Response to PAP Therapy and the Ceiling Effect

Starting the new year is a good time to address the ceiling effect, a common occurrence among PAP therapy users in which the individual normalizes the response to the PAP device, and then assumes no room for further improvement. When explaining the ceiling effect to our patients in clinic, I place one hand flat on the table and hold the other hand parallel a foot above. I say “here’s where you started” (lower hand), and then say “here’s how much better you are now” (high hand). After a brief pause of acknowledgement by the patient, I then move my low hand above the high hand and ask, “So, what’s up here? Is there ‘more better’ to be gained?”

Although most patients have no difficulty appreciating the intellectual concept expressed by these images, their actual experience with PAP more often than not leads them to normalize their new found results and presume no “more better” is attainable. That is, it is difficult for them to imagine there is room for improvement. This response is quite natural, akin to the way your head feels so much better after you stop banging it against a wall. However, sleep changes are much more subtle than the cessation of physical pain. We are dealing with qualitative measures of feeling tired, sleepy, fatigued or the elusive psychophysiological measures of inertia, motivation, or energy level. 

For every one of these factors, the untreated sleep apnea patient usually reports abnormal symptoms: more tired, sleepy, or fatigued; more inertia, lower energy, or a lack of motivation. When the patient receives a bolus of energy from using the PAP device, it is nearly axiomatic the individual would report some new bounce in his or her step, some sense of greater productivity, or simply noticing a lesser struggle with chronic feelings of exhaustion. 

Once a treated sleep apnea patient experiences these improvements, he or she would not necessarily raise the question, “Is this as good as it gets?” But, at some point on the path of sleep recovery, some patients will intuitively question “are these the best results I should be receiving;” whereas, a larger proportion of patients will in effect normalize their experiences, assume the new “normal” is as good as it gets, and may no longer wish to pursue further treatments.

For patients and sleep physicians alike, this new normal creates a quandary that may only be resolved with time. However, we have found it useful to broach this topic with nearly all patients using PAP therapy, whether they are individuals initiating treatment for the first time or they are second opinion patients who have wondered about the potential for greater benefits after having used PAP therapy for many months or years. 

The issue of the ceiling effect, then, is nearly ubiquitous. However, if the patient or doctor or both are not engaged in a conversation about “room for improvement,” it would be quite common for both parties to presume the patients will express satisfaction with or acceptance of their results and never consider a return to the sleep lab let alone a return for follow-up assessments in the sleep clinic.

In my experiences with the ceiling effect, I have noticed some distinctive types of patients who manifest their own unique ways of managing this conundrum.

The first and most obvious type is the individual who denies there is a ceiling effect. Whatever the gains they are experiencing, their perceptions are geared toward a sense of sufficiency, as in “I did the tests, I got the machine, I use the machine, and I feel better.” For these patients the concept of how much better they could feel does not register as something of great import and certainly not something needing more intricate measurement. PAP is used, PAP works, PAP provides benefits…why pursue more?

Another type of patient could present exactly like the example just mentioned, but due to personality differences, this individual is more sensitive to changes, and therefore, the positive experience with PAP may promote even more curiosity about further gains. These patients are not necessarily difficult to please. Rather, they may be functioning with a much broader window of complaints about specific sleep-related symptoms, such as low energy, daytime fatigue, or drowsy sensations. In other words, when such a person feels a little bit of drowsiness, it may concern him or her more, because the “way” they feel this sensation may trigger a greater sense of lost energy and therefore a greater sense of dysfunction looming on the horizon. In this type of patient, it may be difficult to budge the outcome measures more than a few points in the direction of improvement. This perspective suggests these folks would have no difficulty speculating on what might be found above the ceiling of their current response. And, these are the types who would more likely declare straightaway, “it seems like I should be doing better.”

In these first two examples, we are looking at extremes. On one pole is the individual who is getting a good response but the perspective on things indicates someone who is more than happy with the response and not imagining more to come. On the other pole we are seeing the individual who likes PAP and gains benefit, but from their point of view, there is no ceiling effect, because they remain fixated on the idea a lot more improvement is needed, which may or may not prove accurate in the short or long-term.

In between these two poles lie many other patients who may experience the ceiling effect and who often need more coaxing from our sleep staff or myself to help them appreciate there are more things they can work on to ramp up their response. One might imagine that a person suffering from mild mask leaks, persistent breathing events on a data download, residual leg jerks at optimized pressures settings, poorly treated nasal congestion or even mild aerophagia would be motivated at some level to treat any or all these conditions to improve their response to PAP Therapy. While some of these treatable issues motivate some people, it is thought-provoking how many patients will respond, “my results are good enough for me right now…how about we check on this issue next year?”

Even people whose outcomes measures for nighttime insomnia and daytime sleepiness remain in the abnormal range may balk at moving ahead with more treatment interventions. And, their objections to treatment may be simply based on the following responses:

  • “I’m not spending another night in the lab”
  • “I’m not taking another medication.”
  • “I won’t spray anything up my nose.”
  • “My mask is comfortable enough for me.”
  • “What are leg jerks anyway and why do I need to treat them?”

In sum, the ceiling effect frequently prevents certain patients from achieving more optimal results. In some cases, we as sleep professionals can help them appreciate the possibilities of an enhanced response, but ultimately the patient must make the decision about moving forward to better his or her outcomes. As I hope I have explained, the ceiling effect has a strong psychological component, because most patients appear to weigh the effort to exert or the hassle to tolerate in the balance against a benefit they may have great difficulty sensing as possible due to the new normal they have already created and adapted to for themselves.

Climbing above or breaking through that ceiling will require time and patience with a substantial portion of sleep apnea patients.



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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