CPAP mask for sleep apnoea: effective but not very popular

Most CPAP masks have a standardised shape and cannot be customised. So it may happen that the mask does not fit properly or slips during sleep and air escapes. The positive pressure of the breathing air required for therapy is then no longer ensured.

In addition, the escaping air flow can lead to eye irritation and even conjunctivitis. Painful pressure sores and pressure ulcers can also be potential consequences if the CPAP mask does not fit. The escaping air can also disturb the bed partner and, in the worst case, lead to colds. In addition, healthy sleep is severely disturbed for both sufferers and their partners.

Switching to a different mask is worth a try, but it does not always eliminate the problems. Please discuss this with your doctor. Alternative treatments should also be taken into consideration.

Breathing out against the continuous positive pressure of the CPAP ventilator is not like natural breathing. Therefore, breathing with a CPAP mask is often perceived as very strenuous and uncomfortable. Some even experience a feeling of breathlessness. If those affected cannot remove the mask quickly enough in this situation, anxiety and panic attacks can even develop.

Many feel constricted by the breathing mask. The mask must fit tightly so that no air can escape at the edge. The rubber bands that hold the mask in place must therefore be relatively tight. Even when set ‘as loose as possible’, the pressure is still oppressively uncomfortable for many. Many people therefore have to get up every night to take off the CPAP mask.

Other reasons for discomfort & panic attacks when wearing the CPAP mask may be:

• previous negative experience, e.g. ventilation via a mask in hospital.
• concern about possible strangulation from the headgear of the mask
• the annoying weight of the CPAP mask.
• the feeling of a foreign body in the face, especially with full-face masks
• panic caused by the cold air coming out of the mask.

To alleviate claustrophobia and possible panic attacks caused by CPAP, it is helpful to be aware of the following facts:

1. The CPAP ventilator always pushes in air to breathe
2. Claustrophobic anxiety often arises because the ventilator wants to continuously push air into the person. But this is exactly the important air to breathe and prevents the dangerous closing of the airways. The risk to health is considerably greater without a CPAP mask
3. Practicing with the CPAP mask during the day can help, e.g. in front of the TV or while reading.
4. There are alternative treatments, so don’t put yourself under pressure. But don’t give up too quickly either. Getting used to the CPAP mask takes time.

Common side effects of CPAP therapy, such as dry mouth/throat and dry/blocked nose, are caused by the increased flow of breathing air through the CPAP mask. In particular, breathing through the nose can be difficult due to the increased pressure. As a result, the nose is often blocked and nosebleeds may occur. In addition, a lack of moisture can negatively influence the natural germ spectrum of the mouth and throat. Numerous bacteria and other microorganisms that are useful for us normally colonise our mucous membranes. If their spectrum changes, this can lead to bad breath, among other things.

In addition, dry mucous membranes of the nose and mouth cannot optimally fulfil their barrier function in the defence against pathogens. There is evidence that CPAP ventilation increases the risk of upper and lower respiratory tract infections.^8,9 To prevent the mucous membranes from drying out, the use of humidifiers that can be connected directly to modern CPAP machines is recommended as a preventive measure.⁷

The consultant should monitor whether the pressure is set correctly – i.e. neither too low nor too high. This is because mouth breathing often increases with CPAP, as the open mouth compensates for the more difficult breathing through the nose. This is problematic, because breathing through the mouth not only dries out the mucous membranes, but is also unhealthy for other reasons. Sleeping with the mouth open causes the mucous membranes to produce more mucus to counteract the dryness, which makes the nose even more congested, which in turn promotes mouth breathing. In addition, mouth breathing also leads to bad breath and, in the worst case, to tooth decay. A dry mouth deprives the teeth of their natural saliva layer, which encourages bacterial foci and causes bad breath. It is best to breathe through your nose while using a CPAP mask. This reduces adrenaline release and increases oxygen saturation in the blood. Snoring and breathing pauses are also reduced.

Another major disadvantage of mouth breathing: The body misses out on nitrogen oxides that are produced naturally in our sinuses when we breathe through the nose. Nitrogen oxides are significantly responsible for endurance and strength of the muscles and regulate blood pressure as well as sleep quality because they dilate the blood vessels.

If dry mouth persists despite mask replacement and adjustment of positive pressure, other aids or alternative sleep apnoea treatment should be used.

Muscle soreness in the chest can be a side effect of CPAP therapy, with which the respiratory muscles react to positive pressure ventilation. The lungs must constantly work against increased pressure during CPAP ventilation. This unusual effort can provoke a strain of the respiratory muscles in the chest.

If the pressure of the CPAP machine is too high, the user may swallow air and some of the air may not enter the airways but pass through the oesophagus into the gastrointestinal tract.

Abdominal pain, bloating and flatulence are possible consequences of this. This can only be avoided by restricting the excess pressure. On the other hand, the pressure must not fall below the therapeutically required level, otherwise the nocturnal breathing pauses will continue to occur. The dangerous consequences and risks of untreated sleep apnoea then remain. Sleeping with the upper body elevated and avoiding eating and drinking late at night can help alleviate the symptoms of CPAP bloating.

Other causes of bloating due to a CPAP mask:

• Hyperventilating: Particularly in the case of medium to high breathing pressure, the difficulty in exhaling can possibly lead to anxiety and panic with hyperventilation, in which air is swallowed and bloating results.
• Open mouth: So-called mouth breathers sleep with their mouths open at night. However, if a patient with an open mouth now wears a CPAP nasal mask, the air pumped by the sleep apnoea device can escape through the mouth. There is an unconscious panic reaction and the feeling of suffocating, meaning the air is inhaled too quickly and forced into the oesophagus. In this case, the mask type should be changed to a full-face mask.
• Rhinitis or nasal congestion: Whether it’s a runny nose or a blocked nose. Flu, colds and allergies mean you can’t take the extra pressure needed to keep your airways open. Air is swallowed, which leads to bloating.
• Air pressure too low: Not only too much pressure can lead to flatulence. If the pressure is too low, the nocturnal breathing pauses will continue. The need for more air in the lungs may also result in air being swallowed.

Some people feel disturbed by the noise of the CPAP machine during sleep. Noise also emanates from the mask valve. Wearing earplugs, which is recommended for noise-sensitive people, is of limited use, as it can impair sleep. The bed partner’s sleep also suffers due to the noise. Often this side effect of the CPAP mask leads to relationship problems and separate beds.

Can CPAP therapy also be used by people with colds or hay fever? Mucus in the airways and a blocked nose can make breathing with a CPAP mask more difficult. In the case of a common cold, the treatment may be paused for a short time. The situation is different with hay fever, which sometimes lasts for months. There is no satisfactory solution to this problem. In any case, if you have a blocked nose, it is advisable to wear a full-face mask that covers your mouth and nose. These in turn can lead to the side effects mentioned above such as dry mouth and pressure sores, as well as leaking air if the CPAP mask does not fit.

CPAP masks should be cleaned after each use. This is because germs attach themselves very quickly to the plastic masks and are inhaled if they are not removed regularly. Dangerous pathogens that cause pneumonia, for example, can also enter the respiratory tract via contaminated masks. Therefore, the manufacturer’s recommendations should be followed very carefully when cleaning the CPAP.

CPAP masks are not sexy. Many partners feel irritated and disturbed by the technical equipment. Some of those affected even report relationship crises. The very thought of having to wear a ventilator and mask night after night for the rest of their lives frightens many patients and their relatives. But this is the only way that positive pressure therapy can lead to success.

Puffy eyes, dark circles and unsightly bags under the eyes are a common side effect of CPAP therapy. This is mainly due to incorrectly adjusted full-face masks, which can exert pressure under the eyes and next to the nose.

A leaky CPAP mask can also be the cause, as tiny air leaks can irritate the eyes. If cold exhaled air is constantly getting into the eyes, they will dry out and swell. There may be additional problems with the tear glands, sinuses or eyelids. The exhaled air can cause fluid to build up around the eyes if it enters these ducts.

The first thing to do here is to remain patient. CPAP therapy takes time. Once a mask is found that fits properly, these side effects often disappear on their own.

What to do about bags under the eyes and puffy eyes:

• Place a metal spoon in the freezer for a few minutes.
• Press the cold spoon on the swelling for a few seconds, moving it slightly.
• Apply alternately to both eyes until the spoon is warmer again.
• Change from full-face mask to nasal mask or nasal pillow mask, unless you are a mouth breather, i.e. sleep with your mouth open.
• The CPAP nasal mask relieves pressure, lymph fluids can drain better and do not accumulate under the eyes.
• Before sleeping, put a plaster on the empty bags under the eyes. This prevents the tissue from filling with fluid during the night.

If you still feel constantly tired and your snoring persists, this might be a sign that the breathing pauses are not successfully stopped by the CPAP mask. This means that your daytime performance continues to be impaired and the risk of secondary diseases remains high.

In this case, you should consult a doctor and discuss possible alternatives.