How to cope with the mask? Experiences of mask ...

EMPIRICAL STUDIES

doi: 10.1111/j.1471-6712.2009.00740.x

How to cope with the mask? Experiences of mask treatment in patients with acute chronic obstructive pulmonary diseaseexacerbations Henny Torheim MSc (Health Sciences), Nursing (Intensive Care Nurse/Lecturer)1 and Eva Gjengedal PhD (Professor)2 1

Department of Intensive Care Nursing, Hospital of Volda, Volda, Norway and 2Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway

Scand J Caring Sci; 2010; 24; 499–506 How to cope with the mask? Experiences of mask treatment in patients with acute chronic obstructive pulmonary disease-exacerbations The aim of the study was to focus on important aspects and issues associated with bi-level positive airway pressure (BPAP) mask treatment in acute exacerbation of chronic obstructive pulmonary disease based on the experiences of patients and nurses. The study has a qualitative design with a phenomenological approach. The data are based on qualitative in-depth interviews with five patients who had used BPAP-mask treatment intermittently over several days in the acute stages and a focus group with eight experienced nurses from a specialized unit in a Norwegian university hospital. The data have been analysed on the basis of Amadeo Giorgi’s phenomenological method. Findings are discussed in the light of the Norwegian philosopher Kari Martinsen’s nursing philosophy with practical implications. The essential structure of being treated with BPAP-mask from the patients’ point of view may be characterised as a feeling of being trapped in a situation of complete dependence on others, combined with a will to mobilize inner strength. The essential structure is presented through three

Introduction The number of patients admitted to hospital for acute treatment of chronic obstructive pulmonary disease (COPD) is increasing. The World Health Organisation (WHO) calculates that by the year 2030 the disease will have become the third most common cause of death in the world (1). Medical experts expect that roughly 200 000 people are suffering from COPD in Norway today, half of

Correspondence to: Henny Torheim, Department of Intensive Care Nursing, Hospital of Volda, Bøgardsvegen 6, Volda 6100, Norway. E-mail: [email protected]

themes describing the patient’s lived experience: Anxiety, panic and loss of control, regaining control and trust through skilled help, and a mobilization of willpower. The nurses’ experiences point to the challenges related to individual needs, ethics, technical, medical and relational competence in addition to constraints on time. The study concludes that mask treatment can be a traumatic experience for the patients. The interplay between dependence and autonomy in the patient’s interaction with health care providers, such as deciding when to take breaks, getting enough sleep, mobilizing inner strength and establishing trust and security are important factors in coping with the mask. Clinical competence, the ability to articulate impressions, and sufficient time on the part of health workers are other aspects that can be decisive to how well the patient tolerates BPAP-mask treatment. Keywords: mask treatment, NIV, COPD-exacerbation, patient experiences, nurses’ experiences, articulating impressions, interdependence, phenomenology, qualitative study and caring. Submitted 5 August 2008, Accepted 7 July 2009

whom have been diagnosed (2). Great efforts have been made internationally via the Global Initiative for Chronic Obstructive Disease (GOLD)-initiative to increase public awareness of the disease. Several studies indicate that the life of patients suffering from COPD are characterised by anxiety, breathing problems, exhaustion and isolation (3–5). They experience themselves as living in an alien body and feel uncertainty about the future (6_8). Studies also show that they suffer distress, depression and a reduced quality of life (9, 10), as well as poor health (11). Research further indicates that nurses could help these patients to improve their coping strategies (12). An acute exacerbation of COPD is a life-threatening condition that is experienced as frightening and extremely traumatic (13–15). The standard treatment is to provide a

2009 The Authors. Journal compilation 2009 Nordic College of Caring Science

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controlled supply of oxygen, systematic steroids, bronchia dilators and, where necessary, antibiotics. Noninvasive positive pressure ventilation (NPPV) as bi-level positive airway pressure (BPAP) ventilation with mask can ‘buy time’ and help the patients through a critical phase until the medicinal treatment takes effect. BPAP-mask treatment offers ventilation support via a respirator coupled to a tight-fitting face or nose mask (16). The respirator supplies air with overpressure to assist the patient’s breathing. The difference in pressure between breathing in and breathing out facilitates the patient’s breathing and supplies more air to the lungs. Hospitals report an increased use of acute procedure to treat COPD-exacerbation and ventilation failure. Major meta-analyses and Cochrane reviews report that mask treatment is less traumatic for the patient and gives fewer complications (17–20) compared to conventional respirator procedures. Mortality is reduced by about 13% and the need for intubations is reduced by up to 50%. Practical guidelines and treatment regimens for COPD-exacerbation based on available evidence and practical experience are drawn up (21, 22). Mask treatment is, however, quite demanding (23, 24). Several factors influence the outcome of the treatment, staff training is a key one (25, 26). Mask intolerance of up to 14% in addition to skin lesions of 20–50% are reported (20, 21). Research shows that patients who are given mask treatment at home report improved quality of life. They experience increased autonomy and feel less dependent on other people (27, 28). The ethical aspects and challenges associated with the treatment are considerable. Mask treatment must not be ‘forced treatment’. Some patients are, however, too ill to be in a position to know what is in their best interests. Such situations may cause ethical conflicts in an already difficult situation. The first author’s experiences as an intensive care nurse reveal large variations in how well patients tolerate the BPAP-mask. Searches in medical databases (Medline, Cinahl and Embase) have not come up with any studies that focus on how the patients experience such treatment during the acute phase in hospital or on nurses’ experience with mask treatment. The purpose of the study is to describe the experience of BPAP-mask treatment in the acute phase of COPD from the perspectives of the patient and the nurse. How do the patients feel when using the mask, and what do the nurses experience in caring for these patients? The study also aims at identifying conditions and interventions that may contribute to making the treatment less traumatic to the patients.

A theory of caring The Norwegian nurse and philosopher Kari Martinsen introduces a phenomenological theory of caring in a clinical

context. She points to important factors that she deems to be decisive in the emotional-moral interaction between human beings (29–31). One of these factors is called interdependence, a term Martinsen has borrowed from the Danish philosopher Knud E. Løgstrup. According to Løgstrup, a person is always and fundamentally dependent on other people; this does not, however, necessarily entail that one person controls the other (32). In some critical situations a person’s autonomy becomes threatened and this mutual dependence becomes obvious. Interdependence presumes a human response expressed in the form of care, which is at the root of all nursing. Martinsen refers to Løgstrup in emphasising the ethical phenomena of life: trust, hope, empathy, speaking openly, giving and forgiving, stating that these are expressed in all forms of human relationships. According to Martinsen, whether care becomes ‘life-enhancing’ or ‘life-constraining’ will depend on the other person. Martinsen emphasises the ability to articulate one’s impressions, such articulation is necessary for the sensed impression to be experienced and understood in order that the ethical phenomena of life be brought into play in a positive way. Professional discernment, an exercise in becoming aware of the sensed impression, is comprised of two components. The first is that the nurse, by being receptive and aware of feelings, registers the other’s will to live in the face of illness or suffering, and the second is that the nurse uses her professional skills to understand and act together with the patients in their best interest.

Method The use of a qualitative method with a phenomenological approach aims at achieving a deeper understanding of the phenomenon under investigation. Phenomenology takes as its point of departure perceived experiences in general where the life-world has a central meaning (33). The study’s main focus is the patients’ lived experience with using the BPAP-mask. The essence of the phenomenon can be uncovered by viewing the matter from different points of view where the phenomena overlap or are interwoven (33, 34). Therefore, the nurses’ experience with caring for these patients may add important data to the understanding of their situation. The study combines in-depth interviews with patients suffering from COPD exacerbations with a focus group consisting of experienced nurses who provide care for these patients at a specialist unit in a Norwegian university hospital. While in-depth interviews are suited to reveal individual experiences of a phenomenon, focus groups will mainly uncover cultural understandings or a group’s opinions, experiences, values and arguments (35–39). A purposive sample of five patients was obtained. A contact nurse at the specialist unit recruited participants who were diagnosed with COPD, had been treated with a BPAP mask for the first time, and had used the mask


Experiences of mask treatment in patients with acute COPD-exacerbations intermittently over several days. She recruited two patients whom the staff found had coped well with the treatment and three who coped less well but who still found the treatment beneficial. The patients were invited to participate in the study after the treatment was ended and they were well enough to be interviewed. Interviews were carried out with three women and two men aged between 45 and 78 who met the inclusion criteria. One of the participants was not diagnosed with COPD, but was under investigation. As he was a first time user of a BPAP-mask and had coped well with the treatment it was decided to include him in the study. In addition one focus group with eight nurses with between 1.5 and 14 years experience with mask treatment was conducted. By obtaining some insight into the nurses’ experiences, we could reflect on how they seemed to be able to meet the patients’ needs. One focus group of nurses was deemed sufficient as the study’s emphasis was on the patient’s perspective.

Data collection Data were gathered between December 2006 and March 2007. The individual interviews were carried out based on an interview guide with questions that invited the participants to tell their own story. The key element was the life world perspective in which the patients’ own experiences was the focal point. They were encouraged to describe their experiences with using the BPAP-mask as detailed as possible. The participants presented spontaneous accounts, and follow-up questions were asked on the basis of their comments. The interview guide contained questions about how the patients experienced the situation before and during the treatment procedure. Four of the interviews were carried out at the hospital a few days after the treatment had been completed, the fifth a short time after the patients had been discharged from hospital. The interviews lasted between 40 and 90 minutes. The nurses’ experiences with BPAP-mask treatment was the topicofdiscussion inthe focusgroups.The main questions addressedhow the nurses experienced the patients’ tolerance of the mask, and what the nurses did to help. The first author moderated the group session and the second author assisted bytakingnotes,observingthegroupinteractionandmakinga summary at the end of the interview. The participants, a homogeneous group who knew each other well and who seemed to trust each other, offered their experiences and reflections spontaneously, an important point which is also underpinned by others (e.g. 37–39). The focus group lasted for two hours. The group conversation and the individual interviews were recorded and transcribed verbatim.

Ethical aspects The ethical principles of the Helsinki Declaration (40) provide the basis for the project, and the study has been

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approved by the regional committee for medical research ethics and Norwegian Social Sciences Data Services. The participants were informed in writing in advance about the central topics of the conversation, the principles concerning voluntary participation, anonymity and their right to withdraw from the study. Signed consent forms were received from both patients and nurses. The project has not been associated with any financial interests. The interviewer did not have any contract of employment with the hospital.

Analysis Giorgi’s (41) phenomenological four-step method was used as the point of departure in the data analysis. The transcribed text was first read through several times in order to try to grasp the meaning of the whole. On the basis of this understanding, the second step involved identifying significant meaning units. For each interview the text was sorted according to themes. In the third step the text was abstracted to a higher level using appropriate new terms, while ensuring that the meaning was retained. Finally, an essential structure of the phenomenon was described and excerpts from the interviews were chosen to illustrate variations of the phenomenon. The focus group interview was analysed based on the interview guide’s main topics in accordance with advice in the literature (35–37), and then subjected to the same process as the individual interviews.

Findings: patients’ experiences From the patients’ point of view the essential structure of being treated with a BPAP-mask may be characterised as a feeling of being trapped in a situation of complete dependence on other people combined with a will to mobilize inner strength. This essential structure, which describes the patient’s life-world, is presented through three themes.

Experience of anxiety, panic and loss of control The patients had all been through a difficult period before they were offered mask treatment. They experienced the lack of air as exhaustion accompanied by a strong feeling of anxiety. They felt the insufficient supply of air as very dramatic: Not being able to breathe is terrible. Dying from not being able to breathe must be really horrible. No-one can imagine what it’s like till they have experienced it. I’ve had a heart attack […], but this is far worse than anything I have experienced. The mask treatment did at times intensify the anxiety. Some patients felt trapped as a result of the feeling of not being able to breathe. Allowing this anxiety to develop did at times lead to a feeling of panic and caused irrational


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behaviour. Many patients experienced a feeling of losing control over the situation. One patient said it was wonderful when somebody else took control until he could regain control himself and felt his anxiety subside. To others, being completely exhausted and not knowing anything about the mask in advance caused a feeling of losing control. Not knowing how to remove the mask and having it on for a long time without a break caused anxiety. Some patients said it was easier to wear the mask when they knew how long they were to have it on. Breaks were very important to some: Having breaks was really important. I think I would have panicked completely if they had said: ‘you must just lie there with it on’. I couldn’t have coped with that. So they gave me breaks. Feeling ready to use the mask and the experience that the nursing staff was aware of that, was considered important. The mask had to be ‘voluntary’, or panic could easily set in: And if they hadn’t sort of listened to me then, I’d have become hysterical. Some patients felt suffocated by the mask. A hand holding the mask in front of their face was an awful experience: I felt that I was being shut in. The one place where one had struggled to get enough air was covered up and I lost some of that feeling of security that must be there in relation to these experts. Tightening the mask as soon as it was put on made some patients afraid, as did not being able to find the bell. One patient described how he was unable to lie back in bed when he had trouble breathing. Sitting in a chair felt safer. The patients tried to hide their fear from the staff: I panicked, but I did not want to show it. But inside I really panicked. The patients experienced the situation as quite strange. They felt trapped and completely dependent on other people. It took time to get used to this: You feel completely trapped. You cannot go anywhere, and I certainly need time to get used to the thought that I am wearing it. It has to do with calming your mind too. That is a good thing for me. Several patients described how their senses became more acute, especially when it came to sounds, as is evident in the following statement by one patient: The sound of my breathing filled the whole room. When I held my breath, the sound disappeared. I think there were two tubes in it, I don’t know. I didn’t understand a thing. Everything that took focus away from breathing made it difficult for the patients to concentrate on coping with the mask. Leaks from the mask causing air in their eyes and a disturbing noise were irritating. Dryness of the mouth was described as one of the worst side-effects. Another patient, given a diuretic without having a catheter, felt it was too much at one time. Having family visits while wearing the mask also upset some individuals. Being told to relax and

not fret was experienced as quite negative. Fellow patients and other activities in the room disturbed their sleep.

Experience of regaining control and trust due to skilled help The patients felt it was all right to use the mask when they felt secure and well looked after. That the staff was around at all times, that their pulse and oxygen supply were being monitored, that they knew how to call for help, gave them a feeling of being in good hands. Being met with professional authority, which in clear and simple terms said what had to be done, created trust: It was important to have a person with authority say what was sensible to do: that should be given priority. We’ll work together now. We’ll stand here and help you and together we’ll cope. And perhaps a comforting hand to hold. Involvement and continuity of staff was considered to be important. The patients gained confidence in the nursing staff when they felt they were taken seriously, when the staff showed recognition of the patients’ suffering and did all they could to help, and this helped the patients mobilise the necessary strength to cope with the mask. The physician’s assurance that the mask treatment was important was crucial. Several patients said that they had no need to call for help at all because the staff was accessible all the time. One patient said this about having confidence in the staff: You have to feel confident that everything around you works. I depended completely on trusting the nurses and the ones present helped me make progress. Feeling able to adjust the mask themselves and gaining control over the situation by being more active and having a say made it easier for the patients to cope with the treatment. When they experienced that the mask helped, they felt more secure. Some were convinced that the mask ‘saved their lives’. To sleep well was also important. After having slept for a while with the mask on, they felt it was easier to breathe. Some patients wished for better help during the day, although they felt safe and well looked after even in the midst of hectic activity; as one participant put it: They put on the mask, made sure it stayed in place – but all in a mad rush. They were very busy. They did their best. You know – people were calling for them all over the place. The mask also caused some physical discomforts which could be quite painful. Pressure sores on the nose, forehead and cheeks were described. Plaster on the sores eased the pain. The degree of discomfort depended on the type of mask used and the respirator’s air pressure. The patients experienced wearing the mask lying down as easier when the pressure was reduced. Switching to another type of mask could also ease the pain. Although the patients did express different needs for information, the general experience was that the


Experiences of mask treatment in patients with acute COPD-exacerbations information given was good. The patients all found it useful to have some advance knowledge of breathing techniques and mask treatment.

Experience of mobilizing willpower The patients described the need to mobilize their inner strength and energy to cope with the mask. They also found support in listening to the staff and adopting cognitive strategies previously used in threatening situations. They gained strength from having a hand to hold and from praise and positive responses from the staff: In the state I was in – perhaps a hand to hold. That is energy. I have no doubt that holding someone’s hand there and then is good. The mobilization of willpower is mentioned as important in order to regain control and reduce anxiety. All patients stated that they could get used to the mask, but that this required a conscious effort.

Findings: nurses’ experiences The findings based on the focus group discussion indicate that the nurses were well aware of the patients’ difficulties. The essential structure of helping the patients with the BPAP-mask treatment may be characterised by efforts to satisfy the patients’ individual needs depending on the nurses’ competence, confidence and having sufficient time. This essential structure of the nurses’ experiences is further presented within three themes.

Trying to satisfy individual needs The nurses emphasised that they tried to satisfy individual needs by spending some time with each patient in order to see and hear the patient’s wishes before putting on the mask. The nurses’ main focus of attention was on letting the patients participate and have a say, optimising the effect of the treatment and easing any discomfort, in addition to dealing with any ethical challenges that might arise. The following excerpt from a conversation between two nurses (N1 and N6) about taking breaks reflects the agreement in the group as the others nodded: N1: Should the patients experience a drop in oxygen saturation, they can handle that; they are used to that, aren’t they? And then they must say what is important to them. N6: Yes, and I feel that making deals with the patients on taking breaks works well. Also letting the patients decide for themselves.

Realising the time aspect as vital The nurses’ capacity is influenced by the level of staffing and other available resources, as well as workload and

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other relevant challenges. The nurses found weekends’ especially trying as the staff is reduced by one half but have to care for the same number of patients. When the nurses were discussing problems associated with constrict of time the whole group seemed to support the following statements: N4: I am convinced that the time aspect has a lot to do with the patients’ experience. To be met in the right way – at least if you haven’t had mask treatment before. Having enough time to explain and be with them for a while. I think that has a lot to say when it comes to how they experience having the mask put on. N8: The early shifts on weekends are horrible. If the patients are admitted on a weekday – on the early shift – they are lucky. Then you can get a good start.

Acknowledging that experience gives competence The nurses agreed that mask treatment is demanding and involves assessment and that experience gives them increased competence, confidence and skill. They saw the administering of the mask treatment and the assessment of the patient’s condition as a great responsibility, as the air pressure setting has to match the patient’s needs based on their blood gas values and ventilation pattern. The following excerpts reflect how the participants supported each other while discussing the problematic issue: N4: It is better to use lower pressure and that they are able to keep the mask on, than using higher pressure. N7: If we reduce the pressure the treatment may not have any effect. The blood gas value will be the same. And so we must come up with something else. Giving a sedative may help, no? N2: Yes, you need basic knowledge when it comes to the technical side of things. That you know all the technical stuff – and then you move up a step – you see the patient more and more clearly.

Discussion The findings based on patients’ and nurses’ experiences point to patients’ difficulties in coping with the mask. The study also reveals the value of the positive encounter between nurse and patient, and there does not seem to be any major discrepancies between the two perspectives. Nevertheless, nurses at a busy ward do not always seem to recognise environmental aspects as a threat to the patients’ ability to cope with the mask. The study indicates that the patients are in a field of tension between dependence and autonomy at various levels. Their great need for help in general and in making decisions about their own situation in particular, emphasise the value of relationships and caring and thereby the importance of interdependence. Anxiety, panic and loss of


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control are strong emotions that require some sort of response in order to re-establish the balance between dependence and autonomy. Receiving the mask that provides life-saving air is a great relief, but coping with the mask it self may cause problems. The experience of receiving air compensates for the loss of autonomy and the patient seems to regain control of his life again. The care provided by the staff demonstrates the interdependence and support the patient’s loss of autonomy when the situation gets out of control. The nurse registers and interprets the patient’s feelings and communicates this acknowledgement through her actions and this encourages the patients to respond. Giving the patient a bit of time before putting the mask on gives the patient a welcome chance to say how he feels. The way the patient is met as a person influences his feeling of security. Seeing with ‘the heart’s eye’ (31), and recognising the impact of ethical values on lived experience enhances patients’ autonomy (15, 27, 28, 42). The present study identifies this as necessary to manage the anguish. Meeting skilled carers, having a say in deciding when to take a break, involvement on the part of the staff, are factors that affect the patients’ perceived balance between dependence and autonomy. The patients feel confident in using the mask when receiving skilled help. Other studies indicate that improvements in nurses’ skills through experience over time allow for successful treatment of increasingly serious cases (16, 25, 26, 43). According to these studies cushioning the forehead and the bridge of the nose prior to attaching the mask and reducing the mask leak by using a different mask or different ventilator setting is helpful. This is in line with the current study. The importance of the nurses’ ability to articulate their acknowledgement of the patients’ experience is emphasised by both patients and nurses in the study. The physicians’ role using their professional authority to inform patients about the importance of the treatment increase the patients’ confidence Trust creates trust, and thus creates a space in which one may feel secure (29). The data indicate that planning breaks with the patients is one way of giving the patients a say in the decision-making process. Making sure the patients are heard, letting them adjust the masks, tightening them gradually, strengthen their experience of autonomy. Breaks are also important in giving some respite from the pressure and pain of the mask. The study shows that the patients experience intense anguish, giving them a feeling of not knowing how to survive. This finding corresponds with earlier studies (3–8, 13, 14). The patients’ emotions open the way for life’s ethical phenomena, giving them access to the life-enhancing effects of emotions (29). Their courage revive when offered a hand to hold and they understand that the nurse acknowledge and feel for their suffering and anxiety. When the patients feel they are ‘taken seriously’ and that their integrity is upheld, care is life-enhancing. Words of encouragement in a

difficult situation seem to have quite a positive effect on the patients’ experience of the situation. According to Martinsen (29) this comes about when the nurse ‘responds’ truly to the patients’ appeal to be seen, to be heard, and to be understood in their pain and need. When the nurse is close at hand and responds to the patients’ vulnerability, the ethical phenomena of life are brought into play and release courage and hope. As other studies also emphasize, the nurses can help the patients improve their coping strategies (6, 7, 10, 25, 44) and to envision a future (45). Only the watchful and experienced eye can interpret the appeal from the other’s felt emotions (31). Concrete life is accessed and opened through our sensed experience and not through our prejudices, our established theories or firmly-cemented opinions (31). Is the encounter with each individual sufficiently emphasised? Or do technology and medical treatment take up too much of the view? Other studies indicate that technology in itself is a challenge to patients (23, 24). However, nurses are oftentimes extremely busy, leaving very little room for human interaction beyond the administering of the technical treatment. Listening for a tone of voice, sensing the other person’s feelings and reflecting on what is best for that individual is time-consuming (31). Does possibly a lack of articulated impressions lead to misdirected caring actions which do not satisfy the patient’s fundamental need for interdependence? Or is it due to the shortage of time? Are the acute and critically ill patients suffering from COPD offered sufficient care time to ensure that they are given the help they need? To answer these questions more research is required.

Strengths and limitations of the study The study was carried out at a ward with nurses possessing great expertise and long experience with BPAP- mask treatment. Although a small number of patients were involved in the study, they provided rich material that described their experiences of using a BPAP-mask. The one patient who did not have a COPD-diagnosis benefited from the mask treatment and provided detailed accounts of how he experienced the problems associated with this form of technical treatment. Conducting only one focus group does limit what could be said about nurses’ experiences. However, the two perspectives together provided some insight into both patients’ and nurses’ experiences of mask treatment and the fact that the two perspectives supported each other may strengthen the validity of the study.

Conclusion and implications for practice The study emphasises the articulation of impressions and emotional awareness as vital aspects in enabling the patient to regain control and gain confidence in using the mask. The patient must be given sufficient time to form an opinion and to communicate what is important there and


Experiences of mask treatment in patients with acute COPD-exacerbations then. The nurses must spend time interpreting the patient’s impression by observing and listening to each individual before the mask is put on. The initial phase is particularly important for mask tolerance. Skilled help, praise and encouragement, continuity in care and the perception of the nurse being truly present are essential factors in establishing the patient’s confidence and mobilizing the willpower needed to enhance the patient’s desire to live. Sufficient sleep is important, and various sedatives can be useful. Adjusting the mask and the air pressure, using a humidifier and offering plenty to drink are important practical measures. It is also useful to document the patients’ responses to mask treatment, in order to better accommodate each person if mask treatment should be necessary at a later date. Issues such as allowing sufficient time and having clinical expertise in the ward with regard to BPAP-mask treatment must be discussed among both nurses and physicians. Guidelines, procedures, techniques and treatment regimens must be clear and all those involved in the treatment must be acquainted with them. Information must be given with professional authority. All patients interviewed stated that prior knowledge of the mask would have been advantageous. Perhaps patients suffering from COPD should learn about the use of the BPAP-mask before they become acutely ill and need this form of treatment? In order to increase patients’ tolerance for the mask and reduce the related discomforts, the wards administering this treatment should increase the focus on BPAP-mask treatment through professional development and research. According to our study, fairly simple measures may make the patients perceive the BPAP mask more as a ‘friend’ than an ‘enemy’.

Acknowledgements The authors would like to thank the patients who generously gave their stories about living with the BiPAP mask in acute COPD. We also wish to thank the nurses at the university hospital in Norway who participated in the focus group discussion.

Author contributions Henny Torheim was the principal author of this paper. Eva Gjengedal participated in the data analysis and critical revision of the manuscript.

Funding The study was financially supported by Helse Sunnmøre (Sunnmøre Division of the Central Norway Regional Health Authority) in Norway (reference number: 2008/ 160, prosjektkode 68-FU-16-08) and Norsk Sykepleierforbund (Norwegian Nurses Organisation).

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