Facemasks as a COVID-19 barrier: a window into the overlooked experience of chronic dyspnoea?
Authors: Thomas Similowski, Caroline Moricot, Nathalie Nion, Maxens Decavèle, Sophie Lavault, Antoine Guerder, Capucine Morélot-Panzini, Laure Serresse
Journal: The Lancet Respiratory Medicine (2020)

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. TS reports personal fees from AstraZeneca France, Boerhinger Ingelheim France, GSK France, TEVA France, Chiesi France, Lungpacer Inc, ADEP Assistance, personal fees and non-financial support from Novartis France, and grants from Air Liquide Medical Systems, outside of the submitted work. All other authors declare no competing interests.