Home Testing Model in Mental Health Patients: Part II: Overcoming “Control of Breathing” Issues

What follows is an encapsulated dialogue between a well-trained sleep tech and a vulnerable patient, which will demonstrate how our sleep techs manage the problem of “control of breathing,” the very common issue when the patient attempts to harmonize his or her breathing cycle with that of the machine. The setting for this dialogue would be in the sleep lab with the patient sitting on the bed and the sleep tech standing up as they might begin a discussion at the standard pre-sleep interview before a sleep study.  

Sleep Tech (ST): Now, in your attempt a few years ago with CPAP, you mentioned the pressure felt uncomfortable…

Patient (PT): Yes, very much so….even to the point of getting a little claustrophobic, and once I remember waking up at night with a lot of anxiety and ripped off the mask. 

ST: When did you find it most uncomfortable?

PT: Not sure what you mean, but I would say pretty much all the time. 

ST: Oh, sorry, I meant did you ever notice a certain time in your breathing when it was most uncomfortable.

PT: (looks puzzled)

ST: For example, did you notice the uncomfortable sensation more when you were breathing in or breathing out?

PT: Hmmm, not sure, let me think…okay, yeah, it would have been when I was breathing out. In fact, come to think of it, I did notice a few times when I first went to sleep that it was very comfortable to breathe in, if that helps.

ST: Yes, very much so. Breathing in was more comfortable in general, and breathing out was where the most discomfort was felt?

PT: Right.

ST: Can you make a guess as to why? 

PT: Not really…although I often wondered whether the pressure was higher when I was breathing out.

ST: Interesting. Did you know that the pressure was the same on your CPAP device, same setting for breathing in and breathing out?

PT: Yes, they told me that, but why did it feel higher breathing out?

ST: Well, let me give you hint….think about the direction of the flow of air when your breathing in or out, and then compare that to the direction of air flowing from the machine?

PT: Breathing in is clearly inward and breathing out….but wait, the machine is always pushing the air in.

ST: Exactly. Now what part of that sequence would feel uncomfortable and why?

PT: Let’s see, I noticed it was comfortable sometimes breathing in…because the pressurized air flow was moving in the same direction?....Hmmm, but, when I breath out, maybe I am fighting with the sensation of the air still coming in….?

ST: Bingo! Any idea how we could make the sensation go away or at least feel less uncomfortable?

PT: Not really, except could you lower the pressure when I breathe out?

ST: We can and will do that for you with a device called bilevel, which lowers the pressure noticeably when you are breathing out. However, can you imagine any other way to reduce the sensation? This one is trickier because it’s something you can do on your own; it’s nothing external.

PT: How about turn off the machine and store it in the closet?

ST: I sense you’re not yearning for the infatuation stage in your relationship with the PAP device?

PT: Nicely put, Captain Obvious.

ST: OK, we’ll come back to this point in a moment. For now, let me ask you if there was anything in particular you attempted when you last tried to adapt to the CPAP device a couple years ago? If you’re not sure, just walk me through the steps of how you would put the device on at night. 

PT: There weren’t that many steps…I plainly remember I was okay putting on the mask and didn’t have much if any anxiety after finding the right mask. But, this same discomfort problem arose as soon as I hit the start button…. 

ST: …excuse me, did the start button trigger a ramp or just the regular settings?

PT: It was either one, because when I was having trouble, the DME showed me how to use the ramp setting, but I didn’t find that the ramp or the regular settings made any difference for the discomfort problem, which occurred as soon as I started the machine…

ST: Right, you were saying…

PT: I could never learn to breathe with the machine. Even though I said breathing in was sometimes comfortable, I could never seem to get into a rhythm where the machine and I were breathing together, so to speak… does that make sense? Do other patients have that problem where it feels like you are fighting with the device to catch your breath sometimes?

ST: A great many people have this specific problem, but let me repeat what you said a different way to make sure we’re on the same page: it sounds like you had to make a conscious effort to control your breathing in some fashion to be in harmony or synchrony with the way the device was breathing?

PT: Yes, I think that’s a perfect description…I always felt I needed to control the way I was breathing.

ST: Now, this is a very interesting area of discussion, because I can assure you we are getting to the heart of matter as to why you struggled with the device, but before I explain these points to you in more technical terms, let me ask another question….what happened to your machine if you took the mask off?

PT: You mean turn off the machine? 

ST: No, I mean, what happened during those times when you might have taken the mask off but for whatever reason you did not turn off the device. What happened soon after you took off the mask?

PT: Still not sure what you mean?

ST: Sorry, what happened to the airflow coming out of the tube?

PT: I think I recall that it stopped.

ST: That’s correct, but you said just a moment ago that the machine was “breathing” different than you were breathing, so why did it stop “breathing“ when you took it off? 

PT: Is this a trick question? 

ST: Absolutely. The machine doesn’t breathe. It’s not a robot; it can only respond to what you do, and here’s one of the most remarkable pearls you will ever hear about PAP devices: if you attempt to control your breathing, you can never, and I mean never adapt to the device. Did I mention, NEVER?

PT: You’re kidding?

ST: You’re suggesting that no sleep doctor or sleep tech ever explained this point to you?

PT: Correct. 

ST: Let’s just call it a regrettable secret that somehow doesn’t get passed on to every patient who struggles when attempting to use the device.

PT: Yes, but what or why exactly is it a problem to try to control my breathing?

ST: Before I answer…do you think you control your breathing now?

PT: Another trick question, eh? 

ST: Sort of. Notice how most of the time when you are awake, you pay absolutely no attention to your breathing unless you are coughing or exercising or suffering from a respiratory illness, right? You just breath, because your brain, or better still, your brainstem knows how critically important breathing is to your survival, so it sends very regular signals to maintain your breathing. 

PT: But I can take a deep breath if I want to…isn’t that a form of control?

ST: No denying it, but you cannot and more importantly do not maintain any sort of regular control over each breath let alone a long series of breaths…the mind-body physiology to breathe is mostly an automatic experience, which brings us to the problem with PAP therapy. When you try to synchronize your breathing with the device, you are actually interfering with the regular workings of the brain. Not only are you confusing the brain by your efforts, but also, and probably of greater importance, you are also confusing the device, which clearly has a less sophisticated algorithm than the brain built into it to deliver pressurized airflow to you.

PT: You are saying I am confusing my own brain’s efforts to breath regularly as well as the machine’s efforts to deliver air flow? Then, how would they ever match up so I could get comfortable with the device? 

ST: Very simply, you must forget about your breathing?

PT: Huh?

ST: As before, how much time do you spend paying attention to your breathing when you are awake?

PT: Honestly, probably only when I get a cold or allergies do I pay much attention to my breathing.

ST: Exactly, so you see, I am not asking you to do anything different than what you already do now. So many people think they have do something to adapt to the breathing cycle of the machine. In fact, you have to do nothing…just let yourself breathe without paying attention to it, just like you normally do not pay attention to it.

PT: Seriously, it’s that simple? Even if that were true, the machine is so annoying I don’t see how I can stop paying attention to the device… 

ST: What you’ve just said supplies the answer to your problem. People get into trouble with the PAP device because they are paying attention to the device and eventually paying attention to their breathing. In fact, we call this process “attention amplification” in which your behavior of spending time thinking about or sensing the airflow from the device is making things much worse, because the added attention to what you feel makes those feelings even stronger. 

PT: That’s interesting, because I have noticed times where the sensations of breathing out against the device seem even worse than usual... I can remember thinking at bedtime something like, “ok, this time I’m really going to make a big effort to match my breathing to the device,” and then quit even faster than previous efforts because the discomfort was so immediate.

ST: Excellent insight. So, can you think of a way to distract yourself so you do not pay attention to your breathing? 

PT: Distract myself? You mean like watch television with the mask on or something?

ST: Television is a very relevant example because it deals in images or the imagination, so yes it could distract, but can you think of another way to distract yourself, let’s say if no television were available? 

PT: Sure, I could look at a book with pictures or I could draw in my son’s coloring book.

ST: Good, now we’re getting closer to the idea of imagination, but here too, what if the books were not available…is there something you could do within your own mind to distract yourself?

PT: Uh, count sheep? 

ST: How about seeing pictures of sheep in your mind…along with the meadow they are grazing in and the fence around the meadow…and the blue sky on the horizon, and so?

PT: So, using my own imagination to distract myself?

ST: Right. It is an extremely powerful tool, one built-in to that amazing thing we call the mind, and in this case, we call the specific tool, the mind’s eye. We have trained thousands of patients to use their mind’s eye to remember great vacation scenery, a walk in the park, even the furniture in their own bedrooms, and once these pictures emerge, the individuals notice the disharmony with the device almost immediately subsides. In fact, it disappears so quickly that some people cannot believe they had this much control over this awful side-effect. For some, we tell them to stop using the mind’s eye so they will once again feel the discomfort with the pressurized airflow, and then re-use the imagery distraction to prove how easy it is to eliminate it.

PT: It does sound too easy, but candidly, it makes so much more sense than anything I’ve heard before about adjusting to the odd sensations of the pressurized air. Let’s give it a try.

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.

Leave a comment

Comments have to be approved before showing up.