The use of a variety of CPAP interfaces may have advantages for patients and encourage therapeutic compliance.
For patients prescribed CPAP therapy, finding the right mask is an essential part of treatment. Although the use of the same mask every night is standard, some patients may opt to use different masks on different nights for a variety of reasons, including comfort, skin irritation, and allergies. This article will explore the potential reasons for the use of multiple masks for therapy, the possible benefits of multiple mask use, and how sleep medicine professionals can promote compliance among this patient group.
Why Use More Than One Mask?
The use of multiple masks is not typical when CPAP therapy is initially prescribed, but patients may opt to use more than one mask over the course of their treatment for a variety of reasons. Nathaniel F. Watson, MD, MSc, president of the American Academy of Sleep Medicine, says, “Patients may choose to utilize different types of CPAP masks for a number of reasons—primarily comfort and preference, minimization of air leakage, claustrophobia, and nasal congestion.” Watson is also co-director of the University of Washington Medicine Sleep Center and director of the Harborview Medical Center Sleep Clinic.
Tracy R. Nasca, executive director of the American Sleep Apnea Association, says some patients may benefit from the use of different masks during their initial days and weeks of CPAP use. Nasca says, “Finding the best mask for their face can really only be determined when used at home. For example, you may suspect a given patient requires a full face mask, but allowing them to trial both full face and nasal mask at home might be the determining factor.” Also, while some patients may like the idea of a nasal pillow, it may take time to get used to the device. While they are adjusting to it, they may use the nasal mask only several times a week and utilize another type of mask in the interim, Nasca says.
Teofilo Lee-Chiong, MD, chief medical liaison for Philips, echoes a similar sentiment. He says patients may struggle with their masks and remain undecided as to which one to eventually use. This dilemma may be further compounded when medical providers, such as durable medical equipment companies or sleep labs, provide conflicting recommendations regarding masks, he says.
Lee-Chiong also says facial pain may be a reason for a patient to use multiple masks. If pain is an issue, then a different mask can be used to alleviate any discomfort. Two additional reasons, according to Lee-Chiong, are travel (a lighter mask may be more convenient when traveling) and multiple homes (patients with different homes may have multiple PAP devices, each with its own mask, at each residence).
Seasonal allergies can be another common reason to have several mask styles on hand, particularly in the height of summer and spring when pollen and mold counts are high, says Susie Justus, inside clinical specialist for ResMed. Justus says, “Many patients can wear a CPAP mask day in and day out without any issues; however, a subset of patients do experience increased congestion, maybe some irritation from a reactive nasal cavity.”
Katherine Duarte, product manager at Fisher & Paykel Healthcare, says some of the reasons that drive patients to utilize more masks beyond the first choice may be determined by factors such as patients’ sleeping environments, allergens, weather, temporary facial abrasions or breakouts, or illness, which may influence the mask that is most appropriate and comfortable at a given time.
Overall, Duarte says, “I believe having multiple types of masks on hand is purely based on patient preference. For example, a patient may prefer a nasal mask but add a secondary full face mask if they are susceptible to any condition that forces them to become a mouth breather.”
Benefits of Multiple Masks
According to Watson, there are specific cases in which having multiple masks can be helpful for a patient. For example, if a patient prefers a nasal mask but is prone to intermittent nasal congestion, having an oronasal mask for occasional use can be beneficial. In addition, Watson says, “Some patients have a tendency to develop pressure sores at mask contact spots. Switching between different masks can address this issue, although it is best to find a single mask that does not have this problem.”
Nasca also says having a full face mask in addition to owning other types of masks may be beneficial to use on nights the patient cannot breathe through the nose due to congestion, a cold, a sinus condition, or seasonal allergies.
Justus says that because everyone has differences in facial anatomy, multiple choices in masks with the correct sizing may ensure continued therapy. She says, “For some patients who regularly experience irritation or problems with their primary mask interface, having options on hand gives them assurance. To have the confidence that they can seamlessly transition to another type of mask knowing therapy will continue to be effective is peace of mind.”
Nasca suggests traveling with multiple masks in case one is broken. She says, “More than once, when traveling, my mask has broken; I now travel with a spare mask just to be safe. There is plenty of room in the CPAP carrying case to accommodate two masks.”
With the importance of consistent therapy for patients with sleep-disordered breathing, knowing what masks are available on the market and what secondary options are available to keep therapy on track is crucial, Justus says. “A patient’s treatment plan is highly individualized and every patient has [their] own set of preferences, so we encourage all patients to do research and know their options in order to mitigate potential disruptions down the line,” she says.
A potential issue to consider with multiple masks of different brands is compatibility between the interface and the CPAP device. However, Nasca notes that she is unaware of any negatives on brand crossover with mask versus machine. Most CPAP machines have settings to choose the specific mask style the patient is using (such as a nasal pillow or full face), so the proper setting must be selected. Nasca says, “Patients need to be instructed on how to change that setting for optimal use should they alter masks.”
According to Justus, most masks and CPAP devices in today’s market are compatible even if they are from different manufacturers and incompatibility is rare. She also suggests patients be conscious that the correct mask type is programmed in the CPAP unit if the device has the capability. Justus adds, “Hoses and mask attachments tend to be universal and will attach to most manufactures’ devices. This can alleviate patient frustration when trying to fit a mask to the appropriate hose.”
In the Lab
For patients considering purchasing multiple masks, there are several considerations for techs in the sleep lab conducting a CPAP titration study. To begin, sampling different masks during the study may be advantageous for the patient to ensure fit and comfort. Watson recommends trialing multiple masks during the titration to ensure a patient is getting the best fit. Watson says, “Mask comfort and fit are key elements to driving CPAP compliance.”
However, Justus explains that since lab testing typically concludes with a patient being prescribed one type of mask that allows for the best titration, it is not common practice to consult on a specific mask purchase in the sleep lab unless it also sells equipment. “Many patients during initial setup do not inquire about different masks, as many are not aware there are choices. We find patients begin to explore secondary options when issues start to arise, versus inquiring proactively,” Justus says. “When a patient wants to explore additional masks, it typically leads to the durable medical equipment provider guiding patients through the best options.”
Nasca also says that at the time of titration most patients have likely not considered purchasing multiple masks. Since the purpose of the titration is to home in on optimal pressure, sleep techs should allow that to be the focus and not overwhelm the patient with too much information at inappropriate times, according to Nasca.
“The sleep tech might inform the patient that if the mask chosen for titration does not seem to be effective, they might come in and change to another mask. If the sleep tech doubles as the equipment provider after diagnosis, then that would be the more appropriate time to discuss the pros or cons of multiple masks,” Nasca says.
For patients who use multiple masks and are participating in a sleep study, a sleep professional should also consider offering specific guidance on the PAP device settings so therapy will be effective with an alternate mask. “The key is to adjust the PAP device’s settings to specify the mask that is being used, so the device can recognize and respond accordingly to the prescription set,” says Justus. “I can’t speak to all device systems, but [for example] I know that ResMed devices come equipped with programming options that allow patients to choose a pillow, nasal, or full face setting.”
Humidity preferences may differ from mask to mask, so Duarte says it is advisable to let patients adjust the comfort settings of humidity during the study to suit their mask type. Duarte also encourages sleep techs and other sleep medicine professionals to ask questions that encompass a patient’s history of allergies, sinus infections, medications, and sleeping environment because these factors can help determine a good mask, or masks, selection.
The use of multiple masks may encourage therapeutic compliance among patients, and sleep medicine professionals can take several measures to help promote compliance in this patient population. First, fit can be one of the most essential elements in ensuring compliance among CPAP patients. “Compliance is often about comfort and the realization of the benefits of therapy. Thus, each mask must fit and be comfortable with minimal leak,” Watson says. “Different masks have different strap configurations so it is important that patients don’t get these configurations confused.”
Nasca also says fit is key in patient compliance whether a patient uses one mask or several. She says fit and adjustment should take place each night before sleep while lying in bed with the head on the pillow in the normal sleeping position. The machine should also be turned on with air blowing. Nasca says, “Think gravity and fit in the sleeping position. One should not assume that mask fit will last or be adequate for multiple or consecutive nights. Straps can slip or stretch. Refit/adjust each night for best use.”
When patients know they have a number of mask options available for therapy, that may also promote compliance, according to Nasca. She says, “The encouragement comes in play when helping a patient understand the importance of reaching therapeutic compliance as soon as possible. When patients know they have options, I believe they are encouraged and more likely to succeed.” Cost may be a factor in the choice to use multiple masks, but sleep medicine professionals should “offer the opportunity and allow the patient to make the [final] decision,” Nasca says.
Nasca also encourages sleep medicine professionals to determine what is in the best interest of the patient and says available options should be presented at CPAP setup as part of the education process. She says, “There are comorbidities and psychological components to consider when treating the whole patient. Taking the time to learn about their fears and expectations will really help you to help them reach compliance.”
Justus says promoting compliance among patients who use multiple masks may be as simple as reinforcing a patient’s routine. Justus says, “Patients who habitually use multiple masks have already developed a strategy that keeps their therapy consistent, and the best thing you can do is reinforce the habit. Whether a patient switches between a nasal, pillow, or full face mask, the most important thing is that they are equipping themselves with what they need to stay compliant with therapy.”
Also, for patients who use multiple masks, Duarte proposes patients be aware of when a good night’s rest is achieved, to take note of the specific mask used, and what symptoms (if any) were present. Duarte says, “The more engaged a patient becomes with understanding their own physiology and environmental factors, the more likely the right mask will be chosen.”
Essentially, Duarte says sleep medicine professionals should “encourage and support any action taken by the patient that improves overall experience to therapy as each patient is unique [with] their own individual needs.”
Masking for Success
Overall, Lee-Chiong says that it is important for patients to be aware that different types of PAP interfaces exist with a large number of designs, configurations, and materials, and advances in construction continue to improve their comfort and effectiveness. In deciding whether to use multiple masks for therapy, a patient may want to consider newer options that may best suit changing needs.
Lee-Chiong says, “Patients should make it a habit to learn about, and to try out, new masks. The best mask for you a year ago might not be the best mask for you today. Mask needs may evolve over time, and significant changes in weight and skin integrity should prompt a reevaluation of mask choices.”
Also, the decision to use multiple masks for CPAP therapy is ultimately up to the patient, but proper maintenance of any and all masks is essential for successful outcomes. Justus says, “Aside from making sure patients properly label masks [to keep track of which masks are older and which are newer], we also strongly recommend patients clean their masks regularly. This doesn’t have to be a complicated process: In fact, we generally advise that patients use a gentle soap, like baby soap/shampoo, which is mild enough to keep masks clean and intact.”
Justus also suggests replacing masks on a regular basis. She says, “There’s an assumption that an old mask that’s gently used is just as effective as a brand-new one. What most don’t realize is, even if the mask hasn’t been used often, the seal gradually breaks down from exposure to the environment, [which] can then impact the mask’s effectiveness and the patient’s comfort levels.”
Lee-Chiong says, “At the end of the day, or rather at the start of each bedtime, it is the patient’s decision to use the PAP device and interface or not. If they truly believe that having multiple mask interface options helps them adhere to their therapy, medical professionals should not discourage this practice.”
Cassandra Perez is associate editor of Sleep Review. CONTACT [email protected]