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Our Collective Wisdom

Solving CPAP Mask Problems (Mile High Sleeper) (Mask)
One man’s meat is another man’s poison, especially when it comes to masks. Mask comfort As Good As It Gets Use a CPAP heated humidifier to make the air more comfortable and keep air passages moisturized and healthier. Get an integrated or stand-alone CPAP humidifier. Experiment with settings from low to high humidity. Dry nasal passages can become irritated, crusty, and bleed. Use an additional nasal moisturizer or spray if you experience dryness. A mask needs to fit the way you breathe– nose breathing or mouth breathing. If you breathe through your nose, use a nasal mask or nasal pillows. If you breathe through your mouth, or go from a clear to clogged nose during the night, use a full face mask. Often, adjusting the headgear and mask too tight will make leaks worse. If a mask leaves marks on your face in the morning that don’t go away for a long time, it’s too tight. A mask and headgear that are too tight may cause puffy, baggy eyes, misaligned teeth, dental pain, headaches, neck aches, and pressure sores on the bridge of the nose or other parts of the face. 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 fleece hose cover, Australian SleepZone heated hose http://www.sleepzone.com.au/index.html, and hose connectors. See the article on Solving Common Equipment Problems. Claustrophobia Sleeping with the Enemy Claustrophobia or fear of suffocation may have three causes. One is machine air pressure that is too low, leading to not enough incoming air and insufficient venting of exhaled carbon dioxide. The easy remedy is to increase the machine pressure. A second cause is nasal obstruction, a blocked nose because of nasal congestion, a severely deviated septum, nasal polyps or large nasal turbinates (bony structure). Remedies may be daily nasal irrigation, a CPAP heated humidifier, or nasal surgery. A third cause is mask claustrophobia. A remedy is to overcome fear through desensitization techniques, such as reading or watching TV with the mask and machine on, gradually increasing the time; or through a few therapy sessions. A book with much good body-mind and mental imagery advice is Sound Sleep, Sound Mind by Dr. Barry Krakow, http://sleeptreatment.com/ Dr. Krakow pioneered a mask adaptation technique called PAP-NAP. An abstract is at http://www.aasmnet.org/jcsm/JCSMAcceptedPapers.aspx. Perhaps you can work with your local sleep doctor and sleep lab using a similar adaptation technique. Nasal pillows, nasal prongs, or nose cushions may be good choices for someone with mask claustrophobia, rather than a nasal or full face mask. Discussion thread on mask claustrophobia: http://www.cpaptalk.com/viewtopic.php?t=13970&highlight=claustrophobia It’s easier to prevent skin breakdownsfrom mask pressure points than to heal them. If you can’t adjust the mask to get rid of the pressure points, such as the bridge of the nose, then switch to another mask for a few nights, or replace the mask with a better one. If your alternate mask also hits the sore area, put a Band-Aid blister bandage on the sore. Try padding the offending mask with Dr. Scholl\'s moleskin or moleskin foam, found in the foot section of the drug store. Apply the moleskin to the mask, not your face.If you experience a sore nostril from nasal pillows, inspect the pillows to see if they are damaged. Nasal pillows (not the whole mask) should be replaced every three months or when worn out. Wear another type mask while your nostril heals. If you have APAP or BiPAP, adjust the mask for leaks at your highest pressure. If it doesn’t leak at the highest pressure, it won’t leak at the lower pressure (unless there is a reason other than pressure for the leak). If possible, remove the mask by undoing a lower clip without readjusting the headgear each time. To get up at night, disconnect the mask from the hose and breathe through your mouth while wearing the mask. Mask Vent Blowing Air on Your Arm, Hand, Bed Partner Strangers in the Night It’s very important that a mask have a vent to clear exhaled carbon dioxide. Never cover the mask vent with bed covers. Allow it to vent. When you get the mask, ask the technician to show you the vent. Vents may be hard to see. If you don’t know where the vent is, put on the mask, turn on the machine, and feel where air is coming out. Unfortunately, almost all vents are placed to vent forward from your face so air blows on your hand, arm, or bed partner. You can learn to sleep with your arm under a cover or pillow and barricade your partner. You can wear long sleeves and even gloves, if you don’t mind looking like Mickey or Minnie Mouse. Most pharmacies sell soft white cotton gloves, worn for hand ointment, behind the counter. If you have a tolerant and resilient bed partner, you need to find creative options so they don’t get caught in nightly windstorms. One well designed mask vents straight upward, like a chimney, towards the headboard. It doesn’t vent on your forehead, arm, or partner. It’s a nasal pillow mask, the Headrest Twilight NP. See https://www.cpap.com/productpage/aeiomed-aura-nasal-cpap-interface.html As time goes on, more mask manufacturers may learn to make masks vent less violently. Leaks are good and bad. A good leak is called the vent flow rate or flush rate, airflow through the vents, purposely designed to flush away exhaled carbon dioxide. Leakage above that rate is a bad leak from a poorly selected, sized, or fitted mask, leaking because it doesn’t rest securely on your face or nostrils. The higher the pressure, the higher the vent flow rate and bad leak rate. Wash your face to remove facial oils before using a mask, and avoid skin moisturizer on your face at night. The mask shouldn’t leak into your eyes (causing conjunctivitis) or anywhere else around its seal. For subtle leaks with nasal pillows, you may not be able to detect leaks by how they feel on your face. Use your hand to feel around the mask for leaks. Another way to detect leaks is by sound. If your mask turns into a sonar device, echoing a new sound off of bed pillows, you have a leak. If your full face mask makes a rude raspberry noise or turns into a wind instrument, you have a large leak. Some masks are made to “hydroplane” on the face, floating on air for a seal. To adjust it, pull the mask away from your face momentarily so it can inflate and float again. Use sound and hand to detect loose hose connections in your machine around the humidifier connection. If your mask leaks, a very common occurrence, keep experimenting with adjusting it and improvise ways to get a custom fit. If you’ve had the mask for a while and then it begins leaking, check the age of the silicone cushion or nasal pillow. The cushion or nasal pillow (not the whole mask) should be replaced every three months or when worn out. Insurance companies start with Medicare guidelines to design their replacement schedule. See Medicare replacement guidelines at http://www.billmyinsurance.com/cpap-faq/Medicare.html#14 For a discussion thread on interpreting leak rates, see http://www.cpaptalk.com/viewtopic/t14536/Meaning-of-System-Leak-Numbers.html For a table of vent flow rates of various masks compiled by cpaptalker dsm from other users quoting the manufacturers’ published vent flow rates, see http://www.internetage.com/cpapinfo/leak-rates-1.html. The numbers along the top line of the chart are machine pressure in cm/H2O. This table is useful if you want to compare the necessary vent flow rate with the leak rate shown by your machine software. The difference allows you to assess how badly your mask is leaking due to a poor fit. It may take several weeks or months of fiddling with your mask and learning to sleep with it, using a data-capable PAP machine with software to track results, before you achieve a satisfactory low level of leaks and AHI (apnea hypopnea index) with a particular mask. You may need to adjust machine pressure up or down for each mask. Learning when to give up, and when to keep trying, only comes from experience. If you give up on a mask, try it again several months later to see if now you can make it work. Mouth breathing and mouth leaks Mouth breathing and mouth leaks are closely related, but not necessarily the same thing. Mouth breathing must occur when the nasal passages are blocked, so the only way for any air to get into the lungs is through the mouth. People with blocked noses breathe through their mouth, not through their nose. The solution to mouth breathing is to use a full face mask. Some effort and time may be required to find the best full face mask, fit it, and adjust to it. Use of nasal irrigation and humidified CPAP, especially with nasal pillows, may open nasal passages that were previously chronically blocked. The person can then learn to breathe through the nose. Mouth leaks may occur if the person is breathing through their nose, but opens their mouth during sleep. If leakage through the mouth is a persistent problem, CPAP treatment can be rendered completely ineffective. CPAP air detouring out the mouth does nothing to keep the airway open. Either mouth breathing or mouth leakage can also cause feelings of suffocation from apneas still happening and/or just the choking feeling of air rushing out the mouth unexpectedly. The safest solution to mouth leakage is to use a full face mask. See http://www.cpaptalk.com/viewtopic/t23863/Why-dont-more-people-use-a-full-face-mask.html Other remedies including using a homemade or commercial chinstrap in hopes that the tongue will maintain an airtight seal inside the mouth if the jaw is kept up. Many people find that chinstraps don’t work to prevent mouth leakage. Another remedy is to use the tongue to maintain an airtight seal inside the mouth. Some people train the tongue by positioning the tip of the tongue behind the upper front teeth or on the roof of the mouth, and let the tongue spread out in back to seal the throat air passage, even if the lips open. Others use a dental splint, custom made by a dentist, or a do-it-yourself mouth guard to help the tongue maintain an airtight seal. “The safety of taping the mouth shut has not been proven and there are potential risks of regurgitation and aspiration of food and of suffocation.” TS Johnson MD et al, Sleep Apnea – The Phantom of the Night, p. 167. Mouth taping is especially dangerous for anyone who ever gets blocked nasal passages during the night. If air can’t get in through the nose, it needs to get in through the mouth. Mouth taping is also risky in case of a hose disconnect or power outage. Bed Pillow What Dreams May Come If you are overly relying on a soft or hard pillow to keep your mask in place, you have a poorly fitted mask or poor choice of mask. Try adjusting the fit or getting a different mask. If your mask is properly fitted and your mask and pillow are fighting, try a smaller firm pillow, so the mask can hang off the side; or a buckwheat pillow, neck pillow, or memory foam pillow which gives the mask some support. Make sure the pillow doesn’t interfere with your mask if you are a side sleeper. When you are pillow shopping, if you don’t mind acting strangely in a store, try out the pillow, imagining what your mask would do. Consider the PAPillow, described at http://www.PAPillow.com, in a low wedge pillow or higher double edge pillow, available at http://shop.talkaboutsleep.com/?action=info.display&category=papillow-difference Similar pillows are available at https://www.cpap.com/simple-find-cpap-products/misc There are also orthopedic, memory foam pillows. Discussion thread on cervical neck pillows: http://www.cpaptalk.com/viewtopic/t16851/Cervical-Positional-Effects-on-Snoring-and-Apneas.html and http://www.targetwoman.com/articles/neck-pillow.html Some CPAP users report a lower AHI (apnea hypopnea index of events per hour) if they use a bed wedge pillow. Linen stores may sell lower bed wedges; medical supply stores and online stores sell slightly higher bed wedges and memory foam bed wedges, which can be used in combination with a PAPillow. See the discussion thread on silent acid reflux at http://www.cpaptalk.com/viewtopic/t14288/Strange-treatment-question.html 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 CPAP Mask Choices, CPAP Adaptation and Recovery and Seven Stages of CPAP and What Is Feeling Good? at http://smart-sleep-apnea.blogspot.com Mike Moran’s humor –The Incredible Growing Mask, http://www.cpaptalk.com/viewtopic.php?p=63381 Sources: Based on personal experience with obstructive sleep apnea, gleaned from the collective wisdom of cpaptalk.com contributors, and TS Johnson MD et al, Sleep Apnea – The Phantom of the Night Want more? See the peer coaching articles on Tips for Newcomers to Sleep Apnea, Solving Common Equipment Problems, CPAP Pressure Settings, Ready to Give Up?, Cleaning Equipment at http://smart-sleep-apnea.blogspot.com . Search or post a message on http://www.cpaptalk.com . 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 2006-2008. Permission to use for free educational purposes.
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Solving CPAP Mask Problems (Mile High Sleeper) (Mask)

One man’s meat is another man’s poison, especially when it comes to masks.

Mask comfort
As Good As It Gets

Use a CPAP heated humidifier to make the air more comfortable and keep air passages moisturized and healthier. Get an integrated or stand-alone CPAP humidifier. Experiment with settings from low to high humidity. Dry nasal passages can become irritated, crusty, and bleed. Use an additional nasal moisturizer or spray if you experience dryness.

A mask needs to fit the way you breathe– nose breathing or mouth breathing. If you breathe through your nose, use a nasal mask or nasal pillows. If you breathe through your mouth, or go from a clear to clogged nose during the night, use a full face mask.

Often, adjusting the headgear and mask too tight will make leaks worse. If a mask leaves marks on your face in the morning that don’t go away for a long time, it’s too tight. A mask and headgear that are too tight may cause puffy, baggy eyes, misaligned teeth, dental pain, headaches, neck aches, and pressure sores on the bridge of the nose or other parts of the face.

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 fleece hose cover, Australian SleepZone heated hose http://www.sleepzone.com.au/index.html, and hose connectors. See the article on Solving Common Equipment Problems.

Claustrophobia
Sleeping with the Enemy

Claustrophobia or fear of suffocation may have three causes. One is machine air pressure that is too low, leading to not enough incoming air and insufficient venting of exhaled carbon dioxide. The easy remedy is to increase the machine pressure. A second cause is nasal obstruction, a blocked nose because of nasal congestion, a severely deviated septum, nasal polyps or large nasal turbinates (bony structure). Remedies may be daily nasal irrigation, a CPAP heated humidifier, or nasal surgery. A third cause is mask claustrophobia. A remedy is to overcome fear through desensitization techniques, such as reading or watching TV with the mask and machine on, gradually increasing the time; or through a few therapy sessions. A book with much good body-mind and mental imagery advice is Sound Sleep, Sound Mind by Dr. Barry Krakow, http://sleeptreatment.com/
Dr. Krakow pioneered a mask adaptation technique called PAP-NAP. An abstract is at http://www.aasmnet.org/jcsm/JCSMAcceptedPapers.aspx. Perhaps you can work with your local sleep doctor and sleep lab using a similar adaptation technique.

Nasal pillows, nasal prongs, or nose cushions may be good choices for someone with mask claustrophobia, rather than a nasal or full face mask. Discussion thread on mask claustrophobia: http://www.cpaptalk.com/viewtopic.php?t=13970&highlight=claustrophobia

It’s easier to prevent skin breakdownsfrom mask pressure points than to heal them. If you can’t adjust the mask to get rid of the pressure points, such as the bridge of the nose, then switch to another mask for a few nights, or replace the mask with a better one. If your alternate mask also hits the sore area, put a Band-Aid blister bandage on the sore. Try padding the offending mask with Dr. Scholl\'s moleskin or moleskin foam, found in the foot section of the drug store. Apply the moleskin to the mask, not your face.If you experience a sore nostril from nasal pillows, inspect the pillows to see if they are damaged. Nasal pillows (not the whole mask) should be replaced every three months or when worn out. Wear another type mask while your nostril heals.

If you have APAP or BiPAP, adjust the mask for leaks at your highest pressure. If it doesn’t leak at the highest pressure, it won’t leak at the lower pressure (unless there is a reason other than pressure for the leak). If possible, remove the mask by undoing a lower clip without readjusting the headgear each time. To get up at night, disconnect the mask from the hose and breathe through your mouth while wearing the mask.

Mask Vent Blowing Air on Your Arm, Hand, Bed Partner
Strangers in the Night

It’s very important that a mask have a vent to clear exhaled carbon dioxide. Never cover the mask vent with bed covers. Allow it to vent. When you get the mask, ask the technician to show you the vent. Vents may be hard to see. If you don’t know where the vent is, put on the mask, turn on the machine, and feel where air is coming out. Unfortunately, almost all vents are placed to vent forward from your face so air blows on your hand, arm, or bed partner. You can learn to sleep with your arm under a cover or pillow and barricade your partner. You can wear long sleeves and even gloves, if you don’t mind looking like Mickey or Minnie Mouse. Most pharmacies sell soft white cotton gloves, worn for hand ointment, behind the counter. If you have a tolerant and resilient bed partner, you need to find creative options so they don’t get caught in nightly windstorms.

One well designed mask vents straight upward, like a chimney, towards the headboard. It doesn’t vent on your forehead, arm, or partner. It’s a nasal pillow mask, the Headrest Twilight NP. See https://www.cpap.com/productpage/aeiomed-aura-nasal-cpap-interface.html As time goes on, more mask manufacturers may learn to make masks vent less violently.

Leaks are good and bad. A good leak is called the vent flow rate or flush rate, airflow through the vents, purposely designed to flush away exhaled carbon dioxide. Leakage above that rate is a bad leak from a poorly selected, sized, or fitted mask, leaking because it doesn’t rest securely on your face or nostrils. The higher the pressure, the higher the vent flow rate and bad leak rate. Wash your face to remove facial oils before using a mask, and avoid skin moisturizer on your face at night. The mask shouldn’t leak into your eyes (causing conjunctivitis) or anywhere else around its seal. For subtle leaks with nasal pillows, you may not be able to detect leaks by how they feel on your face. Use your hand to feel around the mask for leaks. Another way to detect leaks is by sound. If your mask turns into a sonar device, echoing a new sound off of bed pillows, you have a leak. If your full face mask makes a rude raspberry noise or turns into a wind instrument, you have a large leak.

Some masks are made to “hydroplane” on the face, floating on air for a seal. To adjust it, pull the mask away from your face momentarily so it can inflate and float again. Use sound and hand to detect loose hose connections in your machine around the humidifier connection. If your mask leaks, a very common occurrence, keep experimenting with adjusting it and improvise ways to get a custom fit. If you’ve had the mask for a while and then it begins leaking, check the age of the silicone cushion or nasal pillow. The cushion or nasal pillow (not the whole mask) should be replaced every three months or when worn out. Insurance companies start with Medicare guidelines to design their replacement schedule. See Medicare replacement guidelines at http://www.billmyinsurance.com/cpap-faq/Medicare.html#14

For a discussion thread on interpreting leak rates, see http://www.cpaptalk.com/viewtopic/t14536/Meaning-of-System-Leak-Numbers.html

For a table of vent flow rates of various masks compiled by cpaptalker dsm from other users quoting the manufacturers’ published vent flow rates, see http://www.internetage.com/cpapinfo/leak-rates-1.html. The numbers along the top line of the chart are machine pressure in cm/H2O. This table is useful if you want to compare the necessary vent flow rate with the leak rate shown by your machine software. The difference allows you to assess how badly your mask is leaking due to a poor fit.

It may take several weeks or months of fiddling with your mask and learning to sleep with it, using a data-capable PAP machine with software to track results, before you achieve a satisfactory low level of leaks and AHI (apnea hypopnea index) with a particular mask. You may need to adjust machine pressure up or down for each mask. Learning when to give up, and when to keep trying, only comes from experience. If you give up on a mask, try it again several months later to see if now you can make it work.

Mouth breathing and mouth leaks
Mouth breathing and mouth leaks are closely related, but not necessarily the same thing.

Mouth breathing must occur when the nasal passages are blocked, so the only way for any air to get into the lungs is through the mouth. People with blocked noses breathe through their mouth, not through their nose. The solution to mouth breathing is to use a full face mask. Some effort and time may be required to find the best full face mask, fit it, and adjust to it. Use of nasal irrigation and humidified CPAP, especially with nasal pillows, may open nasal passages that were previously chronically blocked. The person can then learn to breathe through the nose.

Mouth leaks may occur if the person is breathing through their nose, but opens their mouth during sleep. If leakage through the mouth is a persistent problem, CPAP treatment can be rendered completely ineffective. CPAP air detouring out the mouth does nothing to keep the airway open. Either mouth breathing or mouth leakage can also cause feelings of suffocation from apneas still happening and/or just the choking feeling of air rushing out the mouth unexpectedly. The safest solution to mouth leakage is to use a full face mask. See http://www.cpaptalk.com/viewtopic/t23863/Why-dont-more-people-use-a-full-face-mask.html

Other remedies including using a homemade or commercial chinstrap in hopes that the tongue will maintain an airtight seal inside the mouth if the jaw is kept up. Many people find that chinstraps don’t work to prevent mouth leakage.

Another remedy is to use the tongue to maintain an airtight seal inside the mouth. Some people train the tongue by positioning the tip of the tongue behind the upper front teeth or on the roof of the mouth, and let the tongue spread out in back to seal the throat air passage, even if the lips open. Others use a dental splint, custom made by a dentist, or a do-it-yourself mouth guard to help the tongue maintain an airtight seal.

“The safety of taping the mouth shut has not been proven and there are potential risks of regurgitation and aspiration of food and of suffocation.” TS Johnson MD et al, Sleep Apnea – The Phantom of the Night, p. 167. Mouth taping is especially dangerous for anyone who ever gets blocked nasal passages during the night. If air can’t get in through the nose, it needs to get in through the mouth. Mouth taping is also risky in case of a hose disconnect or power outage.

Bed Pillow
What Dreams May Come

If you are overly relying on a soft or hard pillow to keep your mask in place, you have a poorly fitted mask or poor choice of mask. Try adjusting the fit or getting a different mask. If your mask is properly fitted and your mask and pillow are fighting, try a smaller firm pillow, so the mask can hang off the side; or a buckwheat pillow, neck pillow, or memory foam pillow which gives the mask some support. Make sure the pillow doesn’t interfere with your mask if you are a side sleeper. When you are pillow shopping, if you don’t mind acting strangely in a store, try out the pillow, imagining what your mask would do.

Consider the PAPillow, described at http://www.PAPillow.com, in a low wedge pillow or higher double edge pillow, available at http://shop.talkaboutsleep.com/?action=info.display&category=papillow-difference Similar pillows are available at https://www.cpap.com/simple-find-cpap-products/misc There are also orthopedic, memory foam pillows. Discussion thread on cervical neck pillows: http://www.cpaptalk.com/viewtopic/t16851/Cervical-Positional-Effects-on-Snoring-and-Apneas.html and http://www.targetwoman.com/articles/neck-pillow.html

Some CPAP users report a lower AHI (apnea hypopnea index of events per hour) if they use a bed wedge pillow. Linen stores may sell lower bed wedges; medical supply stores and online stores sell slightly higher bed wedges and memory foam bed wedges, which can be used in combination with a PAPillow. See the discussion thread on silent acid reflux at http://www.cpaptalk.com/viewtopic/t14288/Strange-treatment-question.html

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 CPAP Mask Choices, CPAP Adaptation and Recovery and Seven Stages of CPAP and What Is Feeling Good? at http://smart-sleep-apnea.blogspot.com

Mike Moran’s humor –The Incredible Growing Mask, http://www.cpaptalk.com/viewtopic.php?p=63381

Sources: Based on personal experience with obstructive sleep apnea, gleaned from the collective wisdom of cpaptalk.com contributors, and TS Johnson MD et al, Sleep Apnea – The Phantom of the Night

Want more? See the peer coaching articles on Tips for Newcomers to Sleep Apnea, Solving Common Equipment Problems, CPAP Pressure Settings, Ready to Give Up?, Cleaning Equipment at http://smart-sleep-apnea.blogspot.com . Search or post a message on http://www.cpaptalk.com .

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 2006-2008. Permission to use for free educational purposes.

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Our Collective Wisdom
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