RemZzzs® Mask Liners & PAP Therapy

A PAP mask often causes redness, bruising or other irritation to facial skin, and these problems are not as widely recognized or addressed in sleep medicine circles despite interference with many patients’ efforts to use PAP. In no small number of cases, mask side-effects literally forces some patients to cease use altogether.

I learned about RemZzzs® mask liners some years back when switching from a nasal pillows style to an over the nose and eventually to a full face mask (FFM). As I went through several iterations triggered by different mask discomfort issues, the two facial areas most affected were the bridge of my nose and the space between my cheeks and the sides of my nose. All were red every morning, and I eventually resigned myself to a mask rotation system in which I could only use the full face mask for one week, then switched to the nasal mask for two weeks, then back to the nasal pillows for a week, and finally back to the FFM. As you can imagine, this system was not optimal and led me on a search for other solutions.

Enter RemZzzs® mask liners, first seen online in their promotional YouTube video; and, soon thereafter I was most fortunate to meet the owner and designer of this simplistic yet subtle interface. Robert Rutan initially designed the mask liner to accommodate his wife’s difficulties in attempting to use PAP therapy. As they say, after that “the rest is history.” When I began using the RemZzzs® I was surprised how rapidly they solved my problems with redness and bruising. I went through various configurations of the mask liners and have received hands-on training and tips from the inventor himself. (Full disclosure, I receive samples of the RemZzzs® products to demo and provide feedback to the company).  

There are several specific application points about RemZzzs® mask liners that OSA/UARS patients need to know to gain the most benefits. You can find more information, including instructions, videos, and graphics on the company’s website or here on the Classic SleepShop. My focus in this post will be on very specific applications to address very specific issues in PAP users, particularly those using FFMs, although the mask liners can be used with virtually every other mask type as well.

The most salient first step when considering the mask liners is whether or not patients need them, and I guarantee a whole lot more people need to be using this add-on if they want to achieve optimal results with PAP. The two main reasons I make this point so forcefully is that RemZzzs® mask liners offer the potential to completely eradicate any mask discomfort issues or to solve different types of mask leaks. For some people, the mask liners solve both discomfort and leak issues, providing a veritable 2-for-1 deal at a most affordable price.

For reasons that remain unclear, manufacturers of PAP masks have been unable to solve the problem of interface irritation to various facial regions. Undoubtedly there are many factors involved in these side-effects. The mask may be a poor fit; the headgear is pulled too tight; the mask is not regularly or properly cleaned; the mask is worn out, or the cushion has not been replaced. Allegedly, when all these issues are addressed in timely fashion, the mask works just fine and causes no irritation to the face…”and if pigs had wings…”

In reality, the points above are valid, but even when they are all sorted out, many—and I mean many—patients continue to suffer facial abrasions, bruising, redness or sufficient discomfort leading to cessation of PAP use. By many, I surmise at least one out of three patients could benefit from the use of a mask liner to resolve one or more of these side-effects. Yet, because these side-effects are so common, it’s conceivable sleep professionals and patients develop a tendency to minimize, or worse, normalize these side-effects, making the broad assumption that the patient must tough it out.

In my opinion, no matter what many sleep professionals and vendors might preach about the science of treating sleep apnea, there really is a fundamental flaw in the development and manufacturing of masks in the sense that so many patients must overcome these adverse effects when the mask surface irritates the face. While it would be useful to know the causes of these effects, it is not always clear. Some say the culprit is the material of the mask cushions, while others point to the degree of pressure on the face from the headgear tension.

If I may be permitted to reiterate, there really should not be any redness on your face when you awaken, let alone bruising or abrasions. Also, there never should be any sensation of discomfort while using PAP, never…as in NEVER or as in NO DISCOMFORT. Without a doubt, there are patients who have none of these problems, but among the one-third who do suffer from these side-effects, the cause of the problem almost invariably starts with genetic predispositions such as fair-skinned, the effects of aging on the skin, and vulnerabilities created by medical illnesses, particularly diabetes or dermatological (skin) conditions. Whatever the causes, the mask liners consistently eliminate these issues in the vast majority of cases, so let’s go through some applications.

The most basic application is applying one layer of the mask liner onto a full face mask or onto other mask styles as well. As soon as you put it on and “dunk” your head into the mask (the liner stays in place better when you lower your face into the mask instead of raising the mask to your face), you will immediately appreciate how much more comfortable the RemZzzs® feels against your facial skin. For a better seal, do not wash your face directly before bedtime, because a little bit of oil on the face adds friction to keep the liner in place. Some people add their own moisturizers to improve this effect.

When the mask liner is situated correctly, you will not feel the need to tighten the mask more than usual to keep it in place. Just the opposite may occur; instead, the seal may be so much more effective, you can loosen the headgear slightly. Unfortunately, while these steps are straightforward, you still may need to work with the liner to insure a satisfactory interface with comfort.

As an important aside, many sleep professionals, especially many sleep technologists who may possess very limited experience with RemZzzs® mask liners seem to believe this add-on actually causes mask leak or aggravates mask leak. The main validity for this idea almost invariably arises from those patients who never learned how to put the liner on correctly (head dunking technique) or who were not instructed to fiddle with the liner to learn how to make the best fit or seal. Our sense has been that many sleep technologists simply have not gone the extra step to learn more about using the mask liners and the precision needed to make them work well. Thus, by superficially evaluating the effects of mask liners, they tend to dismiss them prematurely.

To be clear, you really must pay attention to how well the liner is situated on your face. To do so, the process requires a small degree of experimentation while checking the leak on your PAP device monitor. You literally may need to fiddle with very minor repositioning of the liner edges to make it right. Another important experiment to conduct is whether or not two layers of liners are better than one. One versus two might make a large difference, so you owe it to yourself to run a trial both ways.

One of the odd things about mask liners is that the data from the leak monitor may not always be reliable when you are looking at it while awake or sitting up. You should still look at it, but that should not deter you from trying an experiment the whole night with one or with two liners to see what the actual leak data registers in the morning. At our sleep center, we recommend zero leak as the target goal for all patients, all the time, and with all masks. Personally, I have noticed on several occasions when the leak at bedtime read 2 to 6 liters, the next morning it read 0 to 1 liter, suggesting the sleep time data is more meaningful.

Regardless of the severity of the leak, it is important to understand the distinctions between the two main types of leak that matter most to the sleep apnea patient. One is known as the data leak and the other is called nuisance leak. For additional details, see my post at on Special Adaptation Tips.

Data leak is the one on your machine; and to repeat, a very low value should always be targeted. But, nuisance leak is not exactly measurable, except subjectively by the patient, and yet it plays a huge role in mask discomfort, because the leak could be irritating the eyes or producing noisy flapping noises on the cheeks. Remarkably, we found a special way to use the RemZzzs® to solve the latter problem. Simply by adding more layers, anywhere from 4 to 10 liners padded together, success was often achieved in removing the nuisance leak. I cannot state strongly enough how important this “padding” strategy is for early reluctant users who complain vigorously about nuisance leak. By creating this padding effect, it will almost always stop the flapping or sputtering noises (sometimes affectionately dubbed “mask farts”). The padding works because the mask itself can be more easily molded against the liners on the face, creating a better seal.

The irony is while the nuisance leak resolves, in some patients data leak temporarily increases, because more air can leak through so many layers of liners. Nonetheless, data leak is a moot point compared to nuisance leak, because the latter forces many patients to quit PAP therapy and usually quite abruptly after a very short go at it. The goal here is to engage a patient so they can use PAP therapy for several months, gain some obvious benefits and then revisit the data leak at the proper time. In many such cases, the patient then tapers down the padding thickness over a few weeks and still prevents nuisance leak while the data leak starts to improve in the presence of fewer mask liners. 

The leak around the eyes can be solved by what Robert Rutan describes as the “curtain technique,” where a small rectangular RemZzzs® liner (usually comes with the package) is placed on the top half of the regular mask liners. When a person adds this rectangular piece, it can be placed to rest in front of the eyes. Thus, even if there is a small amount of nuisance leak aimed the eyes, the patient will never feel it. This example shows how much confusion may arise between a nuisance leak and a data leak. In this case, the data leak might read zero, but the patient clearly reports discomfort because the air is hitting his or her eyes. Most sleep professionals understand this distinction and will not discount the person’s complaint just because the data recorder indicates zero leak.

Another 2-for-1 deal with the curtain technique is that it may prove a godsend for patients with reddening of the bridge of the nose. By using the rectangular liner not only can you gain some additional padding between mask and nose bridge, but also, you can also learn to insert your nose lower into the mask opening, which means the top of the mask sits much higher up on the face and not directly on top of the nasal bridge. This positioning takes even more fiddling, but it’s well worth the effort if you have suffered any sort of bruising or reddening on the bridge of the nose. In the worst case, open sores develop on the bridge, and then the patient must stop using PAP for weeks until it heals, unless they can be accommodated with a nasal pillow mask or a total FFM, either of which avoids the bridge of the nose as a pressure point.

Summing up, RemZzzs® mask liners have a great deal to offer many patients. Market-wise, they have developed liners for children using PAP and have also created models for nasal pillows, hybrid mask and the total FFMs. The product is made of 100% cotton knit fiber, which arguably is an important factor in its widespread success in solving mask issues. Ever since using these liners personally and encouraging their use in up to one-third of our patients, I can continue to give a very strong endorsement on their necessity and value in sleep apnea patients using PAP therapy.


Barry Krakow MD

Author

Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.



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