Portal de Periódicos da CAPES

Choosing an Oronasal Mask to Deliver Continuous Positive Airway Pressure May Cause More Upper Airway Obstruction or Lead to Higher Continuous Positive Airway Pressure Requirements than a Nasal Mask in Some Patients: A Case Series

2016; American Academy of Sleep Medicine; Volume: 12; Issue: 09 Linguagem: Inglês

10.5664/jcsm.6118

1550-9397

Justin R. Ng, Vinod Aiyappan, Jeremy Mercer, Peter Catcheside, Ching Li Chai‐Coetzer, R. Doug McEvoy, Nick A. Antic,

Airway Management and Intubation Techniques

Free AccessCPAPChoosing an Oronasal Mask to Deliver Continuous Positive Airway Pressure May Cause More Upper Airway Obstruction or Lead to Higher Continuous Positive Airway Pressure Requirements than a Nasal Mask in Some Patients: A Case Series Justin R. Ng, MBBS, Vinod Aiyappan, MD, Jeremy Mercer, PhD, Peter G. Catcheside, PhD, Ching Li Chai-Coetzer, MBBS, PhD, R. Doug McEvoy, MD, PhD, Nick Antic, MBBS, PhD Justin R. Ng, MBBS Address correspondence to: Justin Raymond Ng, MBBS, Department of Respiratory and Sleep Medicine, Fiona Stanley Hospital, 102-118 Murdoch Drive, Murdoch, Western Australia, Australia, 6150+61421631622; Business: +618 6152 0461 E-mail Address: [email protected] Adelaide Institute for Sleep Health - a Flinders Centre of Research Excellence and Sleep and Respiratory Medicine, Repatriation General Hospital, Southern Adelaide Local Health Network, Daws Road, Daw Park, South Australia, Australia , Vinod Aiyappan, MD Adelaide Institute for Sleep Health - a Flinders Centre of Research Excellence and Sleep and Respiratory Medicine, Repatriation General Hospital, Southern Adelaide Local Health Network, Daws Road, Daw Park, South Australia, Australia , Jeremy Mercer, PhD Adelaide Institute for Sleep Health - a Flinders Centre of Research Excellence and Sleep and Respiratory Medicine, Repatriation General Hospital, Southern Adelaide Local Health Network, Daws Road, Daw Park, South Australia, Australia , Peter G. Catcheside, PhD Adelaide Institute for Sleep Health - a Flinders Centre of Research Excellence and Sleep and Respiratory Medicine, Repatriation General Hospital, Southern Adelaide Local Health Network, Daws Road, Daw Park, South Australia, Australia , Ching Li Chai-Coetzer, MBBS, PhD Adelaide Institute for Sleep Health - a Flinders Centre of Research Excellence and Sleep and Respiratory Medicine, Repatriation General Hospital, Southern Adelaide Local Health Network, Daws Road, Daw Park, South Australia, Australia , R. Doug McEvoy, MD, PhD Adelaide Institute for Sleep Health - a Flinders Centre of Research Excellence and Sleep and Respiratory Medicine, Repatriation General Hospital, Southern Adelaide Local Health Network, Daws Road, Daw Park, South Australia, Australia , Nick Antic, MBBS, PhD Adelaide Institute for Sleep Health - a Flinders Centre of Research Excellence and Sleep and Respiratory Medicine, Repatriation General Hospital, Southern Adelaide Local Health Network, Daws Road, Daw Park, South Australia, Australia Published Online:September 15, 2016https://doi.org/10.5664/jcsm.6118Cited by:19SectionsAbstractPDF ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutABSTRACTStudy Objectives:The choice of mask interface used with continuous positive airway pressure (CPAP) therapy can affect the control of upper airway obstruction (UAO) in obstructive sleep apnea (OSA). We describe a case series of four patients with paradoxical worsening of UAO with an oronasal mask and the effect of changing to a nasal mask.Methods:We retrospectively reviewed the case histories of 4 patients and recorded patient demographics, in-laboratory and ambulatory CPAP titration data, CPAP therapy data, type of mask interface used and potential confounding factors.Results:The 4 cases (mean ± SD: age = 59 ± 16 y; BMI = 30.5 ± 4.5 kg/m2) had a high residual apnoea-hypopnea index (AHI) (43 ± 14.2 events/h) and high CPAP pressure requirements (14.9 ± 6.6 cmH2O) with an oronasal mask. Changing to a nasal mask allowed adequate control of UAO with a significant reduction in the average residual AHI (3.1 ± 1.5 events/h). In two of the four cases, it was demonstrated that control of UAO was obtained at a much lower CPAP pressure compared to the oronasal mask (Case one = 17.5 cmH2O vs 12cmH2O; Case two = 17.9 cmH2O vs 7.8 cmH2O). Other potential confounding factors were unchanged. There are various physiological observations that may explain these findings but it is uncertain which individuals are susceptible to these mechanisms.Conclusions:If patients have OSA incompletely controlled by CPAP with evidence of residual UAO and/or are requiring surprisingly high CPAP pressure to control OSA with an oronasal mask, the choice of mask should be reviewed and consideration be given to a trial of a nasal mask.Commentary:A commentary on this article appears in this issue on page 1209.Citation:Ng JR, Aiyappan V, Mercer J, Catcheside PG, Chai-Coetzer CL, McEvoy RD, Antic N. Choosing an oronasal mask to deliver continuous positive airway pressure may cause more upper airway obstruction or lead to higher continuous positive airway pressure requirements than a nasal mask in some patients: a case series. J Clin Sleep Med 2016;12(9):1227–1232.INTRODUCTIONContinuous positive airway pressure (CPAP) is the gold standard treatment for patients with moderate to severe obstructive sleep apnea (OSA). CPAP was first described and subsequently traditionally delivered using a nasal mask.1 Due to symptoms such as nasal obstruction and leakage of air from the mouth, different mask interfaces have been developed, including the oronasal mask interface.2,3 As highlighted by a recent Cochrane review,4 there is currently very limited information to guide the treating physician on the selection of the most appropriate mask interface. As such, the choice of CPAP delivery interface remains largely based on the clinician's personal experience or patient preference. In our clinical service, CPAP titration is commenced with a nasal mask but an oronasal mask can be selected if a patient reports nasal obstruction or an inability to breathe through their nose. However, there is increasing evidence that CPAP delivered by an oronasal mask may be less effective at opening the upper airway than via a nasal mask,5–14 which could have important implications for clinical practice.BRIEF SUMMARYCurrent Knowledge/Study Rationale: A wide variety of mask interfaces are used to deliver CPAP therapy for patients with OSA, but there is limited literature available to guide the treating physician on the most efficacious mask interface to treat upper airway obstruction (UAO). Four OSA cases are presented demonstrating clinically significant residual UAO with CPAP delivered by an oronasal mask leading to treatment failure, which was corrected by switching to a nasal mask that was set, in two of the four cases, to a substantially lower CPAP pressure.Study Impact: This is a new case series highlighting this clinical problem and demonstrating that changing from an oronasal mask to a nasal mask led to resolution of the problem. If patients have OSA incompletely controlled by CPAP with evidence of residual UAO or are requiring surprisingly high CPAP pressures to control OSA with an oronasal mask, the choice of mask should be reviewed and consideration be given to a trial of a nasal mask.We present four cases where we believe an oronasal mask led to either very high CPAP pressure requirements and/or incomplete control of upper airway obstruction (UAO). In each case changing to a nasal mask interface controlled UAO. Thus, we highlight that the type of interface used to deliver CPAP can affect the efficacy of CPAP therapy for OSA.CASE 1A 37-y-old man (body mass index [BMI] 28.5 kg/m2) underwent an in-laboratory split-night polysomnogram (PSG). Respiratory events in all in-laboratory studies were scored using the 2007 American Academy of Sleep Medicine alternative criteria.15 The diagnostic component demonstrated severe OSA with an apnea-hypopnea index (AHI) of 50 events/h. The CPAP titration was performed with the Philips Respironics OmniLab device (Philips Australia, North Ryde, New South Wales, Australia). The titration was initially commenced with an oronasal interface. CPAP pressures between 4 and 17.5 cmH2O were trialled for 170 min. There was persistent snoring, obstructive apneas and hypopneas at a CPAP pressure of 17.5 cmH2O with an AHI of 55.8 events/h during this portion of the study (Figure 1). Maximum mask leak at this CPAP pressure was 78 L/min. The CPAP titration was recommenced with a nasal mask (Fisher and Paykel Eson nasal mask (Fisher and Paykel Healthcare, Ltd., Auckland, New Zealand)) with a chin strap applied. CPAP pressures between 4 and 12 cmH2O were trialled for 130 min. A CPAP pressure of 12 cmH2O with the nasal mask successfully treated UAO, reducing AHI to 3.8 events/h, and also stopped patients from snoring (Figure 1). The patient was in the supine position throughout the entire study when both masks where applied. The patient tolerated CPAP well and perceived a better quality sleep with the nasal mask compared to the oronasal mask. He continued with CPAP treatment at home using a nasal mask.Figure 1: Polysomnography summary from case 1 showing continuous positive airway pressure (CPAP) titration findings from the two mask interfaces on the same night.There is incomplete control of upper airway obstruction and persistent hypopneas with a full face mask and excellent control of upper airway obstruction with a nasal mask.Download FigureCASE 2A 63-y-old man (BMI 26.9 kg/m2) received a diagnosis of mild-moderate OSA (AHI 25 events/h) during an in-laboratory PSG. He proceeded to an ambulatory autotitrating positive airway pressure (APAP) study using the Philips Respironics PR System One REMstar AutoCPAP device (Philips Australia, North Ryde, New South Wales, Australia). He had a 6-day trial with an oronasal mask. The data16 showed an average residual AHI of 22.7 events/h with a 90th centile pressure of 17.9 cmH2O. The device identified the residual respiratory events as predominantly obstructive with an average obstructive airway index of 12.7 events/h (55.9% of total events), average hypopnoea index of 5.2 events/h (22.9%), average clear airway index of 4.8 events/h (21.1%), and average vibratory snore index of 15.1 events/h. He used the device on all 6 days, with an average daily usage of 4 h, 46 min. There was no clinically significant mask leak (average leak 12.6 L/min and time in "large leak" of only 5 min and 30 sec per night). Using the same APAP device, the patient proceeded to a 16-day trial with a nasal mask. These data showed an average AHI of 2.0 events/h on CPAP with a 90th centile pressure of 7.8 cmH2O, a substantially reduced CPAP pressure needed than with an oronasal mask. He used the device on all 16 days, with an average daily usage of 4 h, 57 min. He reported sleeping in a similar position when using both masks, denied any alcohol consumption, and showed no change in weight. He was converted to a fixed CPAP machine with the CPAP pressure set at 8 cmH2O and he continued with CPAP using a nasal mask. Data downloaded from the CPAP machine set at a fixed CPAP pressure 1 month later showed results similar to those of the APAP study when a nasal mask was used, with an average residual AHI of 6.6 events/h. He used the device on all 30 days with an average daily usage of 4 h, 51 min.CASE 3A 56-y-old woman (BMI 29.4 kg/m2) received a diagnosis of moderate-severe OSA (AHI 35 events/h) on an in-laboratory PSG. A subsequent in-laboratory CPAP titration study found that a CPAP pressure of 5 cmH2O with a nasal mask was adequate to successfully treat UAO and stop the patient from snoring. The patient found the nasal mask uncomfortable and wanted to try an oronasal mask. Using the Philips Respironics PR System One REMstar AutoCPAP device at a fixed pressure of 5 cmH2O, she had a 22-day home trial with a nasal mask immediately followed by a 15-day trial with an oronasal mask. The downloaded CPAP machine data during 22 days of nasal mask use showed an average residual AHI of 4.8 events/h and an average daily usage of 8 h, 22 min. Downloaded data from the 14-day trial of the oronasal mask showed an average residual AHI of 45.2 events/h and average daily usage of 7 h, 32 min. The device identified the residual respiratory events12 as predominantly obstructive with an average obstructive airway index of 36.6 events/h (81.0% of total events), average hypopnea index of 7.9 events/h (17.5%), average clear airway index of 0.7 events/h (1.5%), and average vibratory snore index of 195.9 events/h. There was no significant mask leak with the oronasal mask with an average leak of 18 L/min and time in "large leak" of 0 sec per night. She reported sleeping in a similar position when using both masks, and denied any alcohol consumption or change in weight.CASE 4A 76-y-old man (BMI 37.0 kg/m2) received a diagnosis of severe OSA (AHI 121 events/h) on a background of severe chronic obstructive airway disease requiring continuous supplemental oxygen. He was referred to our service after using the Philips Respironics REMstar Pro CPAP device (Philips Australia, North Ryde, New South Wales, Australia) on a fixed pressure of 15 cmH2O with 4 L/min of supplemental oxygen delivered into the oronasal mask for 1 month. The CPAP machine recorded a high residual AHI of 61 events/h. Subsequently, he underwent an inpatient PSG while using an autotitrating bilevel ventilation device (Philips Respironics BiPAP Auto Biflex (Philips Australia, North Ryde, New South Wales, Australia)) with 4 L/ min of supplemental oxygen and an oronasal mask. This study showed that the residual sleep-disordered breathing was predominantly due to obstructive apneic events with clear flow limitation and snoring preceding obstructive apneas. Despite this device reporting a 90th centile EPAP of 19.4 cmH2O (and inspiratory positive airway pressure of 21.4 cmH2O), there were persistent obstructive events and an average residual AHI of 21.5 events/h. Given minimal apparent requirement for inspiratory pressure support, home treatment using CPAP of 19 cmH2O and 4L of oxygen was commenced. The patient tolerated CPAP treatment well and there was no significant mask leak (average leak of 14.2 L/min and time in "large leak" of 8 min, 2 sec per night). However, downloaded CPAP data for 30 days with the oronasal mask showed a residual average AHI of 48.3 events/h from an average daily usage of 5 h, 51 min. The CPAP device identified the average residual respiratory events as predominantly obstructive with an obstructive airway index of 38 events/h (78.7% of total events) and hypopnea index of 5.9 events/h (12.2%). Subsequently, he underwent a repeat in-laboratory CPAP titration study with a nasal mask and chin strap. A CPAP pressure of 18 cmH2O was adequate to treat UAO. Using the same CPAP machine, subsequent data with the nasal mask for 30 days showed a residual average AHI of 1.7 events/h and average daily usage of 5 h, 22 min. The average mask leak was 3.4 L/min. He reported sleeping in a similar position when using both masks and denied any alcohol consumption or change in weight.DISCUSSIONIn all four cases, we suspected that the high residual AHI while on oronasal mask CPAP (despite a high CPAP pressure in three cases) resulted from a tendency of the oronasal mask interface to induce obstruction of the upper airway. In each case, changing to a nasal mask allowed adequate control of UAO with significant reduction in the average residual AHI to acceptable limits as summarized in Table 1. In two of the four cases, control of UAO was obtained at a much lower CPAP pressure. In the absence of alternative explanations such as change in habitual sleep body position, mask leak, or substantial changes in patient weight and alcohol use to explain the results, we believe the use of an oronasal interface contributed significantly to UAO, thereby reducing or counteracting the beneficial effects of positive airway pressure treatment.Table 1 Summary of four cases.Table 1 Summary of four cases.Teo et al.8 performed the first randomized trial to compare laboratory-attended CPAP titration with nasal and oronasal masks in patients with OSA. One of their findings was that the residual AHI post-CPAP titration study was significantly lower using the nasal mask compared with the full face mask (mean ± standard deviation [SD] 5.3 ± 3.4 versus 11.0 ± 10.4 events/h, respectively; p = 0.01). Although there was no overall difference in the CPAP pressure required between nasal and oronasal masks to adequately treat OSA during the CPAP titration, there were individual patient differences. In particular, one patient showed a 7 cmH2O higher CPAP requirement with an oronasal versus nasal mask, although there was no report of clinically significant differences leading to treatment failure. Our case series reports patients with much higher differences in the residual AHI between the two mask interfaces compared to Teo et al.8A subsequent single case report by Schorr et al.9 reported on treatment failure using CPAP with an oronasal mask. They described a patient with severe OSA (AHI 76 events/h) and persistent obstructive hypopneas and a high residual AHI of 32 events/h during CPAP titration with an oronasal mask. A subsequent CPAP titration with a nasal mask demonstrated excellent control of UAO. They performed a nasoendoscopy during the CPAP titration with both oronasal and nasal masks to directly visualize the upper airway. When using the oronasal mask, they found posterior displacement of the tongue causing a partially obstructed oropharyngeal airway. It was hypothesized that paradoxical obstruction of the upper airway from CPAP treatment using an oronasal mask interface resulted in treatment failure. However, the authors acknowledged that one limitation was the inability to quantify the proportion of nasal and oral breathing while using the oronasal mask, because there is evidence that upper airway resistance during sleep is significantly lower while breathing nasally rather than orally.10Posterior displacement of the mandible is a possible physiological mechanism to explain our findings. A small case series by Kaminska et al.11 found that CPAP pressure requirements could be reduced, resulting in treatment success, using combination treatment with an oronasal mask and a mandibular advancement device compared with an oronasal mask alone in two of their four patients. The authors speculate that posterior displacement of the mandible may promote mouth opening, which is associated with an increased Pcrit (reflecting an increase in upper airway collapsibility) during sleep in normal subjects compared with a closed mouth (mean ± SD −12.7 ± 4.8 versus −16.4 ± 6 cmH2O, respectively; p = 0.03).12 Given that higher CPAP pressures were observed in patients using an oronasal mask compared with a nasal mask to overcome UAO, the authors speculate that an additional factor aggravating posterior displacement of the mandible may be increased CPAP mask strap tension applied to prevent mask leaks. The authors also speculate that tongue strength may be another contributing factor, as our sleep service has observed unanticipated UAO in patients with motor neuron disease (amyotrophic lateral sclerosis).Liang et al.13 found that nasal mask ventilation was more effective than oronasal ventilation during induction of general anesthesia. Therefore, it was postulated that CPAP through an oronasal mask interface applied positive pressure simultaneously in both the nasopharyngeal and oropharyngeal cavities, causing a reduced posteroanterior pressure gradient across the soft palate (velopharynx) and tongue (pharynx and hypopharynx) compared to that achieved with nasal CPAP. This can lead to airway obstruction because gravity is allowed to displace the tongue and soft palate posteriorly. There is also significantly more airway opening in the retropalatal region using a nasal mask compared to an oronasal mask (mean ± SD 4.64 ± 1.51 versus 1.17 ± 0.86 mm, respectively at CPAP pressure 15 cmH2O; p < 0.01) when viewed with real-time cine-magnetic resonance imaging.14 By comparison, CPAP through a nasal mask creates a positive pressure in the nasopharyngeal cavity only. The resulting pressure gradient between the nasopharyngeal and oropharyngeal cavities functions as a pneumatic splint that prevents UAO by pushing the soft palate and the tongue anteriorly and away from the posterior pharyngeal wall.A limitation of this case series was reliance on patient recollection to exclude some potential confounding factors such as sleep position. However, one of the cases had a split laboratory study in a controlled environment, in which a constant body position was confirmed by direct observation. In addition, an endoscopic diagnosis was not made. Unfortunately, we were unable to identify a common underlying factor shared by all four patients to explain this phenomenon. Prospective studies are needed to elucidate the pathophysiological mechanisms underlying this phenomenon. The authors speculate that using a combination of various measurements such as jaw displacement, Pcrit, and tongue strength as well as utilising direct visualisation with endoscopy and real-time cine-magnetic resonance imaging may be able to identify a patient phenotype susceptible to this phenomenon.In summary, clinically significant residual UAO on CPAP delivered by an oronasal mask can be corrected in some OSA patients by switching to a nasal mask. It appears that greater UAO using an oronasal versus nasal mask is only clinically significant and leads to treatment failure with CPAP in certain susceptible individuals. Although there is an increasing body of literature addressing the effect of different mask types on CPAP adherence,4,5,17 there is little evidence available regarding factors affecting the efficacy between different mask interfaces. Prospective studies are needed to identify susceptible individuals to guide the treating physician to select the most appropriate mask interface. We suggest that a trial with a nasal mask interface should be considered if there is incomplete or poor control of UAO or very high CPAP pressure requirements with an oronasal mask in the absence of other explanatory factors.DISCLOSURE STATEMENTThis was not an industry supported study. Dr. Antic has received research funding from the National Health and Medical Research Council of Australia, Philips Respironics and Fisher and Paykel, equipment donations from ResMed, Philips Respironics, and SomnoMed, and lecture fees and payment for development of educational presentations from ResMed, Astra Zeneca and GSK. Dr. McEvoy has received research funding from the National Health and Medical Research Council of Australia, Philips Respironics and Fisher and Paykel, equipment donations from ResMed, Philips Respironics, SomnoMed, and Air Liquide, and lecture fees from Philips Respironics. Dr. Aiyappan has received equipment donations from Fisher and Paykel and lecture fees from Novartis and BioCSL. Dr. Catcheside is supported by an Australian Research Council Future Fellowship and has received research funding from the National Health and Medical Research Council of Australia, equipment provision from Air Liquide, and discounted devices for an unrelated research trial from Gorman Promed Pty Ltd. Dr. Chai-Coetzer has received research funding from the National Health and Medical Research Council, equipment donations from ResMed, Philips Respironics and SomnoMed, travel support from GSK, and lecture fees from ResMed. The other authors have indicated no financial conflicts of interest. The work was performed at Sleep and Respiratory Medicine, Repatriation General Hospital, Southern Adelaide Local Health Network, Daws Road, Daw Park, South Australia, AustraliaABBREVIATIONSAHIapnea-hypopnea indexAPAPautotitrating positive airway pressureBMIbody mass indexCPAPcontinuous positive airway pressureEPAPexpiratory positive airway pressureOSAobstructive sleep apneaPSGpolysomnogramSDstandard deviationUAOupper airway obstructionREFERENCES1 Sullivan CE, Issa FG, Berthon-Jones M, Eves LReversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares. Lancet; 1981;1:862-5, 6112294. CrossrefGoogle Scholar2 Mortimore IL, Whittle AT, Douglas NJComparison of nose and face mask CPAP therapy for sleep apnoea. Thorax; 1998;53:290-2, 9741373. CrossrefGoogle Scholar3 Criner GJ, Travaline JM, Brennan KJ, Kreimer DTEfficacy of a new full face mask for noninvasive positive pressure ventilation. Chest; 1994;106:1109-15, 7924481. CrossrefGoogle Scholar4 Chai CL, Pathinathan A, Smith BContinuous positive airway pressure delivery interfaces for obstructive sleep apnoea. Cochrane Database Syst Rev; 2006CD005308, 17054251. Google Scholar5 de Andrade RG, Piccin VS, Nascimento JAet al.Impact of the type of mask on the effectiveness of and adherence to continuous positive airway pressure treatment for obstructive sleep apnea. J Bras Pneumol; 2014;40:658-68, 25610507. CrossrefGoogle Scholar6 Ebben MR, Narizhnaya M, Segal AZet al.A randomised controlled trial on the effect of mask choice on residual respiratory events with continuous positive airway pressure treatment. Sleep Med; 2014;15:619-24, 24831252. CrossrefGoogle Scholar7 Westhoff M, Litterst PObstructive sleep apnoea and non-restorative sleep induced by the interface. Sleep Breath; 2015;19:1317-2, 25877806. CrossrefGoogle Scholar8 Teo M, Amis T, Lee Set al.Equivalence of nasal and oronasal masks during initial CPAP titration for obstructive sleep apnea syndrome. Sleep; 2011;34:951-5, 21731145. CrossrefGoogle Scholar9 Schorr F, Genta PR, Gregorio MGet al.Continuous positive airway pressure delivered by oronasal mask may not be effective for obstructive sleep apnoea. Eur Respir J; 2012;40:503-5, 22855472. CrossrefGoogle Scholar10 Fitzpatrick MF, McLean H, Urton AMet al.Effect of nasal or oral breathing route on upper airway resistance during sleep. Eur Respir J; 2003;22:827-32, 14621092. CrossrefGoogle Scholar11 Kaminska M, Montpetit A, Mathieu Aet al.Higher effective oronasal versus nasal continuous positive airway pressure in obstructive sleep apnea: effect of mandibular stabilization. Can Respir J; 2014;21:234-8, 24791252. CrossrefGoogle Scholar12 Meurice JC, Marc I, Carrier G, Series FEffects of mouth opening on upper airway collapsibility in normal sleeping subjects. Am J Respir Crit Care Med; 1996;153:255-9, 8542125. CrossrefGoogle Scholar13 Liang Y, Kimball WR, Kacmarek RMet al.Nasal ventilation is more effective than combined oral-nasal ventilation during induction of general anesthesia in adult subjects. Anesthesiology; 2008;108:998-1003, 18497599. CrossrefGoogle Scholar14 Ebben MR, Milrad S, Dyke JPet al.Comparison of the upper airway dynamics of oronasal and nasal masks with positive airway pressure treatment using cine magnetic resonance imaging. Sleep Breath; 2016;20:79-85, 25924934. CrossrefGoogle Scholar15 Iber C, Ancoli-Israel S, Chesson A, Quan SFfor the American Academy of Sleep MedicineThe AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications. 1st edWestchester, IL: American Academy of Sleep Medicine; 2007. Google Scholar16 Phillips RespironicsREMstar Auto Clinical Applications Guide. Murrysville, PA: Koninklijke Philips Electronics N.V.; 2009. Google Scholar17 Borel JC, Tamisier R, Dias-Domingos Set al.Type of mask may impact on continuous positive airway pressure adherence in apneic patients. PLoS One; 2013;8:e64382, 23691209. CrossrefGoogle Scholar Previous article Next article FiguresReferencesRelatedDetailsCited by Efficacy of nasal masks versus nasal pillows masks during continuous positive airway pressure titration for patients with obstructive sleep apneaZonato A, Rosa C, Oliveira L and Bittencourt L Sleep and Breathing, 10.1007/s11325-020-02251-6 Nasal versus oronasal mask in patients under auto-adjusting continuous positive airway pressure titration: a real-life studyDuarte R, Mendes B, Oliveira-e-Sá T, Magalhães-da-Silveira F and Gozal D European Archives of Oto-Rhino-Laryngology, 10.1007/s00405-020-06242-x Treatment of Obstructive Sleep ApneaLettieri C, Williams S, Collen J and Wickwire E Sleep Medicine Clinics, 10.1016/j.jsmc.2020.02.009, Vol. 15, No. 2, (227-240), Online publication date: 1-Jun-2020. Treatment of Obstructive Sleep ApneaDibra M, Berry R and Wagner M Sleep Medicine Clinics, 10.1016/j.jsmc.2020.02.008, Vol. 15, No. 2, (219-225), Online publication date: 1-Jun-2020. Partial failure of CPAP treatment for sleep apnoea: Analysis of the French national sleep databaseBailly S, Daabek N, Jullian‐Desayes I, Joyeux‐Faure M, Sapène M, Grillet Y, Borel J, Tamisier R and Pépin J Respirology, 10.1111/resp.13650, Vol. 25, No. 1, (104-111), Online publication date: 1-Jan-2020. Piper A Positive airway pressure II: Settings and outcomes Obesity Hypoventilation Syndrome, 10.1016/B978-0-12-815290-4.00014-2, (187-202), . Non-Invasive Ventilation in Stable Chronic Obstructive Pulmonary DiseaseValentin-Caius C, Corina-Ioana B, Ana-Maria Z, Florin-Dumitru M and Oana-Claudia D Current Respiratory Medicine Reviews, 10.2174/1573398X15666190104123054, Vol. 15, No. 2, (120-132) Transmission of Oral Pressure Compromises Oronasal CPAP Efficacy in the Treatment of OSAMadeiro F, Andrade R, Piccin V, Pinheiro G, Moriya H, Genta P and Lorenzi-Filho G Chest, 10.1016/j.chest.2019.05.024, Vol. 156, No. 6, (1187-1194), Online publication date: 1-Dec-2019. Mask interfaces for home non-invasive ventilation in infants and childrenCastro-Codesal M, Olmstead D and MacLean J Paediatric Respiratory Reviews, 10.1016/j.prrv.2019.03.004, Vol. 32, , (66-72), Online publication date: 1-Nov-2019. A randomised crossover trial comparing nasal masks with oronasal masks: No differences in therapeutic pressures or residual apnea‐hypopnea indicesShirlaw T, Duce B, Milosavljevic J, Hanssen K and Hukins C Journal of Sleep Research, 10.1111/jsr.12760, Vol. 28, No. 5, Online publication date: 1-Oct-2019. Choosing the right mask for your Asian patient with sleep apnoea: A randomized, crossover trial of CPAP interfacesGoh K, Soh R, Leow L, Toh S, Song P, Hao Y, Lee K, Tan G and Ong T Respirology, 10.1111/resp.13396, Vol. 24, No. 3, (278-285), Online publication date: 1-Mar-2019. The right fit: The impact of patient-device interface in the treatment of obstructive sleep apneaZaheen A, Abhyankar P and Anand A Canadian Journal of Respiratory, Critical Care, and Sleep Medicine, 10.1080/24745332.2017.1387878, Vol. 2, No. 1, (45-48), Online publication date: 2-Jan-2018. A simple intervention that markedly reduces the effectiveness of positive airway pressureColaco B, Olson E, Kolla B, Forde I and Mansukhani M Sleep Medicine, 10.1016/j.sleep.2017.08.025, Vol. 40, , (103-105), Online publication date: 1-Dec-2017. Treatment of Obstructive Sleep ApneaLettieri C, Williams S, Collen J and Wickwire E Sleep Medicine Clinics, 10.1016/j.jsmc.2017.07.005, Vol. 12, No. 4, (551-564), Online publication date: 1-Dec-2017. Treatment of Obstructive Sleep ApneaDibra M, Berry R and Wagner M Sleep Medicine Clinics, 10.1016/j.jsmc.2017.07.004, Vol. 12, No. 4, (543-549), Online publication date: 1-Dec-2017. Influence of interface and position on upper airway collapsibility assessed by negative expiratory pressureHirata R, Kayamori F, Schorr F, Moriya H, Romano S, Insalaco G, Gebrim E, de Oliveira L, Genta P and Lorenzi-Filho G Sleep and Breathing, 10.1007/s11325-016-1445-6, Vol. 21, No. 3, (631-638), Online publication date: 1-Sep-2017. Retrospective: When Were Oronasal Masks First Used to Treat Obstructive Sleep Apnea?Berry R Journal of Clinical Sleep Medicine, Vol. 13, No. 03, (523-524), Online publication date: 15-Mar-2017. Treatment Failure of Continuous Positive Airway Pressure with a Full Face Mask, Reversed with a Nasal MaskKim J and Cho J Journal of Sleep Medicine, 10.13078/jsm.16012, Vol. 13, No. 2, (67-69) CPAP Use: Unmasking the Truth about InterfaceBudhiraja R and Bakker J Journal of Clinical Sleep Medicine, Vol. 12, No. 09, (1209-1210), Online publication date: 15-Sep-2016. Volume 12 • Issue 09 • September 15, 2016ISSN (print): 1550-9389ISSN (online): 1550-9397Frequency: Monthly Metrics History Submitted for publicationOctober 1, 2015Submitted in final revised formApril 1, 2016Accepted for publicationMay 1, 2016Published onlineSeptember 15, 2016 Information© 2016 American Academy of Sleep MedicineKeywordsnasal maskOSAoronasalequivalence of interfacesCPAPACKNOWLEDGMENTSThe authors thank Laura Bandick, RPSGT, and Michaela O'Keefe, RPSGT, for technical assistance and Leanne Cox for administrative assistance.PDF download