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.
Part III: What is CPAP Failure?
One Final Piece of the Puzzle
How would you use all this information to achieve the truly restorative sleep you have longed for? To access this chaotic system in the most effective way, there’s one final piece of the puzzle we must comb through, and it’s a bit of a shocker: nobody has ever defined scientifically the meaning of the term “CPAP failure.”
I know what it means, but the real shocker is most sleep professionals you deal with do not have a great working definition of CPAP failure. Instead, they have another term(s) called CPAP compliance or adherence, and they believe this term must be related to CPAP success or failure.
This discussion is tricky to follow and seems like semantics. It’s not. Let’s examine a common health example, and by comparison you’ll appreciate how tangled up the thinking in the field of sleep medicine has become as it relates to CPAP failure or success.
Consider depression. If you take an antidepressant drug and it doesn’t work well, at some point the continuing problems are obvious to you and your prescribing doctor. Other than filling in surveys to measure depression symptoms, the critical step occurs when you and your psychiatrist (or prescriber) discuss the persisting symptoms. Your doctor listens attentively, asks questions, and then the two of you plan a new course, typically one of three options: (a) raise the dosage of current drug; (b) maintain current drug and add new drug; (c) stop the med and start new one. This process runs its course, and although many depressed patients do not respond well to the first drug attempted, the ensuing trial and error based on educated input from an experienced doctor often leads to notable success rates for treating depression. The method takes longer than we would like, but it is a proven pathway that succeeds in many depressed patients.
Now, before we compare to CPAP, please look back at the last paragraph and note what’s missing: nowhere was the “use” of the drug discussed; “use” was a given. The questions were all about the impact of the drug when used, what is known as “efficacy”—does it succeed in doing the intended job?
A sleep CPAP scenario proceeds very differently than depression, because most sleep professionals get all tied up knots over the “hours of use” measurement. After starting CPAP, you are instructed to use it 4 hrs/night, 5 nights per week (insurance criteria). This goal attains the state called CPAP adherence or compliance. Achieving this status means your insurance typically agrees to cover a portion or all costs associated with CPAP such as masks, headgear to hold the mask, tubing, humidifier, filters and of course the device itself. Because this insurance coverage issue is so important to the patient, sleep professionals overinflate the importance of CPAP compliance and end up equating it with CPAP success.
CPAP compliance has almost nothing to do with CPAP success or failure. Can you imagine a psychiatrist telling a patient, “you’re using the medication, so you must be fine?” Of course not.
Compliance is simply a marker of the time spent on the device, nothing more or less. But when you visit a sleep doc in follow-up, he or she may be so overly concerned about your attaining insurance coverage status (adherence/compliance), a robust conversation about the changes in your symptoms may not occur at the level needed to determine CPAP failure or success. In other words, the discussion should focus on “how is your sleep changing?” just like how is your depression changing when you take this pill?
To be unequivocally clear, you could use CPAP 7 hours per night 7 nights per week, but still wake up from sleep to urinate, wake up and struggle to return to sleep, report no dreaming, notice poor control of blood pressure, no improvements in daytime concentration or attention, feel sleepy during the day and desire a nap, and above all report no clear gains in energy levels, not to mention a host of other symptoms directly tied to poorly treated sleep apnea, such as its impact on diabetes, kidney function, cardiovascular health, brain fog and mental illness. In other words, CPAP Failure! Got it? No matter how much you use the device, the device is failing to correct your symptoms.
CPAP success means your symptoms are markedly better (not just somewhat better) and nowadays there are plenty, many, many thousands of CPAP users who currently meet insurance criteria for adherence/compliance yet are failing CPAP due to the persistence of symptoms.
The single most common reason for the persistence of these symptoms should by now be obvious: CPAP is the wrong machine for the patient. The CPAP device is not correcting 3BE and/or the pressure is so high it causes expiratory pressure intolerance. Either or both these elements means the sleep apnea is only partially treated and therefore symptoms persist.
If your doctor remains overly focused on CPAP hours, then you frequently hear thoughtless comments, like: “well, you’re using CPAP 6 hours a night, that’s great…you’re all set…you’re good to go,” regardless of any lingering symptoms and complaints you might be experiencing. Apparently, many sleep professionals cannot see beyond their noses, imagining only that CPAP must be doing its thing, which leads them to ask, “is there something else wrong with you?” What they should be asking “is there something else wrong with CPAP?” The doctor’s close-mindedness is locked in to the false assumption—if you’re getting 6 hours of CPAP it must equal 6 hours of great sleep.
This is unscientific hot air. Would driving around in circles for six hours lead you to your destination? Of course not. You just “used” the car for six hours without benefit. Yet, sleep professionals hammer away about “use” instead of vigorously scrutinizing CPAP efficacy.
To be fair, no one is questioning the relevance of use. If the sleep apnea patient doesn’t use CPAP, it’s the same as the depressed patient who won’t use the antidepressant. Clearly, choosing not to use a treatment is a major obstacle, but in both such cases, what if the individual has chosen this path because of concerns about side effects. More pointedly, CPAP has a horrible reputation. The vast majority of people know more about CPAP being a royal pain than know about its successes. Indeed, the reason you hear so many alternative sleep breathing therapy commercials and ads touting new treatments is directly tied to skilled advertising agencies cashing in on the awful experiences chronicled by so many failing CPAP users.
Notwithstanding, our focus is on those who try CPAP and gain limited or no benefit, typically due to the problems noted above: failure to treat 3BE or raising CPAP pressures too high. These failings plague the field of sleep medicine, because the vast majority of sleep professionals (with the exception of many sleep technologists) still do not recognize the adverse impact of not treating 3BE. Or, they raise pressures without noticing they are triggering expiratory pressure intolerance. Solving these two issues goes a very long way toward getting a sleep apnea patient back on the highway to success.