Positive Airway Pressure (PAP)

One of the most common and successful treatments for Sleep Apnea (SA) is Positive Airway Pressure (PAP) therapy [1]. PAP consists of a machine that delivers pressurized air into the upper airways through a tube and mask that is worn on the face. The pressurized air enters the throat and keeps the airways open during sleep. This allows SA sufferers to breathe normally and reduces the health and daytime dysfunction risks associated with untreated SA.

PAP is considered a first-line treatment for Obstructive Sleep Apnea (OSA), although specific types of PAP machines may be prescribed for Central Sleep Apnea (CSA) under certain circumstances. PAP is considered appropriate for all SA severity levels and is usually covered by insurance following a SA diagnosis.

PAP machines and supplies are typically acquired through insurance vendors, sleep clinics, and online retail vendors. It is important to discuss with your sleep care team which type of PAP machine is most appropriate before purchasing your therapy.

Types of PAP Machines

There are four main types of PAP therapy, which deliver pressurized air into the upper airways in a slightly different way, depending on the patient's needs. The type of machine you require depends on several factors including the type of SA you have, your SA severity, your insurance provider’s requirements, secondary medical conditions that affect your ability to use PAP, and your tolerance for PAP.

The four types of PAP machines include:

Continuous Positive Airway Pressure (CPAP):

Delivers one continuous air pressure setting that does not change on inhalation or exhalation. Typically, an in-lab “titration” study will be required to adjust the CPAP air pressure to an appropriate setting to keep your airways open.

Bilevel Positive Airway Pressure (BiPAP):

Delivers two air pressure settings. A higher-pressure setting on inhalation to keep the airways open, and a lower-pressure setting for exhalation. Like CPAP, an in-lab titration study to adjust your BiPAP may be required.

Automatic Positive Airway Pressure (APAP):

Automatically adjusts the air-pressure settings throughout the night, depending on how much pressure is required to keep the airways open at any given time. An in-lab titration study is not typically needed for APAP.

Adaptive Servo Ventilation (ASV):

Similar to APAP, ASV is highly sensitive to detect changes in breathing patterns and adjusts air pressure accordingly. The main difference between ASV and APAP is that ASV responds to the volume of each breath and breathing rate. The pressure levels vary based on these parameters, which makes it a good choice for treating CSA and combined OSA and CSA, called Complex Sleep Apnea. [2]. Like CPAP and Bi-PAP, ASV may require an in-lab titration study. 

PAP Components

PAP machines consist of the following components:

1. The machine and motor, which are responsible for pressurizing air and delivering it to the patient through a hose and mask. PAP machines require access to a standard electrical outlet, however, some can be plugged into an external battery for camping or during power outages.
2. The machine has an inbuilt computer that is responsible for regulating the air pressure delivered, detecting irregularities in breathing and making adjustments, and keeping track of breathing quality by collecting respiratory data.
3. PAP machines also contain air filters that need to be changed regularly, typically every 2 weeks unless otherwise specified by your PAP supplier.
4. Most modern PAP machines contain a humidifier, which consists of a water tank that moistens and warms the air. This prevents drying of the mouth and airways, reduces irritation, and increases comfort. The humidifier can be adjusted to suit the individual’s preference. It is recommended that only distilled water be used for the humidifier to prevent damage to the machine and prevent infection and irritation to the patient.
5. Tubing/Hose. A long flexible plastic tube runs from the machine and connects to the mask that the patient wears on their face. Some tubes contain warmers to prevent condensation. PAP tubing usually needs to be replaced every 6 months.  
6. Mask. The PAP mask is connected to the hose and is responsible for delivering pressurized air directly into the throat during sleep. The mask is attached to headgear to keep it attached to your face at night. PAP masks are typically made of flexible silicone and are hypoallergenic. The frequency of replacing your mask will depend on the type of mask you’re using, the mask material, and the manufacturer's replacement recommendation.

Masks come in a range of sizes and designs, and the type of mask a person uses depends on several factors such as how they breathe, their facial anatomy, comfort, and personal preference. The three common mask types include:

1. Full Face: A mask that fully covers both the nose and mouth. Full-face masks are appropriate for all individuals with SA and are ideal for individuals who have nasal congestion or nasal passage obstruction, individuals that breathe through their mouth when they sleep, or individuals whose mouths slack or open during sleep. Full-face masks are typically replaced every 3-6 months.
   

2. Nasal Mask: A mask that covers the nose but not the mouth. This mask is suitable for individuals that breathe though their nose, do not have nasal congestion or obstruction, and keep their mouths shut while they sleep. Individuals that open their mouth during sleep but still prefer a nasal mask may opt to use a chin strap or mouth tape. Nasal masks are typically replaced every 3-6 months.
   

3. Nasal Pillow: A mask that doesn’t cover the nose, but instead has two inserts that fit into each nostril. This mask is often more lightweight and less likely to slip during sleep. Like nasal masks, it is suitable for individuals that breathe though their nose, do not have nasal congestion or obstruction, and keep their mouths shut while they sleep. Individuals that open their mouth during sleep but still prefer a nasal mask may opt to use a chin strap or mouth tape. Nasal pillows are typically replaced every 3-6 months, however, the nasal inserts may need to be replaced every 2 weeks.
   

Using Your PAP

Ideally, you should aim to use your PAP nightly for the duration of your sleep. Most insurance providers require a minimum amount of PAP use per night and will monitor your adherence remotely via the internal computer. Data collected from your PAP also provides valuable information about your respiration and assists your sleep care team to determine how well your machine is working.

When you receive your PAP, your sleep care team or PAP supplier will instruct you on how to set up your machine. This includes how to run your machine, how to connect the hose and mask, how to fit and adjust your mask, and how to maintain the machine. Always follow the manufacturer's guidelines for using and replacing equipment and cleaning equipment.

Getting Started

Before using your PAP, ensure your machine is placed on a solid, flat surface near the head of your bed. Your hose should have an unobstructed path from the machine to your mask, and enough slack so that it doesn’t disconnect from your machine or pull at your mask while you sleep.

Check the humidifier to confirm there is enough distilled water to last through the night.

Most masks disconnect from the hose, so you can get up in the night if needed without having to remove the mask. Place the headgear and mask on your face, position your mask properly, so it is in the correct place, and adjust the straps to ensure there is a good seal between the mask and face. Ensure that your mask is not too loose or too tight, as this may cause a poor seal and discomfort. When you are ready to sleep, connect the hose to your mask.

Get into bed and start your machine. Your PAP should already be adjusted to the appropriate pressure setting. Once the air is being delivered through your mask, check for any leaks around the mask, which would initiate a poor seal on your face or that the mask has shifted. Check your hose for kinks or blockages, and adjust the humidity to the desired setting.

If your mask comes to lose during the night, or you have to remove your mask for any reason, repeat the steps above.

Adjusting to Your PAP

When you start using PAP, it may take a period of 2-6 weeks before fully adjusting. During this time, it’s important to work closely with your sleep care team and your PAP provider to help you adjust and troubleshoot if problems arise.

Common issues when starting PAP therapy include:

1. Difficulties fitting or adjusting your mask

2. Minor discomfort or claustrophobia while using your machine

3. Stress or anxiety while using your machine

4. Difficulty getting used to breathing with the pressurized air

5. Difficulty falling asleep or staying asleep while using your machine 

There are several steps you can take to get used to using your PAP. These include:

Finding a mask that fits properly, is comfortable, and appropriate for how you breathe (nasal breathing or mouth breathing). It’s important to note that some individuals will need to try several masks before finding one that suits their needs. Working with your sleep care team or PAP supplier to fit your mask can make the mask trial process easier. Learn how to place and adjust your mask before you start using your PAP. Consider using a mask liner if you have issues with comfort or difficulty maintaining a seal on your face.

When first starting out, use your PAP during the day to help you get used to using it before trying to sleep. Find a time each day when you can sit and relax while you use your PAP machine. Practice breathing with your machine and focus on the feeling of the pressurized air entering your lungs. If you feel stressed or anxious, do an activity to take your mind off the feeling, such as watching TV or reading a book. Practice deep breathing exercises to help your lungs get used to the new sensation.

Make sure your PAP is set up and ready to use well before you go to bed. Check that all the components are connected properly, the humidifier tank has sufficient water, the machine is in a secure location next to your bed, and the mask and headgear are ready to wear with only minor adjustments needed. Ensure that your hose runs to your mask in a way that is not at risk of becoming tangled. You may consider using a pillow specifically for PAP users to aid in your comfort while you sleep.

When you initially start using your PAP, you may find it difficult to sleep with your maximum air pressure. Most modern PAP machines have a ramp button feature, which adjusts the PAP to a low-pressure setting and gradually increases the pressure over time. This allows the PAP user to adjust to the max pressure slowly and fall asleep easier. Use the ramp feature as much as needed to help you fall asleep, even if you use it multiple times per night.

If you are feeling anxious or claustrophobic while using your PAP, try techniques such as deep breathing exercises, meditation, or visualizations to help calm your mind.

If you remove your mask during the night, find that it is uncomfortable, or slips out of place, consider trying a different type of mask with the aid of your sleep care team.

Modern PAP machines are very quiet, however, some individuals may be extra sensitive to noise. If the sound of your PAP machine is keeping you awake, try using sound-blocking technology such as earplugs or a white noise machine. If your PAP machine seems louder than usual, it may indicate an air leak, either from your hose or mask.

Speak with your sleep care team to discuss any discomfort or side effects that may occur while using your PAP.

Trouble Shooting Guide

Below is a troubleshooting guide to common problems that may occur with your machine.

My mask doesn’t stay on during the night.

If your mask comes off frequently during sleep, this may indicate a mask fit issue, such as the mask not being an appropriate size or the mask is not adjusted properly to your face.

First, identify whether the mask has been adjusted properly. The mask should sit comfortably on your face and form a good seal with your skin. If your mask moves easily, you may need to tighten your straps or adjust your headgear.

If after appropriate adjustment, assess if your mask is the correct size, as a mask that is too large or small is more likely to move.

Finally, you may be physically removing your mask at night, even if you are unaware of doing so. This may indicate a mask comfort issue. Using a mask liner or switching the type of mask you use may improve comfort.

A sudden increase in respiratory events or sleep apnea symptoms while using PAP

Your machine is not maintaining a high enough pressure to keep your airways open. Common reasons this occurs:

The mask doesn’t have an appropriate seal and is leaking air through the side, usually due to a mask fit issue or the mask shifted during the night.

The mask is damaged

The hose is not connected properly to the machine or the mask 

The hose is damaged 

The hose is kinked or obstructed

There is something wrong with the machine itself

The air filter needs to be changed

Your pressure settings may need to be adjusted

Occasionally, an individual may need a higher pressure setting over time to keep their airways open. Contact your PAP provider or sleep, care team. 

Your machine may need to be replaced

If you have an older model machine or your machine is out of warranty, it can become less efficient at keeping your airways open. 

You use a nasal mask or nasal pillow but your mouth opens during the night. 

If you revert to mouth breathing or your mouth slacks open during the night, this may allow air to escape and your PAP will be less efficient. Consider switching to a full face mask or use a chin strap to keep your mouth shut.

Mask Condensation is common when using the PAP humidifier. Condensation in the mask can lead to water pooling, which can make breathing uncomfortable and can lead to mask-slip issues.

How to reduce mask condensation:

Turn down the humidifier 

Keep the tubing warm, either with a tube heater or by running your tube under your blanket. 

Turn up the thermostat in your bedroom

Place your PAP machine on the floor so the condensation pools in the tube instead of the mask.

PAP tubing entanglement

The tubing that runs from your PAP machine to your mask may get tangled if you change sleeping positions frequently though the night.

You can decrease tube tangling by the following methods:

1. Run your tubing behind your bed.
2. Use a mask or headgear that allows you to run the tubing over your head.
3. Use a pillow made for CPAP users that helps keep tubing out of the way.

I keep pulling my PAP machine off my nightstand.

This usually occurs because your PAP is too far away from the head of your bed. Ideally, your PAP machine should be close enough to allow enough slack in your tubing that changing your sleeping position will not affect your machine. A 6-foot tube comes standard for most machines, but many manufacturers also offer a 10-foot option if you need additional length.

My PAP machine is louder than usual

Modern PAP machines are made to be quiet. If your machine is noisy, it may mean there is a mechanical issue with the machine itself or there is an air leak, typically in the hose or mask.

Side Effects Guide

When starting PAP therapy, you may experience common mild side effects while your body adjusts. Below is a guide to avoiding these side effects. Always consult with your doctor if these issues do not resolve.

Dry mouth, nose, lips, and eyes

he delivery of pressurized air into the nasal and oral cavities may cause dry and irritated airways. The easiest way to avoid this from occurring is by ensuring that your PAP humidifier is at a high enough setting to keep your airways moist and comfortable. Start with a low setting on your humidifier, way up until you find a setting that is comfortable for you.

Other ways to alleviate dry mouth and nose include using oral rinses made to prevent dry mouth. For chronic nasal dryness, saline sprays or rinses may help. Dry lips can be avoided with the use of petroleum jelly or lip balm.

Dry eyes may be avoided by ensuring there are no mask leaks and using saline eye drops.

Face irritation, red lines, or abrasions

Irritation to the face by your mask usually indicates one of the following:

1. Your mask is too big or too small and is sliding on your face.
2. Your mask is too tight and needs to be loosened
3. Your mask is too loose and needs to be tightened
4. Your mask isn’t forming an appropriate seal. Using a mask liner may improve the contact with your skin.
5. Your mask is pulling due to poorly positioned tubing or tubing that is too short.
6. Your mask is causing skin irritation due to a sensitivity or allergy to the mask material or the product used to clean your mask. Using a mask liner or switching to a mask made of a different material may help.
7. Your mask is dirty
8. Your mask is old or damaged and needs to be replaced

Swallowing Air

Swallowing air (aerophagia) while using your PAP occurs in about 15% of PAP users. Swallowing air may lead to excess gas, abdominal pain, and bloating. The following may reduce air swallowing:

1. If you are currently using a full face mask, switching to a nasal mask may help reduce air swallowing.
2. Reducing the pressure of your PAP under the guidance of your sleep care team.
3. Using a chin strap to ensure your mouth stays closed during sleep. 
4. Switching from a CPAP to APAP, which only raises air pressure as needed, can reduce the overall amount of air swallowed
5. Changing your sleeping position from your back to your side

Upper respiratory infection

Upper respiratory infections are caused by microorganisms such as bacteria, viruses, or fungi. Common upper respiratory infections include but are not limited to, the common cold, epiglottitis, laryngitis, pharyngitis (sore throat), and sinusitis (sinus infection). The following steps should be taken to avoid upper respiratory infection while using your PAP: 

1. Clean your PAP equipment regularly.
2. Clean your mask daily
3. Clean your tubing weekly
4. Clean your water chamber weekly
5. Change your PAP filter regularly
6. The frequency of your filter change will depend on the PAP brand and manufacturer’s specifications. Many filters must be changed every 2-4 weeks.
7. Only use PAP-appropriate cleaning products and chemicals and follow the cleaning instructions as provided by your PAP manufacturer.
8. Make sure there is no standing water in your equipment after cleaning, and allow your equipment to fully dry before using.
9. Only use distilled water in your humidifier. Never use tap water.
10. Replace your PAP equipment in accordance with the manufacturer’s specifications or if your equipment is damaged.
11. Never share your equipment with another person.
12. Use the humidifier function on your PAP to keep your airways from drying out.
13. Speak to your doctor if you are experiencing recurrent upper respiratory infections or worsening symptoms, as this may indicate a more severe infection.
    

Maintaining Your PAP Machine and Equipment

Proper maintenance of your machine and equipment is essential for your PAP to work properly and prevent infections.

Cleaning Your PAP

Cleaning Your Mask

Your mask should be cleaned daily to prevent a buildup of oils and grime and reduce the risk of infection. Most PAP masks can be cleaned with warm water and non-irritating dish soap. Ensure that you rinse your mask thoroughly after cleaning and allow your mask to fully air dry before use.

Cleaning Your Tubing 

Your tubing should be cleaned weekly to prevent a buildup of mold and bacteria. Most PAP tubing can be cleaned with warm water and non-irritating dish soap. Ensure that you rinse your tubing thoroughly and allow the water to completely drain from the tubing before setting it aside to dry. Do not allow water to stand in the tubing, as this can lead to mold. Allowing your tubing to completely dry before use.

Cleaning Your Water Tank 

Your water tank should be cleaned daily with non-irritating dish soap and warm water to prevent a buildup of mold and bacteria. Your tank should be cleaned weekly with a solution of 1-part white vinegar to 1-part water to kill any lingering microorganisms that could lead to infections. Allow the vinegar/water solution to sit in the tank for 15-20 minutes. Follow the vinegar soak with a thorough rinse with water. Allow the tank to fully dry before using.

Replacing Your PAP Filter

Your PAP will have 1 to 2 filters, depending on the brand and manufacturer. It is important that you change your filters in accordance with the manufacturer's instructions. Many PAP machines require a filter change every 2-4 weeks.

Replacing Your PAP Equipment 

Your mask, headgear, tubing, and water tank require regular replacement. Check with your PAP equipment supplier to determine the recommended frequency for replacement.

Most plastic items, such as your mask and tubing, will need to be replaced every 3-6 months. Masks or tubing with wear and tear or damage should be replaced immediately. 

Your headgear should be replaced every 6 months.  Headgear that has wear and tear, is no longer fitting appropriately, or keeping your mask in place, should be replaced immediately. 

The water tank should be replaced every 6 months. Water tanks with wear and tear, pitting, buildup, or discoloration should be replaced immediately.

Replacing Your PAP Machine 

It’s generally recommended that your machine be replaced every 3-7 years. Your insurance provider may have specific requirements on the frequency of upgrading to a more modern machine. If your device stops working or becomes damaged, contact your PAP provider immediately. Always follow instructions for machine recalls.

Where to Find Support

There are several ways to get support when you are having difficulties using your PAP machine. The following options for support are usually available: 

• Your sleep care team 
• Sleep Physicians and Sleep Technicians 
• Often have tutorials, classes, and educational materials on how to use and adjust to your PAP.
• Sleep Coaches experienced in working with Sleep Apnea patients 
• Sleep coaches can work one-on-one with you to use and adjust to your PAP 
• Your PAP manufacturer or supplier 
• Help you set up your PAP, choose a mask, and help you maintain your machine and equipment 
• Sleep Apnea and PAP support groups 
• In-person or online forums for individuals with sleep apnea who use PAP therapy

References

1. Patil SP, Ayappa IA, Caples SM, Kimoff RJ, Patel SR, Harrod CG. Treatment of Adult Obstructive Sleep Apnea With Positive Airway Pressure: An American Academy of Sleep Medicine Systematic Review, Meta-Analysis, and GRADE Assessment. J Clin Sleep Med. 2019 Feb 15;15(2):301-334. doi: 10.5664/jcsm.7638. PMID: 30736888; PMCID: PMC6374080.

2. Aurora RN, Bista SR, Casey KR, Chowdhuri S, Kristo DA, Mallea JM, Ramar K, Rowley JA, Zak RS, Heald JL. Updated Adaptive Servo-Ventilation Recommendations for the 2012 AASM Guideline: "The Treatment of Central Sleep Apnea Syndromes in Adults: Practice Parameters with an Evidence-Based Literature Review and Meta-Analyses". J Clin Sleep Med. 2016 May 15;12(5):757-61. doi: 10.5664/jcsm.5812. PMID: 27092695; PMCID: PMC4865563.