Comprehensive Guide to Pediatric NIV Mask Selection, Types, Troubleshooting and more

In the realm of Pediatric Intensive Care, achieving optimal patient safety is a pursuit that demands meticulous attention, particularly when delving into the intricate world of Non-Invasive Ventilation (NIV). Thinking NIV as just a mask that delivers pressure is non-sensical, it is a subject as complex as mechanical ventilation if not more. The consequences of overlooking the nuances of the NIV setup can reverberate through the Pediatric Intensive Care Unit (PICU), impacting the delicate balance of patient care.

The correct setup of NIV masks, their accompanying circuits, and essential accessories emerge as a cornerstone in this endeavor. The meticulous assembly and seamless interface of these components become not just procedural nuances but rather pivotal elements, where precision is paramount to avoid or reduce the NIV failure rates.

In the first segment, we delve into the science of various masks that are used in non-invasive ventilation setups. This discussion is not only valuable for understanding the components but can prove beneficial when procuring NIV masks, circuits, and essential accessories for PICUs, especially in India.

Disclaimer: While I've mentioned specific company names and masks here, it's important to note that I derive no financial benefits from these mentions. The inclusion is solely to ensure the availability of these crucial resources in the PICU.

Structure of NIV setup

The basic NIV setup for both intensive care NIV or home ventilation NIV includes the following 3 components

1. A machine that delivers flow, pressure, and volume
2. The circuit that connects the NIV machine to the mask
3. NIV Mask

In this post, we will discuss the intricacies of NIV masks, including their types based on their operation principles, structure, problems with mask fit, and how to troubleshoot them. Let's begin...

Types of NIV Mask - Based on ventilation physiology

The NIV masks can be grouped into two different categories: vented and non-vented. They operate on different physical principles for CO2 clearance. As the name suggests, a vented mask assists in ventilation (CO2 clearance) on its own. On the other side, a non-vented mask will not support CO2 clearance by itself but will require an additional mechanism for the process, such as an active circuit with an exhalation valve or a leak port in a passive circuit. We will discuss these in the second part of NIV.

Now, let's delve into the detailed comparison of vented vs. non-vented masks.

Vented NIV mask

Vented masks feature small perforations or leak ports designed to facilitate the clearance of CO2 when a patient exhales.

These vents are typically situated on the body of the mask, or in some cases, an adapter or elbow is fitted to create a gap at the joint, allowing expired gases to escape. Notably, in some brands these elbows or adapters can be replaced, converting a vented mask into a non-vented one, providing greater flexibility without the need to change the entire mask (e.g., Hamilton BiTrac), See image below.

In younger children, it is advisable to opt for a vented mask with perforations positioned close to the nose. This is particularly beneficial due to the limited tidal volume displacement in this age group, and having perforations nearer to the nose enhances CO2 clearance more effectively.

Vented masks are commonly connected to single-limb non-invasive ventilation (NIV) circuits and are compatible with standalone conventional NIV machines or BiPAP machines. However, it's important to note that they cannot be used with mechanical ventilators due to the risk of ineffective mean airway pressures. Additionally, the presence of a dedicated expiration limb in double-limb circuits eliminates the need for exhalation vents. Consequently, these masks can be used without anti-asphyxiation valves, which are necessary for non-vented masks in case of equipment failure and inadequate flow

The standard elbow that comes with non-vented masks is usually white / transparent in color for ease of identification.

Non-vented mask

There are no perforations or leak ports, CO2 clearance relies on either a leak valve in a single-limb circuit or an exhalation valve in a double-limb circuit. These masks are typically employed with double-limb circuits and mechanical ventilators equipped with a dedicated expiration valve. Refer to post on NIV curcuits for detail discussion in elbows and different types of NIV curcuits.

The mask elbow is usually colored blue to “warn” the user that it does not have an exhalation port. In some brands, you can change the elbow which fits in such as way that a gap is produced to leak air converting it into a vented mask.

Refer to post on type of mask elbows here.

Types of Mask - Based on Anatomy

There are several types of Pediatric NIV masks, ranging from full facial masks to more delicate nasal pillows.

1. Full face mask (Never used it, I think adult ICUs might be using those)
2. Partial face masks or oronasal masks
3. Nasal mask
4. Nasal pillow / Nasal prongs

Face Masks/Oronasal mask

Face masks are the most commonly used interface. Face masks can be full face masks covering the entire face including eyes, I have never used one as such. A partial face mask also referred to as an oronasal mask covers just the mouth and nose.

These are especially important for children with respiratory failure or NIV-dependent neuromuscular cases. face masks are designed to cover both the mouth and nose, ensure a snug and comfortable fit, and also mitigate pressure loss by preventing air leakage around the mask's edges. Many kids with advanced respiratory morbidity resort to mouth breathing to overcome nasal flow resistance where these masks can be extremely effective.

Nasal Masks

Nasal CPAP masks are made to snugly fit over the nose, providing a comfortable interface for delivering airflow. Due to their minimalist design, these masks often offer a less claustrophobic experience compared to their full-face counterparts and also look less scary to children and parents.

These masks find primary use in situations where a reasonable leak is permissible, such as in the application of CPAP for conditions like Obstructive Sleep Apnea (OSA) or other forms of sleep-disordered breathing, as well as in airway stenting.

Nasal Pillows

These options are even more minimalistic. The nasal pillow fits directly into the nostrils, creating a perfect seal through a cushioned surface, in contrast to nasal prongs used for HFNC.

The airflow is directed straight into the nostrils, which might be uncomfortable for some children. Similar to nasal masks, these are typically employed for CPAP rather than BIPAP. Personally, I have primarily used them in older children and only on rare occasions.

I have used nasal pillow during my PICU training occasionaly for older children. For this article, I've scoured the internet for nasal pillows designed for young children but haven't come across suitable options. The majority of these products are tailored for adolescents and adults.

Nasal pillows are exceptionally lightweight, providing greater flexibility in and around the interface. Thus far, I've identified the Philips Respironics DreamWear Nasal Cushion, ResMed Nasal Pillows like AirFit P30i and AirFit P10, and the Philips 3100SP Therapy Nasal Pillow Mask. If you're aware of more options, feel free to share them in the comments.

I am sharing a compiled list of masks I have created for easy reference at the bottom of this post. It's important to note that I derive no financial benefits from disclosing the names of the available brands.

Optimal Tips for Selecting the Right NIV Mask – A Comprehensive Guide

Why it is difficult to find correct NIV masks in children?

In my perspective, the most challenging aspect in the entire initiation process of Non-Invasive Ventilation (NIV) is securing a suitable fit for the NIV mask, particularly in children.

Children present with diverse shapes and sizes, whereas NIV masks, unfortunately, lack corresponding variations, compounded by the limited availability of such options. This scarcity is attributed partly to logistical constraints and partly to a lack of awareness within our community.

Mask Fitting - how important it is?

Selecting the correct mask size is crucial for more than just leak prevention. Consider following things.

• It ensures stable mean airway pressure, appropriate tidal volume
• Enhances patient comfort by minimizing space, allowing clear vision, facilitating daily care, and reducing eye irritation.
• Larger masks, despite minimal leakage, may have increased dead space and are unsuitable for smaller children.

The success or failure of Non-Invasive Ventilation (NIV) is, in part, determined by the adequacy of the mask fit, and entirely so if the patient selection was appropriate before initiation.

There is no perfect NIV mask!

There is no perfect mask, but there are solutions. Work on knowledge, logistics, and past experiences to make choices while selecting NIV masks.

Logistic factors

An important issue lies in the companies producing NIV masks, where it seems that ethnic variations, shapes, and sizes are not adequately considered in the manufacturing process. Many of these providers are based outside of Asia, and as a result, the masks may not cater well to the relatively smaller face sizes of Asian children. Consequently, even the very small masks tend to be relatively larger. As a compromise, many of us resort to using nasal masks as oronasal masks in numerous children, a situation that is indeed outrageous

The lack of uniformity in the supply chain poses a challenge as the masks we require are frequently unavailable through local vendors. I've encountered instances where vendors claim, 'Oh, this mask isn't available in India,' which may not be accurate. I've observed that the same mask is often accessible through other vendors. It's essential for us to conduct our own research and not solely rely on vendor statements.

Logistics - Troubleshooting

While we may not have the ability to alter the manufacturing process, we can make an effort to convey these concerns to manufacturers in any possible manner, aiming to assist them in making improvements

Few tips

• Gather the list of Pediatric masks from the manufacturers' websites. ( Find my list at the bottom of this page).
• Gather the list of available masks from multiple vendors in your area.
• Check whether they are willing to ensure an uninterrupted supply of these interfaces and provide support. It's essential to have multiple options for providers

Compatibility

Brands often have a tendency to design masks in a way that aligns with their specific NIV machines or ventilators, potentially prioritizing their supply chain over broader compatibility.

Compatibility - troubleshooting

Verify the compatibility of the masks with your NIV machines or ventilators. For example, many of us use F&P ventilator tubings, so it's crucial to ensure that NIV masks from other brands can be seamlessly fitted to these tubings or opt for the same brand.

Clinical factors

The judicious selection of masks based on clinical situations is paramount, as using an inappropriate mask can result in NIV failure.

Troubleshooting

Know which mask in general is appropriate for the given clinical situation. For instance, when aiming to maintain a stable mean airway pressure, especially in cases of post-extubation failure or children with restrictive lung disease, a non-vented orofacial mask should be the preferred choice. Conversely, in situations where airway stenting is necessary, such as in laryngomalacia, a nasal NIV mask can be employed.

Take into account the patient's age and tolerance when utilizing high-flow devices. In scenarios where an oro-facial mask might be suitable but patient tolerance is low, opting for a nasal mask initially may be preferable. Once patients become accustomed to the high flows, transitioning from nasal to oro-nasal masks can be more easily accomplished

Exploring different interfaces to determine the most suitable mask is, in fact, a viable strategy. Suitability can be defined by achieving improved clinical parameters, enhanced patient tolerance, or a combination of both.

The initial measurement for NIV mask fit

In addition to selecting sizes based on age or experience, consider adopting a formal approach. Utilize sterilized older masks for fit assessments, or alternatively, maintain at least one of each type in the ICU specifically for fit assessment purposes

While reusing NIV masks is unadvisable, maintaining sterilized masks solely for fit checks before NIV initiation appears to be a reasonable option. Opening a brand new mask and subsequently being unable to use it due to misfit not only compromises economic considerations but also underscores the importance of pre-assessment

Many brands have a scale given in a top compartment in the pack which can be used to measure the appropriate mask size without needing to open the compartment that stores the mask. This can be pretty useful, see the image below.

Face mask Brand That can be used in a Hospital setting

F&P Nivairo Full Face Mask

Although labeled as full face masks, I refer to them as oronasal masks for clarity, as they do not cover the eyes and the entire rim of the face. The F & P masks are available in four sizes: extra small, small, medium, and large. In my experience with ICU patients, I predominantly used extra small and small sizes, with medium being a rare choice. I've observed that the ergonomics are more fitting for non-Asian individuals, as they tend to be relatively larger for Indian faces

F & P Nivairo is available in both vented and non-vented variations. The non-vented mask is further divided into two categories: one without an anti-asphyxiation valve (as explained here) and the other with it. The elbows are fixed, preventing the ability to modify non-vented masks by adding a leak port or changing the standard elbow to the one with an anti-asphyxiation valve. This lack of mix-and-match options simplifies the configuration, which may be beneficial for new users by avoiding confusion. Further details about various types of elbows, circuits, and anti-asphyxiation valves will be discussed in the next post.

The mask and sizes available

1. Vented mask - RT047 (Xs, S, M, and L sizes, just add the letters after the product code to order size, like so, RT047XS )
2. Non-vented without anti-asphyxiation valve - RT046. This can be used with dual limb circuits only like in conventional mechanical ventilators with NIV mode. Sizes same as above.
3. Non-vented with anti-asphyxiation valve - RT045. This can be used in single-limb circuits like in-home ventilators or standalone NIV machines after connecting it to the leak port ( Learn here). Sizes same as above.

All of these masks are designated as non-reusable. In my personal opinion, F & P employs the simplest nomenclature, making it easy to distinguish between their various masks

Visairo Face Mask

I have never seen these in any units where I worked so far, but they look very minimalistic, leaving the nose bridge off the pressure grid and not obstructing vision.

Product codes given on the website are - RT075, 76, and 77, classified just as above. There are some more fancy masks called Nivairo+ mentioned on their website. There are several other masks for home ventilation use given on their website which are quite confusing, take a look if you want to.

Resmed

ResMed mentions the hospital-grade full face mask by the same name, It is available in 3 sizes small (60703), medium (60704), and Large (60705),

AcuCare F1-0 is a non-vented, disposable face mask available in small (60768), medium (60769) and large (60770). I am surprised that even though these masks are seen on the Indian website of Resmed while trying to download the size and fit documents, it says it is a restricted download here. Hmmm.

AcuCare F1-1 is again non-vented but with anti-asphyxiation valve. AcuCare F1-4 is a vented, disposable mask for hospital use, with similar size options. There is no extra small size that we can use for younger children, so the target is adult patients but again I guess may be useful for older children and adolescents. Honestly, why do any of these companies provide these many options for pediatric agegroup?

During my search, I found a very useful compatibility list of various masks and NIV machines on ResMed's website.

MiniMe 2 NIV pediatric nasal mask by Dragger

This is primarily a nasal mask but if the facial profile is very small, I think it might be suitable as an orofacial mask. The official document recommended an age group of 2-12 years.

This comes both as vented small (MP01553), vented large (MP01554), and non-vented small (MP01555) and non-vented large (MP01556) masks. The vented one comes with a leak port.

MiniMe 2 pediatric nasal NIV mask by Intersurgical

I don't know why both Dragger and intersurgical nasal masks have the same name but more importantly, these mask comes in 4 sizes, Xs (part no 2570000), S (part no 2370000), M (part no 2371000), and L (part no 2571000). These sizes are available as both vented and non-vented categories giving more options to choose from.

Again these are nasal masks but can be used as orofacial masks, and it is purely my opinion.

Nasal NIV masks

Already mentioned the nasal mask by Dragger and Intersurgical above for older kids, for very small kids, the following two options are more suitable.

Pixie mask by Resmed

The official documents recommend ages 2 to 7 years but we have used for little younger children with post-extubation stridor. It is a vented mask, I have seen young children comfortably tolerating it, it has a very minimalistic design, and a circuit can be attached to either side. It comes in a single size but with different cushion sizes in the pack.

Wisp pediatric Nasal mask by Philips Respironics

Aesthetically good mask, mostly seen during my training in resipirology in the UK for home CPAP use. As per documentation suitable for children above 10kg. Wisp pediatric nasal mask part numbers Fit pack with 3 cushion sizes, 1104953, Headgear 1104973, Elbow/tube with cover 1104977, Small cushions (SCS) 1104969, Medium cushions (SCM) 1104970, Large cushions (SCL) 1104971

Mirage Kidsta pediatric nasal CPAP mask by Resmed

Nasal mask for older children that can be used on Multiple patients of age above 7 years or above 40lb. It is a vented mask. The item code is 61011. I was not able to download any documentation since it is restricted in India, so I assume this is not available here.

Nasal Pillows

ResMed AirFit P30i Nasal Pillow Mask and AirFit P10 Nasal Pillow Mask

Mostly for adolescent and older children, have used them occasionally during training in PICU.

F&P Evora

It is basically a nasal pillow, never used it. Looks very large, and may be suitable for older kids with large facial profiles.

Author

Ajay Agade | DNB(Pediatrics), FNB(Pediatric Intensive Care), Fellowship in Pediatric pulmonology and LTV

Ajay is a Paediatric Intensivist, currently working in Pediatric Pulmonology & LTV at Great Ormond Street Hospital NHS, London