The COVID-19 pandemic has resulted in the widespread use of facemasks globally. Facemasks
contribute to the protection against contamination of the people wearing them and
those in close proximity, and they also protect against the fear of contamination.
Wearing facemasks is, however, associated with a series of material constraints: you
have to think about the mask, to have it with you, to pay for it, to change it, or
to wash it frequently. Facemasks are also associated with marked sociological inconveniences,
obstructing verbal communication (eg, muffled voice, invisible lip movements) and
hindering non-verbal communication by making facial expressions hard to read. Facemasks
can also be uncomfortable to wear. Primarily, being slightly resistive to airflow
and a possible source of carbon dioxide rebreathing, they change our relationship
with our own breathing. We suddenly become consciously aware of our respirations,
and many of us find this unsettling. What if there was a sociological upside to this
particular consequence of wearing protective masks? What if this could make us more
attentive to the predicament of patients with chronic breathing problems?
Ordinarily, the continual neural bombardment from respiratory-related afferents that
our brain receives is fully gated out, and, once passed the trial of our very first
breath, breathing comes naturally and we are not consciously aware of it, even when
it is disturbed by mild exercise or speech.
But disease-related alterations of the respiratory system arising from lung, heart,
or neuromuscular abnormalities can put an end to this so-called respiratory felicity.
These alterations can result in breathing becoming faster, shallower, laboured, noisy,
or associated with the abnormal use of certain muscles. Most importantly, they can
result in dyspnoea, namely breathing becoming a conscious act (sensory dimension)
and an emotionally disturbing one (affective dimension). This multidimensional negative
respiratory experience, of which the felt intensity can be disconnected from the extent
of the underlying respiratory abnormalities, is a symptom—an alarm signal. But beyond
that, it is a life-altering existential experience, with psychological, behavioural,
and social consequences. This is especially true when dyspnoea cannot be improved
by treatments to correct its causative pathophysiological abnormalities, a situation
termed chronic breathlessness or persistent dyspnoea. In such cases, the ever-present
awareness of breathing becomes a permanent threat, a permanent reminder of impending
mortality. The impact of dyspnoea on the lives of those affected is further aggravated
by the invisibility that unfortunately characterises the experience. Even though observing
acute dyspnoea in others is associated with negative feelings, dyspnoea is not only
under-diagnosed and associated with delayed diagnosis but also under-evaluated, under-addressed,
and often associated with an apparent lack of empathy from others. This invisibility
impedes access to appropriate care and raises a human rights issue. It is explained,
in part, by the disconnection of the dyspnoeic experience lived by the patients from
the respiratory measurements performed by physicians. Also, the experience of dyspnoea,
with the inherent sense of powerlessness that accompanies it, is not one that is universal,
in contrast with pain and other common discomforts that everybody has experienced
and can easily empathise with. Not having lived with dyspnoea presumably limits the
ability of others to sympathise and empathise with patients, which probably goes some
way to explain avoidance behaviours that are sometimes observed in persons confronted
with dyspnoeic patients, and sometimes even in caregivers.
Patients are well aware of the invisibility of dyspnoea, and remarks such as, “They
should have doctors experience these symptoms, especially dyspnoea, so they understand
what patients are going through” are not uncommon. Yet, the experiential learning
theory suggests that personally experiencing dyspnoea could be useful in changing
one's perception of it. This has not been formally studied, but is supported by anecdotal
evidence. Similarly, Robert Lansing and colleagues report the post-hoc verbatim of
a healthy person submitted to an air hunger inducing experiment: “If I felt I had
to live my life feeling like that, I would jump out of the window”. Submitted for
the first time to a similar type of experiment, one of us (AG), a respiratory intensivist,
exclaimed that he would “never again tell an agitated [dyspnoeic] mechanically ventilated
patient to calm down”.
So, wearing a facemask to fight the circulation of severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) makes breathing a conscious experience that can be unsettling
or oppressive. This dyspnoea is mild at rest and is in no way comparable to patients'
experiences. However, it can become sufficiently disturbing—when climbing stairs,
when talking while walking, when in confined or crowded spaces, or in reaction to
heightened emotional states—for people to seek respiratory relief by removing their
masks, at the price of trangressing hygiene recommendations. This amounts to regaining
control, an option not available to dyspnoeic patients, and illustrates the truly
dyspnogenic effect of face masks.
We submit that the respiratory discomfort induced by facemasks could be considered
as a form of mass experiential learning liable to bring a great many people to discover
the overlooked existential experience of dyspnoeic patients. We believe that this
offers a unique opportunity to raise public awareness of what it means to be constantly
aware of, and bothered by, one's own breathing. This phenomenon could be leveraged
by foundations and charities that promote lung health or by teams engaged in the field
of disability studies as a communication tool about the dyspnoeic experience that
is lived by patients afflicted by chronic respiratory diseases, to, in the end, achieve
better levels of comprehension and empathy. Meanwhile, let us have a thought for these
patients when breathing through a facemask bothers us.
© 2020 B. Boissonnet/BSIP/Science Photo Library
2020
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