9 Reasons Why I Hate CPAP

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This is a continuation of my love/hate series on treatment options for obstructive sleep apnea.
 
In my last post, I described 7 reasons why I like using CPAP for my patients with obstructive sleep apnea. In this post, I will go ever 7 reasons why I hate CPAP. As you can see from this post and past posts, I have a love/hate relationship with all the diagnosis and treatment options for obstructive sleep apnea.
 
1. Always the wrong pressure
 
Traditionally, your CPAP pressure is calibrated to cover the worse-case scenario—REM sleep on your back. We know that apneas happen most often in this situation. You’ll get the same pressure the entire night no matter which sleep stage you’re in and which position you’re sleeping in.
 
Automatic machines are designed for limitations of CPAP, but despite advances in APAP technology and algorithms, it’s still not able to predict when you will enter REM sleep or switch onto your back. 
 
2. The Heisenberg uncertainty principle
 
One of the principles of physics is that whenever you observe an atom using light, you’re changing the position of the atom. In the same way, having a mask strapped to your face with positive pressure will by definition change the quantity and quality of your sleep. For many people, the benefits will far outweigh with side-effects, but for others, CPAP causes more arousals than it helps.
 
3. Often used with stuffy noses
 
Many people with obstructive sleep apnea have stuffy noses, and we know from studies that having nasal congestion can significantly lower CPAP effectiveness. Allergy medications or nasal saline irrigation may help some people, but even if you’re able to benefit from CPAP, it’s probably not working as well it could work due to a stuffy nose. To adjust for these issues, a full face mask can be used, which cover both your nose and mouth. In theory, this can work better, but full face masks are generally more uncomfortable. 
 
4. CPAP doesn’t address milder forms of obstruction
 
When you undergo a CPAP titration, the pressure is usually calibrated to get rid of apneas and hypopnea, especially when you’re on your back and in REM sleep, when your muscles are most relaxed. However, more subtle degrees of obstruction that don’t meet the 10 second threshold criteria and not addressed. This is why many people can have CPAP adherence data showing an AHI of .1, no leaks, and using 100% of total sleep time, but they don’t feel any better. 
 
5. Potentially makes your teeth crooked
 
Dentists say that about 50 grams of force is enough to move your teeth. That’s about 2 ounces. Nasal and full-face masks place constant pressure on your front teeth. There are documented reports of patients using CPAP where the upper incisors were found to be shifted back.
 
6. The system is broken
 
Studies have shown that with proper education and good follow-up, most people can do well with CPAP. However, due to a broken health care system, many patients slip through the cracks, with minimal to no education and not enough follow-up visits that are needed for troubleshooting. In the academic published literature, “adherence” rates range from 40% to 80%. In the real world, only about 20 to 30% people who start using CPAP are still using it effectively at 1 year.
 
7. Not a permanent solution for most people
 
Even if you’re able to use CPAP, life situations change. You may gain more weight. Or you may be in a new relationship. Although I see many people who are very happy using CPAP over decades, some people will want other options at a later time. 
 
8. Flawed CPAP “Adherence” requirements
 
Medicare and some insurance companies will require that you use CPAP for about 50% of your total sleep time. Otherwise, your machine is taken away. If you start with an AHI of 50 and use your CPAP 50% of the time (4 hours every night), technically, you’re “adherent.” But your average AHI level during your total sleep time is still 25, since you didn’t use CPAP during the other 4 hours during the night. CPAP may be very effective in lowering your AHI to minimal levels, but it’s completely useless if you’re not using it at all.
 
9. Periodic cleaning and maintenance is needed
 
This may not matter for people who are regimented and find it important to maintain their CPAP devices on a regular basis, but many others find it cumbersome. Additionally, your body’s CPAP pressure needs will change over the course of months to years, so it’s important to check the pressure at least every 6 to 12 months. 
 
Despite these 9 reasons why I don’t like CPAP, it’s the best that we have, so I do recommend it for most people with moderate to severe. obstructive sleep apnea. 
 
Here are three ways to maximize the chances that your CPAP will work for you:
 
1. Find the right mask
 
Many people don’t know that you can ask for a different mask within 30 days. The combination of the right mask and headgear can make a major difference in your comfort levels and whether or not CPAP will work for you.
 
2. Unstuffy your stuffy nose
 
Having nasal congestion wil significantly lower the chances CPAP will work. Higher nasal resistance will raise up your CPAP pressures, and it’s also more likely that you’ll open your mouth, causing a mouth leak, which can cause you to wake up. Do everything to make sure that you’re breathing optimally through your nose. This can involve nasal saline, nasal dilator devices, allergy medications, or even surgery.
 
3. Talk to your health care professionals
 
Communicate with your sleep physician and equipment company often, especially in the first few weeks. They can troubleshoot only if you give feedback.
 
In the following posts, I will go over reasons why CPAP may not work, and why I like and dislike surgical options for obstructive sleep apnea.
 
What has been your experience using CPAP? Was it good or bad? How were you able to overcome challenges to be able to get to the point of sleeping better?

Please note: I reserve the right to delete comments that are offensive or off-topic.

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10 thoughts on “9 Reasons Why I Hate CPAP

  1. I hate it for all those reasons and because it increases my intracranial pressure. for someone with intracranial hypertension and OSA, it is impossible to use CPAP to achieve normal ICP. you eliminate the OSA contribution and take the CPAP contribution to ICP instead. BiPAP should be better but for me it does the same thing. the expiratory pressure is a Valsalva which is known to increase intracranial pressure. it keeps the airway open but I believe this is at the expense of jugular venous drainage.

  2. Dr. Deb,

    Yes I have noted that nasty increase in pressure that occurs as your beginning of exhale meets the momentum of the fan recently “spun up” to meet the needs of your inhale. After reading some comments by Dr. Krakow concerning expiratory pressure intolerance I plumbed into my CPAP air circuit about a gallon of what I think of as “compressible air space” (or perhaps “container expandable space”) which does seem to give a place for that outgoing air to go rather than meeting the fan head on and so gives the system a bit more time for the system to respond – the bottom line is a much much more natural feel to breathing with CPAP. There is also less noise and vibration in the tube which is also a relief.

    I wonder if your ICP issues might stem from ventilatory gain issues fostering arousals and carbon dioxide maintenance issues which would result in cerebral vascular reactivity issues.

    For years I have dealt with a tendency to wake up over breathing while using CPAP. Recently I have come to believe that this stems from insufficient communicating arteries feeding too little the basilar artery making the apparently posture and “tension headache neck muscle” related pinching off of my vertebral arteries result in too little supply of blood to my basilar artery where the central chemoreceptors then go to work to try to compensate with too much breathing for what the body as a whole needs. I have noticed a major change in breathing reflex as I correct my tendency to have forward head posture. I have also noticed considerable “arthritic crackling” as I do neck exercises and better breathing reflexes after doing them. I find that keeping my neck in proper alignment as would be with proper posture standing up makes breathing at proper levels while using my CPAP much easier. Now neck exercises are part of going to bed.

    May we find the best sleep!

    Tod

  3. To whom it may concern if you are a sleep study specialist i just want to know if provents is as good as a sleep cpap mask machine device…….Thanks please reply back .

  4. I have had my CPAP machine for about 4 weeks now. I hate it. I have chronic allergies, constant stuffy nose and negative ear pressure in both ears. I have a full
    Face mask. It physically hurts my ears to wear the stupid mask with pressure on
    (8.0 treatment, begins at 6.5 ramp). I also feel as though I have sinus pressure when using the CPAP. It isn’t helping at all. I end up taking the dumb thing off half way thru the nite (I put it back on early in the am hours). I wish Medicare would cover the expense of the mouthpiece. My apnea is mild in every position but on my back and I rarely sleep on my back. If they could fix my sinus plumbing problems I probably wouldn’t even have apnea!!!

  5. Thank you for taking the time to write this. I have moderate sleep apnea and have been using the cpap for about 2 months and find that everything you have written is right on .I have now begun having stuffy nose and a AHI for 2 out of the last 3 nights of 11 . I have had no follow up from my sleep lab. I did exchange the mask once and after 60 days find it just as irritating . The only benefit is my wife hears no snoring .I still do not see the need for it nor have I been tired during the days I realize the long term benefits and am aware I need to manage my own heath . I feel the same energy wise if not more tired .

  6. I hate this machine, I’m sleeping less with it, the machine is ruining my life!!! I’m so overly exhausted, I’ve been crying all day!!! I’m NOT overweight, I’m 5 feet six inches tall and I weigh 118 pounds, it’s literally not even my own fault. I can’t do anything to fix this, I just want to sleep, and I refusr to use that medevil torture device.

  7. Cpap doesn’t work for such a large percentage of the population. The masks are horrible, the heated air dries out your nose and causes major problems. Sinus problems are worsened. Why are there not more solutions to such common breathing problems.

    Industry is making a fortune and we are forced into this cpap bs and we still can’t sleep

  8. I was diagnosed with mild central apnea and some signs of obstructive. I have been using a cpap for 3 1/2 yrs. with little relief of exhaustion. Never wake feeling refreshed. I have tried several masks, none of which are comfortable. They either cause nose sores, slip up the back of my head, making the nose pillow seal “break”, or the nose pillow does not come in a small enough size. I’ve tried regular hoses vs heated hoses, condensation running down my facing – lovely feeling. Humidifier vs no humidifier. The hoses leading from the nose area wrap around my neck feeling like it’s strangling me. Hoses coming from the top of my head rotate so the air blows against the pillow making a lovely noise and waking me. My husband builds a wall of pillows so the cold blowing air from my face no longer wakes him up. I stopped working because I felt I could no longer make it through the day and then try to drive without falling asleep. Cpap may work for some, but for those of us that it does not achieve a positive result….it is a horrible way to have to sleep. I wish someone would come up with an alternative.

  9. Diane,

    Sorry to hear that CPAP is not helping you. It’s interesting that you say that you have mild central obstructive sleep apnea. In my experience, most (but not all) people with central apneas may have what I describe as “expiratory palatal obstruction,” where as you breathe out through your nose, the soft palate flaps back into your nose, causing a sudden blockage. If you hold your breathe while breathing out for more than 10 seconds, it will be scored on a sleep study as a central apnea. It’s like bearing down mildly during a bowel movement. Most people end the event with a quick puff of air out the mouth. This can in theory prevent CPAP from working properly. This is not something that sleep doctors know about. I’ve submitted a paper regarding this phenomenon for publication in a sleep journal. Unfortunately, the only way to know if you officially have this is to undergo what’s called drug induced sleep endoscopy under anesthesia in the operating room. Here’a blog post I did a while ago with a link to a poster I presented.

  10. I’ve been using a half mask sleep apnea machine for about 9 months now. I dont feel noticeably better and more often than not, I am woken by the tornadic activity across my face when the seal breaks for whatever reason. I’m a mouth breather and side sleeper, not overweight, but come from a family of chronic loud snorers. I wear the mask because my partner insists on it–and because he’s no longer jabbing me, I guess I do sleep somewhat better.

    One to the things no one told me is how bloated your gut gets sleeping with these horrible things strapped to your face. My doctor recently lowered the pressure so it’s better, but I still wake some days with a gut feeling like it’s been percolating for hours, and it takes an hour after waking before I feel normal again.

    Because of the way insurance works, the sleep clinic is not willing to explore other options for what I believe is a architectural problem, not obstruction. Insurance will pay for this because if you comply 100% of the night, you will not have an apneic episode so as a therapy it’s efficacy is rated 100%; whereas, teeth or jaw re-alignment which takes longer and costs more, is only rated at 70%. So this is where insurance will pay, so this is the solution all sleep clinics push–and it’s created a nice little cottage industry in medical equipment suppliers. Since as you mention above, if you have trouble adjusting, the answer is go see your sleep care provider, and every time I do, it’s fees for office visits and facility usage fees for a visit that was 15 minutes and a referral to the medical device supplier for another mask, another refitting, another period of adjustment. And since everyone is making money in this scheme, there is no motivation to create better products or better therapies.

    But I keep strapping the hated beast to my face, feeling as unsexy as hell, old, and a bit like Alien, because, hey, at least if I’m wearing this, my partner does not kick my shins all night.