Tips and tricks for continuous positive airway pressure/noninvasive ventilation mask adjustments

To the editor,

Continuous positive airway pressure (CPAP) and noninvasive ventilation (NIV) are increasingly used in children worldwide, and have proved their efficacy and clinical benefits. ¹ Adequate equipment, such as well‐fitted masks, is crucial for the success of CPAP/NIV. However, finding the appropriate CPAP/NIV mask may be challenging in children, and particularly, for children with craniofacial abnormalities, as the majority of the equipment has been developed for adult patients and children without craniofacial anomalies. Only a few masks are available for infants and young children, while children over 6 years old and adolescents may benefit from all the types of masks developed for adult patients, with a large option panel. ² , ³ , ⁴ But, despite the availability of these masks, the adaptation and optimal fit of the mask are not always easy and may require the use of several masks to propose a well‐fitted mask.

In infants, there are only four pediatric masks, available in France, with the limitation that they can be tricky to adapt, with the risk of important skin marks over the forehead and head due to the headgear support, particularly, when CPAP/NIV is used for a long duration during the day. Persistent skin marks must be screened carefully to avoid further skin injuries or ulcers, which can jeopardize CPAP/NIV use. ⁵ Some “homemade” adaptation may, therefore, be useful to prevent skin injury and increase the mask tolerance. Figure 1 shows a customized commercialized pediatric nasal mask using a normal infant cap and parts of an intensive care unit nasal mask to allow the attachment of the mask on the cap. The parents of a 1‐year‐old child with a neuromuscular disease, who required NIV for a long duration daily, made this adaptation to increase the comfort and tolerance of the mask.

Figure 1.

Homemade adaptation of an infant nasal mask. (A) Soft baby nasal mask, Air Liquide. (B) FlexiTrunk infant interface, Fisher & Paykel. Source: Fisher & Paykel brochure (fisher‐paykel‐healthcare/flexitrunk‐infant‐interface‐brochure). (C) Customized nasal mask combining a normal infant cap, the mask bubble and tubing of the Soft baby mask, and the headgear parts of the FlexiTrunk mask.

Older children may also present issues with their mask. In particular, the headgear may not be always adapted to the size of the head, especially in children with craniofacial abnormalities, or on the contrary for children with small heads. Some adaptations can be made using parts of different masks. However, homemade adaptation may be generally necessary and very effective. A 7‐year‐old child with a neuromuscular disease was ventilated using an oronasal mask because of facial hypotonia causing major mouth leaks with a nasal mask. The child was well adapted to the oronasal mask, but important leaks started to appear because of the sliding of the top headgear on the forehead. We advised the parents to sew a piece of rigid cloth between the top and the back of the headgear to prevent the sliding of the headgear (Figure 2A). Consequently, the mask was perfectly adapted to the child. Another 6‐year‐old boy was perfectly happy with his nasal mask except that the headgear became slightly small on the top of the head. A headgear extension was, therefore, added on the top of the head, using an extension available for another nasal mask, to allow the child to use his colored well appreciated nasal mask (Figure 2B).

Figure 2.

Homemade adaptation of two masks. (A) A rigid cloth was sewed between the top and the back of the headgear of an oronasal mask to avoid the forward mask sliding. Oronasal mask AirFit F20 S + small headgear of the oronasal mask AirFit F10 (ResMed). (B) A headgear extension of a nasal mask (nonny nasal mask, AG Industries) was added to extend the headgear, on the top of the head, of the current colored well appreciated nasal mask of the child (Wisp Giraffe nasal mask, Philips Respironics).

Other adaptations may be made to improve the ease of putting on and removing the headgear. Some parents have replaced magnetic fasteners with snap fasteners to make it easier to put on and take off the mask as well as eliminate the risks of possible magnetic interference with medical implants (Figure S1A). This strategy could also be useful to reinforce the headgear scratches which tend rapidly to damage over time.

Interestingly, another customization of the mask can be very helpful to prevent localized pain due to the pressure support of the headgear. Indeed, several children may complain of pain on the occiput area of the head due to the headgear support or on the junction between the headgear and the frame (rigid structure) of the mask. The use of pads glued directly over the headgear has proved its efficiency to relieve the pain (Figure S1B).

Strategies may also be used to help the patients with weak upper arms or limited arm elevation to close or open easily their masks by attaching a long cord to the bottom sides of the headgear to allow them to easily pull the headgear clips close to the fastener parts of the frame to close the mask, or to pull the headgear downwards to open it.

In conclusion, several masks have been recently developed for pediatrics, however, there are still a few options available for CPAP/NIV treatment in young children. Adaptation using different masks is possible but may require the use of several masks to propose a unique well‐fitted mask, which may be very expensive. Three‐dimensional printing may represent an interesting tool in a close future for mask adaptation, particularly, in infants and young children, but much progress is still needed. Homemade adaptation of masks is very helpful and may be necessary most of the time for real increased comfort and tolerance of the mask or to improve, practicality, and NIV teams, homecare providers and parents can be very resourceful. We strongly encourage other NIV teams to share their tips and tricks to best adapt CPAP/NIV masks in children to optimize the choice and tolerance of the masks.

AUTHOR CONTRIBUTIONS

Sonia Khirani: Conceptualization; methodology; investigation; validation; formal analysis; data curation; supervision; writing—original draft; writing—review and editing; visualization. Marine Dosso: Methodology; data curation; formal analysis; validation; investigation; visualization; writing—original draft; writing—review and editing. Clément Poirault: Validation; visualization; writing—review and editing; data curation. Anais Le: Validation; visualization; writing—review and editing; data curation. Lucie Griffon: Validation; visualization; writing—review and editing; data curation. Brigitte Fauroux: Validation; visualization; writing—review and editing; data curation.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

ETHICS STATEMENT

Ethical approval obtained (CPP Sud Ouest et Outre‐mer IV; CPP2021‐01‐013a/2020‐A003083‐36) and written consent obtained from parents. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Supporting information

Supporting information.

Supporting information.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.