Getting help to successfully treat Sleep-Disordered Breathing
usually defines a few different groups of patients, depending upon
how they approached the gold standard treatment of Positive Airway
Pressure Therapy (PAP):
- Those currently using PAP with less than optimal responses
- Those who tried PAP who have since stopped using it at all
- Those who never attempted PAP Therapy
Current PAP Therapy Users
Current users must recognize that the secret to optimal PAP
Therapy is constant fine-tuning. Ultimately, this usually comes
down to only 5 minutes per day, but those 5 minutes are priceless
in terms of what you can tweak to insure a great night of sleep
night after night.
Start with our PAP Therapy Checklist and you'll quickly discern
which areas are causing most of your problems. Things like mask
fit, comfort with pressure, mask leaks, mouth breathing, and
anxiety responses to mask or pressure are critical factors that
affect nearly all PAP Therapy users at one time or another.
In your fine tuning efforts, you will reap great dividends
through constant vigilance over how to most effectively apply your
breathing mask treatment. However, we find that many SDB patients,
no matter how hard they try, will not get results commensurate with
At this point, and actually much sooner at our sleep center, we
encourage patients to return for a full night PAP therapy
titration, allowing us to professionally evaluate and adjust
everything on the PAP Therapy Checklist.
The well-trained sleep technologist may discover that:
- The mask you thought was not leaking is actually cracked
- You really are mouth breathing, and a chinstrap or partial
mouth taping is the solution
- The pressures you thought were just right from the last
titration turn out to be too high or too low
- The leg jerks you said you've never noticed turn out to be
occurring at a rate of more than 15 movements per minute
- And the list goes on.
And, for a majority of Sleep-Disordered Breathing patients, the
largest problem is that fixed CPAP pressures will never
provide the best treatment results.
No surprise, most of us with SDB respond to different pressures
when we sleep on our backs compared to our sides, in REM vs. NREM
sleep, and during the latter half of the night compared to the
first part of the night. Yet, for reasons I've never been able to
sort out (except maybe through the limitations of cost and
technological advances), most sleep centers continue to prescribe
fixed CPAP pressures for the vast majority of their patients.
See why we rarely prescribe CPAP...
Our Model is Different
We rarely prescribe CPAP because it is an old technology. In
fact, less than 2% of our patients of the last 3 years have
received prescriptions for fixed CPAP. Instead, greater than 90% of
our patients are now titrated with bilevel therapy, which supplies
a higher pressure on inspiration and a lower pressure on
We believe that bilevel treatments as well as some of the newer
technologies that provide auto-titrating technologies or "breathing
assessment" devices are the clear wave of the future, and we expect
that fixed CPAP will be soon recognized as a primitive treatment
option that does not yield optimal results in the vast majority of
Thus, the Pearl that we leave you with here is
to appreciate the possibility that you might never attain an
optimal response while using fixed CPAP pressure. If you have
addressed all the factors you think might be causing your lack of
great results, you certainly should discuss how to proceed with
your sleep doctor, and we recommend that you broach the topic of a
bilevel titration or explore the use of the newer technological
What if you're a former PAP user?...
Former PAP Therapy Users
Sadly, there are probably as many users of PAP Therapy as
there are those who have tried and failed to use it. In fact, the
number of SDB patients who once used a PAP device may outnumber
those who are still using it.
There are many reasons for this lack of success, and I
personally had to travel down many of these paths before I could
find success with my current bilevel therapy. My struggles occurred
during the early phase of the writing of Sound Sleep, Sound
Mind; and, these barriers served as a major motivating
influence to push me to find solutions for myself and others who
were frustrated in their efforts.
While my book goes into more depth on this problem, the
following list reflects the biggest issues I have found that
prevent SDB patients from succeeding with PAP Therapy:
- Wrong mask or poorly fitting mask
- Wrong pressures or wrong pressure delivery system
- Inadequate problem-solving or coaching from the supplier of the
PAP Therapy device or prescribing sleep facility
- Failure of the sleep facility to schedule PAP retitration tests
to fine tune pressure settings and facilitate compliance
- Anxiety or fear about PAP Therapy
- Pain or discomfort with any aspect of the treatment
- Embarrassment, shame or guilt triggered internally by your
sensitive personality or by a non-supportive family
- Co-occurring psychiatric conditions such as depression,
anxiety, and PTSD that trigger frequent episodes of insomnia
- Co-occurring medical conditions such as chronic pain syndromes,
diabetes, asthma, and heart disease that compromise functioning in
general, which then limits the SDB patients ability to fine tune
and follow through with all the necessary adjustments that must be
made on a daily basis.
These barriers are sometimes quite large, but virtually all of them
can be overcome. When you work with the right mix of sleep
professionals, from the sleep staff to the sleep technologists to
the sleep physician to providers of the PAP equipment, then your
chances of achieving success skyrocket. These professionals will
help you directly or motivate you to "help yourself" seek and apply
solutions to the various barriers in your way.
In the past, you may have used CPAP to treat a sleep breathing
disorder, discovered that the treatment worked somewhat well, but
not well enough to put up with the general hassle. We can expect
that you would remain highly motivated if your benefits were
obvious, even while the breathing mask is difficult to use.
More commonly, we see patients who tried CPAP, but did not
receive any benefit and found it a huge hassle. If you
fall into this category, your motivation is of course much lower.
Even though you may initially have been eager to gain something
from treatment, your negative experience may have triggered a
belief that future treatment efforts will also be negative, a
hassle, or simply not worthwhile.
If you have stopped using PAP Therapy and still have a machine
to use, we recommend starting with our PAP Therapy Checklist. The
items on that list can help you organize your thinking to pinpoint
where you need to focus for starting up again.
If it's been awhile and you no longer have a PAP Therapy device,
returning to the sleep lab is the ideal way to start again, or you
could contact your sleep physician to discuss your perceived
barriers before returning to the lab.
Just started PAP?...
PAP Therapy Newcomers
If you've never tried PAP Therapy, you truly do not know what
you're missing! Of course, that could cut both ways as you've
probably guessed in reading the sections above. PAP Therapy really
is a life-saver for a lot of people, but the adaptation process is
quite miserable even for many who eventually obtain a great
At times, you
would feel like the horse constantly striding after the carrot held
out in front of your nose, yet never snatching even a little taste
of your reward. For some, things go very smoothly very quickly,
literally in a matter of days or weeks. Yet, as the complexity of
your sleep disturbance increases, the likelihood of a longer
adaptation period increases as well.
When I've worked with many trauma patients with insomnia,
nightmares, SDB, leg jerks, claustrophobia, and who use multiple
psychotropic medications for PTSD, depresssion, and anxiety, the
process unfolds over a period of months and occasionally a year or
Did these people believe that the effort was worth it? Virtually
every patient who eventually adapts to PAP Therapy, uses it every
night, and all night long will report some benefits that
demonstrate to their satisfaction their sleep quality was restored
in ways never previously achieved with medications, psychotherapy
or any other treatment.
If you find yourself here because you have “Been There,
Done That,” then we want you to know that there is still
hope. While you may have “Been There” before, you most
likely have not "Been Here.” Our Sleep Treatment program is
based on my work with extremely complex sleep disorders patients
who suffer from multiple sleep problems and often a wide range of
other physical or mental health conditions.
We believe we have developed more ideas, systems, and treatments
for which the vast majority of troubled sleepers can benefit. You
see, we don’t believe in the “one size fits all”
mentality that is seen in a lot of approaches to sleep disorders
patients. Our goal is to personally tailor treatments to the
individual, or to coordinate your care with your local sleep
physicians, assisting them to fine tune your results by adding
precise steps not previously utilized.
Our primary recommendation to you is to read Sound Sleep, Sound Mind to
learn about several of these newer approaches to insomnia and sleep
breathing problems. But, we also welcome the opportunity to consult
with you personally, if you think we can help you get started again
with PAP Therapy or fine tune your current efforts. Click here to learn about becoming a patient, or here to learn about setting up
a consultation in which our sleep center works directly with your
local sleep physician to assist in optimizing your care.