How do you handle patients whose PAP download numbers are excellent, yet they are still reporting excessive daytime sleepiness? It may be time to go back to the basics.

Obstructive sleep apnea (OSA) should be approached as a chronic disease requiring long-term, multidisciplinary management.1 In the busy, changing world of sleep medicine today, the management of OSA has become almost a do-it-yourself project in many sectors. Shrinking reimbursement, cost cutting, and six-sigma business practices have made close, long-term patient follow-up almost extinct. Yet, the holy grail of OSA management is acceptance and long-term adherence to therapy, particularly positive airway pressure (PAP) therapy. PAP units provide more information to the patient and clinician than ever before, but who has time to look at it all? A chronic disease model would include continuity of care, patient education, and long-term follow-up for adherence to therapy.

In order to provide the most cost-effective services to patients and to get the best outcomes, every tool available must be used and understood. Additionally, the goals for successful treatment must constantly be at the forefront of all that can be done to maximize acceptance and adherence. What are those goals?  Protect the airway to optimize ventilation, stabilize breathing patterns, and, the ultimate goal, restore restful, uninterrupted sleep.

Sometimes all goals can be met with a particular PAP device and interface. All that may be lacking is a patient’s ability to accept and adhere to the therapy. Other times, no one PAP device can accomplish all the goals due to the complexity and overlapping of the patient’s cardiopulmonary comorbidities. In those cases, getting as close as possible to the goals with the therapy device and settings is success. However, patient acceptance and adherence may be more of a challenge. And, in a third case, the group on which this article will focus, PAP therapy is optimizing ventilation and stabilizing breathing patterns, there are no comorbidities, yet the patient is still reporting daytime sleepiness. What’s the cause?


First, a reminder about the basics of sleep might be in order.  During sleep, we go through several stages, each 90 minutes long. Each stage has unique physiological markers and purposes. During uninterrupted stable sleep, the body is supported by a bed, eyes are closed, and there is minimal vigilance, balance, blood pressure, or respiratory control needed because there is minimal danger, activity, observation, talking, movement, or decision-making going on.  Essentially, resource usage is at a resting, stable, homeostatic level. The brain can manage data gathered during the day, assess and adjust hormone levels, and generally recover from a busy day. If sleep is constantly interrupted by sleep apnea, not only is homeostasis impossible, but the body must repeatedly struggle to recover from the cardiopulmonary insult of apneas. The body’s response to an apnea is no different that it would be from someone putting a pillow over a sufferer’s face to smother him 10 to 30 or more times an hour! Not only is it not restful, but the body is kept from assessing, maintaining, and adjusting its functions from a homeostatic, stable baseline.  The graphic “Pathologic Breathing Cycle of OSA” illustrates this struggle.

Fewer and fewer patients now are diagnosed with sleep apnea using polysomnography with electroencephalographically recorded sleep. Meanwhile, downloads from PAP devices don’t provide that information. So the objective focus is by default on the patients’ apnea-hypopnea index (AHI) and differentiating between central and obstructive sleep apnea.

After therapy is ordered and implemented, the PAP download numbers, including AHI, mask leak, and usage, become what sleep professional and patient become fixated on. From the beginning, patients tend to learn their AHI numbers, but not much else about their sleep.

A common comment when an apneic is asked about the quality of their sleep is “I’m a great sleeper; I can fall asleep anywhere.” But is that really the definition of a “great sleeper”? That  patient doesn’t realize that after a few nights on therapy, when there is no longer a sleep debt, it will take a normal 10 to 15 minutes to fall asleep.

During that time, the PAP mask is likely to become the focus of attention.  The PAP pressure might seem more noticeable. The patient might even blame the PAP for ruining his “great” sleep. For these patients, sleep hygiene is as important to coaching as is the coaching we do on how to put the PAP interface in place and how to properly avoid leaks. Might this patient feel more comfortable about using PAP if taking 10 to 15 minutes to fall asleep was viewed as a successful milestone in restoring normal, restful, restorative sleep?

Here are two case studies. They are fictional based on a montage of patients and PAP downloads. They illustrate typical complaints and possible solutions.  See if you can answer the questions proposed. (Answers follow.)

Patient #1: The patient complains that daytime sleepiness is still a problem. A PAP report shows 100% compliance with at least 4 hours of use every night for more than a month. The interface leak is minimal. On most nights, the PAP is on without any interruption for 4 to 6 hours, with an average nightly use of 5.3 hours. The auto-titrating PAP unit displays a mean pressure of 10 cm H2O operating between 8 and 12 cm H2O and rarely reaching the maximum set pressure of 20 cm H2O. What now? What change is needed?

Patient #2: This patient complains about daytime sleepiness, plus reports having trouble falling asleep sometimes.  The PAP interface “constantly leaks air,” according to the patient. The download shows minimal leak, and the PAP is used nightly and with naps. The average use is 7.5 hours per day, including naps. Bedtime is between 9 pm and 1:30 am.  Wake time is between 4 am and 9 am.   The AHI is <5.

Patient #1 Coaching Option: Verify the patient uses PAP with all sleep…all the time in bed. Calculate the sleep needed for 3 nights (which comes out to 24 hours for an adult). Coach the patient on how to get more sleep without disrupting the circadian cycle, and gradually get the 15.9-hour, 3-night average back up to 22 to 24 hours. Teach the patient about the afternoon and evening circadian dips, and let the patient decide when a nap or earlier bedtime coinciding with one of the dips will fit into his schedule. Maybe the bed and wake times could gradually be extended to allow more time in bed to achieve close to the 24-hour, 3-day average. Give the patient the knowledge to make appropriate choices to manage daytime sleepiness.

Patient #2 Coaching Option: Also verify this patient uses PAP with all sleep…all the time in bed, anytime there is sleep.  That includes “watching TV” in the recliner chair in the evening. Is there sleep in the chair without PAP on those late evening bedtimes? Again, sleep hygiene education would be helpful. That includes finding out why the bed and wake times are so variable. Can they be altered? Also, demonstrate the minimal leak in the PAP interface and explain it may seem louder when trying to get to sleep. Explain that the download does not show any high leaks. Make sure the interface is positioned properly. Help the patient determine a sleep pattern with as regular bed and wake times as possible and have a goal of 22 to 24 hours of sleep every 3 days. (Managing a 3-day average allows quicker correction and easier math than a whole week!)

In short, with both of these patients,  and many more, the sleep professional must look beyond a failure in PAP therapy to resolve problems. In these instances, we must educate patients on the basics of sleep and sleep hygiene to effectively manage them long-term.

Pamela Minkley, RRT, RPSGT, CSE, is president of Sleep & Alertness Services LLC and a member of Sleep Review’s editorial advisory board. She uses these strategies to eliminate daytime sleepiness in many of her patients. 

Pam Minkley



1. Epstein LJ, Kristo D, Strollo PJ Jr, et al; Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical guideline for the evaluation, management, and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009;5(3):263-76.