Edward Michaelson, MD, FACP, FCCP


Scoring a win for CPAP compliance

By Edward D. Michaelson, MD, FACP, FCCP

If someone scores a “Hat Trick” in hockey, it means that a player has scored three goals in one game.

During preliminary evaluation of auto adjusting CPAP units and to attain proper mask fit, I had the opportunity to try different masks. Since I have a goatee, an acceptable seal was not possible with an oro-nasal or full face mask so ultimately a nasal pillows mask was selected.

I coined the term “CPAP Hat Trick” because, by using an ordinary baseball cap, it was possible to achieve the following three goals, which provide improved comfort and functionality when using a CPAP mask. These goals apply to any mask-tubing combination.

First, the cap eliminates or reduces slippage of both the top (vertex) and back (occipital) straps, particularly in individuals who may have areas that are bald.


Sleep apnea patients can improve the comfort and functionality of CPAP by wearing a common baseball cap.


Second, the cap functions as a spacer, eliminating or minimizing scalp and facial strap marks.

Third, for patients who prefer the tubing directed upward and posteriorly, the bill of the cap can serve to reduce facial pressure related to the weight of the mask-tubing system. Further, the bill of the cap can help “lock” the position of the mask-tubing, making the system less prone to be affected by head and body movements and thereby minimizing leak.

Finally, while experimenting with various mask-tubing configurations, I discovered a bonus function for the baseball cap. If the hat is worn backwards (bill in the back), it is virtually impossible to sleep in the supine position. As it has been demonstrated that positional therapy for at least mild to moderate obstructive sleep apnea is effective, the “reverse Hat Trick” is an easily available, convenient, and inexpensive way to avoid sleeping in the supine position compared to other techniques that are commonly suggested.

I highly recommend that all sleep specialists who prescribe CPAP for their patients borrow a CPAP unit from their local sales representative and try various masks and pressure settings on themselves. This will give you real insight into how CPAP and mask fit affect your patients and allow you to better advise them on these issues and improve their comfort and adherence to therapy. If the “CPAP Hat Trick” is recommended, explain to the patient that it will require some trial and error to achieve the most comfortable and effective fit.

Edward D. Michaelson, MD, FACP, FCCP, Diplomate in Sleep Medicine (ABIM).