Positive Airway Pressure Therapy for Sleep Apnea

Getting the most out of your CPAP treatment

Adapted from the ASDA


Positive airway pressure machines, which keep your respiratory tract open when you sleep, can be very effective in treating your sleep apnea. This article is designed to help people who use CPAP find solutions to the problems often encountered when beginning CPAP treatment. If you have obstructive sleep apnea, your upper airway collapses again and again as you sleep. Positive airway pressure (PAP) devices give you just the right amount of pressurized air needed to prevent this collapse. Properly set and used whenever you sleep, PAP machines can eliminate your apnea and snoring so that you get a good night sleep.

Various PAP machines and masks are available, allowing each person to find the combination of equipment that works best. The pressurized air comes through a mask which fits securely over your nose. Some patients will find PAP works best for them using a mask that fits over the nose and mouth or in the nostrils. Most people first try PAP machines that deliver a continuous fixed amount of pressurized air called continuos positive airway pressure (CPAP). Some people prefer two-level PAP machines, which deliver more pressurized air with breathing in and less with breathing out. Self-adjustable PAP will raise pressurized air levels only when apnea occurs.

You CPAP machine needs to be carefully adjusted to provide just the proper amount of pressurized air you need in all body positions, no matter how deeply you sleep. To determine the amount of air pressure right for you, your sleep is monitored in a sleep center while you use a CPAP device, and the pressure of air is raised in small amounts until your apnea is eliminated. You may need higher pressures during some sleep stages and in some sleeping positions. The sleep center technologist is experienced in helping people get used to sleeping with PAP.

Obstructive sleep apnea can usually be completely controlled with CPAP, but you must use it whenever you sleep. Getting used to sleeping with a CPAP machine takes time. While at first you may find it inconvenient or troublesome, you shouldn't abandon it without a good try. It can really help you.

Nasal discomforts

Nasal stuffiness or congestion is the most common side effect of PAP therapy, and is often a nasal reaction to airflow from the PAP device. More than half of patients experience some increased nasal stuffiness when they first begin PAP treatment. These symptoms often disappear within a month.

Nasal itching, runny nose, nosebleeds and nose dryness are other frequent nasal problems reported by PAP users. In general, PAP-related nasal symptoms are treated with the techniques given below.

Nasal symptoms are helped by applying a few sprays of nasal saline solution (a combination of salt and water) in each nostril before using PAP. This solution is available at a pharmacy without prescription. Oral antihistamines and decongestants may also be useful to control PAP-related nasal discomfort. Some commonly used oral antihistamines and decongestants include Benadryl, Contac, Actifed, etc. Decongestant nasal sprays, such as Afrin and NEO-SYNEPHRINE, may help, but should only be used for a few days since regular nightly use can be habit forming and can lead to increased nasal congestion.

PAP devices can be connected to specially designed humidifiers that will greatly reduce nasal symptoms. Humidifiers add moisture to the pressurized air PAP devices use. All humidifiers can add cool moisture, and some can add heated moisture. If a cool air humidifier fails to relieve your nasal symptoms, consider trying a heated humidifier. PAP humidifiers will need to be prescribed by a healthcare provider, and should be carefully maintained according to manufacturer's instructions to avoid nasal and sinus infections.

Several prescription medications can be used to combat PAP-related nasal discomforts. Antiallergic nasal spray (i.e. Beconase, Rhinocort, Vancenase, Nasacort, and Flonase) may be of help, particularly if you have nasal allergies. Atrovent nasal spray can be used to combat nasal congestion and runny nose not caused by allergies.

Nasal discomforts from PAP devices are usually simple to control with one or more of the suggestions above. If symptoms persist, contact your healthcare provider.

Mouth discomforts

Dryness and pain in the throat may be caused by PAP devices. Often the discomfort is caused by air blowing through an open mouth. A chin strap to keep the mouth closed or a mask that covers the nose and mouth can eliminate this complaint. Humidifiers for PAP machines can also help control mouth discomforts.

Mask air leaks

Symptoms of mask air leak are red eyes, loss of beneficial effects of PAP, and return of snoring or apnea. Air leaks are most often the result of a poorly fitted mask. Sometimes a different mask or a mask of a different size is needed. If you continue to experience significant air leaks despite using a chin strap, consider a mask designed to fit inside your nostrils (nasal pillows ) or one that covers your nose and mouth. A custom mask can be made for you if necessary. Remember, if you mask and PAP therapy worked well for you in the beginning, you should check to see whether your mask is worn-out or torn. Contact you PAP equipment supplier and ask for help.

Noise of the machine

Newer PAP machines are much quieter than older models, but all make some sound. Placing the machine under the bed or on the floor usually solves this problem. Again, the PAP supplier can provide advice and assistance.

Sore, dry, or red eyes

These problems can result from an air leak from your mask. Try reapplying the mask and readjusting the headgear. If the problem continues, contact your PAP supplier to determine whether you need to try a different mask size, nasal pillows, or a different headgear.

Redness on the face where the mask contacts the skin

If you develop reddened areas or sores on or above the bridge of your nose or on your forehead, first check to see whether your mask is pressed too tightly to your face. Your mask needs to be fitted and adjusted to eliminated air leaks without undue pressure on your skin. Sometimes spacers and air cushions can help ease the pressure points. If you need to loosen your mask so much that leads develop, ask your PAP supplier whether your mask is the right type and size and is properly adjusted.

If redness occurs wherever the mask touches your skin, loosen the headgear slightly, but not so much as to cause an air leak. If you think you might be allergic to a mask, try applying a paper tape over areas where the mask touches your skin. If that eliminates the problem, contact your PAP supplier to find out whether a different mask or nasal pillows might be beneficial. Fortunately, modern PAP masks are made of materials designed to minimize allergic responses.

Too much air

Especially when first using PAP, some people complain that the pressure of air through the nose seems too high. If this sensation makes it difficult for you to fall asleep, try using a pressure ramp. Most PAP machines have ramp capability. The ramp starts the machine at a very low pressure and gradually raises it to the right amount over a period of minutes. Using lower pressures at the beginning may help you fall asleep more easily.

Most PAP machines will allow you to adjust your ramp time. Many people find they prefer longer ramp times (10 to 20 minutes) when they first start using PAP. As you get used to PAP, or if the air pressure does not bother you, set your ramp to shorter times so you get the full benefits of the correct PAP pressure from the beginning.

Should I try two-level PAP?

If you have trouble breathing out against the continuos air pressure of CPAP, a two-level PAP machine may help you. These machines sense when you breathe in and out, and deliver one pressure of air when you breathe in, and (usually) a lower pressure when you breathe out.

You should consider using two-level PAP if you find that the air pressure with CPAP feels too high or that you are working too hard to breathe out. A lower pressure when you breathe out may feel more natural to you, particularly if you are using a fairly high air pressure when you breathe in. In general, the two-level PAP machines are larger, heavier and more expensive than CPAP devices.

If you were note tested in the sleep laboratory on a two-level PAP device, you will probably need another sleep study to determine the correct air pressures for you.

Should I try self-adjustable PAP?

PAP devices that raise air pressure only when they sense problems with breathing were approved for use in America in 1996. By increasing air pressure intermittently, it is believed that PAP treatment of sleep apnea may be made more comfortable and effective. If air pressure-related complaints limit your use of CPAP or two-level PAP, you should consider asking your doctor about self-adjustable PAP. As with two-level PAPP, self-adjustable PAP machines are heavier and larger than CPAP machines. The mask may also be heavier and more expensive than a CPAP mask, and is not usually interchangeable.

Cleaning PAP devices

Regular cleaning is essential to assure proper function and safety of PAP devices. The method and schedule for cleaning hoses and masks and for changing filters may be different for each PAP device, so you should refer to the manufacturer's instruction manual for details about the maintenance of your PAP equipment. Improper care of PAP devices, filters, mask and hoses can lead to nasal and sinus problems (congestion, infection, etc.).

Can I travel with this machine?

Most PAP machines available today come equipped with transformers which allow them to be used with international (220v) voltages when you travel to foreign countries. Current PAP models are lightweight and portable. A travel case for the device and accessories often comes with the machine, or can be purchased from the manufacturer. A battery power option is available for those who camp.

PAP machines are not harmed by airport x-ray devices. Your healthcare provider can provide you with a letter describing the nature and purpose of your PAP machine for security personnel unfamiliar with the equipment.

High altitudes can affect the performance of your PAP machine. You should consult your healthcare provider or PAP supplier if your travel plans call for sleep at altitudes much higher or lower than those at home.

Cold nose

The air cools as it moves through the PAP hose tubing. To reduce heat loss, try repositioning the tubing so that it runs under your bed or bed coverings.

Should I wear my dentures?

Some people with dentures find that if they sleep without their upper dentures, the PAP mask does not fit properly and air leaks develop. Try sleeping with your upper dentures to eliminate this infrequent but difficult problem. If you have no upper teeth, consider trying a mask that fits inside or just under the nose.

Can I use it when I have a cold?

You may find your PAP more difficult to use when you have a cold. You may need more humidity, or a decongestant. Contact you healthcare provider for recommendations if you find you cannot sleep with you PAP when you have a cold. If you develop nasal, sinus, or ear pain when using your machine, this could be a sign of a developing infection. Contact you healthcare provider for further advice.


Some people experience feelings of claustrophobia, difficult breathing, choking, or suffocation when first using PAP. Let your doctor, sleep technologist, or PAP machine supplier know about these feelings. Spend some time practicing with your PAP machine during the day while awake and watching television or reading. You may need to start by wearing the PAP device for only a few minutes at a time and gradually increase the time you spend breathing with it until you feel comfortable. At first, some people fight the pressure and tend to hyperventilate. Practice regular breathing. If you don't like the mask over your nose, try a mask that fits in or just under the nose. If you find that air pressure is too high, consider a longer ramp time or two-level or self-adjustable PAP. If these measures fail, consider learning a relaxation technique, either from a self-help book or a tape, or from a professional trained in relaxation methods (i.e. a psychologist). Some amount of this discomfort during the initial therapy is not unusual. PAP can work for you if you give it a chance.


Most of the common complaints about PAP relate to how the mask fits and to drying of the airway. The remedies we have suggested should solve the majority of these problems. If your symptoms continue or recur, consult you healthcare provider or PAP equipment supplier. PAP helps most people with sleep apnea, but feeling comfortable with it requires time. Once you have become familiar with PAP, you should find it to be a great help.

Good Sleep Habits

These guidelines can be used for all types of sleep disorders. They will help most people, including those using PAP, sleep better: