"I use my CPAP machine every night, so I don't have to worry about sleep apnea anymore, right?"

WRONG

This is a common and widely held misconception. Sleep apnea treatment is one of those cases in life when "you don't know what you don't know." Since you're asleep, you're completely unable to assess how well the apnea is being treated. Don't fool yourself: even though you use CPAP all night and feel good during the day, your body still may be suffering at night. Treating sleep apnea is definitely not a "one size fits all" or "set it and forget it" proposition. If you even have mild residual sleep apnea while on CPAP therapy, you will be at increased risk for sleep apnea effects such as:

• high blood pressure
• diabetes
• heart attack
• stroke
• sudden death

Read on to learn about the top warning signs that you may need an OSA treatment tune-up.

1) Breathing Symptoms

If you've started snoring again while on CPAP treatment or the snoring never went away, this is a problem. The goal of CPAP is to keep your airway fully open, and snoring is a sign that you are still experiencing partial airway collapse. The same principle applies for other sleep breathing symptoms, such as quitting breathing (called witnessed apneas) and waking up gasping, choking, coughing or short of breath. Unfortunately, people who don't have bed partners, or have bed partners who are really deep sleepers, may not know whether they are having any ongoing breathing symptoms. Some folks try to record themselves while sleeping with their CPAP machines, utilizing smartphone apps to hear what they sound like. The problem is that the CPAP itself produces constant white noise that will distort what your phone's microphone picks up, so these apps aren't too helpful. If you don't have a bed partner and have the opportunity to share a room with someone while on a trip, always ask for feedback about your breathing while on CPAP.  

2) Disrupted Sleep Symptoms

If you've started experiencing any of the following nighttime symptoms, it might indicate that your sleep apnea is not well-controlled:

• waking up multiple times during the night (sleep maintenance insomnia)
• having to urinate multiple times during the night (nocturia)
• acid reflux during the night (nocturnal GERD)

3) Daytime Symptoms

If you used to wake up feeling great and ready to attack the day but you've noticed some backsliding in how refreshed you feel, you might need to talk to a sleep doctor. Other daytime symptoms that warrant a reevaluation of your sleep apnea treatment include:

• feeling more tired or sleepy during the day (excessive daytime sleepiness)
• difficulty concentrating
• irritability
• headaches on awakening
• memory problems
• inattention while driving

4) Weight Gain

If you have gained a lot of weight, your CPAP machine setting might need to be tweaked. You will likely need more pressure to hold the back of your throat open.  Also, added weight can cause the muscles that move the lungs to tire out during the night. This can lead to continuously low oxygen levels during sleep, which is not good for your body, especially your heart and brain. If this is the case, you might need to switch to a BiPAP machine, which takes away some of the burden on your diaphragm and other lung muscles. If your weight has made a significant movement in the wrong direction, talk to your sleep doctor about checking a machine download or undergoing a nocturnal pulse oximetry study while using your treatment to make sure your oxygen levels are in the normal range.  

Check My Oxygen Levels on CPAP

5) New Medications or Medical Problems

If you were diagnosed with obstructive sleep apnea, started CPAP, and then developed one of the following medical conditions, you are at higher risk for central sleep apnea and will need a new sleep study to check for this other type of sleep apnea that might not be fully treated by CPAP:

• atrial fibrillation
• heart attack
• stroke
• congestive heart failure
• kidney failure or renal insufficiency
• brain tumor
• spinal cord disorders affecting the neck
• moving to a high altitude (>4,000') elevation

Opiate pain control medications also increase your risk of central sleep apnea. If you've started taking one of the following drugs, or your dose has been significantly increased since your original OSA diagnosis, you might need another sleep test:

• Norco
• Vicodin
• Percocet
• Dilaudid
• Morphine
• Oxycontin
• Suboxone
• Fentanyl
• MS Contin
• Methadone

Even mixed opiod receptor agonists/antagonists like buprenorphine (Suboxone) can cause central sleep apnea. 

Order a Sleep Study

6) You Chose a CPAP Alternative Treatment and Never Had a Repeat Sleep Study

If you had a sleep apnea surgery such as a UPPP, Bimax, Inspire implant, remedē® or other procedure to help your sleep apnea, it is recommended that you have a follow-up sleep study 2-3 months after the surgery to assess whether your sleep apnea went away.

If you're using Bongo Rx, iNAP, or an oral appliance for sleep apnea, you should have a repeat sleep apnea test while using the treatment to make sure that it's doing the trick. The same goes for positional therapy. 

Order a Sleep Study

7) Download Dysfunction

A download from your machine can be a tip-off as to whether your apnea is under control.  If your download indicates any of the following, you should talk with your sleep apnea doctor about adjusting your machine or reevaluating your condition:

• high leak rates
• significant snoring time
• elevated estimated AHI - in my experience, a machine-calculated AHI of 3 or more should raise an eyebrow
• estimated central breathing events that are new or increasing in number
• new "periodic breathing"

Actual download from a Singular Sleep patient's CPAP machine. Notice the elevated AHI.

Schedule a Consultation to Obtain and Review a CPAP Download

The Bottom Line:

If you fall into any of the categories above, it's time to talk to a qualified sleep doctor, as you might still be at risk for sleep apnea consequences, some of which are severe. In order to evaluate how well your current sleep apnea machine is working, your doctor will take a careful sleep and medical history and might also order any or all of the following:

• a machine download
• checking your machine's pressure with a manometer
• a nocturnal pulse oximetry test
• a new sleep apnea test (home sleep study or in-lab polysomnogram).

Remember to sleep smart and reduce your risk!

Check My Oxygen Levels on CPAP

 Joseph Krainin M.D., FAASM is the founder of Singular Sleep,  the world's first online sleep  center. He is a Fellow of the  American Academy of Sleep Medicine and board certified in both  sleep  medicine and neurology. He has been practicing medicine  for over 10 years.

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