What are the next steps for a patient who is unable to tolerate a mask for Continuous Positive Airway Pressure (CPAP) therapy?

Alternative Options for Patients Unable to Tolerate CPAP Masks

For patients unable to tolerate a CPAP mask, try alternative mask interfaces first, such as nasal pillows or oral masks, before considering more advanced alternatives like bilevel positive airway pressure (BPAP) or oral appliances. 1

Step-by-Step Approach to Mask Intolerance

1. Identify Specific Issues with Current Mask

• Determine the specific problem:
  • Mask leak (unintentional air escaping between mask and face)
  • Skin irritation or pressure sores (particularly on nasal bridge)
  • Claustrophobia or general discomfort
  • Mouth breathing/mouth leak with nasal mask
  • Difficulty exhaling against pressure

2. Try Alternative Mask Interfaces

• Nasal pillows: Shown to have higher compliance rates (94.1% vs 85.7% for nasal masks) and fewer overall adverse effects 2

  • Best for patients with claustrophobia or facial irritation
  • Minimizes contact with face, reducing pressure sores

• Oral mask (Oracle): Effective alternative for those who cannot tolerate nasal masks 3

  • Does not require headgear
  • May cause more upper airway dryness

• Full-face/oronasal mask: Consider for mouth breathers or those with nasal obstruction 1

  • Note: Studies show lower compliance compared to nasal masks (1.0 hour less per night) 2
  • May require higher pressure settings

3. Adjust Mask Fit and Settings

• Ensure proper mask fit by testing seal under treatment pressure 4
• Use barrier dressing to reduce skin ulceration, particularly over nasal bridge 1
• For denture wearers, better fit is obtained if dentures are left in place 1
• Avoid overtightening headgear, which exacerbates skin damage 1

4. Modify Pressure Settings and Features

• Try pressure relief features (modified pressure profile PAP) to reduce expiratory pressure 1
• Adjust rise time (time for pressure change from EPAP to IPAP) for patient comfort 1
  • Shorter rise times (100-400ms) often preferred by patients with obstructive airway disease
  • Longer rise times (300-600ms) often preferred by patients with restrictive disease
• Consider reducing pressure if patient awakens complaining of discomfort 1

5. Add Supportive Measures

• Add heated humidification if patient complains of dryness 1
• For mouth leak with nasal mask, try adding a chinstrap 1
• Elevate head of bed (if not contraindicated) to potentially allow lower pressure 1

6. Consider Advanced Alternatives

• BPAP (Bilevel PAP): If standard CPAP remains intolerable despite interface changes 5
  • Provides lower pressure during exhalation
  • May improve comfort for patients who find it difficult to exhale against pressure
• Auto-titrating CPAP: Adjusts pressure throughout the night as needed
• Oral appliances: For mild to moderate OSA if PAP therapy remains intolerable

Common Pitfalls to Avoid

• Failing to try multiple mask types before abandoning therapy
• Ignoring mask leaks, which can cause asynchrony between patient and ventilator 1, 6
• Not addressing mouth breathing with nasal masks
• Overlooking the importance of proper education and acclimatization 1

Follow-Up Recommendations

• Schedule close follow-up after any mask change to assess effectiveness and comfort
• Monitor for at least 15 minutes after each adjustment to ensure optimal titration 6
• Consider repeat titration study if initial study fails to achieve optimal results 6

Remember that approximately 20-30% of patients with respiratory failure cannot be managed by non-invasive ventilation 1, so persistence with finding the right interface is crucial for successful therapy.