Oronasal vs Nasal Masks: The Impact of Mask Type on CPAP Requirement, Pharyngeal Critical Closing Pressure (P crit ), and Upper Airway Cross-sectional Areas in Patients With OSA

CPAP delivered via an oronasal mask is associated with lower adherence, higher residual apnea-hypopnea index (AHI), and increased CPAP therapeutic pressure compared with nasal masks. However, the mechanisms underlying the increased pressure requirements are not well understood. How do oronasal masks affect upper airway anatomy and collapsibility? Fourteen patients with OSA underwent a sleep study with both a nasal and oronasal mask, each for one-half of the night (order randomized). CPAP was manually titrated to determine therapeutic pressure. Upper airway collapsibility was assessed using the pharyngeal critical closing pressure (P ) technique. Cine MRI was done to dynamically assess the cross-sectional area of the retroglossal and retropalatal airway throughout the respiratory cycle with each mask interface. Scans were repeated at 4 cm H O and at the nasal and oronasal therapeutic pressures. The oronasal mask was associated with higher therapeutic pressure requirements (ΔM ± SEM; +2.6 ± 0.5; P < .001) and higher P (+2.4 ± 0.5 cm H O; P = .001) compared with the nasal mask. The change in therapeutic pressure between masks was strongly correlated with the change in P (r = 0.73; P = .003). Increasing CPAP increased both the retroglossal and retropalatal airway dimensions across both masks. After controlling for pressure and breath phase, the retropalatal cross-sectional area was moderately larger when using a nasal vs an oronasal mask (+17.2 mm ; 95% CI, 6.2-28.2, P < .001) while nasal breathing. Oronasal masks are associated with a more collapsible airway than nasal masks, which likely contributes to the need for a higher therapeutic pressure.