Is My Sleep Apnea Treatment Working? The Seven Deadly Signs  

Joseph Krainin, M.D.32 comments

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


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:

seinfeld smothering someone with a pillow is like undertreated sleep apnea

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.  

patient rips cpap mask off from witnessed apnea

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)

toilet for nocturia from sleep apnea

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

headache from sleep apnea

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.  

scale showing weight gain making sleep apnea worse

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

heart attack from sleep apnea

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

norco causing central sleep apnea

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.

sleep apnea surgery

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"

CPAP download showing a high AHI

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:

Note: there is a new option for checking the status of your sleep apnea while wearing a nasal pillows mask or using Bongo Rx: the NightOwl PAT device. The nasal cannula needed with a traditional home sleep test will be incompatible with nasal pillows or Bongo Rx but the NightOwl doesn't need that sensor - it measures sleep apnea by monitoring changed in the diameter of an artery in your finger. 

    Remember to sleep smart and reduce your risk!

    Check My Oxygen Levels on CPAP


    sleep apnea test home sleep study Joseph Krainin 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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      In the five y.ears I used my first CPAP machine, the AHI number on the machine showed only 0.2-0.4. Only rarely did it go over 0.4. Then the company said after five years I should get a new machine. But the new machine has showed much higher numbers from the first night I used it. The new numbers are 1.9 up to 3.0. Does this mean the new machine isn’t working as effectively as the old one? What can I do to lower the numbers?
      Sincere question: Are you overweight?
      Lorenzo Perez
      Lorenzo Perez
      I have been diagnosed sleep apnea, just received my CPAP , used it for the first time last night,could breath ,and still had shortness of breath, Everytime a was falling asleep my brain would wake me up, having the same problem when I wasn’t using CPAP machine,I have shortness of breath on the day time as well,I’m thinking o don’t have sleep apnea,
      When I first got on APAP my AHI was over 370 events per hour! Now it’s around 50 but I still don’t feel good. My 90% is 14.2-15.5 and settings are 12-16 Don’t know what to do
      I’m on my third machine in three years. This is a variable pressure machine. It worked well during my 725 dollar sleep study. Perhaps my body has found a way to defeat it, because I have better luck when not wearing it.
      Susan Roche
      Susan Roche
      I was told mandatory to have follow up 30 days after starting CPAP but can’t get in for 90 days so it is ok?still waking up and feeling worse…feel like I am going to pass out all day….
      I can relate. Sorry your sleep apnea isn’t under control. I use the bipap machine. I’ve tried several masks. But I wake up several times a night. I feel exhausted in the morning. Can’t focus, irritable. And just overall feel sick. I can’t get an appointment with the sleep doc for over two months.
      Dan Connery
      Dan Connery
      I was diagnosed with sever sleep apnea around 2012 or so my pressure is around 19 and it made it hard to breath and also to keep the mask on. The sleep doctor lower it 16 can breath easier now but I still snore. Stop breathing and I wake up multiple times a night. I feel like I have not sleepers in days even though my wife says I slept 7 hours I don’t feel it. During the day I can fall asleep at the drop or a hat. I wake up take the mask off my lips have dry blood on them from my gums my teeth hurt and if I have the mask loose like the doctor says the air leaks from under the mask. So if any on has an idea on how to help please help… I was about 265lbs in 2012 in Nov 2017 I was 285 and now march 31, 2018 I am 315 lbs and I am very active I eat good and I walk about 5 to 10 miles daily and most of it is at work
      I don’t feel better I feel worse when I use the CPAP machine.
      CPAP does not help me at all. I tried all the masks. My mouth is dry, my breathing is bad, I get up all night to go to the bathroom, I feel like something in my throat. Discussed all this and they mentioned surgery. No freaking way! I’m going to be dead if someone does not help me. I wanted to try a mouth piece but it’s so hard to find a doctor and the ones I did find wanted $500 up front. Ugh! I need a better doctor. I’m still young and so much is happening to me because of this.

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