How Long Should One Struggle in Attempting to Use PAP Therapy? Part I

The range of time taken to adapt to PAP therapy is unusually wide. I have worked with patients who adapt in one night, literally, and those who require more than a year. To boost (or deflate depending on your perspective) patients’ confidence, I often remark “it only took me 9 years,” which is not far from the truth. I first attempted CPAP in 1993 at Stanford University Sleep Disorders Center after I was diagnosed with very mild UARS. I used it for a few nights and immediately noticed a marked increase in dreaming, but being young and foolish at the time, it never occurred to me how relevant PAP might be to my own sleep health. Between 1995 and 1998, I tried an APAP and a BPAP device, but never for more than a few nights. I recall no benefits from the experiences. Finally in 1998, I started oral appliance therapy (OAT) and received an outstanding response for 3 years, including elimination of nocturia and sleepiness and near eradication of insomnia. But, in the 4th year of OAT use everything deteriorated, and I needed to consider PAP.

In 2002 (9 years later) and just prior to opening Maimonides Sleep Arts & Science, I was no longer young and somewhat less foolish. If nothing else, I realized I should know how to use CPAP since I would be prescribing it for so many of my patients. Plus, my motivation was increased because of the recent failure of OAT. In my first concerted effort, I tried a CPAP device for 90 straight nights, using it every night and all night long. Ninety days later, I could not confirm even the remotest sense of benefit from PAP and wondered how in the world any one could use such a contraption without receiving some noticeable changes to motivate them to continue.

On the 91st day, I made two changes to my PAP setup by switching to the Breeze nasal pillow mask and initiating treatment with an auto-CPAP device. The very first night of use completely altered my experience for the better, and from that point on I was able to obtain and appreciate specific benefits from PAP therapy, most noticeably, sleeping through the night, less trips to the bathroom, and fewer episodes of daytime sleepiness.

However, unbeknownst to me, I had several more adjustments to make before attaining a more optimized response. I will summarize these changes below, so you can see how the process unfolded: 

  1. Because I used OAT for so long, I could not easily give it up when switching to PAP, so I combined the two treatments for almost two years until I realized OAT was the most likely cause of persistent mouth breathing.
  2. I scrapped the dental device and added a chinstrap and immediately noticed the elimination of mouth breathing and dry mouth as well as a better objective response.
  3. I then tinkered with various auto-CPAP devices for another two years, but on my titrations in the sleep lab, we continued to see expiratory pressure intolerance and residual flow limitations. As a harbinger of what would occur more than 5 years later, a small proportion of residual breathing events were central apneas.
  4. In 2005, after four years of APAP use, I discovered BPAP and again immediately recognized an upgrade in my response such that it finally sank into my consciousness that a sizeable proportion of PAP users develop the “ceiling effect,” which I previously discussed post wherein a person can only compare his or her own improved sleep with the prior experiences of poor sleep, after which he or she cannot easily imagine improvements beyond the current level (the ceiling) of good sleep.
  5. I used BPAP successfully for almost five years and then briefly experimented with ABPAP.
  6. In our clinical experience, we had begun using ASV devices and noticed a surprisingly and definitively better quality of slumber in nearly every patient on the device. Objective markers of this higher quality were consistently evident: fewer awakenings, fewer arousals, early onset of REM rebound, more REM sleep, fewer residual breathing events and the near absence of expiratory pressure intolerance.
  7. Once again, we noted central apneas on my most recent titration, and I switched to ASV therapy and the rest as they say is history…

I have been on ASV for nearly five years, and although I still believe I am susceptible to the ceiling effect, the response to this device is the best I have ever received. More than any other device, I consistently dream like a fiend virtually every night. Nocturia and insomnia are rare, albeit as I have gotten older, I do notice mild daytime drowsiness sometimes, which resolves with low-dose caffeine (hot chocolate mostly or green tea rarely) or behavioral activation.

Still, there are tweaks that have been required such as the mouth taping procedure, combining the full face mask with the chinstrap or using gentle paper tape as my chinstrap as well as nasal dilator strips and REMZzzs mask liners. I also treat low grade RLS very effectively with low doses of iron supplements.

Reflecting back on these steps, I have been most fortunate to have worked not only as a sleep specialist but also to own and operate my own sleep center, so that I could easily manage the various steps and tweaks needed to find the right combinations of treatment. 

So, yes it took only 9 years to finally become a regular user of PAP, but it also took another 8 years before I attained a very high level response to treatment; and, to achieve this near optimal to optimal response required a concerted effort.

What then should the average patient expect when undergoing his or her personal PAP saga and how long should they endure this process? Find out in Part II.

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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