Mask monograph Continuing education
Mask monograph To 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.
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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
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
Mask categories Patient interfaces, or masks, fall in to three different categories: nasal masks, full-face masks, and minimalcontact 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.
Nasal mask
Full-face masks
Minimal-contact masks
Nasal masks focus on fit and comfort,
Those who breathe through their
These masks are designed for those
and there are a lot of choices.
mouths will find several effective
who prefer alternative solutions but
options in this group of masks.
still demand comfort and effectiveness.
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Choosing the right mask for 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
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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.
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Selecting the right mask for 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: Are you claustrophobic? Are you currently using any nasal therapy or medication? Do you have any allergies or hay fever? Do you sleep on your side? Are you an active sleeper? Patient psychosocial questions: Are you looking for less contact on your face? Patient morphology questions: Have you ever had a broken nose? Have you had previous nasal surgery? Do you have a deviated septum? Do you tend to breathe through your mouth when sleeping? Patient personal preference questions: Do you have a bed partner who is a light sleeper? Are you looking for a simplified mask to fit, clean and assemble? Do you read or watch TV in bed? Questions and suggested mask types for the new user New user questions: Are you new to PAP therapy? Have you researched any masks or interfaces on the internet? Do you have friends or family using masks or interfaces? Questions and suggested mask types for the non-compliant user Non-compliant user questions: Do you continue to snore even with PAP therapy? Do you wake up with a dry mouth and/or throat? Do you use a chin strap with PAP therapy? Does the air flow through the nasal pillows make your nose hurt? Does the mask impede your vision to read or watch TV in bed? Have previous masks created nasal bridge pressure or sores? Is the bridge of your nose easily irritated (by glasses)?
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Suggested mask type minimal contact, full-face minimal contact, nasal, full-face minimal contact, nasal, full-face minimal contact minimal contact, nasal Suggested mask type minimal contact nasal, full-face Suggested mask type nasal, full-face full-face Suggested mask type minimal contact, nasal, full-face minimal contact, nasal, full-face minimal contact Suggested mask type minimal contact, nasal, full-face minimal contact, nasal, full-face minimal contact, nasal, full-face Suggested mask type nasal, full-face nasal, full-face full-face nasal, full-face minimal contact minimal contact, full-face minimal contact
Tips for patient comfort and 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
Common mask issues and tips for correcting Common mask issues Skin irritation or red marks Mask may be too tight Sensitivity to mask material
Mask is stiff from age Air leaks
Claustrophobia
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.
Correction tips • Loosen headgear • Resize mask • Soak in warm soapy water • Change to a different type of mask material • Use a protective skin covering • Replace mask • 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 • 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
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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
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Young, 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. 10
Aloia, 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.
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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
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