By Sree Roy

When the American Thoracic Society (ATS) organized a workshop to discuss the importance of CPAP mask selection for obstructive sleep apnea (OSA) treatment, some of the experts who convened were surprised at how easily they all agreed on the success rates of different types of masks. Peer-reviewed articles were actually quite clear in their conclusions.

But their easy consensus challenges the norms of sleep medicine real-world practices: The workshop’s major conclusion was that nasal CPAP should be the initial mask option for most patients. “It was interesting to learn that the experts agree that oronasal masks are being overused,” says Pedro R. Genta, MD, ATSF, first author of the resulting workshop report.

Oronasal masks, also known as full-face masks, are overprescribed for several reasons, according to experts.

William Hevener, RPSGT, a coauthor of the ATS report, says, “People ask the wrong question: ‘Are you breathing through your nose or mouth at night?'” People with sleep apnea who self-report as mouth-breathers switch to nasal breathing during nasal CPAP, Hevener and Genta both say. “They’re not really breathing through their mouth—they’re breathing through their nose until they have an apnea event,” says Hevener, who is clinical initiatives manager at Sleep Data Services/BetterNight. “So splinting their airway effectively allows them to continue to breathe through their nose.”

Other potential explanations, says Genta, who is on the faculty of medicine at the University of Sao Paulo in Brazil, include issues with durable medical equipment reimbursement of CPAP interfaces, as well as sleep techs starting with full-face masks during CPAP titrations to avoid interventions due to oral leak, patient preference (if they are worried about being a “mouth-breather”), and higher profit margins with full-face masks over other styles. (For the purposes of the group’s discussion and report, nasal pillows masks are counted within the category of nasal masks. “There are very few studies comparing nasal pillows with nasal masks. We decided to focus on the comparison between nasal (including nasal pillows) and oronasal interfaces,” Genta says.)

So, what about those self-reported “mouth-breathers”? Genta says, “We need to detect and treat nasal symptoms before CPAP adaptation. Nasal obstruction is associated with [worse] CPAP adherence and needs to be addressed before CPAP use.” Focusing on nasal symptoms, not on breathing route preference, is key.

Sleep techs, respiratory therapists, and others who help patients with interface selection will be “surprised that the vast majority do well with a nasal mask,” Genta says. “This will lead to better comfort, better adherence, better OSA control, less side effects, and less costs.”

Hevener adds, “They’ll start to see…other troubleshooting methods like mouthwashes for dry mouth and chin straps. Also, they’ll find that every oral leak doesn’t need to be tackled.”

Three mask discomforts that can drive patients crazy are high pressures, the size of the seal, and the leak (in particular, where the leak is blowing) and “all three of those things are more inherent in a full-face mask than a nasal mask,” Hevener says.

[RELATED: CPAP Masks: You Never Get a Second Chance to Make a First Impression]

Of course, as important as mask fitting is, “nothing is more important than coaching and helping the patient through behavior change,” Hevener adds.

Coaching OSA patients is another aspect of mask success that is frequently overlooked, but it bears mentioning when discussing interface selection. There are patients who do great on almost any mask you prescribe to them. But for those who are going to struggle, there is no mask in the universe that will magically make them adhere to therapy. “There is no mask that is immune to patients blaming it for the fact that CPAP is coming through it,” Hevener says. And “jumping to 10 different masks is not the solution.”

What actually works? Patients “need a psychological change to develop behavior change. To get them to trust you, you have to troubleshoot the technical problems out of the way,” Hevener says.

“Patients are going to have discomfort with CPAP for technical reasons, but they will or won’t succeed for psychological reasons.”

Sree Roy Sleep Review
Sree Roy is editor of Sleep Review.

With all that said, are there patients who truly need full-face masks to succeed? Absolutely, say Genta and Hevener, though the percent is probably much smaller than you’d think. Hevener estimates it to be about 9% to 11%. This includes people who are daytime mouth-breathers: “If they are oral breathing through the day, there is no treatment at night that’s going to stop that. Those are the really easy ones,” Hevener says.

But, for about 90% of patients, nasal masks are the best choice.

Hevener says, “My theory on full-face masks has always been that starting patients on nasal masks and being wrong about that is better than starting a patient on a full-face mask and being wrong about that.”

Sree Roy is editor of Sleep Review.


Genta PR, Kaminska M, Edwards BA, et al. The importance of mask selection on continuous positive airway pressure outcomes for obstructive sleep apnea. An official American Thoracic Society workshop report. Ann Am Thorac Soc. 2020 Oct;17(10):1177-85.

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