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PAP Therapy Guidance

‍Below is a list of issues that may occur while using PAP therapy, and associated guidance that may help you and your provider improve your treatment experience and long-term compliance. This information is not intended to diagnose or treat without the assistance of your healthcare provider.

AHI Elevated (PAP device)

  1. ‍Evaluate Medical History - An increase in PAP AHI (the number of times your PAP device indicates that you are experiencing sleep apnea episodes) can be caused by several medical history changes, including but not limited to, nasal congestion, medication changes, alcohol consumption, weight changes, and disease of the heart, lung and/or brain. It can also occur when traveling to a location with a higher or lower sea level. If you see a spike in your PAP AHI, you should talk to your provider.

Air Leaks (mask / PAP device)

  1. Mask Fitting - Check out our Forms and Guides page for some links on how to get a better mask fit. Poor mask fit and not cleaning the cushion on the mask are two quite common reasons why you might be experiencing air leaks.
  2. Clean the mask and cushion - The cushion part of the mask should be washed daily with warm soapy water. This helps the cushion grip the skin and stay in place better. Washing your face prior to putting on the PAP mask can also improve problems with mask leaks.
  3. Replace your cushion - The "cushion" is the part of the mask that touches the face. Some cushions need replacing every two weeks, some once every 30 days. This will depend on how you care for the cushion and how quickly the oils on your face break down the cushion material. Replacing the headgear and mask frame can also help correct air leaks and a mask that does not seem to fit like it used to.
  4. Chinstrap - Talk to your provider about adding a chinstrap to help control air leaks related to breathing through your mouth. A chinstrap can be useful with both nasal and full-face masks.
  5. Grooming - Trimming or shaving facial hair may help improve prolonged issues with air or mask leaks.

Anxiety and Claustrophobia

  1. Acclimation Training - Wear your therapy during a period where you are normally awake for 20 to 30 minutes daily while engaged in an activity that provides mental distraction while wearing therapy. We often recommend watching a movie, reading a book, or listening to the radio.
  2. Temporary Sleep Aid - Talk to your provider about a trial use of a sleep aid for two weeks while adjusting to therapy.

Bloating and Swallowing Air

  1. Pressure Change - Talk to your provider about changing your pressure. Sometimes lowering the pressure by 1-2cm is necessary to prevent swallowing of air that can lead to bloating and abdominal discomfort. Pressure needs may change as your age, weight, and medical history changes.
  2. Positional changes - Try sleeping in a different position during sleep. It is common to need more pressure while sleeping on your back versus on your side. Sometimes sleeping on your back more often can improve air swallowing. If you are sleeping more on your side than on your back and still swallowing air or experiencing bloating, talk to your provider about a trial pressure reduction.

Chest Discomfort / Palpitations

  1. Determine the Source of Discomfort/Palpitations - Talk to your provider about your symptoms if you are experiencing heart palpitations. Positional changes like elevating your head of bed or sleeping on your side or back may offer some relief.
  2. Pressure change - Your provider may recommend a pressure change for chest discomfort.

Difficulty Exhaling

  1. Pressure Change - Talk to your provider about adjusting the pressure relief feature on your device. This feature is designed to make it easier to breathe out with therapy. This feature is often referred to as "EPR" or "Flex".
  2. BPAP Therapy - If you are using CPAP and having persistent difficulty exhaling with therapy, talk to your provider about trying BPAP. BPAP has more settings and features that can help with difficulty exhaling with PAP therapy.

Disrupted Sleep

  1. Determine the Source of Sleep Disruption - Common sources are air leaks, poor mask fitting, the sleep environment, and other sleep disorders. See "Air Leaks" above. If you use a nasal mask and do not use a chinstrap to help keep your mouth closed, you may need to try a chinstrap. Most nasal mask wearers will benefit from a chinstrap. To rule out other sleep disorders talk to your provider about your symptoms. To improve your sleep environment, download and review our Sleep Hygiene Guidance PDF. Pay particular attention to sound, light, and temperature in your sleep environment. Use of a white noise may offer immediate improvement.

Dry Mouth or Nose

  1. Adjust Humidity - Try adjusting the humidity on your PAP device, which will add moisture to the air. Use distilled water only.
  2. Heated Tubing - When available, use a tubing with a heating element, which helps maintain humidity levels.
  3. Chinstrap - Breathing through your mouth can cause excessively dry mouth. Some dry mouth is to be expected when using a full-face mask.

Ears Popping / Discomfort

  1. Pressure change - Talk to your provider about your symptoms. They may suggest a reduction in pressure, use of the EPR (expiratory pressure relief) features, or changes to other settings.
  2. Elevate - Sleep with your head of bead elevated, so that your torso is on an incline. Extra pillows alone are insufficient.

Edema / Swelling Around the Eyes

  1. Change Masks - Certain masks may restrict venous blood flow around the eyes and cause swelling. Finding a mask that distributes the pressure in different areas of the face may help with this issue.
  2. Elevate - Sleep with your head of bead elevated, so that your torso is on an incline. Extra pillows alone are insufficient.

Epistaxis (Nose Bleeding)

  1. ENT Evaluation - Talk to your Ear, Nose, and Throat provider for an evaluation for nose bleeds while using PAP therapy.
  2. Adjust Humidity - Try adjusting the humidity on your PAP device, which will add moisture to the air. Use distilled water only. This may help reduce irritation and dryness that could cause nose bleeds.
  3. Elevate - Sleep with your head of bead elevated, so that your torso is on an incline. Extra pillows alone are insufficient.

GERD / Reflux

  1. Elevate - Sleep with your head of bead elevated, so that your torso is on an incline. Extra pillows alone are insufficient.
  2. Don't eat close to bedtime - Avoid eating heavy meals within two hours of your bedtime.
  3. See your Provider - Talk to your provider about your symptoms and treatment options. Untreated GERD can lead to significant sleep disruption.

Removing Therapy During Sleep

  1. Acclimation - This is very common. You may notice that you wake up and see that your mask is lying beside you and that you do not recall taking it off. This should improve over time, but if you are experiencing it often, consider temporarily applying tube socks to both hands and arms to help reduce your ability to grab the mask and remove it during sleep. This simple tip has helped many patients. If you took a break from using therapy and started back, you may see this issue resurface. If you are intentionally removing therapy, it is important to remember that any therapy can take time to acclimate to. PAP therapy is no exception. See "Anxiety and Claustrophobia" section above.

Sinus Congestion

  1. Elevate - Sleep with your head of bead elevated, so that your torso is on an incline. Extra pillows alone are insufficient.
  2. Nasal Rinse - We often recommend a nasal rinse that your provider has approved for you to use. The Neil Med Sinus Rinse system is an example that we often recommend.
  3. Distilled water - Make sure to use distilled water only in your humidifier.
  4. Wash your equipment - Cushions should be cleaned daily, and all other items at least once a week to help prevent nasal congestion.
  5. See your Provider - Talk to your provider about your symptoms and treatment options. This may include the use of decongestants and treatment for allergies.

Skin Irritation

  1. Talk to your Provider - Your provider should evaluate any skin irritation that persists.
  2. Clean the Mask and Cushion - The cushion part of the mask should be washed daily with warm soapy water. This helps the cushion to grip the skin and stay in place. Washing your face prior to putting on the PAP mask can also improve problems with skin irritation.
  3. Cloth Barrier - Talk to your provider about adding a cloth barrier between the cushion and your skin.

Social Acceptance

  1. Talk about therapy - PAP therapy is widely accepted as the gold standard treatment for sleep apnea. Talk to your family and friends about therapy when they show signs of concerns. Help them understand how it works and improves your health and sleep wellness. Talk with your provider if there are persistent concerns about social acceptance with your therapy.

Suffocating Sensation

  1. Acclimation training - Wear your therapy during a period where you are normally awake for 20 to 30 minutes daily while engaged in an activity that provides mental distraction. We often recommend watching a movie, reading a book, or listening to the radio.
  2. Pressure Change - Talk to your provider about adjusting the pressure and settings.

Water in Tubing or Mask

  1. Adjust the Humidity- We recommend keeping your humidity level within five degrees of your home temperature.
  2. Insulate the Tubing - Run the tubing under your blankets as much as possible.
  3. Lower your PAP Device - Your PAP device needs to be slightly lower than you while in use. This can help any water that forms during sleep to run downward back into the humidifier tank. A couple of inches is sufficient in most cases.
  4. Heated Tubing - Talk to your provider about heated tubing.
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