Looking at Masks and Respiratory Health

This post was originally published on this site

Starting with the first reports of breathing difficulties among people who contracted Covid-19 and extending now to those wearing masks to limit the risk of acquiring or unwittingly transmitting the virus, the ability to breathe normally has become a common concern.

Some worry: Are we taking in enough oxygen to adequately supply our muscles, organs and especially our brains? (I’m among many who purchased a pulse oximeter to do daily checks of my blood’s oxygen level.) Are the masks we wear interfering with our breathing?

As I walk and cycle in my Brooklyn neighborhood, I see many people with masks under their chins who pull them over nose and mouth only when they’re about to pass another person.

Believe me, I understand and empathize. Walking around with half one’s face under layers of cloth, neoprene or some other protective covering is neither attractive nor comfortable, even more so now with summer heat approaching. This is especially challenging for people who must wear masks throughout their workday, as well as those with pre-existing respiratory problems and people with poor hearing who now struggle to participate in mask-muffled conversations without the added assist of lip reading.

Alas, this is a fact of life we will most likely have to endure for many more months, perhaps even years, until an effective vaccine against this deadly virus can be developed and administered widely. There are ways, though, to maintain and even improve respiratory health while following the important guidelines for wearing masks issued by the Centers for Disease Control and Prevention to curb the spread of Covid-19.

But first, we could all benefit from a better understanding of a bodily function most of us have long taken for granted and learn how to maximize its efficiency and life-sustaining benefits. Based on the research I’ve done for this column, it’s apparent that even without a mask as an impediment, many people breathe in ways that compromise their well-being.

“Doctors who study breathing say that the vast majority of Americans do it inadequately,” James Nestor, author of a new book, “Breath: The New Science of a Lost Art,” wrote recently in The Wall Street Journal. “How we breathe matters,” he said, “and our attention to it is long overdue.”

For example, Mr. Nestor noted, “nose breathing is better than mouth breathing” because it’s protective; the nose filters, heats and treats raw air. “Inhaling through the nose stimulates the release of hormones and nitric oxide, which helps to regulate vital functions like blood pressure and increase oxygenation throughout the body,” Mr. Nestor said in an email.

Given that most of us take about 25,000 breaths a day and breathing properly is critical to how well our bodies function, we should try to get the most benefit we can from this life-sustaining activity, with or without a mask.

So, in addition to Mr. Nestor’s comprehensive treatise on breathing, I consulted an unusual expert, Paul DiTuro, a former professional athlete and special forces medic in the United States military who is now a performance breathing specialist for a company called PN Medical, which makes devices to help train respiratory muscles for people with conditions like emphysema as well as professional athletes.

Breathing done properly keeps the body in acid-base balance, which enables tissues to get the amount of oxygen they need to function optimally, Mr. DiTuro explained. This balance is achieved by maintaining an ideal level of carbon dioxide (CO2) in the blood. Too little CO2, which can happen when breathing is rapid and shallow, impedes the release of oxygen to body tissues and can result in feelings of anxiety, irritability, fatigue and lack of focus, Mr. DiTuro said.

Rapid, shallow breathing keeps the body in a high state of alert and engages the sympathetic nervous system, an adaptation that is useful in times of danger but counterproductive to feeling calm and relaxed the rest of the time.

Even during normal times, many people breathe too fast and through their mouths, perhaps because of chronic stress or noses made stuffy by allergies or a deviated septum. I noticed that I tended to do the same when I was wearing a mask, and now consciously remind myself to breathe more slowly, inhale through my nose and exhale through my mouth, especially when I’m out exercising. Without very much effort, you can retrain how you breathe — with or without a mask — so that it is physiologically beneficial when you’re not being chased by a tiger.

A rapid, shortened breathing cycle uses muscles in the neck and chest instead of the diaphragm, which is innervated by the vagus nerve responsible for calming the body. Mr. DiTuro noted, “Lack of diaphragmatic breathing makes it harder to mentally relax.”

  • Frequently Asked Questions and Advice

    Updated June 12, 2020

    • What’s the risk of catching coronavirus from a surface?

      Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.

    • Does asymptomatic transmission of Covid-19 happen?

      So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.

    • How does blood type influence coronavirus?

      A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.

    • How many people have lost their jobs due to coronavirus in the U.S.?

      The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.

    • Will protests set off a second viral wave of coronavirus?

      Mass protests against police brutality that have brought thousands of people onto the streets in cities across America are raising the specter of new coronavirus outbreaks, prompting political leaders, physicians and public health experts to warn that the crowds could cause a surge in cases. While many political leaders affirmed the right of protesters to express themselves, they urged the demonstrators to wear face masks and maintain social distancing, both to protect themselves and to prevent further community spread of the virus. Some infectious disease experts were reassured by the fact that the protests were held outdoors, saying the open air settings could mitigate the risk of transmission.

    • How do we start exercising again without hurting ourselves after months of lockdown?

      Exercise researchers and physicians have some blunt advice for those of us aiming to return to regular exercise now: Start slowly and then rev up your workouts, also slowly. American adults tended to be about 12 percent less active after the stay-at-home mandates began in March than they were in January. But there are steps you can take to ease your way back into regular exercise safely. First, “start at no more than 50 percent of the exercise you were doing before Covid,” says Dr. Monica Rho, the chief of musculoskeletal medicine at the Shirley Ryan AbilityLab in Chicago. Thread in some preparatory squats, too, she advises. “When you haven’t been exercising, you lose muscle mass.” Expect some muscle twinges after these preliminary, post-lockdown sessions, especially a day or two later. But sudden or increasing pain during exercise is a clarion call to stop and return home.

    • My state is reopening. Is it safe to go out?

      States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.

    • What are the symptoms of coronavirus?

      Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.

    • How can I protect myself while flying?

      If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)

    • Should I wear a mask?

      The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.

    • What should I do if I feel sick?

      If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.


Coincidentally, shortly before the pandemic struck, a physical therapist hoping to minimize back pain taught me diaphragmatic breathing, an ancient technique that quiets the body and mind by engaging the parasympathetic nervous system. It’s widely used by opera singers, actors and meditators, among others. I was told to inhale through my nose and exhale slowly through my mouth. But instead of my chest expanding as my lungs fill when I inhale, my diaphragm — the dome-shaped muscle under my lungs — should contract and drop down toward my stomach.

Respiratory therapists teach diaphragmatic breathing to people with lung problems, and you can strengthen this important though neglected muscle on your own.

Lie on your back, knees bent, and breathe in slowly and deeply through your nose as your belly rises but your chest remains still. Then tighten your abdominal muscles and exhale through pursed lips.

Doing five minutes of respiratory muscle training every morning and every night can help you learn to breathe more effectively at all times without having to think about it. Having stronger respiratory muscles may also facilitate an effective battle against the coronavirus. At the very least, they can make living healthfully through the Covid-19 pandemic while breathing through a mask less challenging.

A small investigative trial Mr. DiTuro conducted with assistance from colleagues at the Mayo Clinic and other labs around the country suggests that over prolonged periods, N95 masks, the kind worn by doctors caring for virus-infected patients, “do have the potential to alter respiratory patterns enough to cause negative physical and mental effects.”

While more research on the possible effects of masks on breathing patterns is needed, Mr. DiTuro suggests that in addition to respiratory training, some simple steps may help make wearing a mask easier. Just before putting on your mask, take five “quality” breaths. With each breath, inhale through the nose for four seconds, exhale through the mouth for six seconds, then rest for two seconds. Repeat these five breaths as soon as you put on the mask, and again after you remove it.

If, for example, you are a teacher, medical worker or checkout clerk who must wear a mask for an extended period, take periodic breaks when you can safely remove the mask and breathe normally.