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People who suffer from obstructive sleep apnea (OSA) have trouble getting a full night’s sleep because their throat and tongue muscles block their airways. They can stop breathing for up to a minute, hundreds of times per night, and wake up repeatedly, gasping for air.

Continuous positive airway pressure, or CPAP, is the most common treatment prescribed for obstructive sleep apnea.

CPAP involves wearing a mask that fits into the nostrils, underneath or over the nose, or over the nose and mouth, through which pressurized air is delivered via tubing from a machine to keep the upper airway open during sleep.

CPAP is recommended by the American Academy of Sleep Medicine (AASM) as the initial treatment for moderate or severe OSA, and in mild cases of OSA when associated with insomnia, disrupted sleep, or excessive daytime sleepiness.

When used consistently, and when treatment is effective, CPAP reduces daytime sleepiness, improves quality of life, and can have positive impacts on cardiac and metabolic health.

However, the effectiveness of CPAP depends on using the device correctly and consistently, since OSA is a chronic disease that requires long-term treatment. Most sleep doctors, myself included, recommend that patients with sleep apnea use their treatment whenever they sleep.

Some love it, some can’t tolerate it

While there are many patients who love their CPAP machines and report the treatment to be life-changing, there are others who learn to accept and tolerate CPAP because they appreciate either the functional benefits (such as better mood and less daytime sleepiness) or medical improvements they get from using the device.

However, many patients struggle with CPAP. Clinical data and insurance groups suggest that about half of CPAP users either do not reach minimum adherence criteria or discontinue the treatment. Each patient is unique and may have individual struggles with CPAP; however, there tend to be similar themes among users.

Some of the common complaints I hear from patients who have trouble tolerating CPAP include:

—mask issues, including mask discomfort, skin irritation or marks, feelings of claustrophobia, or discomfort with the appearance of wearing a mask

—dryness, especially waking with a dry mouth

—removing the mask during sleep

—pressure intolerance from either too much pressure or not enough pressure; trouble exhaling against the CPAP pressure; or swallowing air (aerophagia)

—breathing that feels out of sync

—noise from the machine bothering the patient or their bed partner.

Ways to overcome problems

First and foremost, patients should partner with their doctor and healthcare team. OSA is a serious disease that warrants treatment. Before starting treatment, patients should be educated about OSA, learn about all treatment options and new technologies, and know what to expect with CPAP.

Patients benefit from follow-up, including a review of data from their CPAP device (which may also be important for insurance coverage). Family and/or partner support is also important, as friends or family can help encourage and support CPAP use.

Other tips to improve adherence:

Behavioral and medication interventions. Cognitive behavioral therapy or short-term use of sleep medications can help people adjust to CPAP.

The right mask. If the mask does not fit, the treatment may not work well. There are many mask sizes and types, including nasal masks that fit over or under the nose, nasal pillows that fit in the nostrils, full face masks that cover the mouth and nose, hybrid masks that sit under the nose and cover the mouth, and even helmet masks that cover the face. A mask fitting is a good idea, and several fittings may be needed.

Mouth breathing is another mask-related factor to consider. When a patient sleeps with their mouth open, the pressure from the CPAP leaks out of the mouth. This causes dryness and also prevents CPAP from keeping the upper airway open.

A mask that covers the mouth will probably be needed, though sometimes adding a chinstrap can keep the jaw closed and prevent mouth breathing.

The right pressure. Some people require vastly different pressure when on their back or on their side, or in one sleep stage versus another. While a pressure range can be helpful, if the range is too wide, the machine cannot adjust rapidly enough to meet the pressure requirements.

Weight changes may also impact pressure requirements. Following device data and/or evaluating with a sleep lab can help identify the best pressure.

Address coexisting conditions. Some people use CPAP consistently, tolerate it, but are still sleepy.

Sleep apnea can coexist with other sleep problems that might contribute to daytime sleepiness. Sometimes CPAP is not tolerated because sleep is fragmented due to other issues such as anxiety, PTSD, insomnia, poor sleep habits or circadian disorders. These other problems need to be addressed.

Consider alternative treatments. CPAP is the first-line treatment, but it’s not the only treatment for OSA. Consider combining treatments or pursuing an alternative treatment if CPAP is not tolerated or is not desired.

New innovations can help

A variety of technological advances may improve CPAP comfort and adherence. Some of these include:

—heated humidification to help with nasal congestion and dryness

—ramp-up features that allow the machine to start off at a low or minimal pressure as the patient adjusts and falls asleep

—auto-titrating CPAP machines, which allow for a range of pressures to be set; the machine self-adjusts the pressure when it senses that more or less pressure is needed to keep the airway open. This is helpful for those who require higher pressures in one body position or sleep stage.

—modems that allow the machine to transmit data so both the patient and their doctor can determine the effectiveness of the treatment

CPAP is an effective treatment for OSA. If you are struggling with CPAP tolerance, do not give up, but rather talk to your clinician.

© 2021 Harvard University. Distributed by Tribune Content Agency, LLC.