The Comfort Factor in PAP Therapy Compliance and Use: Part I

“Take your medicine” is a widely used metaphor that implies you must accept the consequences for something you did wrong or something bad you did. In effect, it means accept your punishment without complaining about it. I cannot find any specific origin to the phrase, but clearly there would have been a time in the past where the “bad thing” would equate to an illness, and “the medicine” was probably some foul-tasting concoction or some very unpleasant or painful procedure. So, I suspect the origin of “take your medicine” resides in earlier practices in medical fields where the treatments were far less tolerable than they would be today.

In a word, “take your medicine” accepts the premise of discomfort as something one must endure to gain the benefits from the treatment if we imagine that the origin of the metaphor arose from actual experiences. More common today might be the phrase “no pain, no gain.” It is interesting how so many of these phrases imply that suffering must occur before the benefit or the reward is achieved, and certainly it is known that all humans suffer, but often it is the way we cope with the suffering that influences the benefits or rewards that fill up that supposed silver lining.

In sleep medicine, we find a similar, albeit less intense, perspective among sleep professionals, physicians and sleep techs, on how they may interact with patients experiencing difficulty adapting to a PAP device. At some point, the sleep professional may try to engage patients to simply recognize they “just have to use the device” in order to get used to it. There is some truth in this approach, but given the mediocre compliance rates rife within the population of PAP therapy attempters, a more salient question would ask: why is it that so many OSA/UARS patients do not find a mask or pressure settings sufficiently comfortable to keep using the device? A corollary follow-up question would be: why is comfort not a high priority in assisting these patients?

If these two questions seem too obvious in that you would assume everyone in sleep medicine must be already aware of these key barriers, then we are in agreement regarding how obvious this information should be. However, you might be surprised to learn that the comfort issue is not necessarily perceived as a relevant factor by insurance carriers or even larger institutions, such as certain types of medical centers that contract out sleep lab services. As I have discussed in three prior posts on CPAP failure (see: What is CPAP Failure, CPAP Failure Revisited, How Long Should One Struggle Attempting to Use PAP Therapy), questions about comfort and discomfort should be regularly addressed in patients seeking care at sleep centers, but when managing cases through contract work where larger institutions will force their own agenda (as they are paying for the services), the issue of comfort may be viewed quite differently. 

Consider a specific example. Many sleep centers throughout the USA beyond their usual community-based clinical patient services conduct contract work for other medical institutions that do not operate their own sleep labs. The sleep services rendered might be everything involved in managing a sleep apnea patient, or it might be conducting the sleep tests only, after which the larger institution takes over the care. In any of these circumstances, the larger institution sets rules or policies about how to test their patients. 

The most common rule would be to order split night studies on every referred patient. From this vantage point, the larger institution believes it will save money when their patients undergo the split night diagnostic/titration procedure instead of two nights of testing. As an aside, my own experience is that straightforward cases of sleep apnea proceed fairly well with a split night, but more complicated patients with other co-occurring illnesses are more likely to adapt faster when exposed to two nights of testing. This 2nd sleep test allows these difficult cases to receive a full night of experience with PAP therapy. Many sleep professionals would argue otherwise, but I bring this point to your attention so you are aware of how a larger medical institution without a sleep lab might go about developing its policies.

Another common policy might be that these institutions will only cover CPAP devices for their patients, again because CPAP is a less expensive device. Would they permit prescriptions for other pressure delivery modes such as APAP, BPAP, ABPAP or ASV? Most of these institutions shy away from prescribing these advanced devices, strictly because of cost factors. But, the interesting rationales used to make such decisions regarding either testing or equipment often do not take into account a patient’s comfort. 

At one institution for which we conduct sleep studies, the policy is that every patient must start a titration on CPAP no matter how uncomfortable the patient reports feeling during the desensitization. The patients may eventually try BPAP, but not because they are uncomfortable with CPAP. Rather, they must show problems on the titration study, such as residual breathing events, difficulty exhaling again fixed CPAP pressure or failure to consolidate sleep. The odd thing about these factors is that they tend to show up in someone who would be reported discomfort with CPAP in general. Yet, despite patient discomfort with CPAP, this fixed pressure mode must be continued until one of the other listed factors emerges to signal a need for BPAP. 

Even more interesting is the rationale that props up this approach to care, which is the strong belief that virtually anyone can get used to CPAP. In other words, discomfort is an unreliable metric for switching to another device, because everyone should be able to tolerate CPAP, even if it takes weeks or months so do so.

Now, the regrettable and disingenuous thing about this rationale is that it is close to pure nonsense, even though several research papers purport to have studied this problem and have declared that CPAP works in most patients if they just take the time (translation: “if they just take their medicine”). Yet, in our center, which has seen roughly 1500 second opinion patients in the past decade, the vast majority of these OSA/UARS patients arrived at our center partially using CPAP for more than a year and yet virtually none of them affirmed that it was a comfortable experience. Just the opposite in fact: nearly all the patients reported persisting difficulties with adaptation, often related to being unable to overcome the discomfort of a mask or pressurized airflow and often both. 

Our impression is a large proportion of CPAP failure cases (especially among those patients who briefly attempt CPAP and then reject it) reflects the core problem of discomfort with CPAP in every imaginable way. Instead of most sleep facilities drawing attention to this specific issue, however, many buy into the belief the OSA/UARS patient must be told to “take your medicine.”

As we will soon be publishing an article on compliance and sub-threshold compliance in a consecutive series of patients at our own center, I am delighted to report that among those who filled their prescriptions for PAP, more than 85% were currently using a device at follow-up. Some were compliant by insurance standards while others appeared to be on their way to compliance. In virtually all these cases, we had switched patients to other devices when they acutely registered discomfort with CPAP.  In our opinion, we believed we have learned to provide a medicine without such a bad taste.

Last, it cannot go without saying how much “comfort” contributions have been made by CPAP vendors, which highlights a key aspect of healthcare business, because these companies must compete with each other to sell PAP devices and all the supplies to go along with the machine. It is somewhat ironic how their competitiveness has led to great advances in producing more comfortable masks, a key component to PAP adaptation and adherence.

See: Comfort Innovations in CPAP Interfaces on

In my opinion, the sleep medical profession could learn a great lesson by observing how the business end of the field is leading to new advances in technology, and nearly all of these pieces to the PAP puzzle include new designs or features to enhance comfort. If we see an uptick in the more consistent use of PAP devices in the coming years, a major contributor to these greater levels of use will prove to have been directly related to inventors and engineers at many of these CPAP vendors.

And, it remains of further interest that inventors outside of the CPAP manufacturers have also contributed, most notably with the REMZzzs Mask Liners, which assist many patients to overcome specific mask discomfort issue. 

In the next post, I will extend the conversation on comfort to an area of much greater concern, that is, extreme discomfort with PAP devices and masks and how the sleep medical professional appears not to be addressing these situations with the careful attention they deserve.

Barry Krakow MD


Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.

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