Every day we are surrounded by television commercials and advertisements emphasizing how the right mattress can guarantee a good night’s sleep. In the world of sleep medicine, sometimes even the most sophisticated beds fall short in providing quality sleep. The patient’s body mass index, neck size, and sleep history can provide clinical indications that it may take more than a great mattress to provide a restful night’s sleep. For sleep apnea patients, a better night’s rest often depends on proper initiation of PAP (positive airway pressure) therapy. Though a solution for a patient’s disorder, PAP therapy is frequently met with patient apprehension. The challenge for sleep technicians?—Helping patients overcome their anxiety and facilitating their acclimation to a therapy for which noncompliance is the enemy. Whether the appropriate interface is chosen for immediate use in the sleep lab or for long-term use at home, here are a few simple tips you can use to ensure the best mask fit.


Experienced sleep technologists are accustomed to patients saying, “There’s no way that I am going to sleep with that thing on my face!” It is understandable how the idea of sleeping with a mask and headgear can be frightening at first. An empathetic approach by the sleep technologist will enhance the patient’s first-time experience while addressing their concerns or misconceptions prior to initiating PAP therapy.

The sleep technologist can educate an anxious patient on PAP mechanics while emphasizing the goals for treatment. The technologist can explain how the pressurized air will act as a “splint” to prevent the airway from collapsing, thus providing a continuous, more restful night’s sleep. If the patient seems resistant to PAP therapy, the sleep technologist should employ consistent positive reinforcement.


Interface types can be categorized into three main groups: nasal masks, full face masks, and nasal pillows/prongs. Explanation of the titration process while incorporating an interface demonstration may enhance patient understanding of each type of mask. The sleep technologist can display several mask types on a mannequin and provide educational videos to help “visualize” the proper mask fit. Prior to mask selection, the sleep technologist should allow the patient to evaluate at least two nasal masks, one full face, and one nasal pillow.

Documenting the presentation of multiple options provides helpful information for the interpreting physician and the DME company.


The appropriate interface is selected jointly between the sleep technologist and patient. Suitable mask selection may depend on the patient’s preference, comfort, and tolerance level. Upon the patient’s arrival at the sleep lab, the sleep technologist should begin considering the appropriate mask based on visual observations. Quick assessments of the patient’s head and face shape and the presence of facial hair provide clues for appropriate mask selection.

If a nasal interface is chosen, the patient may have a difficult time keeping their mouth closed while asleep. For those with excessive mouth leaks, a chin strap may be applied to keep the jaw closed. If the air leak persists, a full face mask or hybrid may be used. Unless the patient requests the use of a full face mask, this option is typically reserved as an alternative choice to be considered later.

Patient lifestyle may also influence interface selection. Various types of interfaces cater to specific needs of the patient. Nasal pillows/prongs allow patients to read or wear eyeglasses prior to falling asleep. Nasal pillows/prongs and full face masks provide a nonobstructed view with minimal direct contact on the face. This may be an option for those patients with claustrophobia. Nasal masks may be selected by patients who prefer access to their mouths without having to remove the entire mask and headgear.

The appropriate headgear must be properly matched to the specific mask type. Different types of headgear come in contact with the posterior and lateral aspects of the head, then attach to the interface. While securing the mask, it is important to note that the mask should feel snug but not tight. When tightening each strap, apply equal left and right tension. Equal tension will minimize air leak and lower the possibility of mask noise.

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Headgear comfort with regard to weight, type of material, and color may also influence mask selection. Headgear can be changed to adapt to larger heads and different types of hairstyles. One particular nasal mask allows for relatively loose headgear, which enables the interface to move slightly as the patient inhales and exhales.

Mask selection in the pediatric age group is more challenging. There are very few mask choices that fit properly on the smaller face, particularly when craniofacial disorders are present. “It is critical for the technologist to work closely with the pediatric sleep specialist who is ordering the CPAP to come up with an acceptable mask and headgear for the individual child,” says Gary Montgomery, MD, director of the Sleep Center at Children’s Healthcare of Atlanta. For many children, adenotonsillectomy is often considered the first treatment option for obstructive sleep apnea treatment.


Most interface manufacturers provide detailed instructions to obtain the proper mask fit. Size gauges may be included within the interface package or printed off the Internet. A wide variety of size gauges can assist the sleep technologist in obtaining accuracy. “If your size gauges are held within a key ring, separate the gauges most frequently used. This will allow the technologist to better understand the masks available in their sleep lab,” says Susan Keller Yenney with Philips Respironics. Yenney also emphasizes, “A size small in one particular mask may not equate to a size small in a different style mask, even if it appears roughly the same.” Executing a deliberate mask fitting routine will ensure mask type effectiveness and minimize air leak.


Once the appropriate interface has been selected, the sleep technologist can properly fit the mask on the patient. A nasal mask placed too high above the bridge of the nose may cause air to leak and irritate the patient’s eyes. Proper fitting of the lower portion of the nasal mask is evidenced by contact just above the upper lip. Nasal pillows gently lie inside the outer surface of the nostrils, whereas a full face mask should be applied from the fold of the chin first with the mouth relaxed/slightly open, then completed on the bridge of the nose.


Keeping clean contact between the mask and patient can also influence mask fit. Oily skin, makeup, or even a dirty interface may result in a leaky mask. The sleep technologist can encourage the patient to wash their face with mild soap and warm water. This would remove excess oil from their skin and provide a clean contact surface.


Once the mask fitting tips have been successfully completed, allow the patient to experience the air pressure while going through a quick desensitization process. PAP practice may take time for the patient to acclimate to the new experience. Allowing the patient to hold the mask, without the headgear, may provide a sense of control. Once accustomed to the pressure, apply the headgear and encourage the patient to lie in their normal sleep position. The sleep technologist can now leave the patient and observe the leak value, noting that headgear adjustments might be necessary to resolve a high mask leak. Acceptable leak is based on the manufacturer’s recommendation, which is dependant on the mask type and the sleep technologist following sleep lab protocol.


The overall success of PAP therapy requires flexibility and patience from the sleep technologist. While selecting and fitting the mask, the technologist can obtain sleep information that can prove useful during a PAP titration. Relevant information, such as normal sleep position, number of trips to the bathroom, and bedtime medications, can provide insight about the patient’s typical nighttime routine. A trip to the restroom during the study may provide an opportunity to notice early signs of pressure sores, make minor adjustments, or even change the mask type. Taking advantage of appropriate times to assess the patient’s needs without interrupting sleep will further enhance the patient’s “first impression” experience to maximize PAP therapy.

In the spring of 2008, the American Academy of Sleep Medicine (AASM) published “Clinical Guidelines for the Manual Titration of Positive Airway Pressure with Obstructive Sleep Apnea,” which states that “All potential PAP titration candidates should receive adequate PAP education, hands on demonstration, careful mask fitting, and acclimatization prior to titration.” By following AASM guidelines and continuing to refine your mask fitting skills, you can help put an end to CPAP noncompliance.

Emmanuel J. Porquez, RPSGT, has been affiliated with the Atlanta School of Sleep Medicine and Technology since 2004, where he has taught and participated in physician’s board reviews, technician’s board reviews, and technician’s A-STEP program, including lecturing in pediatric courses. He currently works for Children’s Healthcare of Atlanta. Contact the author at [email protected].