By: Teofilo Lee-Chiong MD, Philips Respironics
- Reeducate yourself and the patient about masks. Advances in mask design, materials and construction continue to improve mask effectiveness and to enhance patient comfort. Make it a habit to learn about, and to try out, new masks.
- Always refit. If the patient was not given an optimum mask in the past, do not make the same error by simply giving the same mask. Even if the mask was optimal during a previous mask fitting, the best mask for the patient a year ago is not necessarily the best mask for him today.
- Eyeball the patient thoughtfully. It takes experience and patience to fit a mask properly. Do not waste time by trying out all available masks. More choices in masks are not always better. Select a few masks based on the patient's facial features, and take enough time to try each one on the patient.
- Choose nasal masks over full-face masks, most of the time. By choosing a full-face mask at the outset, we risk creating worse long-term adherence to therapy, greater mask leaks, more treatment-emergent central apneas, and higher residual sleep-disordered breathing. There should be very compelling reasons before a full-face mask is used.
- What to do with a mouth breather? Observe the patient during the interview - if he is breathing through his nose while he is talking to you, he is not a total mouth breather. Manage any nasal congestion or obstruction, if present. Provide humidification if needed. A full-face mask alone is rarely the solution for mouth breathing.
- Have the patient bring his/her own pillow to the office or sleep center. Start the mask fitting session with the patient seated comfortably. Then, have the patient lie supine on his pillow. Have him turn to his left, then right, and finally prone. Readjust the mask and headgear continuously. Do not hesitate to refit a new mask if the first choice is not optimal.
- Pressurize. Once a mask has been chosen, turn the positive airway pressure device on and gradually raise the pressure to about 15 cmH2O to ensure that no mask leaks develop.
- Appropriately address mask leaks during titration. If the apnea-hypopnea index (AHI) is still elevated, increase the PAP setting to achieve a patent upper airway. If the AHI is normal, try a lower PAP setting. If mouth breathing persists but the patient is sleeping comfortably and the AHI and oxygen levels are normal, observe the patient closely. Consider adding a chinstrap if the patient wakes up and complains about mouth leaks.
- Appropriately address mask leaks during chronic use. A mask refitting might be beneficial if any of the following is present:
- Complaints by the patient of mask leaks, mask discomfort or sleep disturbance.
- Higher residual obstructive AHI in a medically stable patient on previously effective continuous positive airway pressure setting.
- Higher-than-expected autotitrating positive airway pressure requirements in a medically stable patient on previously effective APAP settings.
- Increasing number of central apneas in a medically stable patient on previously effective CPAP, bi-level positive airway pressure or adaptive servo ventilation settings.
- Difficulty achieving the desired tidal volume in a medically stable patient on previously effective average volume assured pressure support settings.
10. Understand that mask needs may evolve over time. Significant changes in weight, skin integrity, and patient preference should prompt a reevaluation of mask choices.
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