Treatment of Obstructive Sleep Apnea with Positive Airway Pressure

Why treat OSA with positive airway pressure (PAP)?

OSA is a disease of vicious cycles. Because of this, it does not self-correct, and in fact tends to get worse over time. OSA causes or exacerbates a long list of other problems.

Older patients with very severe apnea sometimes ask “What’s wrong with dying in my sleep? It sounds like a good way to go.” Instead of dying, however, they could have a debilitating stroke or heart attack, leaving them incapacitated and dependent on others for care. We also know that untreated OSA contributes to dementia.

Who does what:

  • Our office (1521 Cooper St., Fort Worth) schedules appointments and sleep studies, evaluates and diagnoses sleep problems, prescribes treatment, and follows up to ensure ongoing treatment effectiveness.
  • Our laboratory (909 8th Ave., Fort Worth) conducts and analyzes sleep studies.
  • Durable medical equipment (DME) companies or our treatment center (also at 909 8th Ave.) fill prescriptions for equipment such as PAP machines and headgear. They are also responsible for replacing or repairing worn out or broken equipment.
  • Medical insurance companies and Medicare/Medicaid pay for treatment. You may have co-pays or deductibles.
  • You use and benefit from treatment, maintain your equipment, and call or schedule a headgear fitting session or follow-up appointment if there are problems.

Getting used to PAP and optimizing your treatment

Some people adjust very quickly and use it all night from the very beginning, and others may require as long as a few weeks during which comfort and treatment are optimized.

We encourage people to experiment with their treatment to see what works best for them. Some common things to experiment with include:

  • Headgear – Insurance typically pays for new headgear every 3-6 months. If people are not happy with their headgear (mask and/or chin strap), they use the replacement schedule to try something different. We prefer that you schedule headgear refitting sessions with us, but your DME company may also provide this service. Many people end up with multiple headgear options that they alternate.
  • Humidification – This is an option to reduce nasal or mouth dryness. Increasing the heat under the humidifier canister increases the moisture in the air from the PAP machine. Without heat, you will still get some cool moisture. Some people never use any humidification, some use it only in the winter, and some use it every night. Use of a full face mask (pressure applied to nose and mouth) may reduce or eliminate need for humidification.
  • Chin strap – Experiment with placing the chin strap on before vs. after your headgear to see what works best for you. A chin strap is practically always necessary to keep the mouth closed with nasal PAP, but a chin strap is only rarely helpful with a full face mask (pressure applied to nose and mouth).
  • Position – You can sleep in any position you want with PAP, even on your stomach! It’s just a matter of learning how to use your pillow and position your head, arms, and hands to minimize headgear air leakage or discomfort.
  • Ramp feature – This option reduces the pressure to a low level, then the pressure slowly rises over the next several minutes as you fall asleep. This feature is sometimes helpful during initial acclimation to PAP, but most patients do not use ramp long-term.

What to expect from treatment

Responses to treatment are as varied as symptoms of OSA, and these vary widely between patients. Patients and research tell us that nightly use of PAP treatment:

  • Reduces or eliminates bathroom trips at night
  • Reduces or eliminates night-time heartburn/reflux
  • Reduces upper airway congestion and allergy symptoms (you’re breathing filtered air all night)
  • Reduces blood pressure
  • Reduces edema
  • Increases energy during the day
  • Improves stamina
  • Reduces daytime sleepiness, including while driving
  • Reduces use of caffeine
  • Improves the ability to think clearly and concentrate
  • Improves work performance
  • Improves relationships with others
  • Improves ability to cope with stress
  • Reduces irritability and anxiety
  • Reduces or eliminates ADD/ADHD symptoms
  • Increases sexual interest and improves function
  • Improves sleep quality for the spouse

Few people experience all of these benefits, but most report at least some of the above. Rare PAP users perceive no benefits from treatment, even after we confirm that their treatment is working, and they are using it all night, every night. Nevertheless, they understand what treatment protects them from, so they are happy to use it.

Helping us help you

Always bring your machine and headgear to follow up visits. We check your machine to ensure it is working properly, we collect data from it concerning your respiratory function and treatment quality, we check your headgear for problems, and we can immediately make changes to your treatment that the doctor may order to improve effectiveness and comfort.

Please don’t wait for us to contact you to schedule follow-up, especially if you’re having problems with your treatment. Be proactive with your medical device company and with us. Yearly follow-up with us ensures that your treatment continues to work well for you.

Your lines of defense are:

  • You (see “Optimizing your Treatment” above)
  • Your medical device provider regarding simple equipment-related problems
  • An office visit with our hardware person/respiratory therapist for more complex equipment problems such as trying different headgear options
  • A follow-up visit with the doctor

Sometimes, problems can be solved with a simple phone call to your DME company or to us.


A few factors can interfere with PAP treatment. Common problems and potential solutions include:

Mouth venting – This is the most common problem encountered by people who use nasal headgear (air pressure applied only to the nose). Solutions include:

  • Increasing humidification
  • Tightening the chin strap (within comfort limits)
  • Trying a different chin strap
  • Changing to a full mask

Condensation – Use of heated humidification sometimes leads to water condensation in the hose or mask, especially in the winter. Solutions to this include:

  • Placing the machine below your head so condensed water drips back down into the humidifier canister
  • Insulating the hose
  • Reducing heat or stopping humidification completely

Note: excessive headgear air leakage can cause condensation problems, so correcting excessive air leakage can reduce condensation

“I just can’t sleep with it on!” – You should schedule a follow-up visit with the doctor for this complaint. Many things could be causing this. Possible causes include restless legs syndrome and claustrophobia. Claustrophobia is corrected though a process called desensitization, and restlessness sometimes requires medication.


Headgear, chin straps, filters, etc. need to be replaced periodically by your medical device provider as necessary to work properly. You will receive care instructions and a replacement schedule.

Looping the hose around a bedpost keeps the hose out of the way and allows you to turn from side to side during sleep without hose interference. If you don’t have a bedpost, you can place something else at the head of the bed (a hook, lamppost, etc.) to loop the hose around.

Your headgear should be just as comfortable when you wake in the morning as when you put it on at bedtime. None of the headgear, including the chin strap, should be on tight enough to cause discomfort. If it needs to be uncomfortably tight to prevent leaks, then it doesn’t fit your face/head, and you should try other headgear.

A full mask (over nose and mouth) is the only sure way to prevent mouth venting. Never place tape over your mouth!

To simplify going to the bathroom at night, many people simply disconnect the hose from their mask instead of taking everything off.

With PAP, you can go all the way under the covers in the winter: your air is piped in to you! In the same way, you can hide under a sheet from mosquitoes in the summer.

For bothersome mouth dryness at night, some people keep a bottle of water by their bed with a straw. Those using a full mask can get a drink without removing their mask by slipping the straw under the mask to their lips.

Tips to facilitate drying of hoses and humidifiers include reattaching the cleaned items to your PAP machine and turning the machine on to “blow-dry” the gear, or holding one end of the hose while rotating it rapidly overhead.

If a power outage occurs while you are asleep with PAP, you will no longer be treated for OSA. You will probably wake up. A valve on your headgear prevents you from rebreathing your own exhaled air.

After they become acclimated to PAP treatment, many people report that they can’t tell if it’s on when they wake up. This is actually a good indicator that they have adapted to treatment well and that it is working well for them.

PAP therapy won’t help you if you don’t use it, and it will help you only as much as you use it during sleep. Those who get the most benefit use PAP all the time they sleep, including naps. However, some treatment is better than none.