Impact of the type of mask on the effectiveness of and adherence to
               continuous positive airway pressure treatment for obstructive sleep apnea

Andrade, Rafaela Garcia Santos de; Piccin, Vivien Schmeling; Nascimento, Juliana Araújo; Viana, Fernanda Madeiro Leite; Genta, Pedro Rodrigues; Lorenzi-Filho, Geraldo

doi:10.1590/S1806-37132014000600010

Rafaela Garcia Santos de Andrade

Vivien Schmeling Piccin

Juliana Araújo Nascimento

Fernanda Madeiro Leite Viana

Pedro Rodrigues Genta

Geraldo Lorenzi-Filho

Correspondence to: Geraldo Lorenzi Filho. Laboratório do Sono, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Avenida Dr. Enéas de Carvalho Aguiar, 44, 7º andar, CEP 05403-000, São Paulo, SP, Brasil Tel. 55 11 2661- 5486. E-mail: geraldo.lorenzi@incor.usp.br

Doctoral Student. Sleep Laboratory, Department of Pulmonology, Heart Institute, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil

Research Physical Therapist. Sleep Laboratory, Department of Pulmonology, Heart Institute, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil

Physical Therapist. Sleep Laboratory, Department of Pulmonology, Heart Institute, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil

Otolaryngologist and Sleep Specialist. Sleep Laboratory, Department of Pulmonology, Heart Institute, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil

Attending Physician. Sleep Laboratory, Department of Pulmonology, Heart Institute, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil; and Postdoctoral Student, Division of Sleep Medicine, Brigham and Women's Hospital/Harvard University, Boston (MA) USA

Director. Sleep Laboratory, Department of Pulmonology, Heart Institute, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil

Figures (4)
Tables (2)

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Figure 1 -
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.

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Figure 2 -
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.

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Figure 3 -
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)

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Figure 4 -
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.

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Table 1 -
Studies examining the efficacy of continuous positive airway pressure masks in the treatment obstructive sleep apnea.

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Table 2 -
Studies examining the impact of the types of masks on adherence to continuous positive airway pressure treatment.

Study	Type of study	Patients, n	Types of masks	Baseline AHI, events/h	Residual AHI, events/h	CPAP, mmH₂O	Performance^a
Beecroft et al.⁽³⁴⁾	Observational study	98	N, ON, and O	40.6 ± 25.8	N: 6.7 ± 13.3; ON: 9.8 ± 12.8; O: 10.9 ± 20.1 (ns)	N: 7.7 ± 2.1; ON: 9.7 ± 3.2; O: 8.8 ± 2.0 (ns)	N≈ON≈O
Borel et al.⁽³⁵⁾	Observational study	2,311	N, ON, and NPs	41.0 ± 21.0	ND	N: ≈ 8.8; ON: ≈ 9.6; NPs: ≈ 8.3 (p < 0.05 for all)	NPs>N>ON
Bettinzoli et al.⁽³⁶⁾	Observational study	109	N and O	41.1 ± 20.5	N: 2.6 ± 2.5; ON: 4.5 ± 4.4 (p < 0.05)	N: 10.0 ± 2.0; ON: 11.2 ± 2.1 (p < 0.05)	N>ON
Teo et al.⁽³⁷⁾	Randomized crossover study	24	N and O	47.0 ± 15.2	N: 5.3 ± 3.4; ON: 11.0 ± 10.4 (p = 0.01)	N: 11.4 ± 1.9; ON: 11.8 ± 2.4 (ns)	N>ON
Bakker et al.⁽³⁸⁾	Randomized crossover study	12	N, ON, and ON+CS	59.8 ± 28.6	N: 0.61 (IR: 1.1); ON: 2.4 (IR: 3.7): ON+CS: 1.7 (IR: 4.0) (p = 0.03 for all)	N: 11.0; ON: 11.1; ON+CS: 11.1 (ns)	N>ON≈ON+CS
Ebben et al.⁽³⁹⁾	Randomized open-label study	55	N, ON, and NPs	ND	ΔCPAP (ON and N): Moderate OSA: +2.8 ± 2.1; Severe OSA: +6.0 ± 3.2 (p < 0.001)	ND	N≈NPs>ON

Study	Type of study	Patients, n	Types of masks	Baseline AHI, events/h	Treatment adherence	Performance^a
Beecroft et al.⁽³⁴⁾	Observational study	98	N, ON, and O	40.6 ± 25.8	Nights/week in the acclimatization period: N: 5.8 ± 1.7; ON: 3.8 ± 3.0; O: 6.6 ± 0.8 (p < 0.01 for all)	N≈O>ON
Borel et al.⁽³⁵⁾	Observational study	2,311	N, ON, and NPs	41.0 ± 21.0	N: 5.7 ± 2.2 h/night; ON: 5.1 ± 2.3 h/night (p < 0.0001)	N≈NPs>ON
Bachour et al.⁽⁴⁰⁾	Observational study	703	N, ON, and NPs	ND	N: 5.8 ± 2.8 h/night; ON: 4.7 ± 2.8 h/night; NPs: 4.7 ± 3.2 h/night (p < 0.001 for all)	N>NPs≈ON
Mortimore et al.⁽²⁰⁾	Randomized crossover study	20	N and ON	34.0 ± 5.2	N: 5.3 ± 0.4 h/night; ON: 4.3 ± 0.5 h/night (p = 0.01)	N>ON
Massie et al.⁽⁴²⁾	Randomized crossover study	39	N and NPs	47.1 ± 35.4	% days of use: N: 85.7 ± 23.5%; NPs: 94.1 ± 8.3% (p = 0.02)	NPs>N
Ryan et al.⁽⁴³⁾	Randomized crossover study	21	N and NPs	52.4 ± 21.6	N: 5.1 ± 1.9 h/night; NPs: 5.0 ± 1.7 (ns)	NPs≈N
Anderson et al.⁽⁴¹⁾	Randomized crossover study	25	N and O	85.0 ± 36.0	N: 3.8 h/night; O: 3.5 h/night (ns)	N≈O
Khanna et al.⁽⁴⁴⁾	Randomized open-label study	38	N and O	N: 63.0 ± 39.0; O: 58.5 ± 34.8	1st month: N: 4.3 ± 2.6 h/night; O: 4.6 ± 2.1 h/night (ns) 2nd month: N: 4.6 ± 2.5 h/night; O: 5.5 ± 2.6 h/night (ns)	N≈O

[1] Correspondence to: Geraldo Lorenzi Filho. Laboratório do Sono, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Avenida Dr. Enéas de Carvalho Aguiar, 44, 7º andar, CEP 05403-000, São Paulo, SP, Brasil Tel. 55 11 2661- 5486. E-mail: geraldo.lorenzi@incor.usp.br

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