Mask Primer

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Mask Primer

Getting the right mask is one of the hardest parts of PAP therapy. This article is intended to help guide you through your choice of a mask.

First, all masks can and do handle all pressures associated with PAP therapy machines, this is from 3 to 20 (CPAP) or 25 (BiLevel/BiPAP) cmH2O.

Second, each of us has a different facial structure. This means that what works for me may or may not work for you, and what works for you may or may not work for me. You have to TRY the masks to see what works for you.

Third, You will have to try masks to see what works for you.


I’m going to call out 1 particular online vendor for 2 reasons. First they list masks by popularity within the mask type. This means that you can assume that the more popular masks work for more people. The second is that they offer “return insurance”, some free, some low cost, so that you can return a mask that does not work for you. That Vendor is Supplier #1

Your DME is an excellent resource to try different masks. Use them for this purpose. Make an appointment for a mask fitting, under pressure, and preferably lying down in sleeping position.. If you are using a DME it is their job to help you use your PAP system for effective therapy. If the mask doesn’t fit or is extremely uncomfortable they are not doing their job.

A Mask Trial Strategy

First, even a mouth breather may be able to use ANY style of mask, even the simplest, most unobtrusive, Nasal Pillow. See the Mouth Breathing section to see what to do.

Try masks from the most unobtrusive to the biggest bulkiest of masks. This would typically be starting with Nasal Pillows, Nasal Mask, Hybrid Masks, then finally the Full Face Mask. The smaller masks that you start with leave you with less mask on your face and more visibility.

Finally, as I have said before, you have to try masks on, under pressure, and preferably lying down in sleeping position.

Mask Types

Nasal Pillows

Nasal pillows rest under the nose covering the nasal openings and sealing against them. This mask style is among the least intrusive of all masks. Typically they easily seal and have very low mask leak rates. The main disadvantage of this style is with the light touch if you are a very active sleeper the headgear can shift and cause a mask leak. Generally these masks are for non-mouth breathers. There are ways (chin strap, cervical collar, tape) which may eliminate mouth breathing and allow you to use this type of mask.

Brands are different. The headgear can be anywhere from bulky to minimal, and they will fit differently. The only way to tell what works for you is to try them.

Size matters. Try the different sizes, I have trouble with the small and the medium here, the large works for me. This may differ depending on brands

Some users do not like anything touching their nose. I’d try a pillow to see if this is an issue for you. Don’t assume.


Nasal Prongs

Nasal Prongs are similar to Nasal Pillows except for the fact that they actually sit inside your nose and expand slightly to seal. Nasal Pillows have mostly replaced Nasal Prongs in the marketplace. This mask style is among the least intrusive of all masks. Typically they easily seal and have very low mask leak rates. The main disadvantage of this style is with the light touch if you are a very active sleeper the headgear can shift and cause a mask leak. Generally these masks are for non-mouth breathers. There are ways (chin strap, cervical collar, tape) which may eliminate mouth breathing and allow you to use this type of mask.

Brands are different. The headgear can be anywhere from minimal to bulky and they will fit differently. The only way to tell what works for you is to try them.

Size matters. Try the different sizes, I have trouble with the small and the medium here, the large works for me. This may differ depending on brands

Some users do not like anything in their nose. I’d try a prong to see if this is an issue for you. Don’t assume.


Nasal Mask

These masks cover the nose from the upper lip to the bridge of the nose. The volume of these goes from minimum, just barely covering the nose with minimal volume otherwise to considerably bigger. Most have a hard mask mount up to the forehead, but a few do not. These tend to have mask leaks a bit larger than the Nasal Pillows or Nasal Prongs. This is because they have more area to seal and more force trying to push the mask off your face at any given pressure. With this type of mask it is important to try them because of the difference facial structures. You have to find what works for you. Again these are mostly for non-mouth breathers. There are ways (chin strap, cervical collar, tape) which may eliminate mouth breathing and allow you to use this type of mask.

Brands are different. The headgear can be anywhere from minimal to bulky and they will fit differently. The only way to tell what works for you is to try.

Size matters. Try the different sizes. This may differ depending on brands


Hybrid Masks

Hybrid masks are mix between a Full Face Mask, for the mouth, and Nasal Pillows for the nose, all incorporated into one mask. These masks are growing in popularity because there is NOTHING on the bridge of the nose and nothing blocking vision. The mask does not extend above the bottom of the nose. Like the FFM below this style mask is primarily for mouth breathers.

Like all masks, Brands are different. The headgear can be anywhere from minimal to bulky and they will fit differently. The only way to tell what works for you is to try.

Size matters. Try the different sizes. This may differ depending on brands


Full Face Mask (FFM)

The primary purpose of the Full Face Mask is to eliminate the need to correct for mouth breathing. The FFM covers the nose in a manner similar to a Nasal Mask but the lower seal is below the lips so it surrounds the entire mouth and nose. This is the traditional method of solving mouth breathing. These masks are bigger than most other masks and because of their size have more area to seal and more force trying to push the mask off your face. Generally the bigger the mask the greater the potential for leaks.

Brands are different. The headgear can be anywhere from minimal to bulky and they will fit differently. The only way to tell what works for you is to try.

Size matters. Try the different sizes. This may differ depending on brands

One specific FFM I will call out is the Amara View. I’m not saying that this mask is better than any other mask. This mask seals differently than other full face masks so it is one to try if you are having trouble finding one that fits and works for you.

OK, one more. The “Total” Face Mask. This mask covers the entire face including the eyes and is occasionally used when other choices are not working.


Specialty Masks

These are masks that have a unique feature that may allow application in different situations. This is not a statement that these masks are better or worse than any other masks that may or may not be specifically called out. As with any masks they must be tried on.

  • Cloth Masks -- cloth instead of traditional silicone or plastic for those that have an issue with silicone or plastic contacting their skin.
    • SleepWeaver Cloth Masks by Circadiance (various)
    • Wisp Nasal Mask by Philips Respironics has an optional fabric frame
  • Mirage Activa by ResMed -- A nasal mask with a conventional modern seal (good) that is held in place by a flexible silicone bellows which in turn is mounted on a conventional hard plastic mount. This allows a very light amount of pressure because of the bellows (pictures coming later).
  • Oral Mask by Fisher & Paykel -- Absolutely no contact with the nose.

Mouth Breathing

Mouth Breathing is when you open your mouth and the air pressure from your PAP is venting out your mouth typically showing on your charts as a large leak which can substantially negate the effectiveness of your therapy. It is generally not good. The solution varies depending on the person

With SleepyHead look at your Leak Rate graph where it is shaded (large leak/ LL), flat tops on this graph suggest mouth breathing. In SleepyHead right click on the left header of the Leak Rate graph and click on Dotted Lines then select "Leak Rate Upper Threshold" to get a line across the graph for ResMed. Manually set the value for Philips Respironics. Severity depends on how much over this threshold and for how long it is in the Large Leak territory.

How to manage Mouth Breathing, not in any particular order.

Tongue Trick. Place the tongue on the roof of the mouth, Practice during the daytime. The idea is to train the tongue that this is a good place to be, not overnight, but it works for some.

Cervical Collar. A "soft" Cervical Collar. This helps support and align the neck and keeps the jaw/mouth from dropping. This is becoming a very popular option. Rarely used prior to mid 2016. Users are posting a high success rate with this device. When OA tends to occur in clusters at different times of night. It's an indication that an obstruction may have occured when the chin tucks towards the chest. It's common, and the solution is either an ergonomic pillow or soft cervical collar that prevents the neck and head from being out of alignment and cutting off the airway, but they can be comfortable, prevent leaks and prevent an airway from closing up due to tucking your chin to chest and other issues. You are looking for a comfortable fit 2-inches larger than the circumference of your neck and just tall enough to support the jaw when your head falls out of alignment (measure your neck from collarbone to jaw and subtract 1". It's a very small investment that has worked very well for some people. More pressure may solve the obstruction, or it might go away with positional therapy.

Chin Strap. A chin strap is to manage mouth leaks from a variety of causes. Most result from the jaw dropping or opening either partially or wider. The chin strap is to gently keep the jaw closed. If you have to crank it shut to make it work this is not the correct solution. Note that your jaw is strong enough to open if it wants to. There is one chinstrap that is notably different than others, the Ultimate Chinstrap, Search for it if you desire.

Ergonomic Pillow or CPAP Pillow, The purpose being to maintain a proper head and neck alignment while allowing for the mask maintaing the seal in multiple positions.

Mouth Guard The concept here is a closed mouth guard to keep the air from leaking out.

Taping. Definitely the most controversial. The purpose of taping is to seal the lips and prevent mouth leaks / mouth breathing. It is not to stop the mouth from opening. I make sure that I can easily open my mouth, when taped, if I need to.

FFM – Full Face Mask or Hybrid Mask. This is a very traditional solution and it is generally effective.

Dry mouth is a symptom mouth breathing that is uncomfortable. It can and does occur with some users of a Full Face Mask. Many users use a product called Biotene to get relief from this symptom.

Mask Leak Prevention

There are, somewhat arbitrarily defined, three kinds of leaks.

  1. Mouth Leaks. These are addressed in Mouth Breathing, not here.
  2. Vent Leaks. This is a designed leak with the purpose of eliminating CO2 from the mask, it MUST be there.
  3. Mask Seal Leaks. This is the purpose of this section
    1. incorrect adjustment --- see Fitting a Mask
    2. incorrect assembly --- Owners manual
    3. incorrect size
    4. your mask is worn out and needs replacement
    5. your hose pulled it to a side --- hose management - Search for Hose Buddy
    6. facial features

Mask Seal Leaks. Bridge of Nose – A common issue is air blowing into the eyes.

  • Pick up the nask and lower it on the nose than gently move it up allowing the seal.
  • The PR Simplus is a notable exception. It is meant to be worn further down the nose and so far seems to work better for a number of people that way. Kinda like wearing your reading glasses at the end of your nose but not quite that far down.
  • The Airfit F20 works best the seal at the nasal bridge pushed all the way up against the brow
  • The Mirage Quattro is kinda in between the F20 and the Simplus.

Mask Liners can also help with leaks.

Some of the full face masks will leak up the side of your nose, blowing air into your eyes. This can be irritating and - if carried to extremes - can cause a severe irritation called "dry eye". Users have had this occur with both the Quattro Air and Simplus. To overcome it take some fabric (pajama fabric works well) and fold it into a strip about 100mm long by 25mm wide and 3 or 4 layers thick. Lay that over the bridge of my nose and drape it down, then carefully fit the mask so that it sits on the fabric. It's easier to do than it sounds. This forms a fairly efficient seal, stops your eyes getting irritated and also avoids the mask rubbing on your nose and causing a pressure sore. The size and number of layers will vary depending on the shape of your nose.

How modern masks seal See how thin and wide this seal is. This is typical of today's masks. This seal should almost float on your face. Over-tightening will lead to "hills and valleys" where air will leak. These seals are so soft and flexible that the PAP pressure alone will, if not too tight, conform the seal to your facial structure.

First and foremost it is important that a mask fits.

All PAP masks leak, it’s just a question of how much.

Understanding Leaks with SleepyHead

For this topic I'll reference RobySue's excellent tutorial on
Leaks If you want to understand leaks, read this.

Speaking with a CPAP on

You speak on the exhale part of the cycle and have no problem preventing air from rushing out of your mouth. It is an acquired skill, and all of the control comes from pressure of the tongue against the soft palate, and control of breathing effort. You can breath through my mouth and block the nasal air pressure, and you can equally breath both nasally and orally at the same time under pressure. You can even drink water by blocking the air, taking water into my mouth and swallowing. It can be easy and natural, in spite of IPAP pressure that go to high levels.

Mask Irritations

  1. Strap Marks
    1. Time, (thanks Captain Obvious)
    2. Change Mask – Different masks fit differently, consider a different style of mask
    3. Too Tight – loosen it up a bit and re-fit the mask
    4. Accessories
      1. PAP-Cap / motorcycle-look Doo Rag
      2. Vendor 31 padacheek - pads for mask straps, PurSleep CozyPads
  2. Irritation at bridge of nose, frequently will become a small open wound
    1. Refit the mask by lifting the mask and moving it up a bit higher on the nose and reset it.
    2. Straps are Too Tight, loosen the upper straps, these straps typically should be a little loose
    3. Change Mask – Different masks fit differently, consider a different mask, maybe just a different mask size.
  3. Tingling or going numb -- If the effects are only temporary it is most likely an issue with the mask strap hitting a pressure point, nerve or blood vessel and readjusting the strap position or mask fit may alleviate the problem - if on the other hand the effects are lingering and you are experiencing visual, aural or speech disturbances, or your face "falls" to one side, even if only for a while, then these may be signs of Transient Ischaemic Attacks (TIA) and you need to see your doctor quickly.
  4. Rashes/Skin Irritations/Allergies
    1. Silicone - To the mask material
      1. Vendor 31 mask Liners
    2. Other
  5. Nasal Congestion
    1. Humidity
      1. Adjust humidity up or down, it’s personal, it depends on the person, or like most suggestion here, it may not work for you.
      2. Try a Heated Hose
      3. Try a hose Snugglie
    2. Use a mask at PAP pressure, not always but often the PAP pressure allows you to handle a congestion that you otherwise would not be able to. Give it a little time and it sometimes helps if you position the head in different positions (side on each side)

Fitting a Mask

Let’s get started

  1. While sitting place the mask on your face with all straps loose and the forehead piece is extended
  2. Turn on your PAP, your mask should be leaking like the proverbial sieve.
  3. Lay down on your back and listen, get a feel for the leaks,
  4. I place my hand on a mask and place it on my face, shift its position slightly as needed. If I can’t establish what feels like a comfortable seal at this stage I may reject the mask and try another
  5. Adjust the bottom straps, make sure they are even, tighten until either under the mouth just seals (Full Face) or under the nose just seals (Nasal)
  6. Evaluate, is the mask leaking? Are you comfortable? The mask should be easily and comfortably resting on your face. If it hurts, loosen it.
  7. You will likely have minor leaks, try these easy fixes
    1. run your finger around the mask to ensure the seal is folded under to allow it to form a seal.
    2. For leaks near the eyes, lift the mask from your face a bit, and lay it back down on your face a little low on the bridge of your nose, then slide the mask up a bit to the bridge of the nose to where you want it. That should turn the edges of the mask under and seal any minor leaks while making the mask more comfortable to the nose.
  8. For leaks under the lower part of the nose you can try twitching your mouth and nose every which way you can.
  9. Now test for leaks while on your side, both sides.
  10. Remember it only has to be as tight as you can handle comfortably. If you can't form a comfortable seal then you need a different mask.
  11. Adjust the forehead piece until it is comfortably resting on the forehead
  12. Tighten the top straps, you do NOT want the forehead piece to be digging in
  13. The mask should fit comfortably, not tight.


Fitting points

Modern masks are designed to fit “loose”, NOT tight. Too many users over tighten their masks thinking if I tighten it just a little bit more I’ll stop that leak. Generally this means one of 2 things, either you have over-tightened the mask or it is the wrong size. It’s a fine line.

Medicare Replacement Schedule

United States Medicare Replacement Schedule

Item Frequency
A7034 CPAP Mask (Every 3 months)
A7035 CPAP Headgear (Every 3-6 months)
A7036 CPAP Chin Strap (Every 6 months)
A7037 CPAP Tubing (Every 3 months)
A7038 Disposable Filter (2 new filters every month)
A7039 Non-disposable Filters (1 new filter every 6 months)
A7030 Full Face Mask (Every 3 months)
A7029 Nasal Pillows (2 per month)
A7046 Humidifier Chamber (Every 6 months)
E0601 CPAP (Generally, 3 to 5 years)

This is not a complete list, check with your individual insurance company.

PAP Mask Fitting Guides

Full Face Masks

Nasal Masks


How to achieve the perfect mask fit - GUARANTEED! by Jeffy1958

an Article by Forum Member Jeffy1958, edited by forum Advisory Member and Wiki Editor bonjour and forum Apnea Board Monitor and Wiki Editor PaytonA. This article is intended for nasal or full face masks with air inflating seals.

I am not a doctor or a member of any medical profession. I am not an engineer or a designer of any CPAP equipment. I am not affiliated with any company associated with any type of CPAP Equipment. I receive no compensation for any information I may provide that may be helpful. What you are about to read worked for me and should not be used as a substitute for the manufacturer’s written instructions. This is written to offer guidelines to those who may have a need.

I have been on CPAP, actually APAP, since October of 2010. I came into this kicking and screaming. No way was I going to sleep with a big hunk of plastic on my face every night. Then the first week in December I had a drastic realignment of my thinking thanks to a brilliant cardiologist named Peter. I have heart disease and I may not have had to endure what I did the summer of 2010 had I gone to him in the first place. I won’t bore you with the details, there is post titled OSA-and-your-HEART, you can read about it if you want.

As a result of my thinking realignment, I went all out and started to research as much as possible. I had nine days off over the Christmas Holidays and a computer. I researched until my eyeballs would bleed. Am I an expert? Far from it. There are still things I’m learning. During the course of my research I found there were many who complained about the way their mask would fit. This is when I decided to focus my attention on getting the perfect mask fit and helping as many people (hose heads) as possible.

I have been a mechanic just about all my life. Learned how to trouble shoot and fix things growing up on a farm in the late 60’s and early 70’s. Continued on in the military, U.S.A.F., as an aircraft mechanic the late 70’s, 80’s and early 90’s. Discharged in the early 90’s and have been an Industrial Mechanic ever since. My training and experiences have taught me to never accept the obvious, but to look at all angles and possibilities to find the best solution. I am not an engineer; I use the common sense approach. Please do not take this as disrespecting engineers. {Why is the part that’s broke and held on with only two bolts, behind something that’s held on with 20? So I must thank them for my job security.} Most of what I have learned about fitting my mask, I found on my own using trial and error. But the most important thing to remember is PATIENCE. You need to have patience to obtain the most comfortable (perfect) mask fit. If you can’t be patient and get frustrated, you have no chance. Therefore; don’t waste your time reading any further. It will have no use to you.

CPAP can only help you sleep better if you have a good-fitting, non-leaking mask.

Why does one of the most important parts of our therapy/treatment; have to be the most difficult and/or painful to get right? All CPAP masks work with all machines. Is it an engineering issue? One would hardly think so because of the many different types and styles of mask available to Sleep Apnea patients. There can’t be that many incompetent engineers. So why can’t most patients get a good fit? It has to be the way our minds were/are trained to think. If it leaks - tighten it. When it comes to properly fitting your mask, keep this, the most important thing in mind:

TIGHTER IS NOT ALWAYS THE ANSWER!!!

Go and get your mask. Look at it, touch it, fondle it, caress it, feel it, stroke it, or do whatever it is necessary to become intimate with your mask. It’s going to be intimate with you every night. It’s going to be a part of you. It has to be if you want to enjoy life to the fullest. If your mask has to become part of you, then it should be just as comfortable on your body as the rest of your body parts. If not then what is the point? You will not get the full benefit of your CPAP therapy if you sleep uncomfortable every night.

Fact 1: You need to exercise extreme patience when trying to fit your mask. Yes, this is worth repeating. You need to have patience.

Fact 2: You need to have P. M. A. That is: Positive Mental Attitude regarding anything concerning your CPAP therapy/treatment. Positive attitude = positive results. Negative attitude = negative results.

Fact 3: If you remember nothing from this, remember Jeffy’s philosophy: What the mind can conceive and believe; the body will achieve!!

Fact 4: Hose Heads are normal people; it’s the rest of the world that is abnormal. It takes a very special individual to sleep with a hunk of plastic and a 6 foot hose attached to their head every night!!! And look sexy as hell to our life partners.

Fact 5: Tighter is not always the answer. Just because it leaks do not assume it needs to be tightened. You need to investigate first by adding pressure with your hands to various parts of the mask to determine what straps need to be adjusted.

Fact 6: The air supplied from the machine creates the seal around your face. It also tries to push the cushion out from under the mask which would cause a leak, A certain amount of friction must be maintained between your skin and the mask cushion. You may need to clean your cushion daily and your face just before bedtime to remove oils and maintain this friction.

Fact 7: The head gear holds your mask in place and has very little to do with making a seal and a lot to do with allowing the cushion to maintain the seal.

Fact 8: Your head gear straps need to be even. Uneven straps will cause your mask to shift or twist on your face.

Fact 9: Just because it leaks around the top, don’t assume you need to adjust the top straps. Just as if it leaks around the bottom, don’t assume you need to adjust the bottom straps. Sometimes you need to think in reverse. Investigate as in Fact 5.

Fact 10: Your clinician knows less about you than you do, and they deal with many different types of machines. Therefore; they are experts of none.

Fact 11: You need to know all there is to know about your machine and all its accessories. Especially the mask. How well do you know all your other body parts? You need to know your mask like you do a foot or hand or…

Fact 12: Any strap adjustments should be small, minuscule, minute, little, slight, etc; etc; adjusting the same amount on both sides.

Now that you know the facts, let’s try to get the correct (perfect) fit. You should not feel the pressure of the mask pushing on your forehead. Remove the head gear and hose from your mask, lay flat on your back and place it on your face. This is about how it should feel if it is on correctly, no air flow. Just the weight of the mask. You should not have to “rig” or “modify” your head gear with rubber bands, string, tape, etc; etc; if you do, throw it away and get a different mask. If the engineers and designers of the mask thought it would be necessary, they would have included it with the mask. You should not have any marks on your face when you wake up. Your skin is far more resilient than the rubber or silicone used to seal the mask. Connect the hose to your mask and to your machine leaving the head gear off then turn on your machine. Let it ramp up or use the mask fit feature if your machine has one or do whatever it needs to do to get to maximum operation pressure. Hold the mask in place using your fingertip and slight pressure. Did you notice how the seal fills with air? This is what makes the seal, not the head gear. While holding the mask in place with your fingertip, slight pressure and ensuring there is no leaks, turn on your sides. How much pressure do you need to apply with your finger to keep the mask from leaking? This is about how tight you need to adjust your head gear.

Your mask should be filled with air when fitting.

Now we can attach and adjust the head gear. The head gear needs to be EVEN. If the head gear is uneven your mask will have a tendency to shift or twist on your face which will break the seal and cause leaks. Most head gear, the ones I’ve looked at, are one piece construction. The easiest way to find center is to completely undo the straps from the Velcro and fold it in half. The fold is the center which you can mark with chalk or tape or some other kind of non-destructive marker. You should now have two marks; one for the center of the top straps and one for the center of the bottom straps. The distance from the top mark to the top anchor points on your mask should be equal. The distance from the bottom mark to the bottom anchor points on your mask should be equal. ALL FOUR DO NOT NECESSARILY HAVE TO BE THE SAME – DON”T EVEN TRY!!! The tops have to be equal to each other and the bottoms have to be equal to each other. Yes; exactly would be best!!! You will need to figure out your own “starting” point. Remember how much pressure you needed to hold the mask on your face with your fingertip? That should be your guide to a starting point. When you put the mask on, with head gear, while in the sitting position, it will feel like it’s going to fall off. This is normal because we don’t sleep in this position. Lie down and check for leaks. Keep in mind that the air pressure from your machine will try to blow (push) the mask off your face. The head gear is there to keep that from happening. Think about what is happening for a moment. The silicone seal inflates with air creating the seal, the air also causes your mask to “float” on your face, and the head gear is the “anchor” so to speak. The mask doesn’t weigh that much, air is trying to push it off your face, so why would you need a lot of strap pressure to hold it down? Because if you need high pressure with a full face mask it creates a lot of force trying to push the mask away from your face which can negate the seal.

Now comes the adjusting part. This is critical in obtaining the “perfect” fit. The one that lets you sleep without realizing you are wearing a mask. Well almost. Adjust it until it stops leaking. Make sure you adjust both sides equal. Try it in every sleeping position; on your back (not recommended) left and right side. If it leaks; make the necessary adjustment. Keeping in mind that if it leaks on the top… Fact 9. Once you have achieved “no leaks” try backing the adjustment off about half of what you did. As ridiculous as this sounds, that 16th or 32nd of an inch can and will make the difference. This is where the “patience” part comes in. You need to leave frustration in the hallway and out of your bedroom. Once you have it exactly as you want it, mark the head gear. (A small stitch, permanent marker, etc, etc.) Washing it will change how it fits and you will need a starting point. Your head gear will stretch over time and you will need to make very minor corrections. If you take the time, you can get this perfect for you. I worked at it for a week before I finally got it. When that night comes, you will be doing cartwheels down the hall. Your family members will think you went off the deep end because they won’t understand. Your Apnea family will understand and chances are we will be doing the cartwheels with you!!! I know I will if I hear of any successes based on what was applied using information from this paper.

Remember: Positive attitude = positive results and small, I mean SMALL adjustments. You can and will achieve the ultimate fit. I know it in my heart. I’m pulling for you. GOOD LUCK!!!