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

mailed to you within 90 days upon receipt of a completed post-test that meets the 90 percent scoring standard.

Mail your completed post-test to:

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