High risk mask protocol

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This protocol is under review, and has not been accepted.

We are currently gathering feedback and editing this protocol, and there may be errors or bad wording. Please only use this protocol with caution, and if other organisations have definitive protocol, use that instead.

Please see #protocols on Slack to discuss this protocol further.

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More documents in need of medical review can be found here.

This page describes protocol for using PPE. Please read the PPE principles and remember that appropriate PPE, not simply the most PPE is the correct solution. PPE is not a magical talisman or substitute for good practice and a scene survey
Note regarding COVID: This page is not specifically relating to the COVID-19 pandemic pandemic, but includes information that will be useful for dealing with the pandemic.

When to use respirator masks

Photograph of an N95 mask

Respirator masks are designed to protect the wearer from becoming infected by viruses such as COVID-19. If fitted correctly, they can block small aerosol particles from entering. However, they may not provide their full level of protection unless fitted by a fit tester.

During the current UK supply shortage, highest priority for respirator use must go to healthcare workers undertaking procedures such as intubation which are known to produce quantities of infectious aerosol particles.

If supplies are available, you can wear one in situations where you would be exposed to a high level of COVID-19, or a similar virus:

  • When doing care which requires prolonged close contact with an infected person.
  • When caring for multiple infected people.
  • When in confined spaces with an infected person for a long period of time (e.g. a car ride).
  • If you would be severely at risk from the virus, but cannot avoid being in a confined space with others who may be infected.
  • If carrying out CPR on a person who is, or may be, infected with COVID-19[1]

If respirator masks are not available, you should use surgical masks, with modifications to improve the fit. See the close contact mask protocol for details of how to use these. Cloth masks should only be used in these situations as a last resort.

Respirator masks should not be worn by someone with symptoms of COVID-19, as they may restrict breathing. There is currently no evidence as to whether they are any better than surgical masks at preventing an asymptomatic wearer from infecting others. They should therefore be prioritised for use to protect the wearer from infection, not to prevent the wearer from spreading infection. However, if you do use them around others who are at risk of infection, do not use respirator masks which have a valve, as these will not block particles which you exhale.[2]

How to wear a respirator mask

In Europe, respirator masks are classed as FFP1, FFP2 or FFP3, in increasing order of protection. FFP2 masks are adequate in most of the above situations, except for aerosol-generating healthcare procedures where FFP3 may be preferable.[3]. The N95 is the US equivalent of a FFP2 mask.

Although respirators are far superior to surgical masks in laboratory tests[4], studies suggest that in many real-life situations they may not provide any greater benefit, because they are not used correctly [5].

If using a respirator mask, it is vital that you follow the instructions to get as good a fit as possible.

  • In healthcare settings, workers should undergo a fit test before beginning to use respirator masks. If you don't have access to a fit tester, but do have access to more than one model of mask, choose the one which fits most tightly.
  • If you have a respiratory condition, be aware that a correctly fitted mask may make it more difficult to breathe. It's a good idea to trial one at home before exposing yourself to an infectious environment.

Putting on a respirator mask

  1. Put on your mask before putting on gloves
  2. Wash your hands first.
  3. Check there are no defects, such as holes or tears.
  4. Cup the face of the mask in your hand.
    • Position the nose of the mask at your fingertips
    • Allow the headbands to hang below your hand
    • If you can, touch only the edges of the mask
  5. Hold the mask up to your face.
  6. Use your other hand to position the straps behind your head.
    • Pull the bottom strap over your head and down below your ears, so that it sits at the back of your neck
    • Then pull the top strap over your head so that it sits above your ears.
    • Do not criss-cross the straps
  7. Tighten the straps, if your model allows this, by pulling the ends on both sides at once. Tighten the bottom strap,then the top.
  8. If there is a metal clip at the nose, slide your fingers down both sides to mould it to the shape of your nose.
  9. Make sure the mask is secure, with a tight seal around your nose, and covers your mouth, nose and chin.
  10. Check the seal by placing both hands over the respirator and breathing in and out.
    • The mask should cling to your face as you inhale. If you hold your breath for 10 seconds after inhaling, it should stay sucked in.
    • You should not feel air leaking out onto your hands when you exhale
    • If air leaks, you may need to adjust the position of the straps or the nose clip, or try another size or model
  11. Wash your hands again.

Also see this poster by the Health and Safety Executive for a visual guide.

Wearing a mask

  • The mask must cover your nose and mouth.
  • Don’t touch your face, or touch the face of the mask while wearing it.
    • If you do, sanitise or wash your hands before touching your surroundings.
  • Don’t take it off when talking, using the phone, etc.
  • Respirator masks remain effective for far longer than surgical or cloth masks, so there is no set time limit for wearing them.[6]
  • However, they may be uncomfortable [7], so put on your mask immediately before entering the high-risk situation.
  • If possible, wear your mask continuously rather than removing and and replacing it, to reduce the risk of spreading virus to the inside of the mask.

Taking off a mask

  1. Remove your gloves first, to avoid transferring virus from your hands to your face.
  2. Wash your hands
  3. Do not touch the front of the respirator, as it may be contaminated. Handle the mask by the straps.
  4. Remove by pulling the bottom strap over the top of your head, and then the top strap
    • If you remove the top strap first, the mask will fall down around your neck and may contaminate your clothes.
  5. Dispose of the mask as soon as you can
    • If you can't dispose of it immediately, place it in a sealed bag until you can
  6. Wash your hands again

Reusing masks

  • Respirators should be single-use, but in the current severe supply shortage, they can be sterilised by placing them in a 70C oven for 30 minutes.[8]
    • Do not bring infected masks into the home from other locations. Only use this technique if the virus is already present in your home.
    • Handle unsterilised masks by the straps only, and wash your hands very thoroughly after handling.
    • Be very careful that you do not contaminate any surfaces with the unsterilised masks, and disinfect any surfaces (e.g. taps, oven door) which you may have touched.
    • If possible, reuse no more than 5 times, as the fit may begin to deteriorate.[9]
  • Alternatively, clean undamaged respirators can be set aside in a breathable paper bag and reused when the virus has become nonviable.
    • Place them in the bag immediately after removal - remember that the surface will be contaminated.
    • Don’t use a plastic bag, as this may prevent them from drying.
    • Label the bag with the date of use.
    • Leave for 2 weeks before reuse. A recent study found that the COVID-19 virus survived longer on surgical masks than on any other surface.[10] It did not test respirator masks, but similar considerations may apply.
  • Never share masks.
  • Never use bleach to clean masks.
  1. UK Resuscitation Council 'Statement on COVID-19 in relation to CPR and resuscitation in first aid and community settings' ; Accessed: 2020-04-27
  2. ECDC, 'Using face masks in the community'; Accessed: 2020-04-27
  3. ECDC,'Safe use of personal protective equipment in the treatment of infectious diseases of high consequence'; Accessed: 2020-04-27
  4. Smith et al, 'Effectiveness of N95 respirators versus surgical masks in protecting health care workers from acute respiratory infection: a systematic review and meta-analysis'.; Accessed: 2020-04-23
  5. Long et al, 'Effectiveness of N95 respirators versus surgical masks against influenza: A systematic review and meta‐analysis'; Accessed: 2020-04-23
  6. Fisher et al, 'Considerations for Recommending Extended Use and Limited Reuse of Filtering Facepiece Respirators in Health Care Settings'; Accessed: 2020-04-27
  7. Radonovich et al, 'Respirator Tolerance in Healthcare Workers'; Accessed: 2020-04-27
  8. Liao et al, 'Can N95 facial masks be used after disinfection?'; Accessed:2020-04-27[1]This report warns against home sterilisation, but its target audience is healthcare workers who would be bringing infected material into their homes which would otherwise have been left at the hospital. We therefore advise that this technique should only ever be contemplated in situations where the virus is already present in the home
  9. Bergman et al, 'Impact of multiple consecutive donnings on filtering facepiece respirator fit'; Accessed: 2020-04-27
  10. Chin et al, 'Stability of SARS-CoV-2 in different environmental conditions'; Accessed:2020-04-27[2] This study found infectious virus still present on the mask after 7 days; it did not test how many further days the virus survived, but based on the rate of decay shown here, we suggest allowing a minimum of 14 days