How to manage mask intolerance with Continuous Positive Airway Pressure (CPAP) therapy?

Managing Mask Intolerance with CPAP Therapy

For patients experiencing mask intolerance with CPAP therapy, nasal masks should be used as the first-line interface over oronasal masks due to better adherence, fewer side effects, and improved efficacy. 1

Causes of Mask Intolerance

• Mask fit issues: Poor mask fit leads to air leaks, discomfort, and skin irritation
• Pressure discomfort: High pressure settings can cause difficulty exhaling or claustrophobia
• Skin irritation: Prolonged mask contact can cause skin breakdown, particularly over the nasal bridge
• Air leaks: Unintentional leaks through mouth or around mask edges
• Claustrophobia: Feeling confined by the mask

Step-by-Step Management Approach

1. Optimize Mask Selection and Fit

• Choose appropriate mask type:

  • Start with nasal masks or nasal pillows as first-line options 1, 2
  • Reserve oronasal (full-face) masks for specific situations:
    • Persistent mouth breathing/leaks despite chin strap
    • Significant nasal obstruction
    • Inability to tolerate nasal interfaces

• Ensure proper sizing and fitting:

  • Have multiple mask sizes and styles available 1
  • Fit mask while patient is in sleeping position
  • Avoid overtightening straps (increases skin damage) 1
  • Consider using barrier dressings over nasal bridge to prevent skin breakdown 1

2. Address Pressure-Related Discomfort

• If patient complains of pressure discomfort:

  • Decrease pressure to a more comfortable level that allows return to sleep 1
  • Consider elevating head of bed to allow lower EPAP settings 1
  • Try pressure relief features (flexible PAP) during exhalation 1
  • Adjust rise time (transition from EPAP to IPAP) for comfort:
    • Shorter rise times (100-400ms) for obstructive airway disease
    • Longer rise times (300-600ms) for restrictive disease 1

• For persistent intolerance to high CPAP pressures:

  • Consider switching to BiPAP therapy 1
  • BiPAP may be indicated if obstructive events persist at 15 cm H₂O of CPAP 1

3. Manage Air Leaks

• For mask leaks:

  • Refit or readjust mask whenever significant unintentional leak is observed 1, 3
  • Consider changing to a different mask type if leaks persist 1

• For mouth leaks with nasal mask:

  • Try adding a chin strap first 1, 3
  • If ineffective, switch to full-face mask 1
  • Be aware that full-face masks may require higher pressures to eliminate respiratory events 4

4. Address Skin Irritation and Comfort Issues

• For skin irritation:

  • Apply barrier dressings preventively over pressure points 1
  • Ensure proper mask fit without overtightening
  • Consider alternating between different mask styles to distribute pressure points

• For dry mouth/nasal passages:

  • Add heated humidification 1
  • Humidification significantly reduces side effects including dry mouth/throat, nasal congestion, and nasal dryness 1

Special Considerations

• Claustrophobia:

  • Start with smaller interfaces (nasal pillows) and gradually progress if needed
  • Practice wearing mask during daytime while awake
  • Use desensitization techniques (wearing mask for progressively longer periods)

• Facial hair:

  • May compromise mask seal, especially with nasal and oronasal masks
  • Consider nasal pillows or specialized masks designed for bearded patients

• Anatomical factors:

  • Patients with less nasal obstruction may have better adherence with certain interfaces 5
  • Facial structure can influence optimal mask selection

Monitoring and Follow-up

• Schedule regular follow-up visits to assess mask fit and address ongoing issues
• Monitor leak data from CPAP device to identify persistent problems
• Consider the trend in leak values rather than absolute numbers 3
• Reassess mask fit if sudden increases in leak occur without pressure changes 3

Remember that mask intolerance is a common barrier to CPAP adherence, and addressing it promptly and systematically is essential for successful therapy and improved clinical outcomes.