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Introduction
Noninvasive ventilation has been shown to be effective for acute respiratory failure, particularly in
COPD and immunocompromised patients. Despite increased applications of NIV, reported failure
rates may exceed 40% and mask intolerance is cited as the most common reason for failure. Both
nasal and full face masks (FFM) have been used successfully in acute respiratory failure but according
to recent studies, a full face mask is better tolerated and provides improved outcomes. Mask fit is
important for comfort and to ensure effective ventilatory support without causing patient/ventilator
asynchrony. In the acute care setting mask application must be quick, simple and cost effective
because NIV is often used for short duration.
The choice of mask can also have a major impact on the quality of ventilation, sleep, patient comfort
and tolerance during long-term noninvasive ventilation. In a physiologic study designed to asses short
term effects of NIV delivered with three types of interfaces, Nava et al concluded that in patients with
chronic hypercapnic respiratory failure, irrespective of the underlying pathology, noninvasive
mechanical ventilation outcome can be more affected by the type of interface than by the mode of
ventilation. Nasal masks are most commonly the first interface choice in chronic respiratory failure
but FFM’s are being used more and more.
Nocturnal monitoring of noninvasive ventilation can provide valuable information in assuring proper
mask choice and effectiveness especially in regard to leak.
The need to select an appropriate and properly fit mask cannot be overemphasized.
3rd Dimension -
relative variation in:
1st Dimension—length
of nose or face –nasal depth
¾ can vary –cheek bone height
significantly –chin position
¾ indicated as S, ¾ Indicated as
Nasal
M, L standard,
2nd dimension—nasal or shallow or
FFM deep
mouth width
This is particularly
helpful when chossing
the best size FFM.
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Over tightening headstraps to overcome air leaks is the number 1 cause of facial pressure sores
especially at the bridge of the nose.
Some fitting tips :
¾ Follow manufacturer suggestions for choosing the proper size mask and use the tools for mask
fitting that they provide.
¾ Use the smallest size nasal mask that encompasses the nose without pinching the nares
¾ Use forehead supports to redistribute the pressure away from the nasal bridge
¾ Size FFM’s with mouth slightly open
¾ Use the various depth sizes available, especially for FFM’s, to help avoid pressure on the
bridge of the nose while maintaining good seal around the nose and/or mouth.
¾ Avoid over-tightening: Lift and repositioning the mask to eliminate leaks vs. tightening
headstraps
¾ Masks should not rest on the teeth (above or below the lip)
¾ Avoid leaks into the eyes
¾ Check skin regularly and intervene early if signs of a pressure sore develop.
¾ Use mask/skin barriers such as artificial skin and/or alternate different types of masks
changing the pressure points.
Air Leaks :
NPPV is inherently leaky. Achieving an airtight seal between the mask and face is nearly impossible,
but mask leaks can and should be reduced to an acceptable level.
Mouth leaks are highly prevalent during NPPV and are associated with sleep fragmentation. Mouth
leaks are typically larger leaks for shorter duration when measured during sleep. Glottic narrowing has
been shown to be one mechanism contributing to mouth leaks. Other reasons may include weak
muscles of the oral pharynx in addition to positioning of the soft palate and mandible.
What is an acceptable leak level? Non-intentional leak levels can be measured and monitored during
NPPV. Most bi-level devices provide this information as a calculation of total flow minus intentional
leak giving the sum of mask and mouth leak. The measure is typically in LPM but can also be
represented in L/sec The accuracy of this measure depends on the algorithm used by the ventilator
and the accurate input of the intentional leak data. With some devices this is done by choosing the
correct mask during the set-up procedure. With others this may be done by testing the intentional leak
of the circuit at set-up.
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Non-intentional leak rates of 6-24 lpm (0.1-0.4 l/sec) are usually considered acceptable during sleep.
In awake patients non-intentional leak rates should be < 12 lpm (0.2 l/sec).
New monitoring programs incorporated into the ventilator will allow the clinician to better evaluate
the effect of leak on minute ventilation and SpO2 during sleep. This data could prove very helpful
when combined with clinical and patient information.
Nocturnal Monitoring and how it can help assure proper mask choice and fit
Saturation
Assuring independence for patients with limited arm mobility and hand dexterity
Alternatives to traditional strapping systems:
53
Main References
General
Mehta S, Hill NS. Noninvasive ventilation: state of the art. Am J Respir Crit Care Med 2001:
163:540-577
Schneerson JM, Simonds AK. Noninvasive Ventilation for chest wall and neuromuscular
disorders. Eur Respir J 2002; 20:480-487
Leger P, Jennequin J, GerardM, et al. Home positive pressure ventilation via nasal mask for
patients with neuromuscular weakness or restrictive lung or chest wall deformities. Respir Care
1989; 34: 73-77
Leger P, Bedicam JM, Cornette A et al. Nasal intermittent positive pressure ventilation: Long-
term follow-up in patients with severe chronic respiratory insufficiency. Chest 1994; 105: 100-
105
Bach JR, Alba AS, Saporito LR. Intermittent positive pressure ventilation via the mouth as an
alternative to tracheostomy for 257 ventilator users. Chest 1993; 103: 174-182
Comparative Studies
Kwok H, McCormick J, Cece R, Houtchens J, Hill NS. Controlled trial of oronasal versus nasal
mask ventilation in the treatment of acute respiratory failure. Critical Care Medicine 2003;
31(2):468-473
Gregoretti C, Confalonieri M, Navalesi P, et al. Evaluation of patient skin breakdown and comfort
with a new face mask for noninvasive ventilation: a multi center study. Intensive Care
Med(2002)28: 278-284
Hill NS, Carlisle C, Kramer NR. Effect of a Nonrebreathing exhalation valve on Long-term Nasal
Ventilation Using a Bilevel Device. Chest 2002; 122:84-91
54
Leak
Bach JR, Robert D, Leger P, et al. Sleep fragmentation in kyphoscoliotic individuals with alveolar
hypventilation treated by NPPV. Chest 1995; 107:1552-1558.
Meyer TJ, Pressman MR, Benditt J, McCool FD, Millman RP, Natarajan R, Hill NS.
Air leaking through the mouth during nocturnal nasal ventilation: effect on
sleep quality. Sleep 1997 Jul;20(7):561-9
McDermott I, Bach JR, Parker C, Sortor S: Custom-fabricated interfaces for intermittent positive
pressure ventilation. Int J Prosthod 2:224-233 1989
Norregard O. Noninvasive ventilation in children. Eur Respir J 2002; 20:1332-1342
55
Mouthpieces
15mm
Angled
Mouth
Piece
#1004524
22mm
Angled
Mouth
Piece #
FC06566
56
Full Face Masks
Mask Company Sizes available Sizing Cleaning Replace
Name Gauge and -ment
available Disinfectio Parts
n Guide
Ultra ResMed Small standard Yes 3D Yes Yes
www.ResMed.com
Mirage™ Small Shallow
Full Face Medium Standard
Mask Medium Shallow
Large Standard
Large Shallow
Mirage® ResMed Small standard Yes 3D Yes Yes
www.ResMed.com
Full Face Small Shallow
Mask Series Medium Standard
2 Medium Shallow
Large Standard
Large Shallow
Comfort- Respironics Small Yes Yes Yes
www.respironics.com
Full™ Full Medium
Face Mask Large
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Nasal Masks
Mask Name Company Sizes Sizing Cleaning Replace
Gauge and -ment
available Disinfection Parts
Guide
Picture not available DeVilbiss® Sunrise Medical / Standard ? yes yes
Mask includes pump
to inflate the foam-
FlexAire™ Devilbiss Shallow
www.sunrisemedical.com
filled air bladder
cushion
DeVilbiss® Sunrise Medical / Standard ? yes yes
Serenity™ Devilbiss Shallow
www.sunrisemedical.com Gel cushions
and forehead
pad available
Aclaim™2 Fisher & Paykel Small Yes Not that I Yes
www.fphcare.com Large could find
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ComfortSelect™ Respironics Small Same as
www.respironics.com Small/Wide Comfort
Medium gel
ComfortGel™ Respironics Petite Small Yes Yes Yes
www.respironics.com Medium
Large
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Nasal Prongs
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