Study with the experts

Interactive Course on

Noninvasive positive pressure

ventilation: state of the art
Pisa, Italy

June 10–12, 2004

ERS School Courses 2004

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 Interfaces: what’s new and how to get it right

Mrs Susan Sortor Leger

RRT, ResMed SA
2 rue Maurice Audibert
69800 Saint-Priest, France
Susansl@resmed.fr

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.

The aims of this presentation are to:

Provide some guidance in the initial choice of interface for long-term noninvasive ventilation.
Provide information to help understand the impact of excessive leak and provide solutions.
Explore monitoring tools which can help evaluate the quality of ventilation and mask choice.
Introduce the participant to alternative mask choices for challenging patients.

Initial mask choice

Masks used to provide noninvasive ventilation can be either nasal masks, nasal prongs, mouthpieces,
oronasal (full face) masks or total face masks. If a patient is mouth breathing during spontaneous
ventilation then it is most logical to begin with a FFM, otherwise one can begin with a nasal mask.
Choosing the correct size mask and obtaining initial comfort is the first objective. Proper fitting of the
mask with the least amount of strap tension to acceptably control leaks is key. Most mask
manufacturers offer guidelines and sizing gauges to help choosing the best size mask. Their
recommendations should be followed.

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.

Daytime mouthpiece ventilation

Mouthpieces have been in use since the 1960’s to provide up to 24 h ventilation. They have been
successfully used in patients with little to no vital capacity and provide an excellent adjunct to
nocturnal nasal ventilation for patients unable to maintain acceptable blood gases using nocturnal
ventilation alone. They have the advantage of being simple and inexpensive to use. Angled
mouthpiece provide the best comfort and find a mechanism to use them without having to hold them
allows patient autonomy for other activities.

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.

52
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

Nonintentional leak in l/sec

Mouthleak vs mask leak

Assuring independence for patients with limited arm mobility and hand dexterity
Alternatives to traditional strapping systems:

Strapless oronasal mask

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Main References

General
Mehta S, Hill NS. Noninvasive ventilation: state of the art. Am J Respir Crit Care Med 2001:
163:540-577

Schonhofer B, Sortor-Leger S. Equipment needs for noninvasive mechanical ventilation.

Eur Respir J 2002 Oct;20(4):1029-36

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

Bach JR. Management of neuromuscular ventilatory failure by 24 hour noninvasive intermittent

positive pressure ventilation. Eur Respir Rev 3: 284-291, 1993

Comparative Studies

Navalesi P, Fanfulla F, Frigerio P, Gregoretti C, Nava S. Physiologic evaluation of noninvasive

mechanical ventilation delivered with three types of masks in patients with chronic hypercapnic
respiratory failure.
Crit Care Med 2000 Jun;28(6):1785-90

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

Dead Space & CO2 Rebreathing

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

Lofaso F, Brochard L, Touchard D, et al. Evaluation of carbon dioxide rebreathing during

pressure support ventilation with BiPAP devices. Chest 1995; 108: 772-778

Ferguson GT, Gilmartin M. CO2 rebreathing during BiPAP ventilatory assistance.

Am J Respir Crit Care Med 1995; 151: 1126-1135.

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.

Teschler H, Stampa J, Ragette R, Konietzko N, Berthon-Jones M. Effect of mouth leak on

effectiveness of nasal bilevel ventilatory assistance and sleep architecture. Eur Respir J 1999
Dec;14(6):1251-1257
Comment in: Eur Respir J. 1999 Dec;14(6):1241-3

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

Richards GN, Cistulli PA, Ungar RG, Berthon-Jones M, Sullivan CE.

Mouth leak with nasal continuous positive airway pressure increases nasal airway
resistance. Am J Respir Crit Care Med 1996 Jul;154(1):182-186

Alternatives solutions and Pediatrics :

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

Name Company Sizes Sizing Cleaning Replace-

Gauge and ment
available Disinfection Parts
Guide
Oracle Fisher & Paykel Standard No Yes Yes
www.fphcare.com Small

Buccal CIM FRANCE One size No

4 route de Longjumeau
C.I.M. 91380 CHILLY
MAZARIN
FRANCE
www.cimfrance.com

Angled Respironics 2 sizes No No No

Mouthpiece www.respironics.com part #
Lip Seal
is #
FC06570

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

Image3™ Respironics Small Yes - No - No

www.respironics.com
Full Face Medium integrated Disposab
Mask Large le
Performa- Respironics Small Yes - No – No
www.respironics.com
trak™ Full Medium integrated Single
Face Mask Large patient
use
Respironics Respironics One Size No No No
www.respironics.com
Total™ Full
Face Mask
Oro-Nasal Hans Rudolph Small No No Yes
www.rudolphkc.com
Face Mask Medium
Large

Castar “R” Distributed by: Pediatric No No- Yes

Adult-Ped Starmed Small Single
www.starmedsrl.com Medium patient
Large use
Extra-Large
Facial
Peters

57
 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

Alizes™ Nasal Hans Rudolph Small Yes Yes- Yes

Mask www.rudolphkc.com Medium dishwasher
Large safe and
steam
autoclavabl
e
Papillon® MAP Standard No Yes Yes
www.map-med.com Medium

Ultra Mirage™ ResMed Standard Yes Yes Yes

Nasal Mask www.ResMed.com Large
Shallow
Shallow/wide

Mirage® Nasal ResMed Standard No Yes Yes

Mask www.ResMed.com Large
Shallow

Mirage Activa™ ResMed Standard Yes Yes Yes

Nasal Mask www.ResMed.com Large
Shallow

Mirage Vista™ ResMed Standard Yes Yes Yes

Nasal Mask www.ResMed.com Deep

Mirage Kidsta™ ResMed Small (child) Yes Yes Yes

www.resmed.com (7 – 16 yrs)

Infant Nasal ResMed Infant - Small No No Yes

Mask www.resmed.com Infant – Large
Child

ComfortClassic Respironics Small Yes Yes Yes

™ www.respironics.com Medium

58
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

Contour Deluxe Respironics Small Integrate Disposable No

www.respironics.com Medium d single
Large use

Profile™ Lite Respironics Small Not that Yes Yes

www.respironics.com Medium/Small I could
Medium find

Profile™ Lite, Respironics Small Not that Yes Yes

small Child www.respironics.com Medium/Small I could
Medium find
Simplicity™ Respironics Small No Yes Yes
www.respironics.com Medium

Phantom® Nasal SleepNet One size Only for Not that I No

Mask www.sleep-net.com headgear could find
Based
on hat
size
IQ® Nasal Mask SleepNet One size Only for Not that I No
www.sleep-net.com headgear could find
Distributed by Based
Breas on hat
www.breas.se
size
Minime™ Nasal SleepNet One size Only for Not that I No
Mask www.sleep-net.com headgear could find
Based
on hat
size

FlexAire Sunrise Medical

Softfit® Tyco/ Small narrow Yes Not that I Yes
Puritan Bennett Small could find
www.puritanbennett.com Small wide
Medium
Medium wide
Large
Breeze Sleep Tyco/ 3 sizes of Not that Not that I Yes
Gear™ with Puritan Bennett mask I could could find
Dream Seal® www.puritanbennett.com interchangeabl find
e with nasal
pillows
Lyra CPAP Viasys Healthcare Extra Small
Nasal Mask Small
Medium
Large
SOMNOmask™ Weinmann Standard Not that Not that I Not that
www.weinman.de Medium I could could find I could
find find

59
 Nasal Prongs

Name Company Sizes Sizing Cleaning Replace-

Gauge and ment
available Disinfection Parts
Guide
Spiritus I think this was an earlier
version of the Nasal Aire
by Innomed

Nasal Aire II Innomed Technologies 5 sizes

www.innomedinc.com

Nasal-Pap Innomed Technologies

Freestyle www.innomedinc.com
(coming soon)

ComfortLite™ Respironics Direct Yes Cleaning Yes

www.respironics.com seal and only
simple
cushions
Small
Medium
Large
Breeze Sleep Tyco/ 7 sizes of Yes Cleaning Yes
Gear™ Puritan Bennett nasal only
www.puritanbennett.com pillows

Lyra™ CPAP Viasys Healthcare Extra Yes Cleaning Yes

Found at the ATS Nasal Mask www.viasyshealthcare.com Small only
but picture was Small
not on their Medium
website Large
Mirage ResMed Small No* Cleaning Yes
Swift™ www.resmed.com Medium only#
Large
* Three # Disinfection
pillow guide available
cushion 2-3 months
sizes after initial
packed release
with every
product

60