Luke Yankowy, RSPGT, demonstrates one aspect of mask selection—gauging facial dimensions—on his friend Tamika Hogan.

Sleep professionals have an unparalleled understanding of craniofacial features and interface options. But patients have a deep knowledge of themselves. By incorporating patient perspective into mask selection, you create a win-win strategy.

Professional-Patient Balance

Selecting the right PAP mask should be a collaboration between sleep professional and patient. First-time PAP therapy patients will need a lot of guidance but will quickly learn what they like and dislike. “At the front end, before they have ever worn a mask (except during their sleep study), patients really don’t realize all the issues and what they will like and require,” says Kelly Rudolph, president of mask manufacturer Hans Rudolph Inc. However, he says patient input should be “99% [of the decision] after they have experienced a few nights of wearing one.”

Returning patients needing refits may come in with a mask in mind. Luke Yankowy, an RPSGT at Howard County Center for Lung and Sleep Medicine, says, “My job at that point is to make sure the mask seals well and the patient knows how to apply, adjust for leaks, and adhere.”

Questions to Ask During Fitting

“Do you know someone who uses CPAP—what was their experience like?” 
Use this input: “Dispel their fears to start with a positive clean slate,” says Tracy Nasca, executive director of the American Sleep Apnea Association. “Assure the patient you will work as a team to help them achieve success…. Be straight, tell all patients there are challenges and not to expect perfection.”

“What’s your sleeping style?”
Use this input: “A side sleeper, for instance, may benefit from a mask that will permit them to sleep in this body position,” says Teofilo Lee-Chiong, MD, chief medical liaison at Philips Respironics. Accessories such as pillows for CPAP users also can resolve sleep style issues.

“Do you breathe mainly through your mouth?” (If unable to observe the patient asleep, ask questions about indicators such as snoring, sore throat, dry mouth, and drooling.)
Use this input: “If the patient admits to any of these indicators, chances are the full-face mask will be ideal,” Yankowy says.

“Do you read or watch TV before falling asleep?”
Use this input: If the patient partakes in these activities, a mask that allows for eyeglass wear could be ideal.

“How often do you travel?”
Use this input: “Finding out if the patient travels frequently may facilitate the need for a smaller style mask. Packing full-face style masks may be cumbersome, whereas nasal style and pillow styles are easier to travel with,” Yankowy says.

“Have you ever been clinically diagnosed with claustrophobia?”

Full face masks, like this one by Hans Rudolph, may be a patient’s choice if he suffers from allergies that cause mouth-breathing.

Full face masks, like this one by Hans Rudolph, may be a patient’s choice if he suffers from allergies that cause mouth-breathing.

Use this input: Claustrophobic patients may be best served by a slim nasal pillows-style mask.

“Do you have allergies?”
Use this input: A stuffy nose may result in mouth breathing, in which case a full-face mask should be considered. If allergies are seasonal only, a nasal steroid spray may resolve the issue.

“Do you use any evening moisturizers?”
Use this input: “Explain how that can cause mask movement resulting in leaking or poor fit. Unless they are willing to give up the moisturizers, these patients might do better with nasal pillows or mask liners,” Nasca says. “The bottom line is to learn about the patient’s lifestyle by asking questions to accommodate their unique needs.”

“What questions do you have for me?”
Use this input: Patients may not have enough knowledge to ask questions at their first appointments. Advise them how best to contact you after they’ve had a chance to try their CPAP at home.

Watch Out For These Negative Reactions

“Patients who like the mask will be able to lie still for the duration of the fitting and breathe at a normal rate. It’s always reassuring to hear the patient say they almost fell asleep during the fitting,” Yankowy says. Of course, not every patient will be so at ease. Below are cues your patient doesn’t like the mask.

  • Becomes tense or fidgety, or repeatedly adjusts the mask
  • Won’t make eye contact
  • Shoulders are stiff and raised
  • Rips off mask once it’s connected to the PAP machine
  • Takes deep breaths, even after being advised to breathe normally
  • Holds the mask with hands while it’s on (may be indicative of claustrophobia)
  • Mask needs to be fitted very tightly to control mask leaks
  • Saying, “I can’t do this”

David Groll, CEO of mask manufacturer Circadiance, says these signs can open a dialogue. “The fitting is a perfect opportunity to engage the patient, ascertain the barriers to adherence, create a plan to address the barriers, and set realistic goals,” he says. “Giving the patient permission to fail is sometimes a good thing; in other words, let them know a few setbacks are a normal part of the change process. If they are having some problems, reinforce the positives that have been achieved, and then create a new goal.”

If a patient is unable to tolerate any of the offered mask styles, then consider referring him to a behavioral sleep medicine professional.

Don’t Forget These Details

Nasca, a passionate patient advocate who was diagnosed with profoundly severe mixed apnea in 1989, offers these pointers for ensuring the patient leaves the fitting with a road map to success.

  • Do the final mask fit while the patient is lying in bed with the machine on. Only then should the straps be gently tightened just until achieving the seal.
  • Teach the patient the nuances of adjusting the top and bottom straps to achieve the proper seal. Caution the patient against needless overtightening.
  • On dual cushion masks, if the cushions are not inflated properly, the seal will not be optimal. This is an important fit step most providers forget to inform the patient about.
  • Take ownership of the mutual responsibility for close follow-up. Sleepy, grumpy patients unhappy with their masks may not be inclined to call you, so take the lead.
  • Send the patient home with written instructions and a reminder to call you should questions or fit issues arise. The newly diagnosed patient is often sleepy and probably has attention span and memory issues.


“Masks are like shoes; the more you wear them, you will find out if it’s the right one or not,” says Sharon Harker, BS, RRT, RPSGT, sleep disorders center supervisor at Carteret General Hospital. “The patient may need to make some adjustments on their end to meet the mask. I do not subscribe that it’s always the mask’s fault. It’s hard to predict how a mask will adjust to a moving target. It takes patience and time.”

Two postfitting issues that are the most likely to result in the patient rejecting the mask are red marks on the face and excessive leaking, sleep professionals say. For red marks, Harker advises, “Mask lines can be decreased if the straps aren’t too tight or if the patient can avoid laying on his hands.” Other options include selecting a mask with padded headgear or recommending a padding accessory.

For excessive leak, Yankowy says, “Sometimes it’s necessary to remind them of proper application and leak adjustments on more than one occasion until they feel comfortable doing it on their own.”

Long- and short-term follow-up are both crucial to keep patients actively engaged in their therapy. As Yankowy says, “The mask fitting goes beyond fitting the mask. It’s about patient satisfaction. That may require more than asking, ‘How does this mask feel?’ If they answer with ‘It’s OK,’ then dig deeper. Find out why it’s just OK”—then take the opportunity to work together to find that perfect fit.

Sree Roy is editor of Sleep Review. E-mail questions to [email protected].