Obstructive Sleep Apnea CPAP get smart fast

Disclaimer: These peer coaching articles describe what some savvy, successful CPAP users have done to make their treatment successful. Not written by healthcare professionals. The information and opinions may not necessarily be correct or helpful for you and your unique needs. Rely on sound, well informed medical advice from your doctors and other healthcare professionals well versed in treatment of obstructive sleep apnea.

Location: United States

IF I ONLY KNEW THEN WHAT I KNOW NOW! Blog Purpose: To help you with your CPAP therapy for Obstructive Sleep Apnea (OSA). For those with OSA, family, friends, physicians, nurses, respiratory therapists, sleep technicians. Why This Came to Be: I didn’t have the information I needed for successful CPAP treatment when I needed it. A kind sleep lab technician with OSA told me about a web site he had heard about from another patient, www.cpaptalk.com. The rest is history. It took me months of reading hundreds of posts to gather the information I needed while suffering through equipment struggles. Not everyone has that time or wants to struggle needlessly. I wrote up my own experience and advice from the collective wisdom of experienced CPAP users on cpaptalk.com. Thanks to them, my treatment is working. I’m not sure I could have done it without them. The online CPAP equipment store www.cpap.com created cpaptalk.com. I appreciate what they are giving back to the CPAP community through their website forum, as well as their fair prices. NOBODY IS AS SMART AS EVERYBODY! To email me, send a private message to Mile High Sleeper at www.cpaptalk.com.

Thursday, December 08, 2011

CPAP Mask Choices

For people with sleep apnea and for their healthcare professionals, peer coaching article #14, updated 1 December 2011

So many masks, so little time.

PAP (Positive Airway Pressure whether CPAP, APAP, or BiPAP) treatment works wonders in many people’s lives. Usually the most difficult part of the therapy is finding the right mask and adjusting to it. Here are some tips for being a smart mask shopper and user. You are the one who needs to sleep with the mask all night, every night. You are the one, not your doctor or respiratory therapist, who needs to discover which mask is best for you.

The problem with masks
Most PAP (Positive Airway Pressure) users have no problems with their machine if it was an informed choice based on their needs and preferences. A CPAP heated humidifier easily makes air passages comfortable and helps keep nasal passages open. Daily nasal irrigation helps reduce congestion in nasal passages. Hose management is easy to do. A PAPillow or other good pillow can be found to use with a mask. Rainout (condensation) in the hose can be easily eliminated with an Australian heated hose from
www.SleepZone.com.au/ .

But masks, also called interfaces, are problematic for most PAP users because of their design and fit. Most masks come in only three to five sizes. It’s as if all the men and women in the world were expected to fit into only three unisex shoe sizes, but worse. Manufacturers make custom eyeglasses, dentures, clothes, orthotics (shoe insoles), shoes, but generally not custom CPAP masks. Despite each person’s unique facial contours, facial hair, and unique muscle relaxation in deep sleep, despite the force of air pressure and humidified air and sweat, masks are expected to fit everyone comfortably and not leak. That doesn’t happen readily. Common mask problems are fit and discomfort at pressure points on the nose and face, uncomfortable and noisy leakage of air from the mask, noise from the air vents, discomfort with the headgear to hold the mask in place, and air blowing from the mask vents onto your hand, arm, or your bed partner. All these mask problems affect the quality of sleep, number of apneaic events, likelihood of adherence or compliance with the treatment, and resulting health and longevity.

Mask evolution lags far behind machine evolution. With so many people yet undiagnosed with sleep apnea, there is a huge potential market which may funnel dollars into better mask design and production in the future.

It’s not “just” comfort
It’s important that your mask (and everything else) be comfortable. With sleep therapy, comfort is not just a luxury, it’s a necessity for successful treatment. In the daytime, when you are awake and not exhausted, you could tough it out and handle a difficult physical therapy for a few hours. But at night, when you are exhausted, vulnerable, extra sensitive, and need to sleep, your mask needs to be compatible with sleep all night long. In other words, comfortable. Although people have great capacity to adjust and “sleep though anything,” there is a limit.

To make a mask more comfortable, consider Pad-A-Cheek strap covers
http://www.padacheek.com/ , a mask-compatible pillow such as PAPillow http://www.papillow.com/ to reduce leaks, proper hose management so there is no drag on the mask causing leaks; a PAP heated humidifier, fleece hose cover, Australian SleepZone heated hose http://www.sleepzone.com.au/index.html , and hose connectors. See the articles on Solving CPAP Mask Problems and Solving Common Equipment Problems.
To minimize mask leaks, go to bed with a clean face, avoid facial moisturizers at night, and wash facial oils off your mask each morning. See the article on Equipment Cleaning.

Mask prescriptions
If you get a mask through a DME (Durable Medical Equipment or Home Medical Equipment) provider which will be paid by insurance, a prescription is required for insurance reimbursement billing purposes. The prescription can be generic, allowing you to make your own choice. If you want a specific brand and model from a DME, it’s better if the prescription is specific for that mask, so you get exactly what you want. If a mask is bought online, it may be helpful to inform your doctor of your mask choice. Check in advance to see if your insurance company will reimburse you for online purchases, unless you decide to pay for it yourself.

Mask types
Three main types are nasal masks which cover the nose, nasal pillows which snug against the openings of the nostrils, and full face masks which cover the nose and mouth. Additional useful types are a hybrid mask that combines nasal pillows and a mouth mask, nasal prongs or cannula which fit into the nostrils, nose cushions which fit under the nose, a nasal pillow interface that is held in place by a mouth piece, and an oral mask that blows air into the mouth only. On cpap.com see Answers, Masks at
http://www.cpap.com/cpap-faq/Masks.html#52 .for mask comparisons.

There are many brands and models of masks in each category. Any type of mask generally works with any type of PAP machine. One manufacturer’s brand of nasal mask may not work for you; another manufacturer’s may work well; and the same for nasal pillows, full face masks, and all the other types.

How to minimize mask discomfort
1. Good mask selection
2. Good mask fitting
3. Get two different types of mask near the start of treatment

There are a lucky few who experience no mask discomfort or leakage from the start. If you find that your first mask works, you may not want to explore another until your insurance will pay for it in six months. More common is the need to try several masks before finding one that works. Ask about a 30-day return policy.

With any mask, do what you can to make sure the respiratory therapist fits it properly at the start and shows you how to adjust the fit yourself. In addition, you will probably have to do your own repeated fitting and tweaking to make it work, tested over many nights. Once you get a good fit, if it’s possible with your mask, don’t change the headgear adjustments. Undo a clip or two to remove the mask, and leave the headgear as is.

There is a time incompatibility. Your working unit of time for mask-success is nightly. The timeframe of your doctor, insurance, and DME to approve and get you another mask is probably in weeks. If your first mask doesn’t work, this means weeks of nightly discomfort and frustration while waiting for your next mask and the temptation to give up on PAP. Discuss with your physician the option of getting two types of masks (nasal mask, nasal pillows, full face mask, etc.) near the start of your therapy. For example, if you start with a nasal mask and discover after two weeks that you have a chronically congested nose on PAP, you may have a medical necessity for a full face mask.

Advantages to having more than one type of mask near the start: you can continue your nightly PAP therapy if one mask doesn’t work or it breaks. If the nasal pillows make your nostrils sore, you can switch to a nasal mask the next night; or if a nasal mask makes your face sore at pressure points, you can switch to nasal pillows. Or, if your nose is stuffy or you have seasonal allergies, you can switch to a full face mask. If you want to take a daytime nap but your mask is still wet from morning cleaning, you have a dry back-up mask.

Disadvantages of having two types of masks: insurance may pay for only one mask at the start or may pay for medically necessary masks only over a period of months. The usual insurance schedule for a new mask due to wear, usually based on Medicare guidelines, is every six months. Mask cushions and nasal pillows are replaced more frequently. You may need to buy the less expensive second mask on your own. Your successful therapy and health are worth it, if your budget allows.

At the start, it may seem overwhelming to research and adapt to two types of masks instead of one. You may not be psychologically ready to try a type of mask you are resistant to, such as a full face, until you have become accustomed to another type, such as a nasal mask, and found that it too has limitations. A remedy is to balance the level of your confusion and resistance with the convenience of having a back-up option on hand. You may be tempted to not give each type and brand of mask a fair trial. A remedy is to stick with one (for example, nasal mask) until it works or you give up on trying to make it work; then switch to the other type (nasal pillows), while you then continue to explore other brands of nasal masks or types of masks, and so on. Exception: if you know in advance that you must breathe through your mouth, you will need only a full face mask. You might try just one, since they are the most costly of the mask types.

Strike a balance between suffering with a badly matched mask for six months, or trying too many masks too fast. If your first mask isn’t working, research other masks online for ideas and revisit your doctor and/or respiratory therapist. Your relationship with your mask and other CPAP equipment is important. Like any other relationship, it requires patience and work and brings its own rewards.

Mask trials and choices
The choice of a mask is best not left solely to your doctor or a respiratory therapist (RT) at a DME (Durable Medical Equipment provider). Consider their advice, but make your own choice, since you have to live with it. The RT may be informed only about the masks in their inventory, which is limited by the manufacturers they represent, and uninformed or misinformed about other masks. For example, it’s said that Apria favors Respironics masks and Lincare favors ResMed masks because of their contracts with those manufacturers. Your patient needs are not necessarily the same as the DME’s business contract or need to move inventory. Beware of a DME that carries only Respironics masks and says that they have found that ResMed masks don’t work very well, and vice versa, because they may be putting their profit motive ahead of your best health option. The DME may be able to special order brands they don’t normally stock, but not initially suggest them unless you request it or have a prescription for a specific mask. Even professional and ethical respiratory therapists may have knowledge gaps and be biased about masks they have experience with, but they aren’t the one who needs to wear it every night. Sometimes it’s difficult to sort out biased opinions from sound professional advice. Keep searching in your region or online until you find someone whose judgment you can trust. A good source of professional help may be a hospital sleep lab supervisor or sleep technician, since they work with different brands and models of masks nightly, and are usually not selling any one product line.

Trial and error is the only way to discover the best mask for you, but you can maximize your chance of success. Because mask selection is so individual and difficult, some people have a collection of masks they’ve bought on their own, many of them expensive failures. To minimize this problem, try before you buy, if at all possible. Research masks on the Internet at online CPAP stores and manufacturers’ web sites. Make a list of masks that look promising. Then try to find a local source for getting those masks for you to try in your size.

An excellent place to try masks, if you can find one, is a hospital sleep lab, morning or early evening when they aren’t doing sleep tests. A sleep lab can sterilize masks, so they are able to have demo masks for trials. The sleep lab may have a supervisor or sleep technicians who are expert mask fitters and advisors, who can suggest a mask size (which varies by brand and model) and can test your mask under your prescribed pressure, checking for leaks with their equipment, while you are lying down on your back and sides. They may do this for free, charge a small fee, combine it with other medical services, or act as a DME. If they also sell masks, do they have a 30 day return policy if the mask doesn’t work?

If you are buying at your own expense and there is a small price difference between the local source and online DME, perhaps it’s worth the difference to pay more locally for high quality service. If it’s two or three times or more the cost of buying online, your income and sense of fairness may be the deciding factors. Masks are also sold on online auctions. If you buy a used mask, there is a risk if the previous owner had a staph infection and the mask has not been sterilized.

Will your local DME get the masks you want and let you try them before buying? Are there other DMES on your insurance plan? Or another DME not on your insurance plan who will let you try masks? How long will it take them to get the masks you want to try? To find the better DME companies, ask for recommendations from a hospital sleep lab or a sleep doctor. Many people get frustrated with repeated inferior service from the only large national DME on their insurance plan, and just order online for more accurate information, better service, faster delivery, and lower prices. For CPAP users comments on using a DME, see the discussion thread
http://www.cpaptalk.com/viewtopic.php?t=11021 .

Mask sizing and fitting
Wherever you try on a mask, it should first be expertly sized and fitted by a technician while you are sitting up, then tried under your prescribed pressure and checked for leaks (by equipment at a sleep lab or by feel at a DME) while you are lying down on your back and sides. Sitting up in a chair with a mask on does not reflect what the mask will do when you are in bed and your facial features adjust to gravity while laying down. If you run into resistance from the DME to trying masks lying down under machine pressure, know that they are pretending to fit the mask, not actually doing it. A few people actually come to the DME with a pillow and insist upon lying on the floor to get their mask fitted and checked for leaks in various positions. If the RT does little more than take the mask out of the box, plop it on your head and say “there,” you aren’t getting a real mask fitting.

Does the respiratory therapist have enough expertise to fit the mask properly and advise you about how well a given mask will work for you? If not, ask for a different RT who knows how to fit masks, or go to another office of the same DME that does fittings lying down, find another DME company for mask fitting, or better yet, go to a sleep lab or center. See the post by rested gal at

People go to optical shops to get their eyeglasses fitted and periodically adjusted. Mask fitting is even more complex. Once you have a mask, you may need help with the initial mask fitting and maybe follow-up. Each mask and each person is different, but the RT or sleep technician should be able to give you some general principles of fitting a particular mask, a show-and-tell. “Keep this part firm, this part looser. Adjust this part first, then this part. Watch for this and that. To take it off, do this.” Remember the tips or take notes and keep them with the mask.

People are sometimes forced to “lab rat” and experiment to customize the fit and comfort, but find the effort worthwhile. They ask for help and share their many ideas on

Warning against giving up on CPAP and instead substituting supplemental oxygen
Understandably, adapting to CPAP and a mask is difficult. It may take 6 weeks to 3 months for most people to adapt, sometimes longer. Some people give up prematurely and quit CPAP, instead going on supplemental oxygen at night. The problem is that if you have sleep apnea, the oxygen is not getting through your air passages to your lungs, whether on oxygen or not. If your physician orders oxygen, be sure that there is a home follow-up by using an overnight recording pulse oximeter to check whether the oxygen is getting into your blood stream. If the oxygen alone isn’t enough, become better informed about CPAP equipment and support and try CPAP again. (As a separate topic, some people are prescribed oxygen to enhance their CPAP. Then they get the benefits of both treatments.)

Nasal masks
A nasal mask covers just the nose. In terms of bulkiness the nasal mask is midway between the full face mask and nasal pillows. As such, it may be a good starter mask, to try out moderate bulkiness and see how you adjust to it. Some people prefer to have just their nose covered; others don’t like it.

See nasal mask selections by manufacturer at
Scroll down to see Nasal Mask Brands Line Preference and comments at

Nasal pillows masks
Myths about nasal pillows:
Nasal pillows are a last resort when all other masks fail.
Nasal pillows make your nose all sore and crusty.
Nasal pillows are not for use every night.
Nasal pillows can’t be used with autopap machines.
Nasal pillows can’t be used with high pressures.

All these myths are untrue.

Nasal pillows nestle up against the nostrils. They are the least bulky of the three mask types and may be good for people with mask claustrophobia. Since they deliver air directly into the nostrils, they may work well along with heated humidification to help clear nasal congestion or for people with a deviated septum. Users find nasal pillows light and comfortable. There is a difference in the comfort level (softness vs. stiffness), shape, and size of the pillows from one brand to another. A larger size nasal pillow than expected may be the right size for you. Some brands have vents that are quieter, some noisier. Nasal pillows should work with all autopap (APAP) machines; if in doubt, phone the mask manufacturer’s customer service number.

With nasal pillows, a light gel nasal moisturizer made for use with nasal cannula is recommended as nightly lubricant and protection, found at medical supply stores or online. One product used in hospitals is Cann-Ease Nasal Moisturizer with aloe vera, http://www.cann-ease.com  Another product is water-based KY jelly or its generic version. To avoid any ingredient that will break down the mask silicone over time, use products made for nasal cannula.

Some people find a nasal gel with saline irritating over time. Avoid the widely used preservative benzalkonium chloride in the nose because it can cause a rebound effect over time. Avoid mercury preservatives (thimerosol). Although some people use products like natural lip balm, bag balm, or other skin salves, others advise against use of any of these oily products because of the rare but potential hazard of lipoid pneumonia in the lungs. This hazard can be avoided by using water-based products made for nasal cannula. Avoid products with mint, lavender, and other fragrances that you don’t want to smell so intensely. If you are using oxygen with CPAP, avoid Vaseline and petroleum-based products because of hazard to the lungs. See
http://www.cpaptalk.com/viewtopic/t14588/Mask-gone-Pillows-hurt-frustration-and-other-delights.html .

See nasal pillows selections at http://www.cpap.com/cpap-masks/nasal-pillow-cpap-mask.php
Scroll down to see Nasal Pillows Brands Line Preference and comments at http://www.cpap.com/cpap-user-preference.php
For a typical user discussion of nasal pillows and similar masks, see

Warning against mouth leakage
Whether you use a nasal mask or nasal pillows (or any other kind of mask except a full face), if air leaks out through your mouth, the PAP therapy will not work. There are two safe options. The first is to learn to keep your mouth closed while sleeping. Since the feel of pressurized air exiting your mouth is an unpleasant sensation, PAP aids in this. Some people position the tongue behind the top teeth and let it spread out in back to cover the throat opening and make a seal so the PAP works. The second option is to use a full face mask. If you are a mouth breather, breathing in through your mouth instead of your nose, a full face mask is required. An alternative practice for mouth leaks, mouth taping or sealing, is understandable but not advisable, and is not safe if your nose gets stuffy at night, you have acid reflux, need to regurgitate; or you have a hose disconnect or lose machine power and need to breathe through your mouth.

Full face masks
Full face masks don’t really cover the full face, but cover both nose and mouth, so you have a choice of breathing through one or both. It seems rather counterintuitive, but a full face mask may be more comfortable for some than a nasal mask; perhaps because it’s more like the feeling of the edge of your hand cupping the nose and mouth. Full face masks work well for people who breathe through their mouth out of habit or because of congested nasal passages. It’s handy to have a full face mask on hand in case of head colds, allergies, or sore nares from nasal pillows. Full face masks require a heated humidifier so your mouth and throat don’t get dry. If you also have a heated hose, the additional warmth helps keep the humidity level up.

Full face masks have more facial contours to fit and so tend to leak more than other masks. They are the bulkiest of the masks, have confining headgear, and don’t work well for people with mask claustrophobia, unless they overcome it through desensitization techniques. If you are worried about what would happen in case of a power outage while wearing a full face mask, the manufacturers have designed vents so you can continue to get air. The Food and Drug Administration approves all masks before they can be sold in the US.

See full face mask selections by manufacturer at http://www.cpap.com/cpap-masks/full-face-cpap-mask.php
Scroll down to see Full Face Mask Brands Line Preference at http://www.cpap.com/cpap-user-preference.php

More mask types

For nasal prongs or cannula, see http://www.cpap.com/cpap-masks/nasal-prong-cpap-mask.php

There are two interfaces using the mouth. Both require that you keep your mouth closed or they will leak. Before considering one, talk with a sleep dentist (one experienced in working with dental devices for obstructive sleep apnea patients) or prostodontist about potential effects of misalignment of teeth and jaw and TMJ because of using such devices. For CPAP PRO nasal pillows that use an oral interface (boil-and-bite mouth piece), see
http://www.nomask.com/. For an oral mask, see http://www.cpap.com/cpap-masks/oral-cpap-mask.php

For most people, masks are the most difficult part of CPAP therapy. With much prolonged problem-solving, patience, and persistence, you can achieve mask success for a good night’s sleep. See the articles on Tips for Newcomers to Sleep Apnea, Checking CPAP Pressure Settings, Solving CPAP Mask Problems, CPAP Adaptation and Recovery and Seven Stages of CPAP and What Is Feeling Good? at

Mike Moran’s humor – Confession of an Interface Junkie,

Sources: Based on personal experience with obstructive sleep apnea and gleaned from the collective wisdom of cpaptalk.com contributors.

Want more? See the peer coaching articles at http://smart-sleep-apnea.blogspot.com , http://www.cpap.com FAQ Learning Center, or search http://www.cpaptalk.com or post a message there.

Not written by healthcare professionals. The information and opinions offered are not intended or recommended as a substitute for professional medical advice.

© Mile High Sleeper, August 2006 - 2011. All rights reserved. You may make copies of this message and distribute in any media for free educational purposes, as long as you credit the author and include this copyright notice and the web address smart-sleep-apnea dot blogspot dot com

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