Why You May Not Feel Better After Using CPAP Therapy for Sleep Apnea

Duration of Use, Initial Symptoms, and Device Settings May Have a Role

If you have started using CPAP therapy for sleep apnea, but you haven't noticed improvement, you may wonder about reasons why this occurs
If you have started using CPAP therapy for sleep apnea, but you haven't noticed improvement, you may wonder about reasons why this occurs. Brandon Peters, MD

When someone has obstructive sleep apnea, the most effective treatment is the use of continuous positive airway pressure (CPAP) therapy. When it works well, CPAP can be a revelation. A subtle response may feel like a veil is being lifted, but those with a dramatic benefit may feel like a light has been turned on in a dark room. Unfortunately, not everyone enjoys a beneficial response to treatment.

Why is this so? Discover reasons why you may not feel better after using CPAP therapy to treat your sleep apnea.

1. You don’t have sleep apnea.

Although it is somewhat unlikely, it is possible that you are not noticing a benefit to CPAP therapy because you were misdiagnosed with sleep apnea. It is also possible that the condition has gone away. There is some night-to-night variability in the results of sleep testing. An in-center attended diagnostic polysomnogram is the gold standard for diagnosis. It can help to identify subtle changes in sleep stages as well as oxygen drops, breathing abnormalities, cardiac anomalies, and even leg movements. Home sleep apnea testing, though convenient, may be less accurate. If you question the diagnosis, or if risk factors such as your weight have changed, consider getting reassessed.

2. You’re not sleepy.

Excessive daytime sleepiness due to fragmented sleep is one of the most common symptoms associated with untreated sleep apnea.

However, not everyone has this symptom. Sleep quality can be greatly reduced due to awakenings related to abnormal breathing. Mild sleep apnea may be associated with waking up to 15 times per hour to resume breathing! It would hardly be surprising if sleep was unrefreshing, even if you got eight hours of it.

Sleepiness can be assessed with an Epworth score. If you are not sleepy prior to starting therapy, you may not notice a dramatic difference after using it.

3. You are not using it long enough each night.

It can be difficult to adjust to CPAP therapy. Waking in the night may prompt removal of the mask. Many people take it off towards morning, convincing themselves that, without it, they can get some “good sleep”. Unfortunately, sleep apnea is often worsened in the last few hours of the night. Rapid eye movement (REM) sleep occurs in the last third of the night. This stage of sleep is associated with vivid dreams and muscle relaxation, to prevent dream enactment. The muscles of the airway relax and this can worsen sleep apnea. If you have removed your mask before morning, you can’t get a benefit. You should try to maximize use, using the CPAP from the beginning to the end of each night, in order to assess how much it helps you.

4. Your sleep is worsened by CPAP problems.

Unfortunately, CPAP can introduce its own set of problems.

Without adequate support and interventions, these issues can quickly undermine your efforts to acclimate to the therapy. At first, it feels uncomfortable to breathe against the pressure, but this can be improved with some practice. Most people who encounter difficulties struggle with the fit of their CPAP mask. If it is not properly sized or adjusted, it can cause pain, marks on the face, ulcers or sores, and lead to air leak. Finding the right mask takes a little guidance from the equipment supplier. There are a lot of options: nasal pillows, nasal masks, and full-face masks. Beyond the mask, the humidity and temperature of the air may need to be adjusted to improve comfort. Nasal congestion or obstruction may lead to mouth breathing and a dry mouth. Excessive pressure can cause air swallowing (aerophagia). These issues may worsen sleep and exacerbate insomnia. If you get upset or frustrated, sleep becomes even more elusive. Reach out to your providers to get all your concerns addressed early so that you can get on the right track.

5. You only have mild sleep apnea.

It is likely that someone with mild sleep apnea will not notice as much of a benefit from CPAP therapy. If you have very severe sleep apnea, with more than 100 breathing disturbances occurring per hour of sleep, and CPAP therapy suddenly drops the number below five, you will notice a dramatic difference. If you have mild sleep apnea, with only 10 events per hour, and the number is reduced to five, you may not experience as much improvement. Many people do notice improvement, even with mild sleep apnea, so this should not be a reason to forego treatment. Reflect on the benefits you may be getting, by comparing your current state with optimal therapy to your baseline symptoms, and consider whether any improvement with CPAP use justifies the inconvenience.

6. You have insomnia.

Insomnia is a surprisingly common symptom of sleep apnea. Many people report waking up at night for an unexplained reason. This may be recalled every few hours, but it may occur far more than that and becomes especially problematic towards morning when it may be impossible to get back to sleep. If you get the cause properly diagnosed, and avoid the futility of sleeping pills, you may struggle with the treatment. People with insomnia are more awake at night and during the day, so sleepiness may be masked. If you already have trouble falling asleep at the beginning of the night, this can be worsened by wearing a mask that is blowing air in your face. Sleeping pills may help to ease the transition, and cognitive behavioral therapy for insomnia (CBTI) may help if the insomnia persists.

7. You don’t have the CPAP set properly.

It is sad to say, but many people don't get the maximum benefit of their treatment due to improper settings of the CPAP machine. These settings are ordered by a physician and may be determined by a titration study in which changes in the pressure level are made while monitoring your breathing. It may also be possible to set a standard range of pressure settings and then adjust them as you return for follow-up and the usage data is reviewed. When the device is set to default settings, often ranging from 4 to 20 or 25 centimeters of water pressure, this may be inadequate. If the apnea-hypopnea index (AHI) persists above 5 events per hour, the pressure setting should be changed. Ideally, the goal is to get this number as low as possible, and most people will benefit from an optimal setting that results in an AHI closer to 1 or 2 events per hour.

8. You weren’t bothered by your sleep apnea prior to treatment.

Although not surprising, some people seek treatment of sleep apnea or snoring solely due to the impacts on their bed partner. Loud and disruptive snoring can affect relationships. It may lead to separate sleeping arrangements. It can ruin a vacation or even a camping trip. As mentioned above, some people are not that symptomatic from their sleep apnea. They may have health impacts, such as high blood pressure or a greater risk of diabetes or atrial fibrillation, but they may not otherwise notice they have a problem with their sleep. If you start from a state of feeling asymptomatic, it can be hard to notice any improvement with treatment. Consider symptoms such as snoring, daytime sleepiness, waking frequently, urinating at night, and teeth grinding as possible signs of sleep apnea. You may also notice mood, concentration, and short-term memory problems from untreated sleep apnea.

9. You have developed complex sleep apnea.

It is possible for CPAP therapy to cause a different condition to occur. Most individuals with sleep apnea initially have obstructive events, due to the collapse of the upper airway (usually the back of the throat and tongue). This may be alleviated by a constant airflow delivered by CPAP. Unfortunately, some people will naturally begin to hold their breath against the pressure during sleep. As a result, complex sleep apnea can occur. There will be pauses in breathing lasting at least 10 seconds in which no effort (no movement of the chest or abdomen) exists. If these events occur at least 5 times per hour, without persistence of obstructive sleep apnea, the condition is present. Fortunately, it resolves in 98 percent of people with continued treatment, often over several months. In rare instances, bilevel therapy may be necessary to resolve it.

10. You have just started using it.

In some cases, people may expect instant results from CPAP therapy, but this is rarely the case. If sleep apnea is very severe with significant symptoms prior to treatment, a dramatic improvement may occur. When it is more subtle, it may take longer to notice improvement. If you have only used the therapy for a few days, and especially if you have not been able to use it through the night, give it some more time. It may take several weeks before you can note the improvement.

If you are not noticing a benefit to your treatment, speak with your board-certified sleep physician about ways that your therapy may be optimized.

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