As fewer patients come into sleep labs for mask fittings and titration studies, telemedicine experts and manufacturers share 6 tips for selecting the correct PAP mask the first time.
When people who suspect they have a sleep disorder live far from the nearest sleep medicine clinic, they may turn to telemedicine providers. These days, even patients who do an in-person initial visit may have subsequent visits handled remotely—such as a diagnosis via home sleep test, followed by auto-CPAP titration. But how do you ensure patients are matched properly to their PAP interfaces, when you don’t have the luxury of an in-person fitting?
There are a growing number of options to make sure that remote patients get an interface that fits, on the first try.
1. Look to CPAP Mask Starter Packs
Several CPAP suppliers have mask starter packs available, which often come with three to four cushion sizes. These packs enable patients to try each cushion size, without ever having to coming into an office, to find the one that works the best for them.
“The starter packs have been an incredible boon for us,” says Joseph Krainin, MD, FAASM, founder of the virtual sleep center Singular Sleep.
Krainin, who has been mailing remote patients their CPAP masks for years, says these packs minimize the possibility of ordering the wrong mask size. These packages typically come with a small, medium, and a large. Authorized resellers can generally get these packs directly from interface manufacturers.
2. Consider Printout Mask Sizing Templates
When starter packs are not available, look to manufacturers for sizing templates. Patients can print out and use these templates to measure their own facial anatomy. The patient can simply hold the paper printout up to their face, and it will tell them which size to order.
“It is surprisingly easy; companies have made these guides to be very user friendly,” says Krainin.
However, issues can occur if the template is not printed out correctly. To capture the most accurate measurement, these tools need to be printed to scale, Krainin cautions.
“At times we would hear people say that they were unhappy; they had a mask that didn’t fit and they swore that they used the sizing gauge. What we found is that a lot of people were not printing the sizing gauge to scale. They were printing it out at like 75% of the scale,” says Krainin.
Now, Krainin suggests that if telemedicine providers want to use these, they should communicate with their patients about how to properly print out the sizing tool.
3. Try Nasal Masks First
When in doubt, research suggests that nasal masks might have a higher rate of success, says Lawrence Epstein, MD, president and CEO of Welltrinsic Sleep Network, which recently launched a telemedicine portal to connect patients with board-certified sleep medicine physicians.
“There is pretty good evidence now that people tend to do better with some of the nasal masks,” says Epstein, a past president of the American Academy of Sleep Medicine.
“The preferred way to breathe is through the nasal passageway. That is how we are designed, so it moistens the air, it cleans the air when it goes in. You bypass that when you breathe through your mouth, so starting with one of the nasal masks is typically a good starting place,” he says.
One study, published in the journal Sleep Disorders, suggests that during home-based auto-adjusting CPAP titration, nasal masks and nasal pillows had lower leak rates for CPAP-naïve patients.1
4. Ask the Right Questions
Each clinic should develop and implement a protocol for asking questions, which can inform the mask-selection process.
“Get a good feel for any symptoms that might direct mask type, for instance, is the person a mouth-breather or nasal-breather, do they have any skin issues, or facial hair? These are some things that might direct you in selection of a mask type,” says Epstein, who is also program director of the Sleep Medicine Fellowship Program at Brigham and Women’s Hospital in Boston, Mass.
5. Engage Patients in Their Care
For certain patients, the ability to monitor their own PAP data may increase their rate of success. Some PAP manufacturers have developed tools for this purpose, including smartphone applications in which patients can track their progress over time.
One such smartphone app, myAir from ResMed, was found to yield positive results in a 2017 study published in the journal CHEST.2 According to the study, patients who are engaged in self-monitoring and who are monitored remotely by a provider are up to 87% adherent on PAP therapy.
6. Monitor PAP Data in Real Time
It’s not uncommon for CPAP machines to transmit data wirelessly. This enables telemedicine providers to spot and address issues, says Anthony Como, services segment director of New Business Solutions for Sleep and Respiratory Care at Philips.
“Optimally, the connected device has an option for the patient to push data to the provider in near real-time, such that the clinician can view and react to a snapshot of use [and] mask fit,” says Como.
Some manufacturers have developed software and smartphone applications to help clinicians and patients monitor their PAP data. With the patient’s consent, a clinician can use ResMed’s AirView program to see how long a patient is sleeping on PAP, how many events are occurring, the degree of mask leak, and on/off events that could indicate seal or comfort issues, says Susie Justus, LVN, ResMed clinical specialist.
“Any red flags can warrant a call or other reach-out to the patient to help talk them through how to modify their treatment for the most comfortable experience and effective results,” says Justus.
Lisa Spear is associate editor of Sleep Review.
 Blanco M, Ernst G, Salvado A, Borsini E. Impact of mask type on the effectiveness of and adherence to unattended home-based CPAP titration. Sleep Disor. 2019 Mar 25;2019:4592462.
 Malhotra A, Crocker ME, Willes L, et al. Patient engagement using new technology to improve adherence to positive airway pressure therapy. CHEST. 2017 Nov;153(4):843–50.