Two reminders: Please share with anyone struggling on CPAP or anxious about attempting CPAP. There are better PAP alternatives, and this essay explains why CPAP fails so frequently and how advanced PAP is superior.
The essay is in 4 installments and includes an audio version (inserted as a black screen video) of the same content. The reference list appears in the final installment but links in the text should take you directly to specific publications.
Crisis of CPAP Failure
Part II: The Players, Partners & Pieces
The Government and the Insurers Have Eyes on Your Bedroom
Suppose you were prescribed a CPAP device. What next? How are you introduced to the device? What instructions do you receive? What followup is involved?
Hold your horses. You think because you got a prescription in your hand, you can waltz into the drug store and pick up a CPAP? Whoa, Nellie!
Welcome to the wonderful world of durable (or home) medical equipment (DME, HME) stores, health insurers, and government regulators. Your prescription is sent directly to a DME/HME, specializing in medical equipment like wheelchairs, oxygen, crutches, braces, etc. Once this entity receives your prescription, it sends copies of the medical records from your sleep doctor visits and your sleep test results to the insurance company of which there are many different types, some operated by the government and others privately run. All enforce strict requirements on who does and does not get a CPAP machine; whereas, your doctor has little say over the matter. In other words, your sleep doctor may know you need a CPAP and recognize you might benefit from the device, but in the 21st century what your doctor thinks is secondary to what the government and insurers control.
For any number of reasons, they could reject the prescription with a nice note like, “no coverage, but the patient is more than welcome to buy all this equipment at his own expense.” The doctor might appeal and clarify something on the medical record or the prescription and voila it’s suddenly covered.
The only reason to hear these details is they crop up again and again during a patient’s early use of CPAP as well as after CPAP failure. We will return to these topics.
Giving CPAP Your Best Shot
You read earlier CPAP fails so many individuals because it did not generate better sleep, so they did not feel better afterwards. With a very short trial, often less than a week, many quit instead of continuing to torture themselves. You might imagine the field of sleep medicine would have figured out by now why so many people neither sleep well nor feel better with CPAP. Sadly, reality has not caught up to your imagination.
CPAP was invented to treat apneas, the event of stopping breathing during sleep. Please guess when this apnea occurs. When you’re breathing in? When you’re breathing out? Actually, neither! Did you know there is a crucial pause in human respiration that occurs at the juncture where you just finished breathing out but not yet started breathing in again, aka “the end expiratory pause.” That’s right—observe your own breathing for a moment—and you’ll feel this pause when no air is moving in or out; it’s quite logical then that the apnea must be occurring here since airflow has already ceased. And to be absolutely clear, the airway collapses and remains collapsed for anywhere from 10 to 60 seconds, all the while blocking air from entering your lungs.
CPAP thrusts positive air pressure into your nose and throat to overcome an apnea at this vulnerable point of collapsibility. By supplying extra air (N.B.: not oxygen, just air), your airway remains open. As a result, CPAP prevents you from choking, gasping or otherwise struggling to breathe; and, it might eliminate snoring.
We must admit it’s a wonderful device with one huge caveat. It’s designed to relieve this most obvious timing of obstruction, that is, the pause just discussed as well as apneas emerging during other phases of exhalation. These breathing events respond surprisingly well to very low CPAP pressure.
The caveat is hypopneas and 3BE occur during inhalation, and both require higher pressure to resolve. CPAP is not well suited to overcome these breathing disruptions, because its increasing pressure leads to increasing levels of discomfort, sufficiently unsettling to force the patient to quit.
Thus, the problem in sleep medicine is that apneas are easy to treat with low pressure; whereas, all other breathing events require higher pressures, and 3BE needs the most pressure to fully open the airway. How then do we reach the higher pressures to keep your airway from collapsing while breathing in compared to the lower pressures used when you’re breathing out?
For simplicity, if someone only suffers from apneas, which is what sleep doctors presumed from the decades 1980 to 2000, then all anyone needed was CPAP. Then, as we learned more about hypopneas and eventually 3BE, we needed to figure out how to raise pressures accordingly.
CPAP Pressure Intolerance
The “C” in CPAP stands for continuous and that’s the big problem. Whenever you raise the pressure, you always receive the same pressure breathing in and breathing out. The increased pressure could still work for many sleep apnea patients if the increase in CPAP is not too great. However, once CPAP rises above a certain number, it becomes increasingly difficult for the individual to breathe out against so much air rushing in.
In the early 21st century, numerous sleep technologists as well as sleep doctors understood this problem with high CPAP pressures, and a sizeable number of sleep professionals chose to ignore some hypopneas and most 3BE, because they acutely recognized their patients could not handle higher CPAP settings. Thus, sleep techs were told, tacitly or explicitly, to completely ignore 3BE and/or not to be so aggressive eliminating hypopneas when treating patients in the sleep lab.
This model of care meant very few patients were actually receiving the “optimal dosage” of pressurized air to resolve 95% of their breathing events. Now, it should be immediately apparent if only 50 to 60% of breathing events are treated and another 30%+ are untreated, the individual is not going to feel like he or she slept great that night or felt great the next morning. You could feel somewhat improved but not convincingly better, especially when compared to the hassle of bedding down every night with a strange object pressed against your face. Please keep in mind this great pearl regarding the perceivable gap between a “fair” response from a patient’s own subjective experience versus his or her expected “great” response: this gap is a huge red flag signaling a patient will eventually quit CPAP.
Although this partial treatment problem paves the way for understanding the most important cause of CPAP failure, let’s first examine the opposite scenario among sleep techs and doctors who applied more aggressive CPAP settings. Despite their good intentions, the pressure sensation became so pronounced, the individual could no longer tolerate breathing out against CPAP. This approach triggered at-risk patients to suffer claustrophobic episodes due to “drowning in air,” which to reiterate typically occurs while breathing out. In those prone to anxiety, the higher air flow triggered panic attacks. Others simply ripped off the mask in the middle of the night and never knew when or why.
These individuals were experiencing worse sleep and thus felt worse the next day. Logic dictates all these side effects could be solved by simply raising the pressure to breathe in while leaving the pressures to breath out at a much lower level.
Bilevel Rocks
In 1994, researchers scientifically demonstrated this technique using a device called bilevel (4), for higher pressure in and lower pressure out. Sounds like an easy fix, right?
To this day, 90% or greater of sleep doctors, insurers, government regulators, and DME/HME personnel do not accept this simple remedy. They have engaged in self-indoctrination (i.e. the echo chamber effect) and believe anyone should be able to get used to CPAP. So, they reject the use of bilevel, despite 2/3rds to 70% of patients failing CPAP.
Did you notice who I did not mention? Sleep technologists who work in the trenches of the sleep lab environment have seen directly how bilevel is the right choice for a sizeable proportion of patients who do not tolerate CPAP due to this difficulty breathing out against the air coming in, aka “expiratory pressure intolerance.” Yet, most sleep techs are ordered by ambivalent sleep doctors to avoid using bilevel devices and stick with CPAP when testing patients in the sleep lab. Can someone please tell me why?
When a patient attempts to move forward while struggling with CPAP, if you ask them what were their follow-up conversations like with the medical support staff including the doctors, the chorus is always in lockstep: “Just use the machine more, you’ll get used to it; just try harder, you can do it.” In addition, if a patient dares to ask about other options, most sleep professionals respond: “CPAP is the only option; bilevel isn’t any better; insurance won’t cover bilevel;” and then back to the chorus: “use the machine more hours, eventually you’ll feel the difference; try harder, don’t give up, you can do it.”
Nearly all these phrases are falsehoods. It is very clear trying harder does not eliminate the problem of trying to breathe out against high air flow pressure coming in. In our newer model of care starting in 2005, we tested thousands of patients in the sleep lab who came to us complaining about the lack of CPAP benefits after months or years of use. Nearly every patient showed signs of or subjectively described the problem of expiratory pressure intolerance, and greater than 90% resolved this side-effect when switched to bilevel as we described in a subset of these patients (5). These research findings have been published in multiple scientific papers, including our landmark 2019 randomized controlled trial appearing in the prestigious Lancet Journal EClinicalMedicine (6), which “ranks 12th out of 325 journals in general and internal medicine” by Journal Citation Reports® and “16th out of 636 general medical journals globally” by CiteScore.
To summarize, we could say there is a cure for CPAP….switch to BPAP (bilevel)!
Why BPAP is not Well-Known or Widely Used
Recall the comments on government regulators and insurers. These two institutions hold outsized influences on healthcare in general and specifically sleep medicine. Any sleep doctor could easily write a medical encounter note describing how the patient is struggling with CPAP, not gaining a good response, and close to dropping out of treatment. With this specific wording, the sleep doctor could request a switch to bilevel.
Why is this easy solution not embraced by the vast majority of sleep doctors? For several reasons, some already alluded to above, but for now let’s focus on what you need to know to gain the sleep care you deserve, not the run-of-the-mill treatment being delivered at many sleep centers.
First, and foremost, sleep doctors are afraid of insurers and government regulators. I cannot blame them for this attitude. These entities frequently conduct audits on doctors, and most recently on sleep doctors. Some audits are scarier than others, and Medicare audits are the scariest. This intimidation is in fact how these systems like to operate. They believe the implied threat from their apparent authoritative position will push many medical professionals to simply accept fault, pay a fine and be done with it.
Nonetheless, just because insurers including Medicare conduct audits does not mean their staff are particularly wise or up to date on analyzing clinical records within the field of sleep medicine, not to mention that the overwhelming majority of sleep doctors (if not most doctors) are not wasting energy and resources committing fraud. As of 2024, 22 million healthcare workers including doctors, nurses, medical assistants and more comprise 14% of our nation’s workforce; yet, Medicare investigations convict far less than a 1000 fraudsters per year (.00045%). Don’t get me wrong, these criminals often go big and steal millions of dollars, so the government should be targeting them. The larger point here is Medicare might function better by focusing on the bigger fish costing all of us huge sums in waste, fraud and abuse. Percentage wise, although it can and does happen, the number of sleep professionals engaged in criminal activity must be miniscule.
Regardless, insurers seem to operate by patterns that catch their eye. For example, they monitor the way doctors practice medicine. Best example here would be a doctor who seems to prescribe more bilevel devices than the next guy or gal. An intelligent, objective observer of this pattern should be asking: “Gee, are these doctors prescribing more bilevel because they are providing higher quality care?” Great question…that never gets asked. Insurer analytics just work to spot the outlier. The sleep doc prescribing more bilevel is the outlier, so outliers should be investigated.
The above reflects the epitome of the stupidity inherent in the medical system. A person should look like an outlier if he or she is providing higher quality care, because such doctors determined a better way to treat and obtain superior results for their patients. A doctor prescribing bilevel, like we did regularly for 15 years from 2005 to 2020, would demonstrate higher rates of PAP therapy use. Indeed, in 2017, we published a peer-reviewed research paper showing the highest rate of PAP use in PTSD (7)(posttraumatic stress disorder) patients compared to any other paper published in the scientific literature. As you know PTSD patients suffer great levels of anxiety and cannot easily tolerate CPAP. Our secret? We used bilevel systems, including advanced auto-adjusting bilevel devices, some with very sophisticated algorithms that so gently deliver the pressurized air anxiety dissolves among those who previously hated CPAP.
To recap, most sleep doctors look at this strategy as “going out on a limb.” We were providing superior care. By publishing our findings in scientific journals, Medicare and all the other insurance companies could actually read the scientific literature and access newer ideas and tools to generate higher quality of care, leading to a deeper more restorative level of sleep, and a more meaningful improvement in the quality of the lives of our patients. Doesn’t this approach seem more likely to build productive collaboration between sleep doctors, insurers, and government regulators?