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Performance and impact of disposable and reusable respirators for healthcare workers during pandemic respiratory disease: a rapid evidence review
  1. Christopher Burton1,
  2. Briana Coles2,
  3. Anil Adisesh3,
  4. Simon Smith4,
  5. Elaine Toomey5,
  6. Xin Hui S Chan6,
  7. Lawrence Ross7,
  8. Trisha Greenhalgh8
  1. 1 Academic Unit of Primary Medical Care, The University of Sheffield Faculty of Medicine Dentistry and Health, Sheffield, UK
  2. 2 Leicester Real World Evidence Unit, Diabetes Research Centre, University of Leicester, Leicester, Leicestershire, UK
  3. 3 Occupational Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
  4. 4 Canadian Standards Biological Aerosols Group, Canadian Standards Association, Toronto, Ontario, Canada
  5. 5 School of Allied Health, University of Limerick Faculty of Education and Health Sciences, Limerick, Ireland
  6. 6 Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford Medical Sciences Division, Oxford, Oxfordshire, UK
  7. 7 Infectious Diseases, Children’s Hospital of Los Angeles, Los Angeles, California, USA
  8. 8 Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
  1. Correspondence to Dr Christopher Burton, Academic Unit of Primary Medical Care, The University of Sheffield Faculty of Medicine Dentistry and Health, Sheffield, Sheffield, UK; chris.burton{at}


Objectives To synthesise evidence concerning the range of filtering respirators suitable for patient care and guide the selection and use of different respirator types.

Design Comparative analysis of international standards for respirators and rapid review of their performance and impact in healthcare.

Data sources Websites of international standards organisations, Medline and Embase, hand-searching of references and citations.

Study selection Studies of healthcare workers (including students) using disposable or reusable respirators with a range of designs. We examined respirator performance, clinician adherence and performance, comfort and impact, and perceptions of use.

Results We included standards from eight authorities across Europe, North and South America, Asia and Australasia and 39 research studies. There were four main findings. First, international standards for respirators apply across workplace settings and are broadly comparable across jurisdictions. Second, effective and safe respirator use depends on proper fitting and fit testing. Third, all respirator types carry a burden to the user of discomfort and interference with communication which may limit their safe use over long periods; studies suggest that they have little impact on specific clinical skills in the short term but there is limited evidence on the impact of prolonged wearing. Finally, some clinical activities, particularly chest compressions, reduce the performance of filtering facepiece respirators.

Conclusion A wide range of respirator types and models is available for use in patient care during respiratory pandemics. Careful consideration of performance and impact of respirators is needed to maximise protection of healthcare workers and minimise disruption to care.

  • occupational health
  • health personnel
  • international health regulations

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  • Contributors The article was collaboratively developed as part of a wider series of evidence reviews on personal protective equipment edited by TG and overseen by the Oxford Covid-19 Evidence Review Service. SS conceptualised the review and undertook extensive background desk research on respirator standards. CB led the shaping of the methodology to align with formal systematic review guidance, led the synthesis and wrote the first draft of the paper, to which all authors made contributions. CB and SS undertook searches. CB and BC contributed to data extraction. AA provided specialist occupational medicine expertise. XHSC and LR provided specialist infection control expertise. All authors approved the final manuscript. CB is corresponding author and guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests SS recently retired from a scientific research position at a major manufacturer of respiratory protective equipment.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.