Sleep Apnea CPAP Compliance Craziness

One of my biggest pet peeves is how doctors use the word compliance. If a patient doesn’t comply, it usually implies it was the patient’s fault. In sleep medicine, compliance is often used to measure how well patients use their CPAP machines. But compliance is not the same thing as success.


Various studies report CPAP compliance rates at 29% to 83%. The problem is that the definition of compliance changes from study to study. More recently, we’ve adopted the new Medicare requirement for CPAP compliance, which requires that the patients use CPAP at least 70% of the time over a 30 day period, for at least 4 hours every night. Otherwise, the machine has to be returned.


If you sleep 7 hours every night, it comes to 210 total number of hours per 30 days that you’re sleeping. Seventy percent of 210 hours is 147 hours. If you sleep only 4 hours every night, then this figure drops to 88 hours, which means that you have to use your CPAP machine only 40% of the total time that you’re sleeping to be considered "compliant." This doesn’t take into consideration if you’re actually feeling better or if the machine is being used effectively. 


Since CPAP works only if you’re using it, if only 40% of people are still using CPAP regularly 5 years after beginning treatment, then the CPAP success rate is at best 40%. But not all people who use CPAP will benefit, so this figure is likely to be much lower. Many more people are likely to stop using CPAP as the years go by. 


There are many patients that are 100% compliant with CPAP, using their machines 100% of the time they are sleeping, with no leaks and a low AHI, and still feel no better. Sometimes they can even feel worse than when they don’t use CPAP.


From what I’ve seen with CPAP compliance studies or even with sleep apnea surgery studies, they all manipulate the numbers to make their results look great. In very tightly controlled research studies with frequent follow-up and intensive intervention, results are likely to be good. But in the real world, with fragmentation of care, poor follow-up and lack of patient education, true success (the patient feels much better AND the numbers show it) is disappointingly low, no matter which option you choose. 


Despite all these obstacles, there are proven ways to improve CPAP success. With a systematic and formalized education program, along  with intense counseling, follow-up, and long-term support, many more people can benefit from CPAP. Ultimately, a major part of poor CPAP compliance is due to the health care system that’s dropping the ball.


Am I being realistic or too pessimistic? Let me know what you think of this issue in the comments box below.

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

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104 thoughts on “Sleep Apnea CPAP Compliance Craziness

  1. I was diagnosed with severe sleep apnea 9 months ago. Having 80 episodes a night with my oxygen levels going down to 36%. I was given a cpap and with a pressure set to 15 with a 3 point variable on this setting.

    I have used it every night since getting it but felelt really ill with all the symptoms I had before starting the cpap, even with the pressure set to 15. My data card said my AHI was down to 3 and that all is well.
    The pressure suddenly went up to 17 for approx 1 month and I began to feel better which was great. Then it dropped again and all the symptoms came back including the neurological problems with memory and clear speech. The sleep clinic told me there is no way my symptoms have anything to do with the OSA. Im feeling confused because on a pressure of 17 I feel ok and anything lower I feel dreadful. Is it possible to have great clinical data and still suffer the symptoms of OSA if the setting is not suited to an individual therapuetic level?
    I think I’ve had this a long time and with the severity of my OSA, how can I find out about any potential brain damage that might have occured? My cognitive ability is definitely a lot less than it used to be. My left foot also drags at times now.
    The other thing that has started to happen is that when I wake up, I can be fully awake, have a conversation etc but cannot get my eyelids to open without physically pulling them open.

  2. Great paper, Dr. Park. I am a patient with Apnea and also am on disability for bipolar and anxiety disorder. Also, i must use the full mask due to mouth breathing. The insurance company, UPMC for Life/medicare, want to take the machine due to non-compliance. It’s bizarre. I am trying to convince them that my sleep patterns and lack of sleep are part of bipolar. When I do use the cpap it helps me tremendously, and a good nights sleep is a wonderful aid to the bpolar and anxiety! But I was not able to make the 4.0 hour per night average within 90 days. Why don’t these people allow me more time to get used to the machine? Seems insane to me. Lol

  3. Diagnosed in 2001 with moderate obstructive sleep apnea. During the overnight test, I had 19 events per hour. Was feeling like a zombie during the day and sleeping at my work desk with my office door closed. I used the CPAP with nasal pillows (and eventually humidifier) every night but usually took it off in my sleep after about 4 hours. It was a real struggle for the first couple of months to even use the darn machine. Sore nose, sore upper lip. Sore cheeks from straps. I called it my iron mask. But I used it … until about 4 months ago. After 15 years, three machines, and countless accessories, I decided that I always sleep on my side and wake up in the same position as I am when I go to sleep. I do not roll over on my back during the night. I use an oximeter to record my oxygen saturation levels and they are regularly 90 – 95 throughout the night with few exceptions. With the CPAP the saturations are 95 to 99. My wife tells me that I snore when I don’t use the CPAP but I don’t see any evidence that I stop breathing from the oximeter readings. I am a 2 phase sleeper – with or without the CPAP – because I have other medical conditions that cause me to sleep/stay in bed only 4 to 5-1/2 hours a night. I stay up as late as I can so that I am really tired then go to bed and fall asleep within a few minutes. I get up and go about my morning rituals then go back to bed after about 3 hours. I sleep another 2 to 3 hours (without my CPAP). I’m then good for the rest of the day, which lasts about 16 hours. The sleep doctors told me back in 2001 that I had excess tissue in my throat that caused the OSA. They said it was a risky procedure to remove it and in my case probably wouldn’t make much of a difference. I do have a fairly thick neck which is considered an indicator for OSA. I am going to use a digital record in a few days to record my sleeping to see if my breathing is regular or I appear to have any times when I am struggling to breath or actually stop breathing. If everything is good, then I’m content that I can continue to sleep without my CPAP. Maybe I’m kidding myself but enough is enough with the CPAP. I gave it my all, which in my case was about 4 hours per night. Now, I’m 71 years old and have less patience with the whole thing. Did I cut my life expectancy by going years before I was diagnosed with OSA? Perhaps. Did I add years to my life by using the CPAP? Perhaps. Am I undoing all the good by not using the CPAP now after 15 years? Perhaps. But I think I’ve found a happy median whereby I sleep without the CPAP and use other devices to measure my quality of sleep. Not scientific but I believe they work. Maybe someday someone will invent a better CPAP – we really need it. Hope these comments still get to someone since the site was first started in 2009.

  4. I had the Deviated septum operation done and was told i may need a cpap last July 2015 i put off getting one as long as i could . SO May of this year i was given one i knew nothing about them , i don’t sleep good to start with some times I don’t sleep at all or maybe only 3 hours a day . I thought i was in compliance so on August 1st before i go to see the DR so he could let me keep it i get a phone call from the supplier told me i wasn’t in compliance return the machine then the lady hung up . to me she very rude and thu out the trial i thought i was doing good but every time she called she ruined my day . your not in compliance etc … sigh . on top of that they have billed me and medicare for supply’s i never got and some of the supply’s they sent me did not fit the machine I did complain about that they ignored it and insisted i was wrong ,the cpad did help me when i did sleep but that doesn’t seems to mater i did use it every time i went to sleep i just didn’t sleep enough to fit the bill .I’m returning it and all ready told my DR, I’m not going thu that again , so don’t even suggest it no matter how much it helped, i don’t need the hassle to keep it . and i know all to well just what those study do and mean, i do one for one of my DR’s and have for years he asks after each stundy to join new unless there is waiting period i have wait, in return I get paid, get to see if there might be a cure one day for me . i won’t lie i do it for money but not just the money . but trying to keep the Cpad when it was clear from the start there was no way I could by the way i felt i was treated while i was using it , like i said to my DR, I’m not wasting more money just to go thu it again when it was clear it did help me but because of other issue i don’t sleep well it’s taken away because i didn’t meet compliance. no lie . I’m sure there are other with similar issues. but with me I’m not going thu it again i don’t want any favors just a little more understanding and them caring and not how much it costs.