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Updated: Jul 26, 2025
Effects of Surgical Masks on Cardiopulmonary Function in Healthy Subjects
Published on: February 12, 2021
Physiologic effects of surgical masking in children versus adults
J Patrick Brooks1,2, Jill Layman1, Jessica Willis3
1School of Anesthesia, Missouri State University, Springfield, Missouri, United States.
Insights
Surgical masks significantly increase inspired carbon dioxide (ICO2) and slightly increase end-tidal carbon dioxide (ETCO2) in children and adults. However, these physiological changes remain clinically insignificant and well within normal limits.
Area of Science:
- Physiology
- Public Health
- Pediatrics
Background:
- Surgical masks are recommended by the CDC to reduce COVID-19 transmission.
- Limited research exists on the effects of masking on ventilation, especially in children.
Purpose of the Study:
- To investigate the physiological effects of surgical masks on carbon dioxide levels in children and adults.
- To compare the impact of masking on ventilation across different age groups.
Main Methods:
- Prospective interventional study with 119 participants (71 adults, 49 children).
- Each participant served as their own mask-free control.
- Measured end-tidal CO2 (ETCO2), inspired CO2 (ICO2), respiratory rate, pulse oximetry, and heart rate before and during mask use.
Main Results:
- Masking significantly increased ICO2 in all age groups, with a higher increase observed in younger children (2-7 years).
- A statistically significant but clinically insignificant rise in ETCO2 was observed in both adults and children.
- Pulse oximetry, heart rate, and respiratory rate were not significantly affected by mask-wearing.
Conclusions:
- Surgical mask use leads to a statistically significant increase in ICO2 and a minor increase in ETCO2.
- These changes are physiologically measurable but clinically insignificant, remaining within normal physiological limits.
Background:
Surgical masks remain a focal part of the CDC guidelines to decrease COVID-19 transmission. Evidence refuting significant effects of masking on ventilation is mostly limited to small studies, with a paucity of studies on children, and none comparing children to adults.
Methods:
A total of 119 subjects were enrolled (71 adults, 49 children) in a prospective interventional study with each subject serving as their own mask-free control. End tidal CO2 (ETCO2), inspired CO2 (ICO2), and respiratory rate were measured by nasal cannula attached to an anesthesia machine D-fend module. Pulse oximetry and heart rate were also followed. After the mask-free period, an ASTM Level 3 disposable surgical mask was donned and 15 min of mask-worn data were collected.
Results:
A steady state was confirmed for ETCO2 and ICO2 over the masked period, and mean ICO2 levels rose significantly (p < 0.001) after masking in all age groups. The increase in ICO2 for the 2- to 7-year-old group of 4.11 mmHg (3.23-4.99), was significantly higher (p < 0.001) than the final ΔICO2 levels for both the 7- to 14-year-old group, 2.45 mmHg (1.79-3.12), and adults, 1.47 mmHg (1.18-1.76). For the pediatric group there was a negative, significant correlation between age and ΔICO2, r = -0.49, p < 0.001. Masking resulted in a statistically significant (p < 0.01) rise in ETCO2 levels of 1.30 mmHg in adults and 1.36 mmHg in children. The final respective ETCO2 levels, 34.35 (33.55-35.15) and 35.07 (34.13-36.01), remained within normal limits. Pulse oximetry, heart rate, and respiratory rate were not significantly affected.
Discussion:
The physiology of mechanical dead space is discussed, including the inverse relationship of subject age vs ICO2. The methodology and results are compared to previously published studies which detracted from the physiologic safety of surgical masking.
Conclusions:
The wearing of a surgical mask results in a statistically significant rise in ICO2 and a smaller rise in ETCO2. Because ETCO2 and other variables remain well within normal limits, these changes are clinically insignificant.
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