Taming the Mirage Quattro

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.


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!


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.


  1. Thanks for the help! I had quit that mask and am using a zest nasal mask with a chinstrap because my mouth opens. Had heard about the new mask but was afraid to try. Yep, I’m a newbie!

  2. Thanks so much for putting this information together! I just used it last night, and I think this mask is *finally* going to work out. I haven’t slept through the night (due to various issues with various masks) since mid-November when I started APAP therapy, so this is a huge step in the right direction.

    • I’m always happy to hear it helped! I hope you have more good nights.

  3. I’m a newbie with about 2 weeks using the Mirage Quattro. I’ve tried using your method but I’m waiting up every 1 to 2 hours with air leaks. I understand there some liner that can be used. Any experience with them?

    • There are two types of liners. REmzzz’s http://www.remzzzs.com are disposable liners that can help with the seal. I haven’t used them personally, but some people really like them–they are a little bit pricey. You can also make your own out of old t-shirt materials–I’ve done that with good results. Just trace around the outside of your mask with a 1″ “margin” then make a smaller opening in the center than you think you will need (the hole stretches!).

      The other option is Padacheek’s anti leak strap and mask liner, see http://www.padacheek.com. I don’t have experience with that product, but I’ve used her other products and really like them. People rave about the mask liner for the Quattro, and I’m thinking of ordering one myself. Sometimes my face prespires, and I think that causes the seal to break, too.

      There could be another reason you are having air leaks every few hours if you are on an APAP or using the ramp feature–the pressure could be ramping up and “blowing” out your seal. If you have a ResMed machine, try using the “mask fit” feature–that allows you to fit the machine at it’s top set pressure, so that when your APAP or ramp setting increases the pressure the mask won’t blow out. If you don’t have a ResMed machine, it may require going into the clinician’s menu to set the machine temporarily in straight CPAP mode at the highest set pressure just so you can fit your mask, and then return it to the normal settings before going to sleep. If you are on a CPAP but using a ramp feature, try turning it off and fitting the mask at full pressure. Then you can turn it back on to go to sleep if you really still need the ramp.

      • Thanks for the comments. By the way, I have Phillips system one bipap machine.

  4. Then you are going to have to go into the clinician’s menu to change the settings. Do you know how?

    • In your preparation portion you say to dial the forehead pad all the way out (set dial to 0). On my mask the fully extended position reads 24 and the fully retacted position reads 0 so I am confused. Thank you so much for your store of knowlege and willingness to share with others. Here’s a toast to better sleep for all of us.

      • Bob, you are correct, it should be 24, I will correct this in the post.

  5. Thanks for your time in writing such detailed notes. These are an immense help and I have added this to my toolbar so I have quick access to the instructions. This was my first mask (10 months ago) and so I am in dire need of a cushion replacement (local DMEs have none !) so I am waiting to go into Toronto for one next week. I use your instructions with the old cushion, but I’m sure they will work much better with the new one ! It is so nice that saavy experienced users like yourself take the time to share your knowledge with beginners. Again my thanks.

  6. Bingo!,

    • Bingo????

      I hope that means it helped, John. :o)

  7. Is anyone familiar with CPAP Seal Gel Cushion (a product not sold by DMEs nor by stores) but avalable over the internet (through cpapseal.com). I am thinking of trying either it or a cpap liner such as padacheek or Remzzzzz. The cpapseal looks like it might POSSIBLy be superior, although I like the look of the padacheek as well……just not sure it would work as well. I think the CPAP Seal Gel Cushion is a brand new product fresh out on the market. Any comments?

    • I bought one of those little gel pads for the bridge of the nose and it did not work for me at all, but this looks as if it might. I’d be interested to hear how it works, if you try it, Heather. I am really liking the Padacheek liner–it’s made me realize I don NOT like silicone on my face, and I’m not sure if I would like that gel seal either, but if it can solve the leaking and tightness it might be worth a try.

  8. Thanks for the information. I’ve been struggling with my mask since I got the darn things about a month. I’m going to try this out tonight.

    • Let me know if it helps.

  9. Just tried your suggestions last night – success! No more pressure mark on the bridge of my nose this morning, and the mask was more comfortable throughout the night! Thank you! Now I just need to see if I can do without the little t-shaped gel liner I’ve been wearing on my nose bridge – hopefully just the cloth mask liner is enough tonight 🙂

    • I’m glad to hear these suggestions helped.

      I could never get my mask to seal around one of those gel pads. I’m fine without out. The bridge of my nose is a tiny bit red in the mornings, but it’s just where my glasses rest, so it’s not even noticeable. It doesn’t stay red all day and it’s never sore.

  10. That’s really good info, thanks. Agree with your comments about not being shown how to fit the masks properly as I had the same problem, and have still got some issues with it. I’m going to try your suggestions tonight and see how it goes. One thing I also use are the mask liners. I haven’t tried the padcheek ones but have used remzzzz’s for the last 18 months and found them fantastic. Don’t listen to that rubbish about being one-use only. I use mine for a week at a time then change it. Have even gone 2 weeks with one liner on a couple of occasions without any concern. The only thing that happens with them is that they might get a little facial oil on them – big deal, far less than with a straight silicon mask which i also wash only weekly. Just make sure that you use them the same way around each night and you’ll be fine.

  11. …oh, just one other thing…I found that I developed quite a severe case of dermatitis with the silicon mask on my face which is why I started using the mask liners. If you find you are red or itchy around where the mask sits this is likely to be the case for you too – it’s actually fairly common. In these cases the mask liners are an absolute godsend.

  12. Thanks for this fertile feast of ideas janknitz . I am beginning to see light at end of the tunnel.

  13. How can I make the cushion from an old tshirt.

    • Just lay your mask down on the fabric and trace around it with a 1 inch margin. Cut that out. Start by making the hole in the center small–knit fabric stretches and the hole will be too big if you cut it as large as you think you need. If you get good at that, you can get more elaborate with liners that have velcro or some other method of staying on the mask.

      I highly recommend Padacheek’s liners. They are comfortable and easy to use because they don’t slip around. They are washable and last a long time. Worth the money, IMHO.

  14. The ResMed Quattro mask will eventually leak because the gasket touching your face losses “stickiness”. You can extend the life of the “stickiness” by using a CPAP wipe everytime you take the mask off.
    Washing the mask is advised by ResMed, but soap tends to degrade the “stickiness”, necessitating an earlier replacement.
    There should be some way to restore the stickiness, but I can see why ResMed wouldn’t want that, as the replacement parts are a source of revenue.
    I’ve saved some of my old ones to experiment with, but would like to know if someone has found a way to restore the stickiness.

    • Personally I don’t like the feel of the silicone sticking to my face, so I use a mask liner. But after a while, the cushions do wear out no matter how you care for them. Most insurers follow Medicare guidelines which permit you to get a new cushion every month, but that is excessive IMHO. 3 to 6 months seems to be a reasonable lifespan for the Quattro mask cushion, I’ve actually used mine much longer with the liner.

      I’ve heard from people who try to order replacement cushions that some DME’s are refusing to order cushions only because it’s time-consuming to do the billing paperwork for relatively little reimbursement. They make you wait until you are eligible for a complete mask (every 6 months), and then bill the mask out in parts (mask, cushion, and headgear) even though these components are packaged together for a single price from the manufacturer.

  15. my bi-pap is 21 /15 and the Quattro FX would not stand up to my pressure and nightly sleep movements…. The upper bar on the Quattro seems to help stabilize the mask when I toss and turn at night.

    • I’m amazed that the quattro even works at that pressure! When my pressure creeps up above 13 I start getting face farts ;o)

  16. It works but I have to tighten the lower straps a bit . Now I’m dealing with the ever popular red bridge of the nose syndrome.

    • Try to dial out the nose piece a little more, even if you have to tighten the chin straps to compensate.

  17. thanks, I’ll give it a try….Set & forget does not work for me. Every night I follow your guidelines. They are printed & stored alongside my machine. it’s been working perfect since Sunday

  18. The Respronics System One 60 Series Auto with A Flex now has a mask fit feature. Just press the Ramp button for five seconds and release. If this feature is turned on (default?), you will have 30 seconds to fit mask before therapy begins.

    • Awesome!

  19. Interesting blog you have here. I’m a newbie and have a face that the tech says “Looks medium” but measures large…..OR the medium is too small and the large is a bit too large…..I’m trying a Philips Gel mask right now (arrived in the mail today) and I have a quattro FX that has been the best so far but still isn’t perfect…..The advice you gave about a mask liner might be worth a try

    • You can download a fitting template from Resmed and Respironics sites to do your own fittings. Good luck with the gel.

  20. Thank you so much for all the information! I am happy to hear I’m not the only one who has issues with the full face mask. I have the Mirage Quattro and every couple of hours I wake up to major leakage around my chin area. Tonight will be my 3rd night on the machine. It’s so frustrating. I can’t wait to try these tips and hopefully get some good sleep. Thanks again:)

    • Let me know how it goes. I still have leaks but not too bad any more.

  21. Has anyone used the panda cheek liner with a size small quatro fx? Does the top part that fits over the top fit under the plastic strap holder so it doesn’t slip around?

  22. Are all betts off with a beard or should this fitting work for me also?

    • Dave, I’m sorry, I have no beard, so I have no clue. All I can suggest is that you go to a brick and mortar DME and try it on. Or ask about good masks for beards on cpaptalk.com–I’m sure you’ll find people with beards there.

      • I have a beard and had a Mirage Quattro when they did my 2nd sleep study. I guess it worked good, My first study did not get my setting correct. They were way too low for me, and they gave me a CPAP. Now I have much higher settings.at 22cm on a BIPAP. My old mask is leaking, and it is time for my insurance to get me a new one, so I am researching this mask since it is the one that was used for my sleep study. Hopefully I can get it.

      • Make sure they fit you properly. The dme should let you try it and maybe give you a sample mask to try at home.

  23. I wash the cloth mask liners in a small zippered lingerie bag, and let them air dry flat, and have been using the same ones for over 3 years. Works great.

    • Great idea!

  24. Hi, I’ve had sleep apnea all my life and have been using a CPAP/ APAP since 2000. One very useful tip I worked out is that you can stop mouth leaks by sealing your lips shut with Listerine Strips. I use two every night and 95% of the time my mouth remains sealed until I wake up.

    The way I do it is by slipping them in half length ways, putting two at the top and two at the bottom. I moisten the lips till it’s gluggy and close them.

    You will probably experience heat for the first time or so, but after that you become immune to it.

    Hope this helps people.

    • Thanks, Gary. Sounds like a great tip if you can toerate the Listerine Strips (sounds awful to me, but I have a lot of chemical sensitivies).

  25. I have had my cpap machine for three nights. I was wondering if the pad a cheek cpap full face liner helps with the itchy feelings around my nose and on my cheeks. Also does it help prevent waking up with dry and/or irritated eyes. Thank you so much for all of the information contained on this site. This is the best information I have seen yet.

    • I find the Padacheek liner much more comfortable against my skin than bare silicone, and yes, it can help with leaks.

  26. Thanks.

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