Mask monographContinuing education
2
Mask monographTo optimize patient compliance and PAP therapy adherence, several criteria have to be taken
into consideration when selecting the appropriate mask or interface. Criteria include patient
medical condition and pathology, patient morphology, patient psychosocial issues and patient
personal preference.
Introduction
Obstructive sleep apnea (OSA) is a well-recognized clinical disorder
characterized by repeated obstructions of the upper airway during
sleep. OSA occurs in 2% to 4% of the middle-aged population and results
in sleep fragmentation that disrupts the normal sleep architecture,
causing periodic oxygen desaturations.1 Severe OSA has been
associated with a significantly higher mortality rate from co-morbidities
than mild and moderate OSA.2 Both sleep fragmentation and oxygen
desaturation often go unnoticed by patients, but can be related to the
development of many concomitant physical and psychological problems.
Consequences of untreated OSA include excessive daytime sleepiness,
mood changes such as depression and irritability, and impairments in
attention, concentration, and memory.3 Despite recent advances in
physician recognition of the disorder, a large proportion of OSA
patients remain undiagnosed and untreated. This statistic is particularly
troubling in light of the fact that patients with undiagnosed, or
untreated, OSA, often have, or are at increased risk for, co-morbid
conditions such as hypertension and cardiovascular disease.4
Continuous positive airway pressure (CPAP) is undoubtedly the
first-line therapy for OSA5 and is delivered through a nasal interface
attached to a device that supplies positive pressure to the upper
airway, thus preventing the upper airway from collapsing during sleep.
CPAP, at an appropriate pressure, reduces nocturnal breathing
disturbances and improves oxygen saturation and sleep architecture.
The efficacy of CPAP treatment has been validated on functional
measures including measures of daytime sleepiness, cognitive function,
and mood. Studies have shown a relationship between the amount of
time a patient uses CPAP and positive clinical outcomes. Despite its
efficacy, roughly 25% of patients discontinue treatment within the first
year6 and of those who continue to use CPAP; the majority do not use
it as prescribed.7 Symptoms of OSA may improve with an average
nightly compliance of 4.5 hours. However, alertness is impaired even
with a single missed night of therapy.8 Studies have shown that effective
treatment of OSA may result in stabilization of blood sugar and the
reduction of cardiovascular events.9 Such results were not realized
when treatment was less than 4 hours nightly.
Maintenance of successful PAP therapy is the duty of both the user
and clinician in order to improve compliance from both OSA and its
co-morbidities.
Adherence predictors
Although investigators have studied several potential demographic,
disease severity, and psychosocial predictors of adherence, few
consistent findings have been reported. Surprisingly, disease severity,
age and prescribed PAP pressures have all been unrelated to adherence.
Only one side effect, feeling “closed in” by the PAP interface, has been
consistently predictive of poor adherence.10
Of the OSA patient population there are about 20% that will never
accept therapy and another 20% that comply and are easy to follow.
It is the last 60% of the PAP patients that represent a challenge and
take the extra time to support their compliance.
Mask categories
3
Clinician choice and timing is crucial
Patient perceived symptom improvement is related to self-reported
compliance. Improvement in daytime energy, daytime concentration,
overall well being, and especially sleep quality is found in those who
are compliant with PAP therapy.11
Acceptance and adherence to PAP therapy is greatly impacted by
the type of interface that has been chosen. Adverse effects such as
claustrophobia and mask discomfort, air leaks, pressure sores, and
mask dislodgement can all compromise PAP use. Initial exposure to
a mask normally occurs within the sleep laboratory setting prior to
a titration study. In the lab, proper mask fit and choice is vital, as
the early experience may be particularly important in the long-term
adherence to therapy.12 Duration and frequency of CPAP use during
the first month can reliably predict treatment compliance rates within
the following months.7
Patient interfaces, or masks, fall in to three different categories: nasal masks, full-face masks, and minimal-
contact masks. Minimal-contact masks are also commonly known as nasal-pillows style masks.
Nasal masks that cover the nose only, are focused on fit and comfort, and offer the most choices. About 45%
of the OSA population will be fitted with a nasal mask. For those who breathe through their mouths while
sleeping, a full-face mask that covers both the nose and mouth may be a more effective option. Alternative
solutions that also result in comfort and effectiveness can be found in the minimal-contact category.
Did you know?
• More insurers are requiring objective evidence of adherence to
PAP therapy to receive reimbursement
• Interface usage can have a significant impact on acceptance and
adherence to positive airway pressure (PAP) therapy
• It is important that the interface be matched to the individual
patient needs and that patients be followed closely to assess
their clinical response to therapy
• Adverse effects such as claustrophobia, mask discomfort, air
leak, pressure sores, and mask displacement compromise PAP use
• Minimizing interface-related adverse effects early in therapy may
result in greater acceptance of long-term PAP use
Nasal mask
Nasal masks focus on fit and comfort,
and there are a lot of choices.
Full-face masks
Those who breathe through their
mouths will find several effective
options in this group of masks.
Minimal-contact masks
These masks are designed for those
who prefer alternative solutions but
still demand comfort and effectiveness.
4
Choosing the right maskfor the right patient
Clinical studies, medical advice, and user experience have helped
identify four criteria to take into consideration to optimize patient
compliance and therapy adherence, when selecting a mask. These four
criteria are:
• Patient medical condition and pathology
• Patient morphology
• Patient psychosocial issues
• Patient personal preferences
Patient medical condition and pathology
The first criterion used to select a mask is the patient’s medical
condition and pathology. An evaluation of the patient and the
circumstances may help focus the clinician on a specific type of mask.
Items to investigate are if they are a new user with no experience using
a CPAP or bi-level device, a compliant user of the therapy, a patient
who breathes through the mouth, a facial muscular disease, and a
current acute or chronic clinical situation.
For example, if the patient breathes through the mouth during the
initial interview or if there is a complaint of a dry mouth when wearing
a nasal or pillows style mask may indicate that the most appropriate
mask is a full-face mask that will cover both the nose and mouth.7
5
Patient morphology
Patient morphology is the second criterion and takes into account the
shape and size of the facial features, especially the nose format, nares,
facial hair and skin sensitivities. The symmetry of the face in relationship
to the contact points of the mask can be a determining factor of
whether a particular mask style will provide the best fit for a specific
PAP user. Choosing a different style of mask may be due to the
variations in nose or facial structure, such as an “eagle nose”, a flat
nose, a narrow nose, flat face or a short or protruding upper or lower
jaw. A person with a deviated septum or narrow nares may be difficult
to fit in to a nasal pillows mask but another person with nose bridge
pain, scars or deformation might be best fit with a nasal pillows mask.
Patient psychosocial issues
Patients may discontinue PAP therapy due to psychosocial obstacles
such as: feelings of anxiety, claustrophobia or simply how they believe
they look or look to others while wearing the interface. Behavioral
sleep medicine has a growing role in the assessment and treatment
of sleep disordered breathing and the psychosocial impairments
co-morbid with sleep disordered medicine.13
Both men and women have been described as having anxiety disorders
relating to the mask giving them a feeling of claustrophobia.13 In a case
study by Dr. Parthasarathy, the presence of a neuropathic trait such as
nail biting can give clues to the underlying anxiety state of the patient.
In this particular case, a nasal pillow mask was prescribed which was
less claustrophobic and anxiety inducing.14
Patient personal preferences
The last criterion is more difficult to measure and implies an
understanding of the patient’s social and cultural environment. It is
as important as the others as it involves the patient in the decision
making process and whenever the patient is actively involved in
the choice he or she is more likely to use the mask and comply
with the therapy.15
Personal preferences include: the desire for improved visibility,
dissatisfaction with aspects of standard alternatives, and preference for
less facial contact that will cause fewer pressure points or less bulk.
6
Selecting the right maskfor the right patient
On the initial setup, choosing the right mask will lead to long-term
compliance to PAP therapy.16 Clinicians should let the new user become
familiar with the mask and allow them to take part in the decision
process if applicable. A proper fit mask will be the smallest mask size
that is snug but does not pinch the nostrils, minimizes air leaks in to
the eyes and the cushion is not crushed against the face. Final
adjustments to the mask and headgear should be made with the PAP
therapy unit turned on and delivering pressure. Remember, a tight fit is
not necessary for effective therapy.
The questions below can direct the clinician to the appropriate mask for each individual’s situation.
Questions and suggested mask types for the 4 criteria
Patient medical condition and pathology questions: Suggested mask type
Are you claustrophobic? minimal contact, full-face
Are you currently using any nasal therapy or medication? minimal contact, nasal, full-face
Do you have any allergies or hay fever? minimal contact, nasal, full-face
Do you sleep on your side? minimal contact
Are you an active sleeper? minimal contact, nasal
Patient psychosocial questions: Suggested mask type
Are you looking for less contact on your face? minimal contact
Patient morphology questions:
Have you ever had a broken nose? nasal, full-face
Have you had previous nasal surgery? Suggested mask type
Do you have a deviated septum? nasal, full-face
Do you tend to breathe through your mouth when sleeping? full-face
Patient personal preference questions: Suggested mask type
Do you have a bed partner who is a light sleeper? minimal contact, nasal, full-face
Are you looking for a simplified mask to fit, clean and assemble? minimal contact, nasal, full-face
Do you read or watch TV in bed? minimal contact
Questions and suggested mask types for the new user
New user questions: Suggested mask type
Are you new to PAP therapy? minimal contact, nasal, full-face
Have you researched any masks or interfaces on the internet? minimal contact, nasal, full-face
Do you have friends or family using masks or interfaces? minimal contact, nasal, full-face
Questions and suggested mask types for the non-compliant user
Non-compliant user questions: Suggested mask type
Do you continue to snore even with PAP therapy? nasal, full-face
Do you wake up with a dry mouth and/or throat? nasal, full-face
Do you use a chin strap with PAP therapy? full-face
Does the air flow through the nasal pillows make your nose hurt? nasal, full-face
Does the mask impede your vision to read or watch TV in bed? minimal contact
Have previous masks created nasal bridge pressure or sores? minimal contact, full-face
Is the bridge of your nose easily irritated (by glasses)? minimal contact
7
Tips for patient comfortand performance
Once a mask has been chosen and the PAP user is adherent to the
therapy, there are some tips to keep each night more comfortable for
the patient. Occasionally the mask may need to be adjusted to reduce
leaks and maintain comfort. Reseating the mask by briefly lifting the
cushion away from the face will allow it to recreate a new seal. Along
with reseating, either loosening or minor tightening of the headgear
may help. Looping the tubing over the headboard may reduce the pull
on the mask and therefore decrease leaks that it might cause.
Common mask issues and tips for correcting
Common mask issues Correction tips
Skin irritation or red marks Mask may be too tight • Loosen headgear
• Resize mask
Sensitivity to mask material • Soak in warm soapy water
• Change to a different type of mask material
• Use a protective skin covering
Mask is stiff from age • Replace mask
Air leaks • Change position of the forehead adjuster if available
• Loosen headgear and reseat mask by briefly lifting the
cushion away from the face to allow it to create a new seal
• Be sure headgear straps are positioned correctly
• Resize mask to support a proper fit
• Consider a different mask type
Claustrophobia • Let user become desensitized to the mask
• Empower patient in the mask decision process
• Try a minimal-contact mask to decrease bulk around the face
8
Mask care and replacement
Proper care, cleaning and timely replacement of the mask can help
users maintain adherence with their therapy. Prior to applying the mask,
the face should be cleansed thoroughly. The mask itself should also be
cleaned with warm water in a mild dishwashing detergent (do not use
bleach, alcohol, or soap containing perfumes and moisturizers). After
cleaning, the interface should be rinsed thoroughly with water and air
dried out of direct sunlight.
For best results, supplies should be replaced regularly. New masks
may be needed when leaks are getting worse and reseating no longer
creates a good seal, the headgear is stretched and needs to be very
tight to attain a seal or the mask shows signs of wear. An alternate
style should be obtained if there is a need to rest tender facial areas
or there is frequent congestion due to a cold or sinus issues. Many
insurance plans allow for a replacement mask every three to six
months based on medical need.
Summary
It is important to choose the right mask for the right patient within the
first few months of PAP therapy to lead to increased adherence that
also leads to more effective treatment of the obstructive sleep apnea
and its co-morbidities, such as hypertension, cardiovascular disease and
diabetes.4
1Young, T., Palta, M., Dempsey, J. Skatrud, J., Weber, S., Badr, S., The
Occurrence of Sleep-Disordered Breathing among Middle-aged Adults, NEJM,
1003, 328:1230 – 1235.
2Marin, J.M., Carizo, S.J., Vicente, E., Augusti, AGN. Long-Term
Cardiovascular Outcomes in Men with Obstructive Sleep Apnea- Hypopnea
with or without Treatment with Continuous Positive Airway: an Observational
Study. The Lancet 2005:365:1046-1053.
3Cheshire, K., Engleman, H.M., Deary, I.J. Shapiro, C., Douglas, N.J.,
Factors Impairing Daytime Performance in Patients with Sleep Apnea/hypopnea
syndrome. Arch. Intern. Med, 1992, 152:538- 541.
4Young, T., Peppard, P., Palta, M., Hla, K.M., Finn, L., Morgan, B., Skatrud, J.,
Population-based Study of Sleep-Disordered Breathing as a Risk Factor for
Hypertension, Arch. Intern. Med, 1997, 157:1746-1752.
5American Thoracic Society, Indications and Standards for the use of Nasal
Continuous Positive Airway Pressure (CPAP) in Sleep Apnea Syndromes,
AJRCCM, 1994, 150: 1738-1745.
6McArdle, N., Devereauz, G., Heidarnejad, H., Engleman, H.M., Mackay,
T.W., Douglas, N.J., Long Term Use of CPAP therapy for Sleep Apnea/
Hypopnea Syndrome, AJCCM, 1999:159(4), 1108-1114.
7Kribbs, N.B., Pack, A.I., Kline, L.R., Smith, P.L., Schwartz, A.R., Schubert,
N.M., Objective Measurement of Patterns of Nasal CPAP used by Patients
with Obstructive Sleep Apnea, American Review of Respiratory Diseases,
1993b:147:887-895.
8Kribbs, N.B., Pack, A.I., Kline, L.R., Smith, P.L., Schwartz, A.R., Schubert,
N.M., Effects of One Night Without Nasal CPAP Treatment on Sleep and
Sleepiness in Patients with Obstructive Sleep Apnea, American
Review of Respiratory Diseases, 1993a:147:1162-1168.
9Babu, A.R., Herdegen, J., Fogelfield, L., Shott, S., Mazzone, T., Type 2
Diabetes; Glycemic Control, and Continuous Positive Airway Pressure in
Obstructive Sleep Apnea, Archives of Internal Medicine 2005: 165:447-452.
10Aloia, M.S., Arnedt, J.T., Stepnowsky, C., Hecht, J., Borrelli, B., Predicting
treatment Adherence in Obstructive Sleep Apnea using Principles of Behavior.11Turnpenny, B., Mehdi, S.B., French, L., Henderson, M., Kwong, G.,
Houghton, C., Patient Perceived Symptom Improvement with CPAP in Sleep
Apnoea Syndrome is Related to Self Reported Compliance, AJRCMM,
abstract, May 16, 1020.
12MedSage Data
13Massie, C.A., Hart, R. W., Clinical Outcomes Related to Interface Type in
Patients with Obstructive Sleep Apnea/Hypopnea Syndrome Who Are Using
Continuous Positive Airway Pressure, Chest 2003;123;1112-1118.
14Haynes, P.L., The Role of Behavioral Sleep Medicine in the Assessment and
Treatment of Sleep Disordered Breathing, Clinical Psychology Review,
2005; 25 (5):673-705.
15Parthasarathy, S., Mask Interface and CPAP Adherence, JCSM, 2008, Vol. 4,
No. 5.
16Pepin, J.L., Krieger, J., Rodenstein, D., Cornette, A., Sforza, E., Delguste,
P., Deschaux, C., Grillier, V., Levy, P., Effective Compliance during the First 3
Months of Continuous Positive Airway Pressure, AJRCCM, 1999, Vol 160. pp
1124 – 1129.
9
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Post-test questions
1. Obstructive Sleep Apnea (OSA) patients are at increased risk for:
a. Hypertension
b. Cardiovascular disease
c. Type 2 Diabetes
d. All of the above
2. Poor adherence can by predicted by:
a. Disease severity
b. Age
c. Feeling “closed in”
d. Prescribed PAP pressures
3. The 4 criteria to consider when selecting a mask are patient medical condition and pathology, patient
morphology, patent psychosocial issues, and patient personal preferences.
a. True
b. False
4. The suggested mask type of someone who suffers from claustrophobia is:
a. Minimal contact masks
b. Full Face Mask
c. Nasal Mask
d. Both A and B
5. The suggested correction for a mask that is too tight and causing red masks is to loosen the headgear and resize
the mask.
a. True
b. False
6. Masks can be separated into 3 different categories:
a. Nasal, minimal contact, mouthpiece
b. Full face, mouthpiece, nasal
c. Minimal contact, nasal, full face
d. Mouthpiece, minimal contact, nasal
7. The patient morphology criteria includes:
a. Nose format
b. Facial hair
c. Skin sensitivities
d. A, B and C
e. A and B
8. A naïve PAP user should not be asked if they have researched masks on the internet.
a. True
b. False
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Identify the different categories of masks
Identify the predictors of adherence to PAP therapy
Identify the four criteria for selecting a mask
Understand the importance of choosing the right mask for the patient
Identify the questions to direct the clinician to the appropriate mask
Post-test
This monograph has been approved for 1 hour of AARC and AAST credits. A certificate of course completion will be
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