Follow doffing, re-donning, extended use, and reuse best practices to reduce risks.
Hospitals and clinics have experienced severe personal protective equipment (PPE) shortages since the COVID-19 pandemic began, requiring them to be strategic in optimizing use and reuse of all PPE, including N95 respirators. N95 respirators are single-use items that are disposed of after each patient encounter, so they should be available in sufficient quantities to avoid reuse. However, given the current shortages, nurses have been forced to use one N95 respirator for their entire shift or for multiple days.
Based on current evidence, extended use and limited reuse may be safe if proper doffing and re-donning steps are followed, but more research is needed. In addition, reusing a potentially contaminated N95 respirator adds risk of exposure to pathogens. Nurses should follow best practices for safe extended wear, reuse, and multiple-day use of N95 respirators.
What’s the difference between surgical masks and respirators?
A surgical mask protects nurses from large airborne droplets, splashes, or sprays of hazardous body fluids. It also protects others from the nurse’s large-droplet respiratory emissions. Surgical masks aren’t considered complete respiratory protection because they don’t prevent inhalation of smaller airborne particles.
A respirator is designed to form a tight seal around the nose and mouth. In contrast to a mask, a respirator is considered higher-level respiratory protection because it filters out at least 95% of airborne particles and reduces the wearer’s exposure to particles including small particles, aerosols, and large droplets that can be generated during SARS-CoV-2 infection.
Respirators aren’t one-size-fits-all devices; each person using a respirator must be fit-tested, which requires trying on different styles and sizes of respirators to see which gives the best facial seal. In addition, a compound is aerosolized into a hood while the nurse is wearing various respirators to determine if a scent or taste can be detected. If it can be, the respirator doesn’t fit properly. After the fit test, the nurse should be provided with documentation about the best-fitting make, model, style, and size of respirator. Nurses should be fit-tested every 12 months to ensure the respirator type continues to fit correctly.
If N95 fit-testing isn’t successful with currently available models and sizes, a nurse may need to use another method of protection such as a powered air-purifying respirator (PAPR). The PAPR is a loosely fitted hood with a full facepiece, which avoids the tight seal over the nose and mouth. Superior protection against SARS-CoV-2 contamination hasn’t been demonstrated with the PAPR technology, and observations indicate that their use impairs mobility and communication; however, the devices appear to reduce heat buildup under the hood, which may improve comfort.
What types of respirators are available?
Several types of particulate-filtering facepiece respirators are available. Some have a dome-like shape and some a duckbill shape. N95 respirators can filter 95% of airborne particulates as long as the mask remains free of oily substances like makeup, hence the label N95 (not resistant to oil). An R95 is somewhat resistant to oil and a P95 is strongly resistant and considered to be oil proof. N99s and N100s can filter at even higher levels.
When do I need to use an N95 respirator?
If you expect to have contact with a patient on airborne precautions—for example, someone with known or suspected COVID-19, tuberculosis, or measles—you’ll need to wear an N95. Follow these donning and doffing recommendations when using your new N95 respirator or reusing it.
Donning your new N95 respirator
N95s are fitted for individual use; they should never be shared. Label your respirator and its storage container according to your organization’s policy to confirm ownership. Inspect your N95 for damage before donning it, and follow a consistent sequence of actions. Always lean slightly forward to avoid self-contamination. You may prefer to position the bottom strap at the nape of your neck and the top strap at the crown of your head. A slight wiggle of the straps while donning will help to get it over your head, especially if you wear glasses or have a ponytail.
Checking the respirator seal
A previous fit test and inspection for structural integrity don’t ensure a proper seal, so check the seal every time you don your N95. A good seal between the N95 and your face is essential for 95% filtration. Gently shape the N95 around the bridge of your nose, being careful to mold it without pinching it, which may cause tenting. To test the seal, inhale and exhale briskly—the respirator should pucker slightly on inhalation and expand slightly on expiration. Then, with bare hands and without touching the outside of the respirator, check to feel if your breath is escaping around the edges as you forcefully exhale. You’ll be able to detect escaping air more easily if your hands are slightly moist after using hand sanitizer. A repeat seal check is recommended if you ever doubt mask fit. Discard your N95 and replace it with a new one if you can’t achieve a tight seal.
Doffing your N95 respirator
After doffing your other PPE, wash your hands and re-glove. Move slowly, mindfully, and consistently when removing the N95 so you maintain control. The natural elastic properties of the taut straps can unpredictably recoil if they’re not managed with care, so begin by grasping the strap at the nape of your neck and slowly bring it over your head. With your other hand, grasp the top strap at the crown of your head and slowly bring it over your head as you gently pull the N95 away from your face. If you’re not planning to reuse your N95, the Centers for Disease Control and Prevention (CDC) recommends using both hands to remove the bottom and top straps immediately before discarding.
Visually inspect the inside and outside of your N95 for oily substances, secretions, blood, or makeup; discard it if obvious soiling has occurred. Place the respirator into an open paper bag or breathable storage container provided by your institution. The container should be labeled with your name. Store the respirator with the exterior (contaminated) side up so that it’s exposed to the air; don’t let the straps fall into the mask. Storage containers should be cleaned or disposed of after use. (See N95 decontamination.)
Use the glove-in-glove technique to remove your gloves; hold the first glove you removed in your remaining gloved hand and pull the second glove off by putting your fingers inside the glove at the top of the wrist and turning the second glove inside out, leaving the first glove inside the second. Perform meticulous hand hygiene to reduce contamination risk.
Decontamination should not be standard practice; however, If personal protective equipment shortages force you to reuse your N95 respirator, the Centers for Disease Control and Prevention recommends three decontamination methods:
- ultraviolet light
- vaporized hydrogen peroxide
- moist heat.
Currently, limited research is available for these measures, and their efficacy may vary depending on the N95 manufacturer and model. All decontamination methods result in some degree of N95 degradation, which may reduce respirator effectiveness and frequency of safe reuse. More research and guidance is needed to determine how decontamination might impact a respirator’s straps, filtration, fit, structural integrity, and performance.
If decontamination is used, carefully assess the respirator’s seal:
- Inhale and exhale quickly to check for collapsing and puckering, which indicates a good seal.
- Hold your bare hands around the respirator (don’t touch it) and exhale forcefully to check if you can feel your breath, which indicates air leak.
Re-donning your previously used N95 respirator
Before re-donning, examine your N95’s structural integrity, including the straps. Apply the same technique you used when donning a new respirator, but always consider the exterior of the N95 to be contaminated. Practice meticulous aseptic technique to prevent contamination of the inside of your N95. Pay careful attention to avoid touching your face during the seal check. The need for meticulous hand hygiene during this step can’t be overstated.
Extended, rather than intermittent, use is best practice
When done correctly, the risk of contamination from doffing and re-donning is minimal; however, the risk is even lower if you keep your N95 on for several hours or during an entire shift (extended use), rather than frequently removing it and putting it back on. Consider extended use if you’ll have repeated close contact with several patients who are infected with the same respiratory pathogen. Wearing a well-fitting N95 for long periods can be uncomfortable, so your decision to doff it or wear it continuously will depend on your practice setting and shift length. Wearing your N95 for up to 8 hours is considered safe and effective.
When adequate supplies of N95s are available, donning and doffing for each patient encounter is recommended. When reuse is necessary, best practice is to cycle and store five different N95s. Seventy-two hours should pass before using a previously used N95. Hang the respirator in a designated storage area or place it in an open paper storage container labeled with your name and the date. Paper containers are preferred over plastic because they’re more breathable, which is better for decontamination.
Reuse and extend use with confidence
Reusing or extending the use of your N95 respirators is a safe and effective way to protect yourself from respiratory illness when PPE is in short supply. It takes practice to don, doff, and re-don appropriately. As an added layer of protection, ask a colleague to check your technique. Having an illustrated guide to follow can serve as a reminder of important steps to follow when you don’t have someone available to verify the steps. (See N95 reuse best practices.)
Getting into the habit of following a few simple steps for donning and doffing a respirator will help you perform them correctly.
Boston College Connell School of Nursing has established these best practices when reusing N95 respirators. (Note: Reuse should be avoided.)
Suggested best practice techniques to doff and re-don an N95 respirator*
- Before using a respirator, check with your primary care provider to determine if you have a chronic respiratory, cardiac, or similar medical condition; a respirator may make breathing more difficult.
- All styles of N95 respirators require fit testing.
- A fit test and inspection for structural integrity don’t ensure a proper seal, so perform a seal test each time you don the N95.
- Always assume the exterior of a used N95 respirator is contaminated. Don gloves if touching the N95.
- Extended use of an N95 respirator, when worn appropriately, is preferred to repeated doffing and re-donning to reduce the risk of contamination.
- Ask a trained peer to assist in doffing and re-donning.
- Inspect the N95 for damage before donning (label the respirator per institution policy).
- Oil-based makeup and facial hair will reduce N95 effectiveness.
- Consider wearing a hairnet or placing hair in an elastic band to limit interference with respirator fit.
- Use a wriggling motion to guide straps over glasses and hair.
- Gently shape the respirator around the bridge of the nose, then test the seal by inhaling briskly to verify collapse and puckering.
- Discard N95 if breathing becomes difficult or the respirator lacks structural integrity.
- If wearing a face shield, ensure it doesn’t interfere with the N95 seal.
- Decontamination processes alter the integrity of duckbill N95 respirators, so reuse them with caution.
*Reusing N95 respirators should be avoided, and the evidence supporting reuse continues to evolve.
Click here for an illustration to remind nurses of the proper steps for doffing and re-donning used N95 respirators.
Artwork by Nicole Sly, BS, MA candidate, Teachers College, Columbia University
The authors work at the Boston College Connell School of Nursing in Chestnut Hill, Massachusetts. Beth Clarke is a clinical instructor, Nanci Haze is a clinical assistant professor, Jacqueline Sly is a clinical instructor, Allan Thomas is a clinical instructor, Patricia Reid Ponte is an associate clinical professor, and Corrine Y. Jurgens is associate professor.
References
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Centers for Disease Control and Prevention. Understanding the difference: Surgical mask, N95 respirator. cdc.gov/niosh/npptl/pdfs/UnderstandDifferenceInfographic-508.pdf.
Centers for Disease Control and Prevention. Using personal protective equipment. August 19, 2020. cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html
Centers for Disease Control and Prevention. Implementing filtering facepiece respirator (FFR) reuse, including reuse after decontamination, when there are known shortages of N95 respirators. August 4, 2020. cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html
Degesys NF, Wang RC, Kwan E, Fahimi J, Noble JA, Raven MC. Correlation between N95 extended use and reuse and fit failure in an emergency department. JAMA. 2020;324(1):94-6.
Fisher RJ, Morris DH, van Doremalen N, et al. Effectiveness of N95 respirator decontamination and reuse against SARS-CoV-2 virus. Emerg Infect Dis. 2020;26(9).
Licina A, Silvers A, Stuart RL. Use of powered air-purifying respirator (PAPR) by healthcare workers for preventing highly infectious viral diseases—a systematic review of evidence. Syst Rev. 2020;9(1):173.
National Institute for Occupational Safety and Health. NIOSH-approved particulate filtering facepiece respirators. April 9, 2020. cdc.gov/niosh/npptl/topics/respirators/disp_part/default.html
National Institute for Occupational Safety and Health. Pandemic planning: Recommended guidance for extended use and limited reuse of N95 filtering facepiece respiratory in healthcare settings. March 27, 2020. cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html.
Occupational Safety and Health Administration. Transcript for the OSHA training video entitled Respiratory fit testing. osha.gov/video/respiratory_protection/fittesting_transcript.html.
