Ventilator-Assisted Living©

Fall 2000, Vol. 14, No. 3


UnMASKING the Issue: A Subjective Review of Seven Masks/Headgear

Audrey J. King, MA

Wouldn't it be wonderful to find a nearby accessible "Mask and Headgear" store where every known interface for noninvasive ventilator users is on display, where staff are experienced, and the products are available for trial and purchase? Such is the dream of those who have struggled for years to find the right device. Noses and faces come in a zillion shapes and sizes but are harder to fit than feet. Thousands of well-stocked shoe stores exist, yet the common scenario when shopping for masks is to be offered one, perhaps two, by a therapist or vendor who does not have or may not even know all the options available.

Increasing use of CPAP and Bi-PAP units during the last 10 years by thousands of people with sleep-related breathing disorders has stimulated the development of many new masks and headgear. As long-term ventilator users, we need to know what the choices are.

Recent attendance at the Eighth International Conference on Post-Polio and Independent Living in Saint Louis provided an opportunity to see and compare several masks. I talked with ResMed, Respironics, and Mallinckrodt representatives and brought home a variety of their newer masks to evaluate.

Three post-polio nocturnal ventilator users, including me, tried and compared five new masks/headgear, as well as the ones we currently use. We were already mask users, having converted from negative pressure cuirass use years earlier. Allan Gouldburn and Sheila Keogh both use a standard Contour™ mask; Allan with a Bi-PAP® S/T since 1992, and Sheila with a PLV®-100 since 1988. I used a Contour™ mask with a PLV®-100 since 1986, but have preferred the Healthdyne Soft Series™ which I began using in 1994. (Healthdyne has since been acquired by Respironics.)

Our evaluations were limited by the size of mask provided and length of trial. It is difficult to persist with a device that is uncomfortable and disruptive to one's sleep, especially if your current mask works well. Getting used to something new is like breaking in shoes: the longer you wear them the more you accommodate and the better you become at resolving some of the adjustment problems. It takes several weeks to fine-tune position, tightness, etc. In some cases, our opinions were based on only a few hours of use.

CAPS AND STRAPS. Limited arm function presents a challenge in managing and adjusting mask/headgear devices, especially in the middle of the night. Allan manages his mask/headgear independently, albeit with difficulty, but Sheila and I require total assistance. Over the years we all have found the Respironics Softcap™ to be the most suitable for getting on and off and for keeping the mask in place. I particularly like the Softcap™ with the clip fastener because you do not have to deal with Velcro once the straps are initially adjusted. The Ultra Mirage™ has similar release clip fasteners that are even easier to manage.

The newer masks (Simplicity™, Ultra Mirage™, and Contour Deluxe™) feature neoprene straps that are thicker, stretchy, and spongy. With the Simplicity™ and Contour Deluxe™, the user is supposed to be able to pull the headgear off and on (once the straps are adjusted) by stretching it over the head like a very tight toque or balaclava. Such maneuvers were not possible for any of us due to limited hand and arm function. The Velcro was difficult to unstick and the strap elasticity seemed to cause shifting and looseness.

The Simplicity™ has five straps rather than the usual four. This extra strap (which comes down from the forehead) simply added to the adjustment challenge and created no extra securement. We all found that the fifth strap would not stay in place.

The Breeze™ is a semi-rigid C-shaped piece which carries a narrower hose centrally from the back of the head to the nostrils and utilizes ADAM™ nasal pillows, thus combining interface and headgear in one. Once the straps on either side of the head from the back plate to the top of the head plate are set up, there are no other straps to deal with regularly.

The rigidity and absence of straps make it quick and easy to put on, but also make it less secure and difficult to keep in place. Allan and Sheila found this to be a problem, particularly Allan who moves in bed and gets up during the night. I solved this problem by attaching an extra ½-inch wide elastic strap to the side straps; a standard chin-strap can also be adapted.

The semi-rigidity of the Breeze™ headgear enabled me to easily readjust it with one hand by grasping the nasal part or by grasping the nasal part or by moving the back of my head against the stiff rear plate. Sheila found this rear piece uncomfortable to rest her head on for any length of time, perhaps because she sleeps with a pillow instead of a soft neck roll as I do.

CHEEKS AND LEAKS. People using ventilators have different pressure needs and different tolerances for leaks. In general, the higher the pressure needed, the tighter the mask needs to be and the greater the pressure exerted on the face.

We found that the Ultra Mirage™ and the Contour Deluxe™ bit into the cheeks. The regular Contour™ and Soft Series™ did not. The second membrane of the SoftFit™ Ultra, which inflates with each breath, was noticeably cushioning and did not leak or dig into the cheeks, providing a snugger and more comfortable fit. Sheila found this inflating feature, similar in the Simplicity™, to be comfortable at first, but bothersome with each breath after a while.

The Simplicity™, which is small, soft, and pliable,was satisfactory at first. However, its lack of rigid underframe required the mask to be secured more tightly in order to prevent leaks. Even when tightly secured, the Simplicity™ was difficult to keep in place and leaks occurred as it shifted.

The Breeze™, which uses ADAM™pillows, does not rest on the cheeks at all. When the headgear shifts out of position, air leaks from the nostrils. Realigning the headgear, twisting the nasal pillows sideways, and using the proper size of pillows can help solve this problem.

Not all masks/headgear have rotating and/or swivel connectors. A rotating connector allows the hose to lie in any position. A swivel connector prevents the hose from twisting and causing leakage and pressure areas. These connectors are particularly important to those who move frequently or who do not have attendant assistance.

NOSE WOES. The bridge of the nose seems to universally take the most abuse when using mask ventilation. Allan's nose is constantly red with a recurring scabby sore. Sheila's nose is pink in the morning, but fades rapidly. Mine is red and indented for a few hours, but it is not sore and the skin has never broken down.

Allan thought he had a winner with the Contour Deluxe™ but after several nights of use the soreness returned. Although we liked its smaller size, Sheila and I were not able to use this mask for more than a few hours due to cheek pressure. However, there was no nose redness. Allan found some relief with the Simplicity™, but after several nights the pressure area simply moved further down his nose. I had the same problem.

The Ultra Mirage™ features an adjustable hinge that can be set to angle the pressure off the bridge of the nose. Allan liked this feature, but felt the adjustment didn't have enough range. He would also like a more secure lock to eliminate any accidental angle changes. I found the adjustment merely transferred pressure from my nose to my upper lip and forehead. Sheila felt the mask was big, bulky, and extended too high on her forehead.

Although impressed overall with the comfort of the SoftFit™ Ultra, similar to the Soft Series™, my nose was still red in the morning as was my forehead where the spacer rested. Sheila's nose became extremely red and sore.

Pressure on the bridge of the nose is eliminated with the Breeze™ because it does not rest on the face at all. Sheila, who has high pressure needs, found the direct force of air into her nostrils painful. For me, the air delivery felt more like normal breathing than with a mask and similar to the more direct air delivery I experienced when ventilated via tracheostomy last year. Allan was not happy with the nasal prongs and the weights of the Breeze™ tubing.

COSMETIC COMFORT. I have used the Breeze™ continuously since June and will continue to do so unless problems, such as cold sores, necessitate a return to my Soft Series™ mask. I believe it is important to have an alternative back-up system. I like the openness, freedom, ease of use, and modern non-medical look of the Breeze™.

Allan liked the SoftFit™ Ultra and intends to use it regularly. He is pleased to have found a mask which will resolve his nose soreness once he establishes the right degree of strap tightness and connects a swivel adapter to stop hose twisting.

Sheila will continue to use her standard Contour™ mask which has proven problem-free for many years.

We have greatly appreciated the opportunity to try a variety of masks and headgear and thank Mallinckrodt, ResMed, and Respironics for their generosity in providing them. We would be pleased to share our ideas further. And we did come close to finding that imaginary "Mask and Headgear" store at

Mallinckrodt (800-497-4979;
Breeze™ SleepGear™
Soft Fit™ Ultra

ResMed (800-424-0737;
Ultra Mirage™

Respironics (800-638-8208,
Contour (older mask)
Contour Deluxe™
Soft Series™ (older mask)

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