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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97 thoughts on “Sleep Apnea CPAP Compliance Craziness

  1. I have been using a CPAP for over a year now, and I love it. I had a bit of an adjustment period at the beginning, but now I find I don’t feel ready to sleep unless I’ve got my mask on. I started using nasal pillows earlier in the summer, and now I hardly notice there is anything there. One thing I have found is that I don’t seem to sleep quite as long – it seems I get 7-7.5 hours per night instead of 8-9 hours. When I’m not working I tend to sleep a bit longer. I wonder if it’s because I am getting more deep sleep. In any case, I feel for people who can’t adjust to CPAP. It’s been a very good thing for me. So it is not all doom and gloom!

  2. I wasn’t sick until I was force to be on the cpap thru crete carries. I’ve suffer facial injuries plus I’m experience real bad side effects now and in order to keep my job I have to endure this. Both of my bmi are 31.9.i am deteriorate as I speak

  3. I was forced onto the cpap machine 4 months ago. The first 30 days was a battle for me to adjust to it so I could get the remainder of my dot med card. Since I have been on the cpap, I have noticed that my elbows that were in severe pain since I started with the company I am with now, has long since stopped hurting. But over the summer I battled to adjust to it more as every time I find a setting to let me sleep with the humidifier the next night I could not sleep. If I did sleep it was not for long.

    I have repeatedly asked Group Health for the proof that I have sleep apnea. They keep telling me I have it and they are extending my life by putting me on the cpap. I have had extensive sinus surgery and the doctor made sure that I would never have any problem breathing when I sleep. I use to get 8 hours of sleep a night. Now I am down to 4 or 5 hours of sleep. I have found myself hyperventilating in the middle of the night when using the cpap. I have also noticed that I am way more tired at work than I use to be.

    Group health doctors swear I have sleep apnea. How can that be when I did the test, I never once fell asleep. I am currently writing the FMCSA to get more information on whether or not that what group health has been doing to us drivers is legal.

    Oh and now I am feeling the old pain I had before the doctors went in to rebuild all my sinuses and nasal passages. Am I heading back to go through the pain from all that surgery again? If so, I am going to sue group health for being the cause and they will pay for all surgery done by a non group health doctor.

    My brother just underwent a procedure to run a camera down his mouth to look for another hernia. During the procedure, my brother started coming out of the anesthesia and started coughing and choking on their tool. So they hit him with enough drugs to knock out an elephant. After the procedure they told him that he has sleep apnea (group health doctors). I told him that it is a lie and they are trying to cover something up. Think about it. You have a freaking camera down his throat blocking off his airway and you knocked him out so far that half his organs started to react to the lack of oxygen. Next morning he woke up and his eyes no longer had any white to them. They were all full of blood. He went into the clinic who done the procedure and cornered them on what happened. It was not until 24 hours later that they told him that they had screwed up so bad that they caused him to wake up, cough and gag and vomit so hard that he had ruptured every blood vessel in the eyes. It took 2 months for that to clear up. To this day they keep hounding him to do the test to diagnose the sleep apnea.

    Oh another piece of information I found on my paperwork. I never claimed I have a problem sleeping. Not once! Stress? A ton of it. Strain? A ton of it. I have no time to do what I want as I am taking care of my elderly parents and working damn near 18 hours a day. But the doctors state that I have a problem sleeping. How the hell would they know unless they have been in my bedroom when I sleep.

    The DOT doctor at group health stated that I looked exhausted. Geeze Really? I have been up since 2 am and had to be at work by 4:30 am and then ran 10 hours for my job to her 3 hours of her job. She never once asked me what my schedule was. She just assumed I was a 9 to 5 worker.

    This is just a scam for doctors to make money. Since I have been dealing with this. I have spent $4000 dealing with appointments and freaking group health falsifying billing and I had to pay bills I had already paid and showed them proof of it. They have gone as far as charging me for supplies I get for the cpap machine. I pay apria for the supplies. Not group health.

    I can safely say that when child support is done in 18 months. I am telling the trucking industry and group health doctors to take a long walk off a short pier. I am done jumping through hoops that are not even there!!!!!!!!!!

  4. Tom, would like to be a part of a suit. I’m on seizure meds after using cpap. On 10/1/2012 I tried to sleep all night on cpap woke to EMT’s.

  5. The industry really does need some help toward looking the respiratory gain issues[1], induced through the pressure of xPAP, in the face. If hypocapnia is induced through the increased “motor” gain from the pressure of xPAP – well now – damage to the brain is likely I would think.

    I think a modified version of EERS[2] should be provided with all xPAP units to help prevent intermittent hypocapnia while using xPAP. That would likely save brain cells and lives.

    But at the base of it you really need to determine the case of the respiratory gain issues. More about that in my “blog to be”.

    Go team!!!

    [1] Eckert DJ, White DP, Jordan AS, Malhotra A, Wellman A. Defining Phenotypic Causes of Obstructive Sleep Apnea. Identification of Novel Therapeutic Targets. American Journal of Respiratory and Critical Care Medicine. 2013;188(8):996-1004. doi:10.1164/rccm.201303-0448OC.

    [2] Gilmartin G, McGeehan B, Vigneault K, et al. Treatment of Positive Airway Pressure Treatment-Associated Respiratory Instability with Enhanced Expiratory Rebreathing Space (EERS). Journal of Clinical Sleep Medicine : JCSM : Official Publication of the American Academy of Sleep Medicine. 2010;6(6):529-538. [mods outlined in my “blog to be”]

  6. I went to a sleep clinic and was told I only had apnea when I was lying on my back. The fact that I always roll onto my back didn’t seem to factor in to the diagnosis that I do not need a cpap prescription,

    The thing is, I already have a cpap machine which I used for about 15 years, when I originally was diagnosed. So I just need masks and filters, which used to be provided by my HMO. Now that I no longer have a prescription, I can no longer obtain those items. The sleep clinic did however recommend using a special belt to keep me from rolling onto my back(why would I want to be restricted that way?), or surgery. Surgery over a cpap machine?!

  7. I lasted 3 nights on the CPAP (full mask), was exhausted from lack of sleep, followed by PVCs at a level that endangered my life. Spent the next 8 years devising and testing a suite of airway exercises that I now offer to seniors who attend my lectures. Should have it all finished by early summer 2016, along with a model of a asleep terrain designed to manage ofter issues such as sleep position.

    Can post a feqw graphics here as I trudge along.

    Sleepy Bob

  8. Well in July I was diagnosed with obstructive sleep apnea and the Dr really scared me to the point that I can’t get any good sleep. He told me when I sleep at night that my apnea is so bad that I needed to sleep sitting up and if I didn’t I could actually die in my sleep he said when sleeping I only get 38 % oxygen and he said that’s not good at all. So now Im afraid to sleep and iv been waiting since July to receive a machine. And it’s almost mid Nov now and it’s not comfortable to sleep sitting up at all. The reason I come to find out why I haven’t received my device yet is because my dr and insurance company don’t agree on the method of obtaining the device in the first place. Stupid I know the insurance company says all I need is for my dr to write me a prescription and the Dr says no I need to do another sleep study and the insurance company won’t pay for that and my dr won’t write a prescription so here I am trying not to die while I sleep . Can someone help me please.

  9. Think about this. Dr. Wants you to do another sleep test. Insurance already paid for 1. Dr. Won’t write a prescription. Why? The Dr. Just got caught by insurance by fraudulently claiming you have something you don’t really have. If you did have apnea he would have put you on a cpap machine right away.

  10. Christina perhaps it is time to do some Google searching and get some help to sort things out.

    Search for:

    medical ombudsman [your state]

    insurance commissioner [your state]

    medical licensing commission [your state]

    And find those who you can talk with to help yourself.

    I hope you do find good resources.

    If you really do have your blood oxygen levels going down to 38% to leave the matter without treatment for an extended time is irresponsible wherever it may come from.

  11. Christian. Tod has some good thoughts. I wonder how all these people lived for years with out cpap. Air force used a mouth piece for apena years ago. I have read that data for sleep studies was manipulated. Years ago I learned self hypnosis to relax. Meanwhile I’d suggest deep breathing. Breath In healing energy and breath out or let go of the stress. Book by Barbara Ann Brennan Hands of Light gets into healing. Published in 1988. I also use herbs for healing. Roy

  12. I’ve been using my cpap machine for 6 months or so. Have no problem using it but it’s just not helping. Sleep test showed over 40 episodes per hour and cpap brought that down to under 5. Until now. Sometime over the last month my episodes started averaging 30 per night w the machine. Dr. accused me of drinking too much but I drink no more than I did first 4 months. Now to my question. Over the last few nights, I’ll wake up around 3 and check my machine and it will tell me I’ve had an average of 4 to 5 episodes but when I check it in the morning, it says I averaged 27. Why would that be? Could the machine be defective? Doesn’t make sense to me. If alcohol caused the high readings, shouldn’t the numbers go down through the night?

  13. I have to admit the tendency of doctors to accuse the patient of causing problems with CPAP use causes me to both disrespect and loose trust in them. If you told him “alcohol levels have not changed” and he still insists “it is alcohol” you probably need a new doctor. If he asked no questions about stress levels in your life, about how you are sleeping, about how you are eating, about exercise levels, about diseases (flu/cold etc…), and regarding possible sources of toxins in your life but simply goes into the “accuse the patient” mode you definitely need a new doctor.

    As for why a reading early in the night may not tell the whole story of the night well consider that each event ratchets up your stress hormone levels – which increase inflammation levels – which increase the tendency to have more apneas – which, when they occur, increase stress hormone levels. So the basic tendency is that if you have events early in the night there will tend to become more and more of them as the night proceeds. And the stress hormone axis is only one of many which have this similar tendency to cause more and more events as the night proceeds. I am not shocked to hear about the numbers you name.

    What I would recommend is that you establish “data feedback” using, perhaps, such as SleepyHead software to see what is going on. Whatever software you use should show actual air flow waveforms and show the events as they occur over the course of the night. For years I have used this to see problems as they occur and adjust my lifestyle so that CPAP will work for me (note the issues the doctor should have asked about – more about that in my “blog to be”).

  14. Thanks for the reply. I wouldn’t know how to use the software you mentioned. I am lucky to even be able to access the information I do have access to. My doctor never bothered to tell me that the number of episodes per night was available for me to see. I thought I had to wait 2 months to see him and have him tell me how badly I was doing. But then I was reading the owners manual and saw that the machine could give me immediate results so I went in and had the nurse show me how to do it. So as I said, I would have no idea how to get the kind of information you are talking about and I doubt the doctor has any interest in showing me. His only interest is getting out of the room as fast as possible to get to the next patient.

  15. What I would really like to see is the doctors and manufacturers working with the actual users of CPAP to produce a system which uses the data gathered from the sensors in the CPAP machine. The system would report the nightly data to a central server. The incoming data would there be analyzed in the server (a computer dealing with the data) and any apparent problems would result in “alarm” e-mails or calls or letters to the CPAP user and/or the doctor of the CPAP user. But at any rate the data would be available to either via a website where one could see what is going on night by night.

    Using what is available I have been able to correct problems before they became serious. If this had not happened my health would have been affected.

    I know that my CPAP data is never the same any two nights. I have found that it can and does indicate problems which do need to be addressed. I do believe that much of what drives people away from CPAP[1] can be attributed to the problems that do come up but which are never noticed because they were never looked for. And so they were never effectively addressed. In such a case I believe it is possible for a CPAP machine to do more harm than good but at any rate the user comes to understand that it is not helping and drops it by the wayside as useless.

    [1] Usefulness of reinforcing interventions on continuous positive airway pressure compliance. Lo Bue et al. BMC Pulmonary Medicine 2014, 14:78

  16. losing my cdl due to non-compliance with apnea treatment. cannot take any device on or in my face trying to sleep. cpap was a nightmare. mouth piece felt like it was stretching my jaw. dr. said last resort is surgery(breaking my jaws and setting my jaw forward). I loved my job, and was a safe driver 37years. it really is a money scheme. have to find something else to do. I would rather die in my sleep than to smother in their devices.

  17. I am so sorry for your loss James I am also a truck driver and also 30 years with no ticket , accidents, or incidents, I posted a blogged a couple years ago on this site I want to let you know that there is now a oxygen on finger sensor to see if you are one of us who have been scammed. I did not use this however as I found away around this career killing scam in the name of the almighty dollar. I am a independent inventor and built my own breathing gismo. Most truckers just wait tell the last month and a half to suffer the mind altering cpap and then take the chip to be read by the DOT physical Doc and pass that way. I want my brain to work so I use the later. Its looking like there scam is exposed after talking to my doctor I am sure if you can find another Doc who is younger and not part of this plot you can get your CDL back. We need pro drivers then ever and we need you so fight for your rights even if you need to scam the scammers you are important to our country and its economy so do the right thing and show them that we run the show not them. What happened to the BRETHREN. We really should unite but I am afraid its to late as the most safe and experienced drivers are run off to bring in low paid younger blood to bring up profits. More deaths on the highway is happening now when will we wake up oh wait a minute I am using a Cpap ooops.

  18. To David Vasko Adverse Effects in the Lungs Providing the airways with a constant level of pressure can also lead to some adverse effects in the lungs. If the alveoli at the end of the airway are distended too much, they block the flow of blood which normally passes nearby in order to pick up oxygen and drop off CO2. Blocking this bloodflow results in gas which does not participate in the exchange of oxygen and CO2, commonly known as deadspace. Excessive deadspace interferes with oxygenation just as surely as does ineffective ventilation. In addition, too much pressure in the lungs can result in trauma to the airways. The alveoli can be damaged, causing air to leak into the tissue of the lung, thorax, or skin. This can lead to potentially fatal complications such as pneumothorax.
    Other Adverse Effects Excessive pressure delivered by CPAP can also cause complications outside of the airways. Increased pressure in the airways translates directly into increased pressure in the intrathoracic cavity, which can interfere with the function of the heart. The return of venous blood to the heart is accomplished, in part, by the negative intrathoracic pressure which occurs during inspiration. “Principles of Critical Care” states that interfering with this negative intrathoracic pressure with positive pressure can result in decreased cardiac output which can be potentially hazardous for people with pre-existing cardiac conditions. This also decreases blood flow to the kidneys and liver, potentially causing problems for patients with diseases of these organs.
    I hope to find someone that would take my case. Using cpap causes me to have seizures. I had all the symptoms of oxygen toxicity. Have also found cases of fraud.

  19. I am so sorry for all the pain and suffering you have to put up with so the fat cats can get richer. I have noticed a up take of gout in drivers who are forced to strap on these needless death machines and wondering if there is a strong link. I just lost two very close trucker friends to blood clots in the lungs and they were Cpap prisoners as well. I was told that the truck seats were to blame and the clot made it to there lungs just food for thought.

  20. For the many truckers who do suffer from sleep breathing and other sleep disorders I must say that the sorry state of sleep medicine currently makes them a very ineffective indeed completely unreliable source of help to keep the rigs on the road and people safe. Their track record simply stinks. Doing a quick sleep test and sending a person back out on the road with a new untested and acclimated CPAP device seems downright irresponsible to me. Yet I hear about it all the time.

    We need a different direction here I think. Make smart driver monitoring. We currently have technology which could drive the rig. How hard would it be to use this technology to make systems that would see that the situation is getting dangerous and set off the alarm? We have the technology to monitor mental vigilance real time all the time. How hard would it be to make systems for those at risk and show how much risk actually exists?

    To Roy: .. Roy, I am not a doctor. However I have read several books and many many dozens of medical papers concerning how CPAP works and affects the body along with hundreds of abstracts. I have also read over 10,000 sleep apnea web forum posts (back in the day before excessive trolling destroyed this resource) contributing over 2,000 myself. As well I have used CPAP for over a decade.

    Much of what you mention I have never seen. So please provide citations for your points. Document your work please.

    As for how use of CPAP might well relate to seizure activity I have come to believe that the hypocapnic excursions during ventilatory (loop gain related) instability which does occur in at least a third[1] of us who use CPAP is a likely contributing source. But that is just my suspicion. I do not believe that they really want to look into that as it is not a selling point for CPAP.

    Perhaps you should look into EERS[2] which I find helps stabilize my breathing during CPAP use and makes the nights go better. I also find that neck exercise helps as I mention in my blog to be.

    I do hope we find what we really do need to get better and stay safe.

    [1] Danny J. Eckert, David P. White, Amy S. Jordan, Atul Malhotra, and Andrew Wellman “Defining
    Phenotypic Causes of Obstructive Sleep Apnea. Identification of Novel Therapeutic Targets”, American
    Journal of Respiratory and Critical Care Medicine, Vol. 188, No. 8 (2013), pp. 996-1004.

    [2]: Gilmartin G, McGeehan B, Vigneault K, Daly RW, Manento M, Weiss JW, Thomas RJ. Treatment
    of positive airway pressure treatment-associated respiratory instability with enhanced expiratory
    rebreathing space (EERS). Source: J Clin Sleep Med. 2010 Dec 15;6(6):529-38. Division of
    Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA,
    USA.

  21. Unfortunately for the Cpap pushers any ailment that may manifest its self while under the influence of Cpap use may be suspect to the root cause. I smell a class action law suit right around the corner and one the likes that no one has ever seen. when the smoke clears there will be big reform in how the medical and DOT work together in making laws that are suppose to protect us all.

  22. If these devices are necessary for highway safety they should applied to the entire driving population including non-commercial drivers. To not do so is discriminatory and ineffective as the are 10x as many non-commercial drivers on the road and the rate of fatigue related accidents is at least as high as with commercial traffic per mile driven. A Prius hitting a pedestrian at 60mph with a sleepy driver behind the wheel can and does have the same ultimate effect s a commercial vehicle. DOT regulates all traffic not just commercial. Lets see how well requiring medical cards for non-commercial driver licenses with the same hap-hazard discriminatory screening and requirements for expensive unproven devices that may actually cause detrimental effects including death, and mandate home privacy invasion for your entire life if you intend to hold a license goes over with the entire population. After all driving is a privilege for everyone … not just those who make a living at it.

  23. Keith Walden wrote on February 20th, 2016 1:38 am

    [Keith Walden said] If these devices are necessary for highway safety they should applied to the entire driving population including non-commercial drivers.[end quote]

    Last time I checked the UK was doing this.

    However as many have mentioned the devices are simply unproven in terms of long term relative safety and I have good reason to believe that most who try to use CPAP are less safe on the road during the “run in” time (up to three months or perhaps longer). I believe we are putting people in danger during that time.

    A better direction, I believe, would be to move toward smarter and smarter vehicles. Ones that sense danger and that keep a record of the drive. A person, any person as you say, could be a danger to themselves and others on the road. They should be found before the accident happens if possible. The current regulation structure does appear very likely to cause much more harm than good. The regulators are not doing their honest home work and should be held accountable.

    [Keith Walden said] To not do so is discriminatory and ineffective as the are 10x as many non-commercial drivers on the road and the rate of fatigue related accidents is at least as high as with commercial traffic per mile driven. [end quote]

    If you are going to make statements like this, fine. But document. We need citations of studies that show inclusion, exclusion, and threshold parameters.

    Frankly, considering that researchers have found that some 70% of those who drive truck have sleep apnea[1] I kind of doubt that you can.

    [Keith Walden said]A Prius hitting a pedestrian at 60mph with a sleepy driver behind the wheel can and does have the same ultimate effect s a commercial vehicle.[end quote]

    A Prius hitting a bus full of children vs a nerve gas loaded truck hitting the same bus!?…

    [Keith Walden said] DOT regulates all traffic not just commercial. Lets see how well requiring medical cards for non-commercial driver licenses with the same hap-hazard discriminatory screening and requirements for expensive unproven devices that may actually cause detrimental effects including death, and mandate home privacy invasion for your entire life if you intend to hold a license goes over with the entire population. After all driving is a privilege for everyone … not just those who make a living at it.[end quote]

    We absolutely agree that the current approach is dead and deadly wrong.

    I do believe we need to move toward using the kind of technologies which can actually drive a car without human intervention (the parts of it which watch the road and other drivers) to watch the driving of those who are at risk. I agree that we all are at risk. Since this will take time and dollars to implement lets start with those we screen to be at risk.

    You can sing your sad song to others about how hard this is. I took myself off the road because I believe that I cannot guarantee vigilance. My “deal with myself” is that if I use my bicycle regularly and do well for a six month period I will consider getting a license again. But frankly I would want to install the kind of technologies I mention above. That way if there still really is still a problem I will know most likely before an accident occurs and can respond appropriately.

    Not knowing could be deadly.

    [1] Mentioned in “The Promise of Sleep” by William C. Dement Ph.D MD

  24. Understanding Oxygen Toxicity

    By Petar J. Denoble, M.D., D.Sc.

    Due to the risk of seizure from central-nervous-system oxygen toxicity,
    the maximum depth for use of pure oxygen should not exceed 20 feet
    of seawater (equivalent to 1.6 ATA of oxygen).

    Oxygen toxicity has been known since the 19th century, but we are still learning about its causes and mechanisms. In diving practices of years past, pure oxygen and gas mixtures with oxygen content different than that of air were used exclusively by military and commercial divers. In the last several decades enriched air nitrox (EAN) became a part of mainstream recreational diving, while technical diving, which maximizes the use of oxygen to minimize decompression risks, is becoming increasingly popular. The accumulated experience in recreational and technical diving now exceeds the previous experience of military and commercial diving. Both scientific research and diving practices advanced our knowledge of oxygen toxicity, and from time to time we should take a step back to make sure we are all sharing the benefits of this knowledge.

    Oxygen convulsions were first described by Paul Bert in 1878. He noted convulsions in larks in air compressed to a pressure of 20 atmospheres absolute (ATA). When he compressed larks in pure oxygen, they convulsed at pressures as low as 5 ATA. Bert concluded that convulsions represent a sign of oxygen toxicity upon the central nervous system (CNS), which was shown to be correct in later research.

    In 1899 Lorrain Smith described pulmonary oxygen toxicity in rats. Problems started when rats breathed 45 percent oxygen at normal pressure. When breathing 73 percent oxygen, rats developed fatal pneumonia in four days. At higher oxygen pressure, these symptoms developed sooner.

    Prolonged, repetitive breathing of gas with elevated partial pressures of
    oxygen can lead to temporary nearsightedness and narrowing of the visual
    field.

    Since that time we have learned more about the manifestations and some of the underlying mechanisms of oxygen toxicity. All manifestations of oxygen toxicity are dose dependent. Symptoms of CNS oxygen toxicity, which include seizures, may occur after short exposures to partial pressures of oxygen greater than 1.3 ATA in exercising divers, which equates to breathing pure oxygen at 10 feet of seawater. Resting divers in comfortable conditions tolerate 1.6 ATA of oxygen well. Pulmonary manifestations occur after days of exposure to partial pressures of inspired oxygen greater than 0.45 ATA. In addition, repetitive and prolonged use of hyperoxic gases (at least 30 hours in 10 days of an oxygen partial pressure greater than 1.3 ATA) in modern diving has revealed ocular manifestations (hyperoxia-induced myopia). Cold, exercise, some drugs and increased partial pressure of carbon dioxide increase susceptibility to oxygen toxicity.

    Who is Exposed to the Risk of Oxygen Toxicity?

    Divers using EAN as well as both open-circuit and rebreather divers who use mixed gases are exposed to the risk of oxygen toxicity. CNS oxygen toxicity may occur in divers using EAN if they exceed depth limits for a given oxygen content or if they mistakenly breathe gas that contains more oxygen than they thought it did. Cold, strenuous exercise, some medications and other known and unknown individual and environmental factors may increase the risk of oxygen toxicity — even within limits for a given EAN mix.

    Divers using mixed gases in open-circuit scuba diving incur the risk of confusing the various gas mixes they carry and of using too much oxygen during decompression. Closed-circuit-rebreather divers run the risk of incorrectly selecting the partial pressure of oxygen as well as mechanical errors. These may include errors in gas mixing, displaying erroneous oxygen values and excess carbon dioxide in the breathing loop due to equipment malfunction.

    CNS oxygen toxicity is the main form seen in diving. Pulmonary oxygen toxicity is not of concern except in very long technical dives (extended cave or rebreather dives, for example) lasting six to 12 hours or more. Prolonged dives within the safe limits for CNS oxygen toxicity may still cause ocular toxicity, which manifests as a narrowing of the visual field and myopia. You are going to believe what you want. All you have to do is type in cpap fraud and many site come up. Billing fraud and how stats were changed to put device on market. I am different. I have seen my left arm grow to be even with right when prayed for. Many times driving by being aware of inner voice I would get through areas others would not. Have been helped by so many over the years I learned to trust in the God aspect more. Can you prove GOD?.. Using self hypnosis for breathing was one of those blessings. Told my wife before our twins were born we would have twins she said it doesn’t work that way. They are about 33 now. I’ve used natural healing for years. I had all symptoms of oxygen toxicity. My medical records show that. And is hard to prove with out an autopsy. It also has to be looked for. If I had speech to text I’d get into more detail. Which you would most likely blow off anyway.

  25. For Roy:

    one ATM = 14.69595 psi [1]
    one cm/H2O = 0.0142233433342921 psi [2]
    -so-
    1.3 ATM = 19.104735 psi = 1343.19579799068 cm/h20
    -so-
    1.3 ATM is a pressure approximately 112 times higher than 12 cm/h2o

    .. I think he posted in the wrong place – great post however …

    note: url(s) spaced to avoid the need to review (use google)
    [1] wikipedia Atmosphere_(unit)
    [2] convertunits from psi to cmH2O

  26. To: Tod Merley, thanks for your reply. I don’t know if my diver msg was deleted or not. I Have been looking for honesty in the cpap reporting. I have found cpap to be part of multi million dollar law suits. Also some may be protected form law suits.

    How would you like your child to be in this study? By: Martha Garcia | Published: April 15th, 2013
    Nearly two dozen universities failed to properly warn parents that a national oxygen study may put their premature infants at risk, federal officials say.
    According to a letter (PDF) issued by the Department of Health and Human Services (DHHS) to the University of Alabama at Birmingham, the lead institution in the study, research institutions involved in the study did not offer informed consent to the parents of the premature infants.
    The study involved 1,300 premature infants between 24 to 27 weeks of gestation. Researchers evaluated the results of increased or decreased oxygen through a continuous positive airway pressure (CPAP) treatment to determine the levels of oxygen saturation and neurological effects on premature infants.
    According to the letter, the institutions involved were aware of the potential adverse affects the treatment may have on the infants, including blindness and even death. The DHHS Office of Human Research Protection says the institutions had sufficient evidence to know such treatment may cause serious consequences, but never properly informed parents participating in the study about the potential risks. The office considers the failing a violation of regulatory requirements for informed consent.
    The study took place between 2004 and 2009 and 130 infants of 654 in the low oxygen level group died, while 91 of 509 infants in the high oxygen group developed a serious eye problem, which can result in blindness.
    The study, published in the New England Journal of Medicine in 2010, was financed by the National Institutes of Health and involved 23 high profile Universities, such as Stanford, Duke and Yale.
    The consent form only mentioned risks involving abrasion of the infants skin, and claimed there was a potential benefit of decreased need for eye surgery if the infant was assigned to a certain oxygen level group.
    DHHS officials say the consent form should have highlighted that the risks of the trial were not the same as the risks of receiving standard care, so parents could make a more informed decision. .
    Is cpap pressure greater at higher elevation?
    I was tested in Springfield MO 1st time. Felt disoriented in Salt Lake City UT. Cpap folks kept telling me there are no harmful effects. I don’t expect an honest answer on a Doc’s web page. I have learned a little about how ATA can cause a seizure. Which none of the sleep clinics would talk about. A seizure can cause brain damage. I now have seizures about every 3wks. Since 10/1/12. Wikipedia is a good source on how breathing is triggered. My wife limits my pc use as she worries it may contribute to a seizure. I try to be thankful. I know people that just bumped their head and have seizures. It’s hard for me to believe I survived my roll down the highway. My Shoulder hurts from last seizure. I went to sleep in my chair and woke up to my chair. Had grass stain on socks, many bumps and bruises.

  27. After being diagnosed through a sleep study with an OSA and an AHI of 22, I got a CPAP machine with the nasal pillows mask. Prior to the CPAP, I was not having any problems with daytime sleepiness. In fact, due to some changes in my sleep environment, I felt like I was getting the best sleep I’d had in my entire life. I have a long history of insomnia. I also have Generalized Anxiety Disorder and claustrophobia.

    I got the machine on 1/26/2016. It was a nightmare. I tried it for 4 consecutive nights. The longest I was able to tolerate it was an hour and a half on one night. I felt like I was suffocating which caused my heart to pound. I tried turning off the ramp up and that helped some but it was difficult to breathe out which caused my heart to pound. It also irritated my sinuses so much that I had nosebleeds. The pressure in my ears was very uncomfortable. Not to mention, I sleep on my side and I could NOT find a comfortable position with the mask on. The machine completely disrupted my sleep and amped me up so much that I was unable to get to sleep for at least 2 hours after I took the thing off.

    Before using the CPAP, I was sleeping well. After? I was fatigued, sleepy during the day, woke up with splitting headaches, nose bleeds, ear pain, headache and a foul dark mood.

    Then, I got a really bad cold. I wasn’t even going to try it while I had the cold

    Then, the compliance e-mails from the DME provider starting. I had complete strangers in my data, sending me vaguely threatening e-mails about how I should be using the thing 4 hours a night despite the difficulties I was having and despite the fact that even after only a total of 4 hours over 4 nights, my job was at risk due to my distress and fatigue.

    Forget that noise. I took the thing back last Friday. I hope my sleep apnea never gets worse because I seriously do not know what I would do if I had to try one of those blasted things again.

  28. I find myself tonight simply wanting to say “Thanks!” to Dr. Park for his continuing efforts to help those afflicted with OSA. His efforts have helped me greatly. Indeed, after listening to his most recent podcast I find myself planning a way that may finally facilitate me to become honestly free from CPAP.

    Thanks again!!

    Tod Merley

  29. to Kristi I think I would still be working if I had got rid of cpap. I had all symptoms you had was told to use it or be fired. I Know have seizures. Hope it goes well for you without cpap. If you like research look under fraud. I’ve also read some clinics are closing. I used self hypnosis to improve my breathing 30yrs ago. I was never ask about my breathing history. Was just hooked up and run through. I’ve read a mouth piece may be helpful. Air force used it long before cpap started making there billions world wide. Now breathing problem qualifies you for disability. Before you could still serve??

  30. Roy on February 23rd, 2016 12:02 am

    to Kristi I think I would still be working if I had got rid of cpap. I had all symptoms you had was told to use it or be fired. I Know have seizures. Hope it goes well for you without cpap. If you like research look under fraud. I’ve also read some clinics are closing. I used self hypnosis to improve my breathing 30yrs ago. I was never ask about my breathing history. Was just hooked up and run through. I’ve read a mouth piece may be helpful. Air force used it long before cpap started making there billions world wide. Now breathing problem qualifies you for disability. Before you could still serve??

  31. I have trolled all of the comments made and have come to the conclusion that there is a need to look much more closely into a individuals underlying cause of Sleep Apnoea. What struck me with many of the comments is the fact that distance driving seems to come into the equation and somewhere I feel there is a link.
    I was diagnosed in 1994 and used my CPAP machine every night since then. I am now 73 years of age, and carry much less weight than I did whilst working. My job required me to spend many years driving the length and breadth of the U.K.
    The card that registers my nightly performance is read annually at the Clinic to check correct pressure is being applied. Surprisingly in all the twenty two years I’ve used it no variation has been required in air pressure.
    I seriously believe it is a serious condition where “one size definitely does not fit all”.
    Because of hip problems I’ve had to sleep on my back for years so the mask does not bother me personally.
    Based on what I have read on this site I am leaning towards the conclusion that there are different root causes of Sleep Apnoea, Weight does seem to be a factor particularly so in the neck area, I have a friend in his thirties whom I would not call overweight and works out. He told me recently the fact that if he gets careless with his eating habits and puts on even a couple of pounds his “Apnoea” kicks in.
    He does not use a machine because he exercises weight control.
    So the experts appear to be correct when they focus their attention on the neck area in both men and women but oddly very little is mentioned about how the nose takes in the air. I would be interested to see more In depth research in this area as I personally can date the start of my “sound breaking” snoring after breaking my nose in an accident and a subsequent operation to shut the row up that I was making.
    My concern increased when I read about brain damage people speak about. If this is the case then the CPAP machine might be the wrong tool for their condition.
    I have only one concern re my own appliance. Why on earth is there not a battery back up when there is a power cut!!!! Perhaps if the inventors had Skeep Apnoea themselves I would not be asking this question. A very insensitive oversight in my opinion, even a warning alarm would be better than nothing.
    To my fellow snorers, here’s to a future even better understanding of this frustrating condition.

  32. Just an update for everyone to see the progressively growing problems I am running into since being on a cpap machine for the last year. I have posted on here before.

    As of today, I been struggling with the cpap machine. Over the extremely hot summer I had nothing but problems trying to use it all night. Or at least the 5 hours that I was told. It did not matter if I was using the air conditioner or not. I ended up with hot air blowing through and it suffocated me. I never had a problem falling asleep or staying asleep before the cpap machine. As of 3 months ago. I have had to start using Unisom to get to sleep.

    Then out of nowhere, I was having problems hearing out of my left ear. Since I was 10 I have had sinus problems. So my sinuses constantly drain all night down my throat. That was until the cpap machine. Now it is pushing my sinus drainage into my ear canals. Every morning my ears are draining the mucous that should have gone down my throat. Now my ears are constantly ringing. I wake up with a huge headache that does not go away for a few hours. I went from 7 hours of sleep a night down to 3 or 4 hours a night. Unless I take unisom then I will get 6 or 7 hours.

    Tomorrow I have an appointment to see my primary care doctor. Yes the very same butthead that wont do jack about it unless he gets paid to do his job. He refused to listen to me or even pass the information on to the sleep institute. I am updating my blood pressure meds tomorrow. But while I am paying him to see me for 15 minutes just to check my blood pressure, I will make him actually listen to me and get him to confront the sleep institute about putting me on the cpap machine.

    Really, you have to look at your data and you can tell if you have been railroaded into a cpap machine. Supposedly they say I had 25 apnic activity and hour. When I used the cpap machine for the very first time. It showed that I hade only 1 apnic activity the entire 7 hours I slept. Really? No one should respond that fast to a cpap machine. No one responds that fast to any medicines. Every day I look at my data. It shows that I have only 1 apnic activity all night long.

    Well, I will update as I learn more about what is going to happen.

  33. Tom I sleep walked and had a seizure using cpap. I’m now on disability. Sleep folks are protected by law. Can’t remember where I read that. About your breathing.. I went 25 +years ago and got tested for what I was allergic. I took shots to build my immune system. I also used self hypnosis, and later found Ann Sutton that helped me to detox. The air pressure in body effects many things. Until I used cpap I was told how safe it is. I have found fraud, deaths, and still learning about breathing process. Lawyers I’ve contacted so far will not take on AMA. I quit using cpap after seizure with cpap. Air force let people use a mouth device years before cpap started making billions world wide. Some clinics have closed with out notice in New England states. Cpap qualifies you for disability. Do you think Air Force would of put people with disability in aircraft? Your device may be putting to much pressure out. More than your body can take anyway.

  34. Both my mother and grandmother benefit from their pap machines but don’t like putting them on so will continually deny that they are falling asleep. So, it makes my life fairly miserable. I basically have to ignore the fact they sleep without it or wait around to go to bed until they do so I can verify they put it on. They also don’t seem to understand the ramifications of not wearing it, as they do not seem outwardly over concerned when the other falls asleep (for example in a recliner) w/o the mask on. Yet, it is apparent to me that they were suffering before they were prescribed these machines. Terrible memory (to the point the doctor gave a MRI looking for brain tumor), pre diabetic and type 2 diabetes developed. Just DRIVES ME NUTS. Love/hate relationship.

  35. Tom, who commented on Feb 25 2016 – YES, it does work that fast to control apnea episodes. Unlike a drug which may have to build up over time in your system, all the machine does is keep your throat open with the force of air. If your throat is open, your breathing doesn’t suffer and your apnea ceases. You might try buying an O2 monitor with an alarm. If you fall asleep without wearing the machine, the alarm will go off because nothing is preventing your throat from closing and your cells will begin to lose blood & oxygen supply, thus triggering the alarm (and thus causing cells to die which is why sleep apnea is a problem)!

  36. to: David Vasko if you could send me a link to your blog. oxygen on finger sensor The hemoglobin sends blood into body. I’m sure I wont get this all correct. Anyway the oxygen is not some at finger tip as in lungs. These fraudsters know a lot about making the numbers look the way they want. I’ve read reports that even with an autopsy if doctor doesn’t know what to look for. Damage from cpap it will not be found. I’m on seizure meds do to cpap. Have to be ten years seizure free and off seizure meds before I can even think about a CDL. My wife and granddaughter saw me have sleep walk type episode on cpap also. No cpap no headaches, my eyes still hurt, but not like they did on cpap.

  37. I have went twice and had a sleep study done.I done fine until a few nights ago I had a sinus infection,now who can sleep with a cpap when you can’t breathe out you nose.I missed 2 nights sleeping with it,when I went to log in my account had been inactive. Now I’m sure they will take it from me because medicare won’t pay for it unless it is used 4 hours each night.I really done good on it and I hate to have to give it up but sometimes other things cause the reason we might miss a night or 2.I don’t think that’s fair and this should be looked into,just my opinion.

  38. http://normalbreathing.com/ I lost my job because I sleep walked out of semi while on cpap. I used to have hay fever. Was taught self hypnosis. That helped me a lot. While in hospital after sleep walking I had sinus infection. Wife and I had 2million mile safe driving awards before using cpap. There are deaths and blindness connected with cpap. There is many things that effect breathing. I now have seizures which I never had before using Cpap.

  39. Hi Roy!

    I have been looking into the whole “ventilatory instability with sleep apnea and cpap”[a] issue since a traumatic assault and robbery occurred about two years after I was diagnosed and placed on CPAP. CPAP use then became much more problematic.

    Simply the changes in personal stress level apparently changed the activation levels of my sympathetic nervous system likely greatly exacerbated my already existing tendency toward ventilatory instability. Apparently my “respiratory control system gain” increased to the point where “oscillation” became present and carbon dioxide maintenance was compromised.

    I have a theory and an approach to the management of this which I share on my little “blog to be”[b].

    It is easy to become “stuck” on thinking about one symptom or issue when it comes to health. Likely many things were involved in you becoming one who sleep walks. And while I would agree with you that the use of CPAP has the tendency for the pressure of CPAP to enhance any carbon dioxide maintenance issues which an individual may already have and that this may result in hypocapnically induced hypoxia and thereby result in damage such would be difficult to prove. And since looking into this issue might cause many to shy away from CPAP and the ones who finance the studies (the manufactures) likely see that as a “business negative” I do not at this time expect to see them looking into it carefully. That said I do see that they are a bit more looking into it as the years have passed.

    For one that has ventilatory stability issues using CPAP or variants of CPAP is often difficult to impossible. And in my opinion may be harmful due to the hypocapnically induced hypoxia[1]. I think that functional medicine and other alternative directions for healing may be necessary to make CPAP usable in such cases. Or to provide an alternative useful path to health.

    FWIW I still use CPAP every night. I also look forward to the possibility that the many other things I am doing to get back my health may result in a time where CPAP no longer provides a boost to it and I can finally be free of it.

    May we all find that time.

    Disclosure: I have no financial interests in making or selling CPAP machines

    [1] Google “cerebrovascular CO2 reactivity and chemoreflex control of breathing: mechanisms of regulation, measurement, and interpretation” and then choose “Scholarly articles for…”.

    [a] While a Google of “ventilatory instability with sleep apnea and cpap” does yeild some useable results sites with less propaganda are more likely to be found using a Google Scholar search. And breaking it down more is useful (sleep apnea or CPAP searched separately).

    [b] Google my name and “honesttocpap” then find the articles about neck exercise and EERS use.

  40. The thing is noisy. I just bought a new TV for the bedroom so I can return to listening to TV as I go to sleep. I can’t hear the livingroom TV in bed with the C-PAP on. I’ve had to become a back sleeper instead of being a natural side sleeper. It can be difficult to put the full mask on again after a late night trip to the bathroom. I’m fully awake after struggling to get it back on. I was told I have both obstructive and central apnea, though I was also told I have a fairly mild case (I actually use a bipap machine.) To further complicate matters I have a circadian rhythm problem: I’m up till 4:00, 5:00, 7:00.

    I’m on Year Three with the machine. And my usage goes down and down each year. This year I’m barely using it at all. I don’t think I’m going to make it with this.

  41. I have been on an ASV machine and when it broke I had to have 2 sleep studies (don’t understand that one at all) and each time I got a machine but not the ASV that
    I needed (I was told it was due to the insurance). I finally got an ASV machine yesterday and used it last night. The pressure was really high (I have central apnea) and I felt a popping in my left arm immediately upon using it along with some twinges in my chest. I went to sleep and in the morning was short of breath. Called the provider to tell them I thought the settings were to high and at the end of today they called and said call my Primary immediately……..wonderful!!!! I thought this machine would extend my life not shorten it………

  42. For 6 months I have been forced to use this machine. It was my understanding that the machine was suppose to improve my sleep. I have felt that it has made it worse. I do not sleep through the night and now I’m faced with big brother watching over me and getting e-mails saying i’m not in compliance, because i’m feed up. I have stopped using the mask for over a week and I have felt more refreshed and relaxed than I did with the curse of a machine. I know I have sleep apnea. But the machine has to be the worst idea, I can’t understand how there is not a better option than being chained down to a machine which in my tossing and turning I have managed to yank off the night stand. These machines in my experience have done nothing positive and only provided aggravation.

  43. Air Force used a mouth piece for years. Your blood oxygen is not only sign of health in my opinion. Sleep clinics have ripped off Ins companies to the point even congress knows about it and still enforce it. You can type in fraud and cpap and still find stories. I’m on total disability after using cpap. I no longer use cpap. Had sleepwalked on cpap and after grand mal seizure also I have no desire to use cpap. Lost job and you think sleep lab will admit any fault? http://normalbreathing.com/ I lost my job because I sleep walked out of semi while on cpap. I used to have hay fever. Was taught self hypnosis. That helped me a lot. While in hospital after sleep walking I had sinus infection. Wife and I had 2million mile safe driving awards before using cpap. There are deaths and blindness connected with cpap. There is many things that effect breathing. I now have seizures which I never had before using Cpap.

  44. I’m a truck driver, I’m 6’1, 265pounds. I work out everyday after work, I’ve never had a problem falling asleep till my job said because of my height to weight I’m required to use this machine to continue working… Now I’m exhausted and have to take a nap on my lunch break without the machine just so i can do my job.

  45. Say Doc what’s up, you hit the cpap compliance craziness, nail, right on the head. I was on a bipap machine for one year and the only reason why I tried to get used to it was because of my job required it, it came to the point where i started to yank the darn thing off while asleep. the sleep people didn’t believe what that was happening and just told that i had to be compliant in order to keep my cdl the last time i went to the dot physical everything else was ok but was non- compliant with the machine and was disqualified for 30 days the dot doctor said for me just to focus on my health to forget about driving, so i did, now I sleep 8 to 10 hours straight without the machine, the sleep industry found a cash cow and the sleep industry is not going to give it up.

  46. I sleep walked out of semi using cpap. Now on seizure meds from grand maul seizure after trying to sleep all night on cpap 10/1/12. Have over 2 millino safe driving miles before cpap. Now I can’t drive and on total disability. I can breath at 2 breaths per/min. 20 sec. in 20 sec. hold 20 sec. exhale. They make millions off cpap. Congress has piad millions in known fraud to sleep clinics. http://www.researchgate.net/publication/21161247_Sleepwalking_precipitated_by_treatment_of_sleep_apnea_with_nasal_CPAP At sea level!! not 7,700ft.
    Having a normal level of CO2 in the lungs and arterial blood (40 mm Hg or about 5.3% at sea level) is imperative for normal health. Do modern people have normal CO2 levels? ? When reading the table below note that levels of CO2 in the lungs are inversely proportional to minute ventilation rates, in other words, the more air one breaths the lower the level of alveolar CO2.
    Breathing rates in healthy, normal people vs diseases
    CO2 molecule picturePin it!Share on Facebook Hypocapnia (CO2 deficiency) in the lungs and, in most cases, arterial blood is a normal finding for chronic diseases due to prevalence of chronic hyperventilation among the sick.
    Furthermore, as we discovered before, over 90% of modern people (so called “normal subjects”) are also hyperventilators (see the link below to the Hyperventilation Table with over 20 medical research studies related to normal subjects). Hence, chronic hypocapnia is very common for modern man.
    Main CO2 health effects and uses in the human body
    Follow the links for dozens of research references
    CO2 vasodilation health benefitsPin it!Share on Facebook – Vasodilation (expansion of arteries and arterioles). As physiological studies found, hypocapnia (low CO2 concentration in the arterial blood) constricts blood vessels and leads to decreased perfusion of all vital organs
    – The Bohr effect was first described in 1904 by the Danish physiologist Christian Bohr (father of physicist Niels Bohr). This law can be found in modern medical textbooks on physiology. The Bohr effect states that arterial hypocapnia will cause reduced oxygen release in tissue capillaries.
    – Cell Oxygen Levels are controlled by alveolar CO2 and breathing. Hyperventilation, regardless of the arterial CO2 changes, causes alveolar hypocapnia (CO2 deficiency), which leads to cell hypoxia (low cell-oxygen concentrations).
    – Oxygen Transport, therefore, depends on breathing and these 2 effects (Vasoconstriction-Vasodilation and the Bohr effect) explain the influence of hypocapnia (low CO2 content in the blood and cells) on circulation and reduced O2 delivery.
    – Free Radicals Generation takes place due to anaerobic cell respiration caused by cell hypoxia. Hence, antioxidant defenses of the human body are also regulated by CO2 and breathing, as these medical studies have found.
    http://www.normalbreathing.com/CO2.php a chart on web page shows effects of breathing

    Carbon Dioxide: Health Effects, Uses and Benefits
    CO2 (carbon dioxide) health benefits, uses and effects…
    normalbreathing.com