Retrospective: When Were Oronasal Masks First Used to Treat Obstructive Sleep Apnea?

Journal of Clinical Sleep Medicine, Vol. 13, No. 3, 2017 Two articles1,2 and a commentary3 concerning the use of oronasal (ON) masks for treatment of obstructive sleep apnea (OSA) were published in a recent issue of the Journal of Clinical Sleep Medicine (JCSM). Such interfaces are also known as full face masks. Physicians who have entered the field of sleep medicine in the past 15 y probably cannot remember a time when ON masks were not available for use for positive airway pressure (PAP) treatment of OSA. From the first description of continuous positive airway pressure (CPAP) as a treatment for sleep apnea in 19814 until 1994, the terms CPAP and nasal CPAP were virtually synonymous. Essentially all CPAP treatment of OSA was via a nasal mask (or nasal pillows mask). Use of ON masks had been described for treatment of acute respiratory failure but not OSA. In fact, it was believed that ON-CPAP would not work in patients with OSA.5,6 However, in 1994 two papers were published asserting that ON masks might be an acceptable treatment alternative for OSA. The first paper was authored by Glen Prosise and myself 7 and the second a few months later by Sanders and coworkers.8 Neither group was aware of the other’s use of ON-CPAP. Because we had patients unable to tolerate PAP titration with a nasal mask due to severe nasal congestion, we chose to develop and study an ON mask. When we began the project, we were not aware of a commercially available ON mask for OSA treatment. Rather than use a mask designed for treatment of respiratory failure, Glen hand-made a custom mask for each patient using a thin rubber membrane wrapped over the opening of a full face mask designed for bag-mask ventilation. An appropriatesized hole was cut in the membrane to allow entry of the nose and mouth. Pressure pushed the membrane out against the face and provided a reasonable seal without the need for an uncomfortable level of strap tightening. An orifice in the mask prevented rebreathing of carbon dioxide. We studied a group of 10 patients who did not tolerate CPAP titration because of severe nasal congestion. During titration with the ON mask the apnea-hypopnea index (AHI) was reduced from a baseline of 58.3 to 5.2 events/h. We were gratified to see that the ON mask worked but were hesitant to submit our findings for publication given the widespread view that ON-CPAP would not work. A potential objection to our findings was the possibility that our patients breathed entirely through the nose. We hypothesized that patients might breathe nasally, orally, or with a combined LETTERS TO THE EDITOR