There was the police officer who never filled his prescription. The elderly woman who rejected more than a dozen masks. The construction worker who kept dreaming he was drowning. For patients, CPAP setups—and particularly the masks that go with them—can be intimidating, uncomfortable, and, all too often, ineffective.

But it doesn’t have to be that way. Today’s manufacturers offer ample options, and sleep masks can be remarkably successful. “The key is to get the patient compliant within the first few weeks,” says Sandy Fermoile, president/owner of Apnea Care Inc, in Buffalo, NY. “That means spending a lot of up-front time on patient education.”

According to the National Institutes of Health, some 12 million Americans suffer from sleep apnea, a serious, potentially life-threatening condition that owes its name to a Greek word meaning “want of breath.” Sleep apnea is a breathing disorder characterized by brief interruptions of breathing during sleep. Early recognition and treatment of sleep apnea are important because it may be associated with irregular heartbeat, high blood pressure, heart attack, and stroke. Continuous positive airway pressure (CPAP) is the most common treatment for obstructive sleep apnea and a profitable market for DME providers willing to invest the time and energy it takes to keep patients compliant.

“The whole key to an effective CPAP setup is matching the right mask to the right individual,” says Jill Myers-Glenn of the Pacific Sleep Center in Vancouver, Wash.

Essentially, there are three major product types or interfaces—the nasal mask, full-face mask, and nasal pillows. The nasal mask goes over the nose. The full-face mask goes over the nose and mouth, making it especially suitable for patients who sleep with their mouths open. Finally, the nasal pillows, which are soft silicone plugs, are inserted into the nostrils, an effective option for patients who are claustrophobic, move around a lot while sleeping, or are allergic to the mask material.

In all cases, the interface is attached to tubing connected to the CPAP machine, which delivers the pressurized air that prevents apneas from occurring. However, within each of the three product types, there are numerous features that vary. So how does a provider go about selecting the right mask for a specific patient?

It’s All in the Fit
Most experts agree that the single most important factor that affects compliance is the fit of the mask. “Fitting a CPAP mask is similar to fitting shoes,” says Kevin Metz of Metz Medical Inc in Kenosha, Wis. “If the shoes do not fit, you will not wear them; and if the mask does not fit, the patient will not comply with therapy.”

For DME providers, noncompliance costs money. If a mask fits improperly from the outset, a patient can develop ulcers on the nose from tightness or conjunctivitis (eye infections) from air leaks. The provider then needs to make additional patient visits and provide replacement masks—often absorbing the cost of the replacement masks. Hence, getting the fit right—right from the start—is critical to the provider’s bottom line.

Moreover, providers receive a fixed dollar amount from insurance companies for sleep therapy masks. Some providers aim to maximize profits by delivering a less expensive mask. But the strategy backfires when the patient complains of discomfort.

“The margin on masks is quite small to begin with,” Myers-Glenn says. “If you end up replacing too many masks, you’ll cut into your profits.” Worse still, patients may give up on therapy altogether, which means the provider loses out on the bigger profit margin associated with the CPAP units themselves.

“The goal of a proper fitting is threefold: To ensure patient comfort, ease of use, and effective treatment,” says Diana Guth, RRT, owner of Home Respiratory Care in Los Angeles. To make sure her clients receive a proper fitting, Guth has them come to her facility, which features two fitting rooms complete with beds so patients can experience the masks lying down.

Metz, too, prefers his clients to visit his facility for their fittings. “One big benefit is that I have an entire inventory of masks available for every fitting,” he says. While in-home fittings can be successful, some providers fail to bring along enough mask options. Worse yet, a provider may simply ship a mask to a patient without a proper fitting or any education.

Start with the Sleep Study
Successful providers dedicate a good deal of time and service in order to fit a sleep mask. First, they read and evaluate the sleep study prior to the CPAP setup appointment. “The patient’s sleep study gives me an understanding of the severity of his apnea, and it tells me how well that patient tolerated a particular type of mask,” says Chris Solitaire, RRT, clinical manager of San Antonio Extended Medical Care.

Myers-Glenn recommends that providers work closely with sleep laboratories, watch studies in progress, and review the results with a sleep technologist. “The more a provider understands about the study, the better he or she can support the patient’s needs,” she says.

Moreover, building a strong rapport with sleep laboratories leads to referrals. “We give referrals to the DMEs who are service-oriented,” says Michael Salemi, general manager of the California Center for Sleep Disorders in Oakland. “The best DME providers come to the lab, interface with our people, and work hard to accommodate patients.”

The sleep study can also provide clues as to how receptive a new patient will be to the CPAP setup. “Sleep studies can involve big masks and large, loud machines,” Guth says. “Patients may be turned off from the start because they don’t understand that we’ll be setting them up with a smaller mask and a quieter CPAP unit.” Conversely, sleep laboratories can sometimes recommend a particular type of mask because the patient responded so well to it in the study.

Communicate, Educate, Demonstrate
The interview is the next important step in the mask fitting. Whenever possible, providers interview the patient along with his or her bed partner. The intention is to learn about the patient’s sleep habits, lifestyle, and physical limitations, as these factors will influence the choice of mask.

A wide variety of factors—from the position the person sleeps in to allergy problems and skin sensitivity to manual dexterity—need to be considered. Guth offers a common example, “If a patient has arthritis, we veto masks with small parts and tend toward headgear that is stretchy and easy to use.” Or, if a person suffers from allergies or sinus problems, treatment will be more effective with a humidifier.

Information gleaned from the interview process helps narrow down the mask options. For example, a bed partner may point out that the patient is a mouth breather. The provider then knows to rule out nasal pillows, as treatment would be ineffective. This patient requires either a nasal mask that features a chin strap to hold the mouth closed, or a full-face mask.

Good communication with the patient is one of the most important factors in arriving at a proper fitting. This means listening carefully and providing education. At Apnea Care Inc, the education program includes an overview of sleep apnea, how CPAP works, and mask-related problems patients should watch for. “The better educated the patient, the more likely they will stick with the treatment,” Fermoile says.

The actual physical fitting of a sleep therapy mask is part science, part art. A correct fit means there will be no air leaks and the patient will get full pressure. Manufacturers provide templates for DMEs to work with. Gauges help the DME provider size the mask. But Guth says gauges are just a starting point. “You have to assess the size and shape of the nose,” she says. “People with a very high, prominent, or narrow nose bridge can be a challenge to fit.”

The key is to allow ample time for the process—often up to one full hour. In addition to fitting and adjusting, it is important to demonstrate any unique features and explain mask maintenance. The process is complete only after the patient masters a hands-on trial. “I have the patient try on the mask, adjust it, and do away with any leaks,” Solitaire says. “If they’re having too much difficulty, we try another mask style.”

Features and Follow-Up
Matching the right features of a mask and headgear to the right patient goes a long way toward improving compliance. For example, several masks feature a quick release device. Some have an adjustable pad that rests on the forehead. Many patients derive a sense of control from options like these. On the other hand, simpler models with fewer parts are more appropriate for elderly patients.

The objective is to find features that make the patient physically and psychologically most comfortable. A light sleeper, for example, might prefer a mask that features sound-absorbing material over the exhalation port. Other masks are very small, which can be ideal for patients who feel claustrophobic with a larger apparatus. There are even special masks for patients who wear eyeglasses and prefer to read in bed.

Another key to compliance is thorough follow-up. Smart providers make it their business to call the patient within a week or two of the mask fitting to assess progress. If a patient is experiencing difficulty, early intervention is critical. “If there’s a concern with the mask, I’ll meet with the patient again,” Solitaire says. “I observe exactly what they’re doing so I can correct the problem before the patient gets frustrated.”

If the DME provider does not take the time to follow up with patients, the sleep laboratory may wind up with the burden of lost paperwork, patient calls, and general confusion. “Labs are here for diagnosing,” Salemi says. “We need to count on the DMEs to deliver the patient service.”

From a business standpoint, it makes good sense to stay in close contact with patients. For starters, satisfied patients can be lifelong customers. Replacement masks, headgear, and other supplies are an ongoing source of revenue. Most insurance will cover replacement masks after 6 months, so providers should alert patients with either a mailing or a phone call just prior to the 6-month point.

Finally, happy patients can be the provider’s best source of advertising. When CPAP therapy is effective, it can change a person’s life—eliminating depression, lowering blood pressure, and improving one’s energy and outlook. Indeed, some of the most reluctant patients end up as “poster children” for the cause. “Patients refer friends and neighbors all the time,” Guth says. “If you provide the service and support to keep them compliant, your patients will be your best advocates.”

Marianne Matthews is a contributing writer for Dealer/Provider.