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      Modified full-face snorkel masks as reusable personal protective equipment for hospital personnel

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          Abstract

          Here we adapt and evaluate a full-face snorkel mask for use as personal protective equipment (PPE) for health care workers, who lack appropriate alternatives during the COVID-19 crisis in the spring of 2020. The design (referred to as Pneumask) consists of a custom snorkel-specific adapter that couples the snorkel-port of the mask to a rated filter (either a medical-grade ventilator inline filter or an industrial filter). This design has been tested for the sealing capability of the mask, filter performance, CO2 buildup and clinical usability. These tests found the Pneumask capable of forming a seal that exceeds the standards required for half-face respirators or N95 respirators. Filter testing indicates a range of options with varying performance depending on the quality of filter selected, but with typical filter performance exceeding or comparable to the N95 standard. CO2 buildup was found to be roughly equivalent to levels found in half-face elastomeric respirators in literature. Clinical usability tests indicate sufficient visibility and, while speaking is somewhat muffled, this can be addressed via amplification (Bluetooth voice relay to cell phone speakers through an app) in noisy environments. We present guidance on the assembly, usage (donning and doffing) and decontamination protocols. The benefit of the Pneumask as PPE is that it is reusable for longer periods than typical disposable N95 respirators, as the snorkel mask can withstand rigorous decontamination protocols (that are standard to regular elastomeric respirators). With the dire worldwide shortage of PPE for medical personnel, our conclusions on the performance and efficacy of Pneumask as an N95-alternative technology are cautiously optimistic.

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          Most cited references12

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          Coronavirus Disease 2019 (COVID-2019) Infection Among Health Care Workers and Implications for Prevention Measures in a Tertiary Hospital in Wuhan, China

          Key Points Question What are the exposure details and clinical characteristics of health care workers with coronavirus disease (COVID-19) in Wuhan, China? Findings In this single-center case series including 9684 health care workers, 110 of whom had COVID-19, a higher rate of infection was found among those working in the low-contagion area during the early stage of the disease outbreak, especially among nurses younger than 45 years. Most health care workers with COVID-19 had nonsevere disease, with an asymptomatic carrier prevalence of 0.9% and a mortality rate of 0.9%. Meaning In this study, most infections among health care workers occurred during the early stage of the COVID-19 outbreak and in low-contagion areas; routine screening may be helpful in identifying asymptomatic carriers.
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            Is Open Access

            Prevalence and Clinical Presentation of Health Care Workers With Symptoms of Coronavirus Disease 2019 in 2 Dutch Hospitals During an Early Phase of the Pandemic

            Key Points Question What was the prevalence and clinical presentation of coronavirus disease 2019 among health care workers with self-reported fever or respiratory symptoms in 2 Dutch hospitals within 2 weeks after the first patient with coronavirus disease 2019 was detected in the Netherlands? Findings In this cross-sectional study that included 1353 health care workers with self-reported fever or respiratory symptoms, 6% were infected with severe acute respiratory syndrome coronavirus 2. Most health care workers with coronavirus disease 2019 experienced mild disease, and only 53% reported fever. Meaning The high prevalence of mild clinical presentations, frequently not including fever, suggests that the currently recommended case definition for suspected coronavirus disease 2019 should be used less stringently.
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              Headaches and the N95 face‐mask amongst healthcare providers

              Background:  During the 2003 severe acute respiratory distress syndrome epidemic, healthcare workers mandatorily wore the protective N95 face‐mask. Methods:  We administered a survey to healthcare workers to determine risk factors associated with development of headaches (frequency, headache subtypes and duration of face‐mask wear) and the impact of headaches (sick days, headache frequency and use of abortive/preventive headache medications). Results:  In the survey, 212 (47 male, 165 female) healthcare workers of mean age 31 years (range, 21–58) participated. Of the 79 (37.3%) respondents who reported face‐mask‐associated headaches, 26 (32.9%) reported headache frequency exceeding six times per month. Six (7.6%) had taken sick leave from March 2003 to June 2004 (mean 2 days; range 1–4 days) and 47 (59.5%) required use of abortive analgesics because of headache. Four (2.1%) took preventive medications for headaches during this period. Multivariate logistic regression showed that pre‐existing headaches [P = 0.041, OR = 1.97 (95% CI 1.03–3.77)] and continuous use of the N95 face‐mask exceeding 4 h [P = 0.053, OR = 1.85 (95% CI 0.99–3.43)] were associated with development of headaches. Conclusions:  Healthcare providers may develop headaches following the use of the N95 face‐mask. Shorter duration of face‐mask wear may reduce the frequency and severity of these headaches.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: SoftwareRole: ValidationRole: Writing – original draftRole: Writing – review & editing
                Role: InvestigationRole: MethodologyRole: Project administrationRole: VisualizationRole: Writing – original draft
                Role: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: SoftwareRole: ValidationRole: Writing – original draft
                Role: ConceptualizationRole: Formal analysisRole: InvestigationRole: MethodologyRole: ValidationRole: Writing – original draftRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SoftwareRole: ValidationRole: Writing – original draft
                Role: Formal analysisRole: InvestigationRole: MethodologyRole: ResourcesRole: ValidationRole: Writing – original draft
                Role: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: ResourcesRole: SupervisionRole: ValidationRole: Writing – original draft
                Role: Formal analysisRole: InvestigationRole: MethodologyRole: ValidationRole: VisualizationRole: Writing – original draft
                Role: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: ValidationRole: Writing – original draft
                Role: InvestigationRole: MethodologyRole: Project administrationRole: ValidationRole: Writing – original draft
                Role: MethodologyRole: Validation
                Role: InvestigationRole: MethodologyRole: SoftwareRole: VisualizationRole: Writing – original draft
                Role: InvestigationRole: MethodologyRole: SoftwareRole: VisualizationRole: Writing – original draft
                Role: InvestigationRole: MethodologyRole: Software
                Role: InvestigationRole: MethodologyRole: SoftwareRole: Visualization
                Role: SoftwareRole: Visualization
                Role: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: ResourcesRole: ValidationRole: VisualizationRole: Writing – original draft
                Role: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: SoftwareRole: ValidationRole: VisualizationRole: Writing – original draft
                Role: Project administrationRole: Visualization
                Role: Formal analysisRole: InvestigationRole: MethodologyRole: ValidationRole: VisualizationRole: Writing – original draft
                Role: InvestigationRole: MethodologyRole: Visualization
                Role: InvestigationRole: Software
                Role: InvestigationRole: Software
                Role: InvestigationRole: Methodology
                Role: Investigation
                Role: InvestigationRole: Resources
                Role: InvestigationRole: Methodology
                Role: Investigation
                Role: Investigation
                Role: Data curationRole: InvestigationRole: Methodology
                Role: Investigation
                Role: InvestigationRole: Validation
                Role: InvestigationRole: Validation
                Role: ConceptualizationRole: InvestigationRole: MethodologyRole: Validation
                Role: InvestigationRole: MethodologyRole: Project administrationRole: ValidationRole: Writing – original draft
                Role: InvestigationRole: Validation
                Role: InvestigationRole: Validation
                Role: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SupervisionRole: ValidationRole: Writing – original draft
                Role: InvestigationRole: Validation
                Role: InvestigationRole: Validation
                Role: InvestigationRole: MethodologyRole: Project administrationRole: Validation
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: Project administrationRole: ResourcesRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS One
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                13 January 2021
                2021
                13 January 2021
                : 16
                : 1
                : e0244422
                Affiliations
                [1 ] Department of Mechanical Engineering, Stanford University, Stanford, CA, United States of America
                [2 ] Department of Bioengineering, Stanford University, Stanford, CA, United States of America
                [3 ] Swiss Federal Institute of Technology (EPFL), School of Engineering, Lausanne, Switzerland
                [4 ] Swiss Federal Institute of Technology (EPFL), School of Life Sciences, Lausanne, Switzerland
                [5 ] Department of Electrical Engineering, Stanford University, Stanford, CA, United States of America
                [6 ] Stellar Design LLC, San Mateo, CA, United States of America
                [7 ] Stanford University, Biophysics Program, Stanford, CA, United States of America
                [8 ] Olin College of Engineering, Needham, MA, United States of America
                [9 ] Deakin College, Australia
                [10 ] Department of Bioengineering, University of Utah, Salt Lake City, UT, United States of America
                [11 ] Department of Anesthesiology, University of Utah, Salt Lake City, UT, United States of America
                [12 ] Waymo, Mountain View, CA, United States of America
                [13 ] Department of Applied Mathematics, Harvard University, Cambridge, MA, United States of America
                [14 ] Mountain View, CA, United States of America
                [15 ] Independent Contributor, Italy
                [16 ] Wildhorn Outfitters, Draper, Salt Lake City, UT, United States of America
                [17 ] Decathlon (Subea), Product Engineer, Hendaye, France
                [18 ] University of Michigan, Entrepreneurial Leadership Faculty, Ann Arbor, MI, United States of America
                [19 ] iSnorkel Inc, Dexter, Salt Lake City, UT, United States of America
                [20 ] Swiss Federal Institute of Technology (EPFL), Safety, Prevention and Health Domain, Lausanne, Switzerland
                [21 ] U.S. Anesthesia Partners Texas, Dallas, TX, United States of America
                [22 ] University of Alabama at Birmingham, Birmingham, AL, United States of America
                [23 ] Hospital for Special Surgery, New York City, NY, United States of America
                [24 ] Miki & Alfonso Hand & Upper Extremity Center, Miami, FL, United States of America
                [25 ] Instituto de Oftalmologia, Ophthalmologist, Santiago, Chile
                [26 ] Hospital Universitario Infanta Leonor, Madrid, Spain
                [27 ] Anesthesiologist, Santiago, Chile
                China University of Mining and Technology, CHINA
                Author notes

                Competing Interests: Schmidt Futures, Moore Foundation, Autodesk and CZ BioHub provided financial support of the project. Authors Gerry Ayala (Wildhorn Outfitters), Quentin Allinne (Subea Decathlon), and Dave Kasper (iSnorkel Inc) have company affiliations with snorkel-mask manufacturers or distributors. They consulted on original designs of these masks, and in some cases to help with adapter design strategy. None of the scientific data included in this report, nor the conclusions of this report were written or substantially influenced by these co-authors. John Pearson has a conflict of interest as a stake holder in a for-profit entity focused on snorkel based PPE (True Health). Patrick Kolbay is volunteering his time at this company. Stellar Design and Waymo provided support in the form of salaries for authors DP and SE. We certify that none of the other authors have any affiliations with or involvement in any organization or entity with any financial interest in the subject matter or materials discussed in this manuscript. None of the other authors (beyond what is listed above) have any affiliations with John Pearson's company. There are no patents, products in development or marketed products associated with this research to declare. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

                Author information
                https://orcid.org/0000-0001-7860-2632
                https://orcid.org/0000-0002-0501-2006
                https://orcid.org/0000-0003-4426-6794
                https://orcid.org/0000-0002-8046-8388
                Article
                PONE-D-20-25634
                10.1371/journal.pone.0244422
                7806161
                33439902
                972876af-c106-4031-8726-cd12b4354d94
                © 2021 Kroo et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 22 August 2020
                : 9 December 2020
                Page count
                Figures: 7, Tables: 0, Pages: 18
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/100000936, Gordon and Betty Moore Foundation;
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/100004675, Autodesk;
                Award Recipient :
                Funded by: Schmidt Foundation
                Award Recipient :
                MP thanks Schmidt Futures, Moore Foundation, Autodesk and CZ BioHub for financial support of the project. Stellar Design, Waymo, Wildhorn Outfitters, Decathlon, and iSnorkel Inc. provided support in the form of salaries for authors DP, SE, GA, QA, and DK, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section.
                Categories
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                Data from this study is available at www.pneumask.org, and within Supporting Information files of this manuscript.
                COVID-19

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