In search of the perfect HC respirator

VHA seeks prototypes of a new design

Imagine the perfect respirator for health care workers: They wouldn't mind wearing it for an entire shift. They wouldn't have any trouble communicating with each other or with patients. Yet it would protect them from infectious diseases, and it wouldn't cost too much.

Anyone can dream. But a group, spearheaded by the Veterans Health Administration (VHA) in collaboration with the National Institute for Occupational Safety and Health (NIOSH), is trying to make this a reality.

The VHA issued a notice in the Federal Register asking for proposals from manufacturers who want to collaborate with Project B.R.E.A.T.H.E. (Better Respiratory Equipment using Advanced Technologies for Healthcare Employees). The manufacturers would need to meet a list of criteria that broadly meet these goals: Respirators should perform their intended functions effectively and safely. Respirators should support, not interfere with, occupational activities. Respirators should be comfortable and tolerable. Respiratory protective programs should comply with federal standards and guidelines, state regulations, and local policies.

The project is on a fast track. Manufacturers would be expected to develop a prototype within six to 12 months and to be able to produce respirators within six months.

"There's no shortage of need [for better respirators]," says Lewis J. Radonovich, MD, and director of Biosecurity Programs for the Office of Program Development at the North Florida/South Georgia Veterans Health System in Gainesville, FL. "The 2009 pandemic made it very clear to the public health and health care communities that respirator problems are a significant issue for health care workers."

Current models are 'intolerable'

Currently, health care workers don't tolerate N95 respirators very well. Radonovich and colleagues studied tolerability in 27 health care workers who wore eight different respirators or surgical masks for an entire eight-hour shift, with two 15-minute breaks and one 30-minute lunch break.

In more than half the sessions (59%), health care workers stopped wearing the masks or respirators because they could not tolerate them. Their complaints included diminished speech communication, heat, pressure, and dizziness. The powered air-purifying respirator (PAPR) and N95s with an exhalation valve were the best tolerated; the N95 worn with a surgical mask over it was the least tolerated.1

Short-term use — such as wearing a mask to treat the occasional tuberculosis patient — doesn't seem to be much of a problem, notes Radonovich. But during a pandemic, or with a newly emerging pathogen such as SARS, health care workers need continuous protection.

"Prolonged wear is a lot different than short-term wear. No matter what you put on, it appears there is substantial discomfort if it is worn for hours and hours," he says.

Yet this is a problem that must be solved, he notes. "If you look across other occupations, there are settings where workers have equipment that's worn for long periods [such as] the mining industry," Radonovich says. "It's conceivable that workers can learn to wear respirators for long periods. We need to do our job in the health care sector and respirator manufacturing sector to produce a respirator that's as comfortable as possible."

What is it that bothers health care workers most about respirators? What would they like to see in a respirator?

A survey of 159 health care workers at two hospitals revealed that most found them to be too hot (80%) and had experienced difficulty breathing (64%) or difficulty communicating verbally (78%) while wearing them. Only 24% reported N95 respirators to be comfortable most of the time or always, and almost 90% said they would rarely or never be able to tolerate wearing an N95 most of the time or always.2

"There hasn't been much research assessing the features that health care workers would want in respirators," says Aliya Baig, RN, MPH, MSN, former associate with the VA respiratory project. The survey "helps confirm some of the assumptions that have been made," she says.

However, health care workers aren't longing for an elastomeric or powered-air purifying respirator (PAPR). The surveyed health care workers said they want a disposable respirator that is comfortable and can be worn with facial hair. They also would like a respirator that doesn't require fit-testing.

The preferences of health care workers will play a role in the development of the new respirators. Radonovich envisions the VHA working with more than one manufacturer — possibly one large and one small. The system's massive work force — some 180,000 health care workers — will provide an ample platform for testing designs and getting feedback. (Health care workers will need to simulate work functions as they test out respirators because they can only use NIOSH-certified respirators on the job.)

"We are open to considering radical changes, completely new designs that are completely innovative," says Radonovich.

The VHA is developing a detailed list of criteria. "We're challenging our partners to think about how we can combine all the 28 different needs we have and turn them into something that the health care sector will want to buy," he says.


1. Radonovich LJ, Cheng J, Shenal BV, et al. Respirator tolerance in health care workers. JAMA 2009; 30:36-38. Available at

2. Baig AS, Knapp C, Eagan AE, et al. Health care workers' views about respirator use and features that should be included in the next generation of respirators. Am J Infect Control 2010 (in press) n:1-8.