There are several opportunities for mask education and fit assessment to occur: during a desensitization period before PSG, HSAT, or APAP test setup; during discussions of results of the study before ordering the PAP machine; or during PAP setup and follow-up PAP management encounters. Equipment manufacturers provide mask-fit kits with sizing gauges and, in some cases, multiple-size cushions. This prevents cross-contamination and provides patients the opportunity to size themselves at home. If issues arise, the manufacturers’ 30-day mask-fit guarantee facilitates a change to a more suitable style following an assessment.

Mask procurement, however, can happen in various ways. Patients can order through the Internet, or possibly receive one from a friend or family member, or even pick one up at yard sale. The ideal situation is that patients have been assessed by a health care professional and recommended or given an appropriate mask option. When patients have made a decision as to which mask type they want before a clinical fitting or assessment, it is important to listen to reasons why they made the choice and then provide further education. Patients who have been educated on treatment intervention and the disease state have increased adherence than those who did not receive education and support (2).

Whether by phone or in person, review the patient history and determine physical attributes (facial hair, facial features), claustrophobia, airflow limitations (restrictive or obstructive lung disease, hypoventilation,
rhinitis, or sinusitis), physical limitations, and mental or emotional issues. Try to observe the physical attributes rather than asking if patients are “mouth-breathers.” Try to observe when the patient is unaware and in his or her natural state. Avoid giving the diagnosis. Observe or discuss if mouth breathing is situational or observable. Self-diagnosis by patients or by health professionals can lead to suboptimal mask choice, suboptimal pressures, and increased side effects and abandonment of therapy. Striving to achieve a positive experience within the first week on therapy can affect the patient’s perception, side effects, and tolerance. An estimated 50% of patients do not use therapy a year later because of mask discomfort, nasal dryness/irritation, and intolerance of pressure. Predictors of patient adherence include the type of mask used (3, 4, 5, 6). Pre- and post-PAP mask education should include a review of mask types and common side effects.

There are a variety of masks and interfaces available to patients using PAP therapy. Each type of interface has pros and cons, and the interface selection should be personalized on the basis of the patient’s individual needs.

Common side effects to therapy are pressure sores, aerophagia, dryness, sinusitis and rhinitis, headaches, irritated eyes, ear pain, mouth breathing, and claustrophobia.

The strategy to mitigate these side effects is the alignment of PAP with humidification and a properly fitting mask. Leaks are dependent on mask fit and pressure.

Mask leaking issues should be explored in conjunction with reviewing pressure and humidification. If PAP is suboptimal, it can cause intolerance, mouth venting, destabilize the mask fit, cause leaks, increase dryness, headaches, ear pain, and aerophagia. If humidification is suboptimal, it can lead to headaches, nasal constriction/inflammation leading to a high-pressure response, patients reporting not receiving enough air, and mouth venting (7, 8). If mask fit is suboptimal, it can result in excessive mask leak, eye irritation, erratic machine pressure detection and response, patient discomfort, and increased dryness. This negative feedback loop can lead to artifact and inaccurate results that can cause multiple mask changes, misdiagnosis of complex breathing, suboptimal pressure changes, ongoing side effects, and poor compliance.

Aerophagia can occur because of therapy intolerance whether the patient is getting too much air or feeling as though he or she is struggling to get sufficient air (9). Patients may report complaints of excessive burping, choking, chest pain, stomach pain, and inability to get air in or out, and may exhibit higher leaks. This is associated more often with full-face mask, PAP intolerance, pressures too high or too low, and the acclimation period.

Pressure sores are a result of a poor-fitting mask or overly tightened mask in an attempt to maintain a good seal. Corrected leaks (to satisfy leak data) should not impact patient comfort or tolerance of therapy. Having to wear a mask extremely tight to maintain a seal can result in sores on the neck, head, or face, limitation in sleep positions, and frequent disruption of sleep. An alternate mask should be tried first.

A full-face mask used with a chinstrap to hold down the mask should be avoided. It is best to try to identify the source of the issue. Avoid oversaturating the patient
with air. This can result in frequent use of ramping to decrease pressure, increased arousals and awakenings, poor sleep continuity, low PAP usage, and discomfort. The goal is to improve sleep and compliance with a “less is best” approach to mask type for long-term comfort. Nasal mask types should be recommended as first option because full-face masks have the highest negative impact with lowest adherence (10, 11). Mouth breathing can be a result of untreated or undertreated sleep apnea, over-treated sleep apnea, and sinus flow limitations. Given time, mouth venting often will reduce with effective pressure and humidification. Strive for the lowest optimal level of PAP to correct sleep-disordered breathing while improving sleep continuity, reducing sleep disruptions, and mitigating side effects. Nasopharyngeal problems are frequently found in patients with obstructive sleep apnea syndrome before starting treatment, with a tendency to increase with treatment (12). However, with regular PAP use, nasal inflammation and infection can revert (13).

Claustrophobia can be associated with larger mask profiles, full-face masks, headgear, and intolerance to PAP. Complaints may occur with pillow masks or nasal masks that constrict sinus airflow. It is important that time and effort are spent to ensure comfort during the initial phase of treatment and to develop strategies for ongoing success (14). Consider all available avenues of patient support and education: literature, Internet educational tools, video demonstrations, phone and remote support, automated feedback apps, and/or clinic visits.

When patients are at home using therapy, they have ability to track their PAP usage either by cloud-based technology or data displayed on their machine. This access allows patients to be engaged in their therapy and monitor progress. Although patients are given user manuals and provided education during PAP setup, frequently they will have questions later about comfort, function, and management.

Many health care teams are providing clinical, phone, and virtual support during follow-up including a discussion of PAP usage information. Current advances in technology allow for PAP data results to be accessed wirelessly and by data card download if needed. This allows the clinician to review the data reports while communicating with the patient and quickly provide feedback, address issues, suggest changes, titrate pressures, and follow-up on improvements. Team-based clinical protocols will allow timely intervention and better patient management when managing high patient volumes.