigated the physiological effects of SM and N95 mask wearing on obese operating room staff through self-comparison.

This crossover trial showed that continuous SM or N95 masks wearing for 4 h significantly increased PvCO2, PetCO2, and RR in obese operating room staff. It was most likely the increase in dead space volume created by the masks, which increase frequency and depth of breathing. Compared with SM, N95 masks wearing had a more significant effect on PvCO2, but there was no significant difference in other venous blood gas and physiological indices between the two types of masks. Combined with the venous blood indices, these changes are unlikely to have clinical significance. We also observed a significant increase in the PetCO2 immediately after SM and N95 mask wearing compared to no mask wearing. This change may be related to psychological factors, and the increase in the RR may be a compensatory mechanism for the increase in PetCO2 17.

After continuous mask wearing for 2 h, the subjective VAS scores of obese participants in the N95 mask group were significantly greater than those in the SM group; however, all of these scores were within a tolerable range. Indicating that the subjective discomfort of the two types of masks will not seriously affect obese medical staff in the operating room. The study by Che-Yu Su et al. also found that for healthcare workers, compared with the SMs group, the N95 masks group had significantly higher incidence of shortness of breath, headache, dizziness, difficulty speaking and fatigue17. However, a study showed that during the COVID-19 pandemic, SMs had more subjective interference with healthcare workers compared to N95 masks, including nausea, dizziness, blurred vision, irritability and memory loss and sleep disorders18. Our study was the first time to investigate the effects of two of the most commonly used masks on the physiological and subjective feeling of obese healthcare workers.

The impact of SMs or N95 masks on healthy nonobese healthcare workers has been extensively confirmed12,15,16. A study of ICU medical staff confirmed that wearing N95 masks for prolonged work did not result in a significant decrease in SpO2 or a significant increase in heart rate19. These research results are basically consistent with our research data, indicating that it is safe for obese health care workers without a history of cardiopulmonary disease to use masks for extended periods during daily medical activities.

However, studies on the impact of masks on obese people are rare. A study showed that obese children were more likely to experience respiratory distress while wearing masks. After walking tests, overweight or obese children showed a significant increase in PetCO2 and in the PR and RR, but no significant changes in SpO2 were observed20. Consistent with our research findings, they also observed a significant increase in PetCO2 when obese children used masks immediately.

In healthy individuals, N95 masks cause minimal changes in blood gas and other physiological parameters during physical activity, even during very intense exercise21. A recent study of healthy volunteers suggested that even with mild exercise, prolonged wear of N95 masks can increase respiratory resistance, leading to a decrease in RR and SpO2 within 1 h and an increase in heart rate after 2 h until the mask is removed22. Consistent with our research findings, this study also did not find any changes in BP, as healthy individuals can compensate for this cardiovascular overload.

Although our data support that SMs and N95 masks have a smaller impact on physiological indices, N95 masks have higher subjective sensation scores, which are related to tighter facial seals. After wearing N95 masks for 4 h, the inhalation and exhalation resistance increased by 0.43 and 0.23 mmH2O, respectively. The average moisture retention in the mask is 0.26 ml23. Compared to no mask, N95 masks increase the temperature of inhaled air by 1.13 times during eight breaths and increase the CO2 concentration by 7.3 times24. An increase in heat and humidity inside N95 masks directly leads to an increase in respiratory resistance, repeated CO2 breathing, and an increase in subjective sensations such as dyspnoea.

Based on the findings of our study, we believe that headaches are unlikely to be caused by physiological changes in the balance of O2 and CO2 and may be due to facial pain behind the ears or other contact points caused by mask straps9. Indirect factors, such as insufficient hydration and an irregular diet, may also lead to headaches when individuals wear masks for a long time25. Recent research data suggest that prolonged use of masks in medical environments has limited effects on the PR and HR of healthcare workers. Although the subjective perception score for palpitations significantly increases, more consideration should be given to psychological factors9,26.

Masks are usually used to prevent respiratory virus infections, but their effectiveness may vary depending on the type of mask used. There is currently insufficient evidence supporting the use of medical masks or SMs to combat influenza or coronavirus infections, with N95 masks being the most effective27. Our research suggested that there was almost no difference in the impact of SMs or N95 masks on the physiological indicators of obese healthcare workers. These findings may help to persuade obese healthcare workers to wear N95 masks for better protection.

Our research advantage lies in the monitoring of obese medical staff during daily medical work in the operating room rather than during intense exercise or running, which has more practical significance for clinical guidance. This study has several limitations. First, venous blood was used for blood gas analysis to avoid harm and possible complications to participants from arterial puncture. The obese healthcare workers involved in our study had no cardiovascular disease, and venous pH and PCO2 may be potentially good surrogates for arterial pH and PCO2 in those participants28. In addition, due to the rapid response of arterial blood to changes in ventilation, fear and anxiety caused by arterial puncture may lead to short-term hyperventilation, which may affect the true PaCO2 values29. Second, activity levels can affect physiological indicators. Although our study used self-crossover control and attempted to have participants perform similar work in two stages, it may still affect the accuracy of the research results. Third, we only observed participants for 4 h and did not collect data on the safety of using masks for longer periods, as masks are disposable, and their protective effects weaken over time; it is generally recommended that masks be replaced every 4 h8,30. Finally, to minimize interference with surgery, obese surgeons were not included in this study, which affected the generalizability of the results.

Obese operating room staff who participate in routine medical work can wear SMs or N95 masks for 4 h without significantly increasing the risk of physiological burden. It is recommended that N95 masks be worn under high-risk conditions for better protection and replaced every 4 h according to established guidelines.

The datasets used in the present study are available from the corresponding author upon reasonable request.

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The authors thank all the involved obese operating room staff for their contributions to this trial.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Department of Anesthesiology, Qilu Hospital of Shandong University, No. 107, Wenhua West Road, Jinan, 250012, Shandong, China

Chuanyu Fang, Yu Liu & Shaozhong Yang

Department of Anesthesiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, No. 107, Wenhua West Road, Jinan, 250012, Shandong, China

Yanzhe Ba

Department of Anesthesiology, Center for Reproductive Medicine ShandongUniversity, No.157, Jingliu Road, Jinan, 250001, Shandong, China

Yuanlei Gao

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S.Y. and C.F. conceived and designed the study; C.F. and Y.L. collected the data; Y.G. and Y.B. analyzed the data; S.Y. and Y.L. wrote and revised the manuscript; C.F. and Y.B. accompanied and monitored the participants.All authors reviewed the manuscript.

Correspondence to Shaozhong Yang.

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Fang, C., Ba, Y., Gao, Y. et al. Physiological impact of surgical masks and N95 masks on obese operating room staff. Sci Rep 15, 6533 (2025). https://doi.org/10.1038/s41598-025-91578-9

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