Abstracts
Continuous positive airway pressure (CPAP) is the gold standard for the treatment of obstructive sleep apnea (OSA). Although CPAP was originally applied with a nasal mask, various interfaces are currently available. This study reviews theoretical concepts and questions the premise that all types of interfaces produce similar results. We revised the evidence in the literature about the impact that the type of CPAP interface has on the effectiveness of and adherence to OSA treatment. We searched the PubMed database using the search terms "CPAP", "mask", and "obstructive sleep apnea". Although we identified 91 studies, only 12 described the impact of the type of CPAP interface on treatment effectiveness (n = 6) or adherence (n = 6). Despite conflicting results, we found no consistent evidence that nasal pillows and oral masks alter OSA treatment effectiveness or adherence. In contrast, most studies showed that oronasal masks are less effective and are more often associated with lower adherence and higher CPAP abandonment than are nasal masks. We concluded that oronasal masks can compromise CPAP OSA treatment adherence and effectiveness. Further studies are needed in order to understand the exact mechanisms involved in this effect.
Sleep apnea, obstructive; Continuous positive airway pressure; Masks
O tratamento com continuous positive airway pressure (CPAP, pressão positiva continua nas vias aéreas) é o padrão ouro na apneia obstrutiva do sono (AOS). Apesar de a CPAP ter sido originalmente aplicada através de máscara nasal, várias interfaces são atualmente disponíveis. Revisamos conceitos teóricos e questionamos a premissa de que todas as máscaras produzem resultados semelhantes. Compilamos as evidências na literatura sobre o impacto do tipo de máscara na eficácia e na adesão ao tratamento com CPAP em pacientes com AOS. Foram pesquisados artigos escritos em inglês na base de dados PubMed com as palavras-chave "CPAP", "mask" e "obstructive sleep apnea". Dos 91 artigos encontrados, somente 12 foram selecionados por descrever o impacto do tipo de máscara sobre a efetividade (n = 6) ou a adesão (n = 6) ao tratamento. Apesar de alguns resultados conflitantes, não encontramos efeitos significativos da máscara pillow nasal e da máscara oral na eficácia ou adesão ao tratamento da AOS. Em contraste, a maior parte dos estudos mostrou que a máscara oronasal é menos efetiva e mais frequentemente associada a menor adesão e maior abandono do tratamento do que a máscara nasal. Concluímos que a máscara oronasal pode comprometer a eficácia e a adesão ao tratamento da AOS com CPAP. Estudos futuros são necessários para a compreensão dos mecanismos exatos envolvidos neste efeito.
Apneia do sono tipo obstrutiva; Pressão positiva contínua nas vias aéreas; Máscaras
Introduction
Obstructive sleep apnea (OSA) is characterized by repeated episodes of partial
pharyngeal obstruction (hypopnea) or complete pharyngeal obstruction (apnea) associated
with oxygen desaturation and sleep fragmentation.(
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) Polysomnography is the gold standard for the diagnosis of OSA, and the main
parameter is the apnea-hypopnea index (AHI), which indicates the number of apnea and
hypopnea events per hour of sleep. In a recent study, in which a representative sample
of patients in the city of São Paulo, Brazil, underwent polysomnography (n = 1,042), it
was found that approximately one in every three adults (32.8%) met the criteria for OSA
syndrome, characterized by an AHI of more than 5 events/hour of sleep with symptoms or
an AHI of more than 15 events/hour of sleep with or without symptoms.(
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) The consequences of OSA are many, including sleep fragmentation,
nonrestorative sleep, excessive daytime sleepiness, impaired quality of life, and
increased cardiovascular complications, such as systemic arterial hypertension, cardiac
arrhythmia, and increased risk of mortality.(
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Application of continuous positive airway pressure (CPAP) during sleep is the gold
standard for the treatment of patients with moderate to severe OSA. In patients with
OSA, treatment with CPAP can reduce excessive daytime sleepiness,(
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) improve cognitive function, improve quality of life,(
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Continuous positive airway pressure for obstructive sleep apnoea in adults. Cochrane
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) reduce blood pressure in those with hypertension, and reduce the risk of
cardiovascular morbidity and mortality.(
1212. Sharma SK, Agrawal S, Damodaran D, Sreenivas V, Kadhiravan T,
Lakshmy R, et al. CPAP for the metabolic syndrome in patients with obstructive sleep
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,
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) The efficacy of the treatment depends on the use of CPAP each night during
sleep.(
1414. Weaver TE, Grunstein RR. Adherence to continuous positive airway
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) However, adherence to CPAP therapy is extremely variable (46-80%).
(
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al. Objective measurement of patterns of nasal CPAP use by patients with obstructive
sleep apnea. Am Rev Respir Dis. 1993;147(4):887-95.
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,
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) Predictors of adherence to CPAP therapy include the severity of OSA, the
degree of daytime sleepiness, the socioeconomic status, the level of patient
understanding of the therapy, and the type of mask used.(
1717. Weaver TE. Adherence to positive airway pressure therapy. Curr Opin
Pulm Med. 2006;12(6):409-13. http://dx.doi.org/10.1097/01.mcp.0000245715.97256.32
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Redline S, et al. Race and residential socioeconomics as predictors of CPAP
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)
Treatment of OSA with CPAP was first described by Sullivan et al. in 1981.(
2121. Sullivan CE, Issa FG, Berthon-Jones M, Eves L. Reversal of
obstructive sleep apnoea by continuous positive airway pressure applied through the
nares. Lancet. 1981;1(8225):862-5. http://dx.doi.org/10.1016/S0140-6736(81)92140-1
http://dx.doi.org/10.1016/S0140-6736(81)...
) The key idea was that CPAP applied with a nasal mask acted as a pneumatic
splint to maintain upper airway patency, moving the soft palate anteriorly. An
increasing number of masks that are lighter and more comfortable are becoming available
for use in patients with nasal obstruction. Currently available types of masks include
nasal masks, nasal pillows, oronasal masks, and oral masks (Figure 1). Nasal masks cover only the nose and must surround it so
as not to compress the nasal alae, sitting just above the upper lip and near the angle
of the eye. Nasal pillows consist of two nasal inserts and have emerged as an
alternative to nasal masks because they are smaller and have less contact with the face.
Oronasal masks cover the nose and the mouth and allow patients to breathe through their
nose and their mouth. Oronasal masks were initially described for noninvasive
ventilation in patients with respiratory failure and high ventilatory demand.
(
2222. Barach AL, Martin J, Eckman M, Martin J. Positive pressure
respiration and its application to the treatment of acute pulmonary edema. Ann Intern
Med. 1938;12(6):754-95. doi:10.7326/0003-4819-12-6-754
http://dx.doi.org/10.7326/0003-4819-12-6-754
http://dx.doi.org/10.7326/0003-4819-12-6...
) Oronasal masks are considered an option for OSA patients with complaints of
nasal obstruction and mouth breathing.(
2323. Olsen KD, Kern EB, Westbrook PR. Sleep and breathing disturbances
secondary to nasal obstruction. Otolaryngol Head Neck Surg
1981;89(5):804-10.
24. Lavie P. Rediscovering the importance of nasal breathing in sleep
or, shut your mouth and save your sleep. J Laryngol Otol.
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2525. Figueiredo AC, Lorenzi MC, Prezzoti S, Cabral MM, Sennes LU,
Lorenzi-Filho G. Efeitos da pressão positiva contínua em vias aéreas sobre os
sintomas nasofaríngeos em pacientes com a síndrome da apnéia obstrutiva do sono. J
Bras Pneumol. 2004;30(6):535-9. http://dx.doi.org/10.1590/S1806-37132004000600008
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) Oral masks are made of silicone and resemble a butterfly, sitting between
the lips and teeth. Oral masks include a tongue guide designed to hold the tongue in
place and prevent it from blocking the flow of air from the CPAP. In clinical practice,
oral masks are not widely used. With the objective of improving CPAP treatment
adherence, a variety of materials are used in the manufacture of CPAP masks, including
silicone, gel, and fabrics. A Google(r) search returns approximately
1,600,000 results for the search terms "nasal mask", "oronasal mask", and "nasal
pillows"; this illustrates the diversity of interfaces and materials that are currently
available. Despite this diversity, the level of scientific evidence for the efficacy of
new models and their impact on treatment adherence have been questioned. In the present
review, we sought to answer two questions: Can the type of mask affect the efficacy of
CPAP treatment for OSA? Can it influence adherence to CPAP treatment?
Photographs showing the types of continuous positive airway pressure masks currently available for the treatment of obstructive sleep apnea: nasal mask, in A; oronasal mask, in B; nasal pillows, in C; and oral mask, in D. Source: Sleep Laboratory, Heart Institute, University of São Paulo School of Medicine Hospital das Clínicas.
The impact of the type of interface on the efficacy of OSA treatment with CPAP
The mechanisms of airway obstruction in patients with OSA and the effects of CPAP can be
explained by the Starling resistor model. The Starling resistor consists of two rigid
tubes connected by a collapsible tube. The two rigid tubes represent the nose and the
trachea, which are bony and cartilaginous structures. The pharynx, which is a
collapsible, muscular tube, lies between the two. In this model, the pharyngeal critical
pressure is the pressure at which complete pharyngeal collapse occurs.(
2626. Gold AR, Schwartz AR. The pharyngeal critical pressure. The whys and
hows of using nasal continuous positive airway pressure diagnostically. Chest.
1996;110(4):1077-88. http://dx.doi.org/10.1378/chest.110.4.1077
http://dx.doi.org/10.1378/chest.110.4.10...
) The trend toward pharyngeal collapse depends on nasal and tracheal
pressure, as well as on the pressure surrounding the pharynx. The fundamental concept is
that the pressure that nasal CPAP applies to the pharyngeal lumen is greater than the
pharyngeal critical pressure, thus ensuring pharyngeal patency (Figure 2). It is of note that the Starling resistor model involves
variations in nasal pressure. It is clear that the model assumes that the mask is nasal
rather than oronasal. Accordingly, Sullivan et al. proposed that CPAP be applied via a
nasal mask when they first described the treatment of OSA with CPAP.(
2121. Sullivan CE, Issa FG, Berthon-Jones M, Eves L. Reversal of
obstructive sleep apnoea by continuous positive airway pressure applied through the
nares. Lancet. 1981;1(8225):862-5. http://dx.doi.org/10.1016/S0140-6736(81)92140-1
http://dx.doi.org/10.1016/S0140-6736(81)...
) Although it works, the application of CPAP via an oronasal mask for the
treatment of OSA violates the principles of the Starling resistor model (Figure 2) and those of the model originally described
by Sullivan et al. (Figure 3). From a conceptual
standpoint, the pressure that opens the pharynx when applied nasally can also lead to
pharyngeal collapse when applied orally.
Schematic illustration of the Starling resistor. In A, the nose and the trachea are represented by two rigid tubes connected by a collapsible segment (the pharynx). In B, pharyngeal collapse occurs when the pharyngeal critical pressure (Pcrit) is greater than the upper airway pressure (Pnasal). In C, nasal continuous positive airway pressure (CPAP) applied to the upper airway is greater than Pcrit and can therefore maintain upper airway patency. In D, oronasal CPAP; the hypothesis is that upper airway collapse occurs when oral pressure (Poral) is greater than Pcrit. Source: Sleep Laboratory, Heart Institute, University of São Paulo School of Medicine Hospital das Clínicas.
In A, schematic illustration of the normal upper airway (left) of a patient with obstructive sleep apnea, showing retropalatal obstruction during negative pressure generated during inhalation (center) and during continuous positive airway pressure (right). In B, schematic illustration of a patient wearing an oronasal mask, and, in C, patient with significant mouth breathing. The tongue (red) is displaced posteriorly and obstructs the upper airway. Adapted from Sullivan et al.(21) Source: Schorr et al.(31)
The efficacy of oronasal masks can be questioned on theoretical and experimental
grounds. Upper airway resistance during sleep and the propensity for obstructive apneas
are significantly greater during mouth breathing than during nasal
breathing.(
2727. Fitzpatrick MF, McLean H, Urton AM, Tan A, O'Donnell D, Driver HS.
Effect of nasal or oral breathing route on upper airway resistance during sleep. Eur
Respir J. 2003;22(5):827-32. http://dx.doi.org/10.1183/09031936.03.00047903
http://dx.doi.org/10.1183/09031936.03.00...
) A study of 6 patients with severe OSA(
2828. Smith PL, Wise RA, Gold AR, Schwartz AR, Permutt S. Upper airway
pressure-flow relationships in obstructive sleep apnea. J Appl Physiol.
1998;64(2):789-95.
) showed that the pressure required to maintain upper airway patency with the
use of a nasal mask was insufficient to maintain upper airway patency when an oronasal
mask was used. A study of 11 patients with OSA showed that oropharyngeal resistance was
higher with the use of an oronasal mask than with the use of a nasal mask or a nasal
mask with a mandibular advancement device.(
2929. Borel J C, Gakwaya J F, Masse J F. Impact of CPAP interface and
mandibular advancement device on upper airway mechanical properties assessed with
phrenic nerve stimulation in sleep apnea patients Respir Physiol Neurobiol.
2012;183(2):170-6. http://dx.doi.org/10.1016/j.resp.2012.06.018
http://dx.doi.org/10.1016/j.resp.2012.06...
) The deleterious effect of the oronasal mask was reversed by concomitant use
of the mandibular advancement device. Therefore, the authors of that study hypothesized
that the increased resistance observed with the use of an oronasal mask was caused by
posterior tongue displacement. This hypothesis was confirmed in a study of two patients
with Down syndrome,(
3030. Flecker RJ Jr, Mahmoud M, McConnell K, Shott SR, Gutmark E, Amin RS.
An adverse effect of positive airway pressure on the upper airway documented with
magnetic resonance imaging. JAMA Otolaryngol Head Neck Surg. 2013;139(6):636-8.
http://dx.doi.org/10.1001/jamaoto.2013.3279
http://dx.doi.org/10.1001/jamaoto.2013.3...
) in whom CPAP applied via an oronasal mask resulted in posterior tongue
displacement and reduced upper airway patency. We have recently reported the case of a
69-year-old male patient with severe OSA and persistent sleepiness, despite adequate use
of CPAP applied with an oronasal mask.(
3131. Schorr F, Genta PR, Gregório MG, Danzi-Soares NJ, Lorenzi-Filho G.
Continuous positive airway pressure delivered by oronasal mask may not be effective
for obstructive sleep apnoea. Eur Respir J. 2012;40(2):503-5.
http://dx.doi.org/10.1183/09031936.00145111
http://dx.doi.org/10.1183/09031936.00145...
) We conducted an oronasal CPAP titration study and found a residual AHI of
32 events/hour of sleep, despite the fact that CPAP was gradually increased to 16
cmH2O. A new CPAP titration study confirmed that the interface was
affecting the efficacy of CPAP; we found that a nasal CPAP of 7 cmH2O was
enough to eliminate OSA in the first half of the study. The nasal mask was changed to an
oronasal mask during the second half of the study, and the latter was found to be
ineffective in eliminating OSA. In order to clarify the mechanisms involved in this
apparent paradox, we conducted a CPAP titration study during midazolam-induced
sleep.(
3131. Schorr F, Genta PR, Gregório MG, Danzi-Soares NJ, Lorenzi-Filho G.
Continuous positive airway pressure delivered by oronasal mask may not be effective
for obstructive sleep apnoea. Eur Respir J. 2012;40(2):503-5.
http://dx.doi.org/10.1183/09031936.00145111
http://dx.doi.org/10.1183/09031936.00145...
) The mask was customized to allow passage of the endoscope for direct
visualization of the oropharynx. As expected, a nasal CPAP of 7 cmH2O opened
the oropharynx during sleep. In contrast, the oropharynx was found to be partially
obstructed by posterior displacement of the base of the tongue with the use of an
oronasal CPAP of 16 cmH2O (Figure
4).(
3232. Genta PR, Eckert DJ, Gregorio MG, Danzi NJ, Moriya HT, Malhotra A,
et al. Critical closing pressure during midazolam-induced sleep. J Appl Physiol
(1985).2011;111(5):1315-22. http://dx.doi.org/10.1152/japplphysiol.00508.2011
http://dx.doi.org/10.1152/japplphysiol.0...
) In that patient, oral CPAP caused posterior tongue displacement, which
affected the efficacy of nasal CPAP. The case of that patient does not appear to be
unique; our observations are couched in a solid theoretical framework and are
corroborated by the findings of several experimental studies, prompting us to conduct
the present literature review.
In A, polysomnography summary of a continuous positive airway pressure (CPAP) titration study during natural sleep. In B and C, sleep endoscopy images showing the patient wearing a nasal mask and an oronasal mask, respectively. During the first half of the CPAP titration study, a nasal CPAP of 7 cmH2O was enough to control obstructive events. During the second half of the CPAP titration study, an oronasal mask was used. Obstructive events persist, despite the fact that the pressure was gradually increased to 16 cmH2O. The endoscopic image obtained when a nasal CPAP of 7 cmH2O was used (B) shows that the oropharynx is open. In contrast, the image obtained when an oronasal CPAP of 16 cmH2O was used (C) shows posterior displacement of the base of the tongue, which pushes the epiglottis and significantly narrows the airway lumen. Respiratory events are expressed in seconds (sec). SpO2 measured by pulse oximetry. CA: central apnea; OA: obstructive apnea; MA: mixed apnea; Hypo: hypopnea; PAP: pulmonary artery pressure; and REM: rapid eye movement.
Methods
We searched the PubMed database using the search terms "CPAP", "mask", and "obstructive
sleep apnea". The process of selection of articles for the review was divided into three
stages. First, we selected the titles of interest. Second, we analyzed the abstracts of
the selected articles to ensure that the studies addressed the impact of the type of
CPAP mask on OSA treatment adherence, efficacy, or both. Although we thus identified 91
studies, only 12 met the inclusion criteria. A study comparing nasal and oronasal masks
in only 5 patients receiving CPAP was inconclusive and was therefore not included in the
final analysis.(
3333. Prosise GL, Berry RB. Oral-nasal continuous positive airway pressure
as a treatment for obstructive sleep apnea. Chest.
1994;106(1):180-6.http://dx.doi.org/10.1378/chest.106.1.180
http://dx.doi.org/10.1378/chest.106.1.18...
) Of the 12 studies included in the review, 6 described the impact of the
type of CPAP interface on treatment efficacy. Of those, 2 also addressed treatment
adherence and were therefore analyzed in conjunction with the 6 studies describing the
impact of the type of CPAP interface on treatment adherence. The included articles were
divided into observational studies and randomized studies.
Impact of the type of mask on the efficacy of OSA treatment with CPAP
We found 6 studies evaluating the efficacy of CPAP masks in the treatment of OSA. Table 1 shows an overview of the studies. Of the 6
studies, 3 were observational studies(
3434. Beecroft J, Zanon S, Lukic D, Hanly P. Oral continuous positive
airway pressure for sleep apnea: effectiveness, patient preference and adherence.
Chest. 2003;124(6):2200-8. http://dx.doi.org/10.1378/chest.124.6.2200
http://dx.doi.org/10.1378/chest.124.6.22...
35. Borel JC, Tamisier R, Dias-Domingos S, Sapene M, Martin F, Stach B,
et al. Type of mask may impact on continuous positive airway pressure adherence in
apneic patients. PLoS One. 2013;8(5):e64382.
http://dx.doi.org/10.1371/journal.pone.0064382
http://dx.doi.org/10.1371/journal.pone.0...
-
3636. Benttizoli M, Taranto-Montemurro L,Messineo L, Corda L, RedolfiS,
Ferliga M, et al. Oronasal masks require higher levels of positive airway pressure
than nasal masks to treat obstructive sleep apnea. Sleep Breath. 2014 Feb
15.
) and 3 were randomized studies. Of those, 2 were crossover
studies(
3737. Teo M, Amis T, Lee S, Falland K, Lambert S, Wheatley J. Equivalence
of nasal and oronasal masks during initial CPAP titration for obstructive sleep apnea
syndrome. Sleep. 2011;34(7):951-5.
,
3838. Bakker JP, Neil AM, Campbell AJ. Nasal versus oronasal continuous
positive airway pressure masks for obstructive sleep apnea: a pilot investigation of
pressure requirement, residual disease, and leak. Sleep Breath. 2012;16(3):709-16.
http://dx.doi.org/10.1007/s11325-011-0564-3
http://dx.doi.org/10.1007/s11325-011-056...
) and 1 was an open-label study.(
3939. Ebben MR, Oyegbile T, Pollak CP. The efficacy of three different
mask styles on PAP titration night. Sleep Med.
2012;13(6):645-9.http://dx.doi.org/10.1016/j.sleep.2012.02.004
http://dx.doi.org/10.1016/j.sleep.2012.0...
) Comparisons were made between nasal masks and oronasal masks, in 3
studies(
3636. Benttizoli M, Taranto-Montemurro L,Messineo L, Corda L, RedolfiS,
Ferliga M, et al. Oronasal masks require higher levels of positive airway pressure
than nasal masks to treat obstructive sleep apnea. Sleep Breath. 2014 Feb
15.
37. Teo M, Amis T, Lee S, Falland K, Lambert S, Wheatley J. Equivalence
of nasal and oronasal masks during initial CPAP titration for obstructive sleep apnea
syndrome. Sleep. 2011;34(7):951-5.
-
3838. Bakker JP, Neil AM, Campbell AJ. Nasal versus oronasal continuous
positive airway pressure masks for obstructive sleep apnea: a pilot investigation of
pressure requirement, residual disease, and leak. Sleep Breath. 2012;16(3):709-16.
http://dx.doi.org/10.1007/s11325-011-0564-3
http://dx.doi.org/10.1007/s11325-011-056...
); among nasal masks, oronasal masks, and nasal pillows, in 2(
3535. Borel JC, Tamisier R, Dias-Domingos S, Sapene M, Martin F, Stach B,
et al. Type of mask may impact on continuous positive airway pressure adherence in
apneic patients. PLoS One. 2013;8(5):e64382.
http://dx.doi.org/10.1371/journal.pone.0064382
http://dx.doi.org/10.1371/journal.pone.0...
,
3939. Ebben MR, Oyegbile T, Pollak CP. The efficacy of three different
mask styles on PAP titration night. Sleep Med.
2012;13(6):645-9.http://dx.doi.org/10.1016/j.sleep.2012.02.004
http://dx.doi.org/10.1016/j.sleep.2012.0...
); and among nasal masks, oronasal masks, and oral masks, in 1.(
3434. Beecroft J, Zanon S, Lukic D, Hanly P. Oral continuous positive
airway pressure for sleep apnea: effectiveness, patient preference and adherence.
Chest. 2003;124(6):2200-8. http://dx.doi.org/10.1378/chest.124.6.2200
http://dx.doi.org/10.1378/chest.124.6.22...
)
The patients included in the 3 observational studies reviewed here had moderate to
severe OSA. Beecroft et al.(
3434. Beecroft J, Zanon S, Lukic D, Hanly P. Oral continuous positive
airway pressure for sleep apnea: effectiveness, patient preference and adherence.
Chest. 2003;124(6):2200-8. http://dx.doi.org/10.1378/chest.124.6.2200
http://dx.doi.org/10.1378/chest.124.6.22...
) studied 98 patients, who were shown nasal masks, oronasal masks, and an
oral mask for CPAP treatment and were allowed to choose one. Most (66%) of the patients
chose a nasal mask, whereas 27% chose the oral mask (27%) and 7% chose an oronasal mask.
Although the three groups of patients were similar in terms of anthropometric
measurements and OSA severity, optimal CPAP (as determined by a CPAP titration study)
was on average 2 cmH2O higher and the residual AHI was on average 3
events/hour of sleep higher in those who used an oronasal mask than in those who used a
nasal mask. Although the difference was not statistically significant, all parameters
were worse in those who used an oronasal mask. In addition, one third of the patients
who initially chose an oronasal mask chose to change it to a different type of mask
during follow-up.(
3434. Beecroft J, Zanon S, Lukic D, Hanly P. Oral continuous positive
airway pressure for sleep apnea: effectiveness, patient preference and adherence.
Chest. 2003;124(6):2200-8. http://dx.doi.org/10.1378/chest.124.6.2200
http://dx.doi.org/10.1378/chest.124.6.22...
) The oral mask also showed a trend toward a worse performance, the residual
AHI being higher in those who used it than in those who used a nasal mask. Borel et
al.(
3535. Borel JC, Tamisier R, Dias-Domingos S, Sapene M, Martin F, Stach B,
et al. Type of mask may impact on continuous positive airway pressure adherence in
apneic patients. PLoS One. 2013;8(5):e64382.
http://dx.doi.org/10.1371/journal.pone.0064382
http://dx.doi.org/10.1371/journal.pone.0...
) conducted an observational cohort study of 2,311 OSA patients who had
received a prescription for CPAP treatment and found that nasal masks, oronasal masks,
and nasal pillows were used by 62%, 26%, and 11%, respectively. There were statistically
significant differences among the three groups of patients regarding CPAP, which was
higher in those who used oronasal masks than in those who used nasal masks, being higher
in the latter than in those who used nasal pillows. In a multivariate analysis, oronasal
masks were associated with subtherapeutic CPAP and low adherence to CPAP treatment
(Table 2).(
3535. Borel JC, Tamisier R, Dias-Domingos S, Sapene M, Martin F, Stach B,
et al. Type of mask may impact on continuous positive airway pressure adherence in
apneic patients. PLoS One. 2013;8(5):e64382.
http://dx.doi.org/10.1371/journal.pone.0064382
http://dx.doi.org/10.1371/journal.pone.0...
) Bettinzoli et al.(
3636. Benttizoli M, Taranto-Montemurro L,Messineo L, Corda L, RedolfiS,
Ferliga M, et al. Oronasal masks require higher levels of positive airway pressure
than nasal masks to treat obstructive sleep apnea. Sleep Breath. 2014 Feb
15.
) evaluated 109 patients who were allowed to choose between nasal masks (67%)
and oronasal masks (42%) for a home titration period of 3-4 nights with an automated
CPAP device. Therapeutic CPAP and the residual AHI were significantly higher (+1.2
cmH2O and +1.9 events/h, respectively) with the use of an oronasal mask.
In a multivariate analysis, the oronasal mask was associated with higher pressure
levels.(
3636. Benttizoli M, Taranto-Montemurro L,Messineo L, Corda L, RedolfiS,
Ferliga M, et al. Oronasal masks require higher levels of positive airway pressure
than nasal masks to treat obstructive sleep apnea. Sleep Breath. 2014 Feb
15.
) The observational studies reviewed here showed that oronasal masks had the
worst performance. The results of those studies should be interpreted with caution
because they seem to suggest a potential lack of effectiveness with oronasal mask use.
In a randomized crossover study, Teo et al.(
3737. Teo M, Amis T, Lee S, Falland K, Lambert S, Wheatley J. Equivalence
of nasal and oronasal masks during initial CPAP titration for obstructive sleep apnea
syndrome. Sleep. 2011;34(7):951-5.
) evaluated 24 patients with moderate to severe OSA and no history of
oronasal surgery or signs of significant nasal obstruction. The therapeutic CPAP level
as determined during titration was similar for nasal and oronasal masks. However, the
residual AHI was on average 5.7 events/h higher with the use of an oronasal mask than
with the use of a nasal mask (p = 0.01). The standard deviation of the residual AHI was
on average 3 times higher with the oronasal mask (10.4 vs. 3.4 events/h), indicating a
higher variability in the residual AHI. Arousals and leaks were also greater with the
oronasal mask.(
3737. Teo M, Amis T, Lee S, Falland K, Lambert S, Wheatley J. Equivalence
of nasal and oronasal masks during initial CPAP titration for obstructive sleep apnea
syndrome. Sleep. 2011;34(7):951-5.
) Bakker et al.(
3838. Bakker JP, Neil AM, Campbell AJ. Nasal versus oronasal continuous
positive airway pressure masks for obstructive sleep apnea: a pilot investigation of
pressure requirement, residual disease, and leak. Sleep Breath. 2012;16(3):709-16.
http://dx.doi.org/10.1007/s11325-011-0564-3
http://dx.doi.org/10.1007/s11325-011-056...
) evaluated 12 patients with severe OSA and showed that changing from a nasal
mask to an oronasal mask significantly increased leak and the residual AHI; however,
there was no difference between the two types of masks in terms of the CPAP level. Ebben
et al.(
3939. Ebben MR, Oyegbile T, Pollak CP. The efficacy of three different
mask styles on PAP titration night. Sleep Med.
2012;13(6):645-9.http://dx.doi.org/10.1016/j.sleep.2012.02.004
http://dx.doi.org/10.1016/j.sleep.2012.0...
) evaluated 55 patients with mild, moderate, or severe OSA. Patients were
randomized to CPAP titration with a nasal mask, an oronasal mask, or nasal pillows. The
nasal mask and nasal pillows were similar in terms of CPAP levels. Although the oronasal
and nasal masks were similar in terms of the residual AHI, the former required higher
pressures than did the latter. This difference increased as the degree of OSA severity
increased, being +2.8 ± 2.1 cmH2O in patients with moderate OSA and +6.0 ±
3.2 cmH2O in those with severe OSA.(
3939. Ebben MR, Oyegbile T, Pollak CP. The efficacy of three different
mask styles on PAP titration night. Sleep Med.
2012;13(6):645-9.http://dx.doi.org/10.1016/j.sleep.2012.02.004
http://dx.doi.org/10.1016/j.sleep.2012.0...
) Therefore, all of the randomized studies reviewed here showed consistent
results, showing that the performance of oronasal masks is worse than that of nasal
masks. The studies also show that the performance of nasal pillows is similar to that of
nasal masks.
Impact of the type of mask on adherence to OSA treatment with CPAP
We found 8 studies evaluating the impact of the type of mask on adherence to CPAP
treatment (Table 2). As previously mentioned, 2
of the studies describing the impact of the type of mask on adherence to CPAP treatment
also included relevant data on the impact of the type of mask on treatment
efficacy,(
3434. Beecroft J, Zanon S, Lukic D, Hanly P. Oral continuous positive
airway pressure for sleep apnea: effectiveness, patient preference and adherence.
Chest. 2003;124(6):2200-8. http://dx.doi.org/10.1378/chest.124.6.2200
http://dx.doi.org/10.1378/chest.124.6.22...
,
3535. Borel JC, Tamisier R, Dias-Domingos S, Sapene M, Martin F, Stach B,
et al. Type of mask may impact on continuous positive airway pressure adherence in
apneic patients. PLoS One. 2013;8(5):e64382.
http://dx.doi.org/10.1371/journal.pone.0064382
http://dx.doi.org/10.1371/journal.pone.0...
) their characteristics being therefore described in Tables 1 and 2. Of the 8
included studies, 3 were observational studies(
3434. Beecroft J, Zanon S, Lukic D, Hanly P. Oral continuous positive
airway pressure for sleep apnea: effectiveness, patient preference and adherence.
Chest. 2003;124(6):2200-8. http://dx.doi.org/10.1378/chest.124.6.2200
http://dx.doi.org/10.1378/chest.124.6.22...
,
3535. Borel JC, Tamisier R, Dias-Domingos S, Sapene M, Martin F, Stach B,
et al. Type of mask may impact on continuous positive airway pressure adherence in
apneic patients. PLoS One. 2013;8(5):e64382.
http://dx.doi.org/10.1371/journal.pone.0064382
http://dx.doi.org/10.1371/journal.pone.0...
,
4040. Bachour A, Vitikainen P, Virkkula P and Maasilta P. CPAP interface:
satisfaction and side effects. Sleep Breath. 2013;17(2):667-72.
http://dx.doi.org/10.1007/s11325-012-0740-0
http://dx.doi.org/10.1007/s11325-012-074...
) and 5 were randomized studies; of those, 4 were crossover
studies(
2020. Mortimore IL, Whittle AT, Douglas NJ. Comparison of nose and face
mask CPAP therapy for sleep apnoea. Thorax.
1998;53(4):290-2.http://dx.doi.org/10.1136/thx.53.4.290
http://dx.doi.org/10.1136/thx.53.4.290...
,
4141. Anderson FE, Kingshott RN, Taylor DR, Jones DR, Kline LR, Whyte KF.
A randomized crossover efficacy trial of oral CPAP (Oracle) compared with nasal CPAP
in the management of obstructive sleep apnea. Sleep.
2003;26(6):721-6.
42. Massie CA, Hart RW. Clinical outcomes related to interface type in
patients with obstructive sleep apnea/hypopnea syndrome who are using continuous
positive airway pressure. Chest. 2003;123(4):1112-8.
http://dx.doi.org/10.1378/chest.123.4.1112
http://dx.doi.org/10.1378/chest.123.4.11...
-
4343. Ryan S, Garvey JF, Swan V, Behan R, McNicholas WT. Nasal pillows as
an alternative interface in patients with obstructive sleep apnoea syndrome
initiating continuous positive airway pressure therapy. J Sleep Res.
2011;20(2):367-73. http://dx.doi.org/10.1111/j.1365-2869.2010.00873.x
http://dx.doi.org/10.1111/j.1365-2869.20...
) and 1 was an open-label study.(
4444. Khanna R, Kline LR. A prospective 8 week trial of nasal interfaces
vs. a novel oral interface (Oracle) for treatment of obstructive sleep apnea hypopnea
syndrome. Sleep Med. 2003;4(4):333-8. http://dx.doi.org/10.1016/S1389-9457(03)00063-7
http://dx.doi.org/10.1016/S1389-9457(03)...
) Comparisons were made between nasal and oronasal masks, in 1
study(
2020. Mortimore IL, Whittle AT, Douglas NJ. Comparison of nose and face
mask CPAP therapy for sleep apnoea. Thorax.
1998;53(4):290-2.http://dx.doi.org/10.1136/thx.53.4.290
http://dx.doi.org/10.1136/thx.53.4.290...
); between nasal masks and nasal pillows, in 2(
4242. Massie CA, Hart RW. Clinical outcomes related to interface type in
patients with obstructive sleep apnea/hypopnea syndrome who are using continuous
positive airway pressure. Chest. 2003;123(4):1112-8.
http://dx.doi.org/10.1378/chest.123.4.1112
http://dx.doi.org/10.1378/chest.123.4.11...
,
4343. Ryan S, Garvey JF, Swan V, Behan R, McNicholas WT. Nasal pillows as
an alternative interface in patients with obstructive sleep apnoea syndrome
initiating continuous positive airway pressure therapy. J Sleep Res.
2011;20(2):367-73. http://dx.doi.org/10.1111/j.1365-2869.2010.00873.x
http://dx.doi.org/10.1111/j.1365-2869.20...
); between nasal and oral masks, in 2(
4141. Anderson FE, Kingshott RN, Taylor DR, Jones DR, Kline LR, Whyte KF.
A randomized crossover efficacy trial of oral CPAP (Oracle) compared with nasal CPAP
in the management of obstructive sleep apnea. Sleep.
2003;26(6):721-6.
,
4444. Khanna R, Kline LR. A prospective 8 week trial of nasal interfaces
vs. a novel oral interface (Oracle) for treatment of obstructive sleep apnea hypopnea
syndrome. Sleep Med. 2003;4(4):333-8. http://dx.doi.org/10.1016/S1389-9457(03)00063-7
http://dx.doi.org/10.1016/S1389-9457(03)...
); among nasal masks, nasal pillows, and oronasal masks, in 2(
3535. Borel JC, Tamisier R, Dias-Domingos S, Sapene M, Martin F, Stach B,
et al. Type of mask may impact on continuous positive airway pressure adherence in
apneic patients. PLoS One. 2013;8(5):e64382.
http://dx.doi.org/10.1371/journal.pone.0064382
http://dx.doi.org/10.1371/journal.pone.0...
,
4040. Bachour A, Vitikainen P, Virkkula P and Maasilta P. CPAP interface:
satisfaction and side effects. Sleep Breath. 2013;17(2):667-72.
http://dx.doi.org/10.1007/s11325-012-0740-0
http://dx.doi.org/10.1007/s11325-012-074...
); and among nasal, oronasal, and oral masks, in 1.(
3434. Beecroft J, Zanon S, Lukic D, Hanly P. Oral continuous positive
airway pressure for sleep apnea: effectiveness, patient preference and adherence.
Chest. 2003;124(6):2200-8. http://dx.doi.org/10.1378/chest.124.6.2200
http://dx.doi.org/10.1378/chest.124.6.22...
)
The 3 observational studies reviewed here examined a total of 3,112 patients with
moderate to severe OSA and showed lower adherence to CPAP treatment with the use of an
oronasal mask than with the use of a nasal mask.(
3434. Beecroft J, Zanon S, Lukic D, Hanly P. Oral continuous positive
airway pressure for sleep apnea: effectiveness, patient preference and adherence.
Chest. 2003;124(6):2200-8. http://dx.doi.org/10.1378/chest.124.6.2200
http://dx.doi.org/10.1378/chest.124.6.22...
,
3535. Borel JC, Tamisier R, Dias-Domingos S, Sapene M, Martin F, Stach B,
et al. Type of mask may impact on continuous positive airway pressure adherence in
apneic patients. PLoS One. 2013;8(5):e64382.
http://dx.doi.org/10.1371/journal.pone.0064382
http://dx.doi.org/10.1371/journal.pone.0...
,
4040. Bachour A, Vitikainen P, Virkkula P and Maasilta P. CPAP interface:
satisfaction and side effects. Sleep Breath. 2013;17(2):667-72.
http://dx.doi.org/10.1007/s11325-012-0740-0
http://dx.doi.org/10.1007/s11325-012-074...
) Beecroft et al. showed that dropout rates were higher in patients receiving
long-term CPAP applied via an oronasal mask than in those receiving long-term CPAP
applied via a nasal mask.(
3434. Beecroft J, Zanon S, Lukic D, Hanly P. Oral continuous positive
airway pressure for sleep apnea: effectiveness, patient preference and adherence.
Chest. 2003;124(6):2200-8. http://dx.doi.org/10.1378/chest.124.6.2200
http://dx.doi.org/10.1378/chest.124.6.22...
) Treatment adherence was higher with the use of nasal pillows than with the
use of nasal masks in one study(
3535. Borel JC, Tamisier R, Dias-Domingos S, Sapene M, Martin F, Stach B,
et al. Type of mask may impact on continuous positive airway pressure adherence in
apneic patients. PLoS One. 2013;8(5):e64382.
http://dx.doi.org/10.1371/journal.pone.0064382
http://dx.doi.org/10.1371/journal.pone.0...
) but lower in another.(
4040. Bachour A, Vitikainen P, Virkkula P and Maasilta P. CPAP interface:
satisfaction and side effects. Sleep Breath. 2013;17(2):667-72.
http://dx.doi.org/10.1007/s11325-012-0740-0
http://dx.doi.org/10.1007/s11325-012-074...
)
In a randomized crossover study of 20 patients with moderate to severe OSA, Mortimore et
al.(
2020. Mortimore IL, Whittle AT, Douglas NJ. Comparison of nose and face
mask CPAP therapy for sleep apnoea. Thorax.
1998;53(4):290-2.http://dx.doi.org/10.1136/thx.53.4.290
http://dx.doi.org/10.1136/thx.53.4.290...
) initially performed CPAP titration with the use of a nasal mask and
subsequently randomized patients to nasal CPAP or oronasal CPAP for 4 weeks each.
Adherence to oronasal CPAP was approximately 1 h lower than adherence to nasal CPAP, and
19 of the 20 participants preferred the nasal mask.(
2020. Mortimore IL, Whittle AT, Douglas NJ. Comparison of nose and face
mask CPAP therapy for sleep apnoea. Thorax.
1998;53(4):290-2.http://dx.doi.org/10.1136/thx.53.4.290
http://dx.doi.org/10.1136/thx.53.4.290...
) Oronasal masks have also been associated with poorer sleep quality, less
slow-wave sleep, more leaks, less satisfaction, and less comfort when compared with
nasal masks.(
3737. Teo M, Amis T, Lee S, Falland K, Lambert S, Wheatley J. Equivalence
of nasal and oronasal masks during initial CPAP titration for obstructive sleep apnea
syndrome. Sleep. 2011;34(7):951-5.
,
3838. Bakker JP, Neil AM, Campbell AJ. Nasal versus oronasal continuous
positive airway pressure masks for obstructive sleep apnea: a pilot investigation of
pressure requirement, residual disease, and leak. Sleep Breath. 2012;16(3):709-16.
http://dx.doi.org/10.1007/s11325-011-0564-3
http://dx.doi.org/10.1007/s11325-011-056...
,
4242. Massie CA, Hart RW. Clinical outcomes related to interface type in
patients with obstructive sleep apnea/hypopnea syndrome who are using continuous
positive airway pressure. Chest. 2003;123(4):1112-8.
http://dx.doi.org/10.1378/chest.123.4.1112
http://dx.doi.org/10.1378/chest.123.4.11...
)
Two randomized crossover studies compared nasal masks and nasal pillows in terms of
adherence to CPAP treatment. Massie et al. evaluated 39 OSA patients using nasal masks
and nasal pillows for 3 weeks each and found that treatment adherence was significantly
higher with the use of nasal pillows.(
4242. Massie CA, Hart RW. Clinical outcomes related to interface type in
patients with obstructive sleep apnea/hypopnea syndrome who are using continuous
positive airway pressure. Chest. 2003;123(4):1112-8.
http://dx.doi.org/10.1378/chest.123.4.1112
http://dx.doi.org/10.1378/chest.123.4.11...
) Ryan et al. studied 21 severe OSA patients using nasal masks and nasal
pillows for 4 weeks each.(
4343. Ryan S, Garvey JF, Swan V, Behan R, McNicholas WT. Nasal pillows as
an alternative interface in patients with obstructive sleep apnoea syndrome
initiating continuous positive airway pressure therapy. J Sleep Res.
2011;20(2):367-73. http://dx.doi.org/10.1111/j.1365-2869.2010.00873.x
http://dx.doi.org/10.1111/j.1365-2869.20...
) The authors found no differences between the two types of CPAP masks in
terms of their impact on treatment adherence. However, the participants complained of
nasal congestion, nasal dryness, nosebleeds, and headaches more frequently when they
used nasal pillows than they did when they used nasal masks.(
4343. Ryan S, Garvey JF, Swan V, Behan R, McNicholas WT. Nasal pillows as
an alternative interface in patients with obstructive sleep apnoea syndrome
initiating continuous positive airway pressure therapy. J Sleep Res.
2011;20(2):367-73. http://dx.doi.org/10.1111/j.1365-2869.2010.00873.x
http://dx.doi.org/10.1111/j.1365-2869.20...
) Two studies showed that oral and nasal masks were similar in terms of their
impact on treatment adherence.(
4141. Anderson FE, Kingshott RN, Taylor DR, Jones DR, Kline LR, Whyte KF.
A randomized crossover efficacy trial of oral CPAP (Oracle) compared with nasal CPAP
in the management of obstructive sleep apnea. Sleep.
2003;26(6):721-6.
,
4444. Khanna R, Kline LR. A prospective 8 week trial of nasal interfaces
vs. a novel oral interface (Oracle) for treatment of obstructive sleep apnea hypopnea
syndrome. Sleep Med. 2003;4(4):333-8. http://dx.doi.org/10.1016/S1389-9457(03)00063-7
http://dx.doi.org/10.1016/S1389-9457(03)...
) However, oral masks are not widely accepted and are rarely used in clinical
practice.
Final considerations
We conclude that the type of mask can influence the efficacy of and adherence to CPAP
treatment in patients with OSA. Nasal pillows constitute an alternative to nasal masks
and appear to be effective in the treatment of OSA. Nasal pillows are lighter, and their
initial acceptance might be higher. However, they can cause more nasal problems,
particularly when a CPAP > 12 cmH2O is used. A recent study showed that
nasal pillows can be used even at pressures ≥ 12 cmH2O.(
4545. Zhu X, Wimms AJ, Benjafield AV. Assessment of the performance of
nasal pillows at high CPAP pressures. J Clin Sleep Med.
2013;9(9):873-7.
) Oral masks appear to be effective in the treatment of OSA because they hold
the tongue in place with a tongue guide; however, they are rarely used in clinical
practice because their level of acceptance is low. Several theoretical and experimental
studies have shown that oronasal masks can affect the efficacy of and adherence to OSA
treatment with CPAP.(
2020. Mortimore IL, Whittle AT, Douglas NJ. Comparison of nose and face
mask CPAP therapy for sleep apnoea. Thorax.
1998;53(4):290-2.http://dx.doi.org/10.1136/thx.53.4.290
http://dx.doi.org/10.1136/thx.53.4.290...
,
2626. Gold AR, Schwartz AR. The pharyngeal critical pressure. The whys and
hows of using nasal continuous positive airway pressure diagnostically. Chest.
1996;110(4):1077-88. http://dx.doi.org/10.1378/chest.110.4.1077
http://dx.doi.org/10.1378/chest.110.4.10...
,
3131. Schorr F, Genta PR, Gregório MG, Danzi-Soares NJ, Lorenzi-Filho G.
Continuous positive airway pressure delivered by oronasal mask may not be effective
for obstructive sleep apnoea. Eur Respir J. 2012;40(2):503-5.
http://dx.doi.org/10.1183/09031936.00145111
http://dx.doi.org/10.1183/09031936.00145...
,
3636. Benttizoli M, Taranto-Montemurro L,Messineo L, Corda L, RedolfiS,
Ferliga M, et al. Oronasal masks require higher levels of positive airway pressure
than nasal masks to treat obstructive sleep apnea. Sleep Breath. 2014 Feb
15.
,
3737. Teo M, Amis T, Lee S, Falland K, Lambert S, Wheatley J. Equivalence
of nasal and oronasal masks during initial CPAP titration for obstructive sleep apnea
syndrome. Sleep. 2011;34(7):951-5.
) In comparison with nasal masks, oronasal masks often require higher CPAP
levels and are associated with a higher residual AHI and lower adherence to treatment.
How can we treat OSA patients who breathe through their mouth either by habit or because
of nasal obstruction? We believe that the first step is to treat their nasal
obstruction, either clinically or surgically. Another important point is that mouth
breathing does not necessarily mean that nasal masks are contraindicated. For example,
there is evidence that the use of nasal CPAP leads to a change of habit, reducing mouth
opening and the number of oral breaths.(
4040. Bachour A, Vitikainen P, Virkkula P and Maasilta P. CPAP interface:
satisfaction and side effects. Sleep Breath. 2013;17(2):667-72.
http://dx.doi.org/10.1007/s11325-012-0740-0
http://dx.doi.org/10.1007/s11325-012-074...
,
4646. Heinz K, Nilius G. Mouth breathing in obstructive sleep apnea prior
to and during nasal continuous positive airway pressure. Respiration.
2008;76(1):40-5.http://dx.doi.org/10.1159/000111806
http://dx.doi.org/10.1159/000111806...
,
4747. Senny F, Maury G, Cambron L, Leroux A, Destiné J, Poirrier R.
Mandible behavior in obstructive sleep apnea patients under CPAP treatment. Open
Sleep J. 2012;5:1-5. http://hdl.handle.net/2268/129588
http://hdl.handle.net/2268/129588...
) However, many patients adapt well to oronasal masks and show perfect OSA
control. Our review suggests two conclusions: first, nasal interfaces (i.e., nasal masks
and nasal pillows) should always be the first choice; second, patients using oronasal
masks must be monitored because the risks of CPAP treatment failure, nonadherence, and
discontinuation are higher. Further studies are needed in order to understand the exact
mechanisms by which oronasal interfaces affect the efficacy of OSA treatment with CPAP.
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Financial support: None
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*
Study carried out in the Sleep Laboratory, Department of Pulmonology, Heart Institute, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
Publication Dates
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Publication in this collection
Nov-Dec 2014
History
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Received
08 May 2014 -
Accepted
27 June 2014