The PAP Paradox: Breathing with PAP

One would think using a breathing machine, in this case a PAP device, would require synchronizing one’s breathing rhythm to the device. There is a certain logic that would conclude: when using a PAP device you must not fight with the machine’s delivery of air pressure; rather, you must learn to breathe in harmony with the rate or volume of compressed air delivered on inhalation or exhalation or both.

Please toss that logic aside - if your goal is to adapt to a PAP device as rapidly as possible - because it is a point of fact that when you pay even the slightest attention to the breathing rhythm generated by the device, you are almost guaranteed not to adapt to it. Instead, you are more likely to experience a great deal of discomfort and anxiety when you attempt to control, or as we like to say “over-control,” your breathing in your early efforts at PAP therapy. 

Among all the reasons that fuel a poor adaptation process to PAP therapy, paying too much attention (“attention amplification” in psychological terms) to your own breathing in a futile effort to harmonize it with the machine almost invariably prevents the exact harmonization you were hoping to achieve.

Why this problem arises may not be readily apparent; an anxious patient may feel the most discomfort when trying to break the habit of attention amplification. By way of analogy, think about the absurdity of the command, “make yourself sleep…now!” A person cannot follow this instruction, because sleep is something you let happen. The greater your productivity and satisfaction throughout the course of the day is what usually brings you to the feelings of tiredness near to your bedtime, which soon transform into sufficient sleepiness to head to the bedroom. Upon lying down, you do not “make” yourself sleep, it just happens quite naturally.

You breathe much the same way; there is no conscious effort to breathe except in unusual circumstances such as becoming winded after running, choking on a piece of food or during an extended coughing or laughing spell. Nearly 99% of the time, you just breathe; it just happens.

When a breathing mask is applied and the pressure is turned on, the system is not designed to take control of your breathing; it is designed to improve your breathing by eliminating obstructions in the airway, which in turn leads to smoother breathing. But, you and your brain are still in charge of your breathing. You are therefore still in control of each breath, but that’s just a technical statement in that you breathe in and out regardless of whether or not there’s a PAP machine attached to your face.

When the PAP device is attached, you may immediately sense the extra or pressurized air and the first thought might be “this machine is supposed to breathe for me.” Again, I cannot reiterate enough times, the machine is facilitating and improving your breathing, but you are the one breathing, not the machine. Once this point hits home, using a PAP device for most modes (CPAP, APAP, BPAP, ABPAP, and ASV) becomes appreciably easier, although there may be slightly different approaches you might need for each PAP mode.

I first became acutely aware of this phenomenon in 2002, after experiencing a deteriorating response to oral appliance therapy. Upon initiating treatment with an APAP device (an experimental unit at the time), I noticed how comfortable the air felt breathing in, but breathing out seemed nearly impossible. In particular, directly after the cessation of inhalation and the commencement of exhalation, I immediately felt pressure was too high. I also noticed the process caused anxiety, so I attempted to relax my breathing by creating a pattern of a very regular and slow rhythm. This made things worse. Then, I tried to focus on the sensation in my chest near the end of the exhalation cycle, because I noticed the most discomfort and anxiety in this spot. This step also had no impact and sometimes made things worse. As you can imagine, during the first several nights of the trial, I removed the mask within less than one hour, and of course as soon as the mask was off, I fell right to sleep. I had tried CPAP or BPAP three previous times in 1993, 1997, and 1998, and each trial only lasted a few days or less before I quit. BPAP was the last device I tried, and the change in the breathing cycle yielded the greatest levels of anxiety experienced than with any prior CPAP device.

In 2002, an opportunity arose to try PAP again. At the time, we had just finished up our major work on the use of imagery rehearsal therapy (IRT) for the treatment of chronic nightmares. In the aftermath of working with sexual assault survivors with PTSD who used the IRT method with remarkable success to treat their nightmares, many of the research participants provided us with post-research feedback about the program. The nearly universal comment received went something like, “Do you guys realize just how awesome this imagery stuff is and what else you can do with your mind’s eye?”

Their feedback was remarkable in its own right, but it was also ironic for me, because I had applied imagery distraction techniques 35 years earlier as a teenager for mild bouts of insomnia. Indeed, the use of imagery distraction at bedtime to overcome insomnia and initiate sleep was the single most specific new feedback we received from these research participants. And, in the 1990s, during the course of the study, I had again suffered mild bouts of insomnia and had been applying imagery distraction techniques with some success. However, when attempting PAP therapy it never occurred to me to try imagery distraction. 

After those first few days of frustrating APAP experiences, for providential reasons as my best explanation of what occurred next, I was lying in bed one night struggling with the same dilemma as before when I suddenly wondered what would happen if I did not or could not pay attention to my breathing? I wondered what might transpire if I dispensed with my efforts to pay attention to my breathing in relationship to the pattern of pressurized airflow delivery.

My very first step was to think of something else of some interest or pleasure to take my mind off the device experience. My mind briefly wandered into a sexual fantasy that was more relaxing and distracting than overly stimulating. In less than 30 seconds, I realized an extremely odd sensation…I realized that while I was engaged in fantasizing, the sensation of the anxiety I felt with the device during exhalation was completely gone. But, this point isn’t quite accurate. Rather, I suddenly recognized the sensation of discomfort was no longer present in my body, but I could not tell you what happened in those 30 seconds that apparently caused its disappearance. The researcher in me asked the obvious question “how did that happen?” So, of a research mind, I chose to pay attention to my breathing and the device again and noticed the anxiety returned in seconds. Sensibly, I began fantasizing again (science must be served!), and again the sensation on exhalation completely dissipated. And, again, I did not observe the sensation diminishing; I was only paying attention to the colorful pictures in my mind’s eye (what dedication!), so that when I returned my awareness back to the sensations of breathing the anxiety and discomfort were gone.

My “aha” moment at this point was that I realized a great psychosomatic medicine axiom: I was the one causing the anxiety, not the machine. If I simply learned to distract myself and pay no attention to my breathing or the device, there would be no experience of attention amplification, which was the real culprit that was ramping up my discomfort and other anxious feelings.

Having studied many different types of psychosomatic (mind-body) processes in my career as a physician, I realized that this experience was an acute psychosomatic response to a “perceived threat” of the PAP device and pressurized air. The threat of course was that something was trying to control my breathing, which would indeed cause most individuals to feel anxious. However, if I simply ignored the pressurized air, the entire process collapsed into nothing at all, while the pressurized air successfully pinned open my collapsing airway.

Going forward, this epiphany occurred at a very propitious time, because we were in the midst of starting up our private, community-based sleep center, Maimonides Sleep Arts & Sciences. Immediately, I trained our staff on how to use the technique during both pre-sleep desensitizations as well as titration studies in the night. 

Our first efforts were more of a discussion with the patient about the use of the mind’s eye, but soon we created a survey to assess their imagery, which derived from a tool Anne Germain and I had created 5 years previously to assess patients’ imagery skills. After the patient described his or her ability to use mind’s eye imagery, we would then ask the individual to practice imagery in some fashion, such as picturing scenes from a most recent or otherwise memorable vacation spot. Nearly all patients demonstrated good skills with this exercise. Then, we carried this practice forward into the desensitization period, asking each patient to conjure up those images when first attempting to place the mask on the face or when first exposed to pressurized air.

The results were very interesting in that while awake nearly every patient could improve their degree of relaxation and thereby decrease their discomfort with their initial trials with the mask or pressurized airflow or both. At this point, the use of imagery was a clear-cut success.

Things got cloudier with our next set of observations after the patient had fallen asleep. In particular, we noticed some people were fighting with the pressurized airflow, which showed up most commonly on the expiratory limb of the airflow tracing during the titration PSG. (We call this objective expiratory pressure intolerance or EPI, and it’s called subjective EPI when the patient complains about this sensation). When some of these patients aroused or awakened fully, they reported some similar sensations of discomfort and anxiety. We then asked them to return to their imagery practice, which again was effective in some but not all patients. For the successful experimenters, they soon fell back asleep.

All of these experiences brought us to the point of recognizing that the mind’s eye was an extremely useful and potent tool, which could indeed diminish anxiety and promote relaxation in the sleep lab environment as well as at home when the patient was using PAP therapy nightly.

However, we also realized that there were really three components to this process. First and most obvious was that the initial PAP user needs to find a way not to pay attention to his or her breathing or to the device’s output of pressurized air. Second, while awake, imagery distraction could often serve as an excellent distraction tool to diminish sensations involving the mask or pressurized airflow (subjective EPI). And, third, we learned that there was something else about pressurized airflow during sleep that added to the mix, and which in many cases proved even more influential than the first two parameters. This third element, which amounts to further discussions about objective EPI and related findings, will be the topic of my next post.

Read more: The PAP Paradox (Continued): Special Adaptation Tips by PAP Mode

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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