MASK ARRAYED

The biggest complaints with the Quattro are:

1.  Leaks

2.  Painful pressure on the bridge of the nose (some people develop open sores from the pressure)

3.  Claustrophobia and fear of suffocating

4.  General discomfort

I had all of these issues with the Quattro myself and more.  I concluded that this was a lousy mask and kept it around only “in case” I got a cold and couldn’t use my nasal pillows.  Deep down I thought that this mask would NEVER work out, but at least I could say I tried when I needed a FF mask.

Meanwhile, I have learned that I cannot sleep without my CPAP.  I REALLY need it.  So when I got a bad respiratory infection and couldn’t use my beloved nasal pillows, I decided I had to make peace with my Quattro.  Here  is what I found helpful for me, and I hope that it will be helpful to you as well.

1.  Dealing with the claustrophobia:  It’s hard enough when you are a newbie trying to get used to all this to remain calm.  But them you strap this chunk of plastic onto your face, and you start to worry—“What if the electricity goes out?  Will I suffocate with this plastic mask on my face?”.  The answer is no, absolutely not, but I had to see and understand why not in order to feel comfortable.

Take a look at the elbow connecting the mask to the hose.  Right at the apex of this elbow is a funny shaped piece of silicone that extends into the elbow.  If you look closely, when there is no airflow from the machine going into the hose, the valve is open, letting fresh air into the mask.  It takes pressure from the machine hose to force that silicone flap across the opening, sealing off the outside air and letting the machine air into the mask.  When the machine is off, the valve opens passively and fresh air comes in.  Seeing that valve and understanding how it works, reduced my anxiety considerably.  There is a video of this valve on the ResMed video page listed below.

The mask is still a big chunk of plastic strapped to your face like an octopus, but at least I understood that I would be able to breathe.

2.  Leaks (and pressure on the bridge of your nose):  Leaks are the biggest issue with this mask.  Because it covers a fairly large surface area of mobile facial structure, it’s easy to spring a leak.  It always seemed to leak at the nose piece, right into my eyes, and I’d wake with swollen, weepy, blurry eyes in the morning.  Just miserable!

What’s the natural response to a leak?  Tightening the straps, in most cases.  But a close examination of the mask shows a double layer of silicone that’s meant to be an air cushion.  An air cushion must be inflated to work, and the more tight the straps are, the less inflation can occur between those layers of silicone.  Experienced Quattro users state that the Quattro essentially floats on their faces, and I just couldn’t fathom how this leaky boat would work that way.

I got part of my answer from a video for a new mask coming out from ResMed, the Mirage Quattro FX.  (see “Fitting at Home” video).  This looks like it’s going to be a great mask, but it is not yet available in the US (see update below).  But the design is based on the Quattro, and shares some similarities.  So I decided to extrapolate.  The first thing I realized is that cushion, particularly the part around the top of the nose, MUST be fully inflated.  So I dialed the forehead support all the way out to 24 and loosened the top straps.

And viola!  Getting that top of the nose part full of air is the key to a good fit—once you have plenty of air filling that part of the cushion, it hugs your nose beautifully and seals off the leaks.  Plus, it has a little give and flexibility around the nose.  I sleep on my side, and I can push my head against the pillow.  The silicone flexes and does not leak.  I have the headpiece so loose that I can slip my fingers in between the forehead pads and my head.  Amazing!  And nothing is hurting my nose—not a bit of pressure.  Unbelievable.  No more bandaids, pads, suffering, etc.

The bottom portion has to be a bit tighter, but only marginally so.  One trick I’ve learned is that when using Flex (EPR), the cushion is more inflated during the inhalation phase, so I ONLY tighten the straps during that part of the breath.

So, here are my fitting tips for the Mirage Quattro.  My face is somewhat unique because of my chin structure, so I’m not sure if these will work for everyone.  Please let me know if they help you and add any tips of your own.

Preparation:

Loosen all the straps and dial the forehead pad all the way out (set dial to “24”).  You want the nose piece tilted away from your face as much as possible.  Lay down in your bed (NEVER fit a mask sitting up!).  Even if you don’t sleep on your back, start out on your back, using your usual pillow configuration.  You will readjust in your normal sleeping position if necessary.  Unclip the bottom straps from the mask.

1.  Arrange the mask over your face with the headgear over your head and the straps lying beside your neck on either side of your head.

2.  With one hand, tilt the mask in toward your nose and away from your chin.

3.  While you are holding the mask as in step two, turn the machine on.  Be prepared for a strong blast of air.

4.  As the air fills the mask, lower the bottom to your chin and hold the mask lightly against your face with one hand while you clip on the lower straps with the other.  Use the lightest pressure possible to push the mask against your face—don’t mash down on that cushion!

5.  Gently tighten the lower straps, only enough to stop any leakage.  Try to time your movements in tightening the lower straps to the inhalation phase of your breathing.  Make them as loose as you possibly can while stopping the leaks.

6.  Now tighten the top straps just enough to stabilize the mask.  It should not be even slightly tight on top, just stabilized enough that movement will not dislodge the mask.

7.  Try to tighten the forehead piece as little as possible.  I’ve come to the conclusion that piece is not really all that necessary (that’s why it’s been removed from the new Quattro FX), but it does hold the upper straps in place. Keeping this as loose as possible is the KEY to keeping pressure off the bridge of your nose.   As I mentioned above, I can easily slide my finger between the forehead pads and my head.

8.  Now, if you move around in your sleep or you sleep on your side, turn to your side and see if you need to make any minor readjustments.  I’ve found that a fully inflated silicone cushion has a lot of “play” and I don’t need to change anything.  I don’t even have to hang the mask off the edge of the pillow anymore—no hard plastic is pushing into my face with the cushion so nicely inflated.

Avoiding late night leaks:

I use an APAP and the pressure ranges from 9 to 15.  Most nights I stay within 2 cm, usually ranging 10 to 12 cm.  But there are some nights when the pressure goes all the way up to 15, and that can cause my mask, fit at a pressure of 9, to leak at 15.

There are a couple of ways to deal with this.  Since my pressure does not go that high every night, I just wake up when the “face farts” start, and tighten the bottom straps just enough to stop them.  This is done quickly and easily and I can usually go right back to sleep.  But these late night face farts can be avoided if you have a “mask fit feature” on your machine (ResMed) or you know how to adjust the pressure on your machine for the mask fitting.

The ResMed mask fit feature shows that ResMed put some real thought into their machines (hear that, Philips Respironics?????).  By pressing that button, the pressure will go to the maximum APAP pressure set, and you can fit your mask at that pressure.  Hitting the button again will return the APAP to the normal program.  You can go to sleep, knowing that your mask will not blow out when the higher pressures are reached.

For those of us on lesser machines, you may have to go into the clinician’s menu to increase the pressure to your full pressure for the mask fitting.  What a pain!  While it’s annoying, that’s the best pressure at which to fit your mask.  Then you can return it to the usual settings before you settle down to sleep.  Too bad other machine manufacturers make it SO inconvenient.  This is not a “newbie” skill.

Soapbox time:

I’ve totally changed my tune about this mask.  I used to think it was a TERRIBLE mask, but now that I have learned how to use it properly I find it quite comfortable and usable.  But it’s not an easy mask to use.  Many CPAP newbies are started with the Quattro mask, and I think it’s often setting newbies up for failure.  These masks are hard to fit properly, they rarely ARE fit properly by the DME, and improper fitting means that they will leak and cause pressure.  Plus, they are big, chunky, and scary looking.   This is a lot to deal with when you are reeling from the diagnosis of apnea and not too sure if you want to face the rest of your life with this chunk of plastic strapped to your face.  I wish sleep techs and DME would give the first mask choice a little more thought and a lot better fitting.

I hope these hints help you.

Additional Resources:

ResMed has a lot of fitting information on it’s website here: http://www.vpap.com/uk/products/mirage_quattro/mirage-quattro.html?nc=clinicians

The video pages are especially helpful.  My one quibble is the fitting guides suggest you start by fitting this mask sitting up.  Do yourself a favor and LIE DOWN to fit this mask.  Gravity does very different things to your face when you are lying down!

Update:

1.  As of January 2011, the Quattro FX is available in the U.S.–I’m dying to try it but may have to wait until Hell freezes over before Kaiser adds it to their formulary.

2.  This fitting technique works for the Mirage Micro, too!

Update #2:

Despite all of the above, I continued to have a LOT of leaks.  In desperation I tried a mask liner–this has made a world of difference.  The mask is 10 times more comfortable and leaks are rarely an issue.

I started with a homemade mask liner, cut from an old T-shirt, but I have a Padacheek liner on order, along with an anti-leak strap.  Go to http://www.padacheek.com to see what fellow CPAPtalk member Karen has to offer.

Other people say they are very happy with Remzz’s as well (www.remzzzs.com) but they are supposedly for one time use and as such are a little pricey.

The medium headgear is also too big for me, and I’ve had greater success by folding the excess material in the headgear so that the top and bottom of the back strap actually meet.  I’m going to sew it down today.  That also changes the angle of the headgear slightly, and seems to make it more stable overall.