Man in bed holding up a CPAP machine mask.

If you’ve received a diagnosis of obstructive sleep apnea (OSA)—which causes numerous brief pauses in breathing as you sleep—your doctor has probably recommended continuous positive airway pressure.

With CPAP, the mainstay treatment for the disorder, you typically wear a masklike apparatus that’s connected to a pump. The pump pushes air into your airway, holding it open while you sleep.

CPAP can significantly cut the number of nighttime breathing pauses you experience—but only if you wear the device. And roughly one-third of CPAP users don’t stick with treatment, according to a 2016 review of studies published in the Journal of Otolaryngology – Head & Neck Surgery. According to the review, users often cited problems with comfort, convenience, and claustrophobia as reasons for giving up on CPAP.

The therapy can be challenging. When David Levey, 60, of Mequon, Wis., started using CPAP some 15 years ago, he found it to be unpleasant. “I was a side sleeper, and the pillow would knock the mask out of place,” Levey says. So instead of sleeping through the night, he’d wake up repeatedly with air from the device blowing into his eyes.

More on Sleep

But it’s important to get a handle on sleep apnea. Untreated, it can cause excessive daytime sleepiness, says Raj Dasgupta, M.D., a pulmonary and sleep medicine specialist at Keck Medicine of USC in Los Angeles. And that, in turn, can lead to falling asleep at inappropriate times: while eating, driving, or talking to others, for instance.

This can pose dangers. In fact, a 2015 Swedish study published in the journal Sleep found that untreated sleep apnea doubled the risk of a car crash. And undiagnosed sleep apnea may have played a role in two commuter-train crashes—one in Hoboken, N.J., in 2016 and one in Brooklyn, N.Y., in 2017—which, together, caused more than 200 injuries and one death, according to the National Transportation Safety Board.

Long-term, sleep apnea also strains the heart, increasing the risk of high blood pressure, arrhythmia, heart failure, and stroke.

“Patients sometimes ask if they can die from not getting their sleep apnea treated. The short answer is ‘yes,’” Dasgupta says.

Whether your doctor has just recommended CPAP or you’ve been struggling with the treatment, here’s how to get the most out of this therapy.  

How CPAP Works

There are currently approximately 5.9 million OSA diagnoses among U.S. adults, according to the American Academy of Sleep Medicine. In those with the disorder, neck and throat muscles relax during sleep, causing the soft tissue at the back of the throat to collapse and block air from reaching the airway. That causes a series of partial or complete pauses in breathing, sometimes hundreds of them each night.

CPAP—which sends enough air into the upper airway to prop it open—has been the cornerstone of therapy for moderate to severe OSA since the 1980s.

The prescription treatment has been shown to improve sleep quality, reduce daytime sleepiness, help normalize blood pressure, and ease other related health risks.

For instance, a study published in 2018 in the Journal of the American Heart Association of more than 40,000 Danish adults with sleep apnea found that those who skipped CPAP had a 38 percent higher risk of heart failure than those who used it.

Not only can CPAP be effective, but the machines are now easier to tolerate—quieter and less clunky than older devices. 

Many newer CPAPs allow you to start the night at a lower air pressure setting—and have that pressure rise gradually after you fall asleep. This can reduce the jarring feeling of air being forced into your nose or mouth.

Some CPAP units even adjust automatically to patterns in your breathing, increasing or decreasing air pressure throughout the night as needed. 

Find the Right Device for You

Finding a CPAP mask that is comfortable enough to allow you to slumber is essential. (You’ll also consider factors like the severity of your OSA and the air pressure setting your doctor has recommended to keep your airways open during sleep.)

But this can take time. Even with the advances above, using a CPAP machine can feel clumsy and awkward, according to Steven Feinsilver, M.D., director of sleep medicine at Lenox Hill Hospital in New York City. “Most people do not end up with the first device they try. Some people may try two or three before finding the right fit,” he says.

That was the case for Hb Alumisin, 33, of New York City, who tried two masks before settling on a third option—nasal pillows (see below)—for his mild sleep apnea.

“I found the masks heavy and hard to sleep with, but the pillows are comfortable and less obtrusive,” he says.

What to do? At your fitting (which may be done at home or at a sleep center), “try masks on with the doctor-recommended air pressure settings you’ll be using to see what it really feels like when the machine is on,” Dasgupta advises.

And make sure any device you’re considering fits snugly enough to form a seal where it’s meant to, Dasgupta says, but not so tightly that it leaves marks on your face.

Also, understand the differences between the three main types of CPAP masks available: 

Nasal pillows. The “pillows” are small plastic plugs that rest directly below the nostrils and direct airflow to your nasal passages. Nasal pillows are the smallest, most lightweight option and require minimal contact with the user’s face. 

Pillows may work best for people who require a low to moderate air pressure setting and may be a good option for people with a lot of facial hair or who feel claustrophobic wearing a larger mask, according to the American Academy of Sleep Technologists (AAST).

But they may cause nasal irritation and discomfort, especially at higher-pressure settings, because air is being forced directly into the nostrils. Some users report nosebleeds or nasal dryness. Mouth breathers may not get as much benefit from this type of mask because it applies pressurized air only to the nasal passages.

Nasal mask. This mask will cover your face from the bridge of the nose to the top of your upper lip, creating a seal over your nose but not your mouth. The AAST recommends nasal masks for people who want a more natural-feeling airflow than they’d get with nasal pillows.

“Some people prefer the mask to the pillows because the air is not as concentrated. Spread out over a larger surface area, it may have a more comfortable feel,” says Edwin Valladares, a CPAP user who works as a sleep technician and manager of the Sleep Disorders Center at Keck Medicine of USC.

The nasal mask may not be best for people who are mouth breathers or those who have trouble breathing through their nose because of allergies, sinus blockages, or medical conditions such as deviated septum. Some people find that the mask causes irritation or discomfort on the bridge of the nose.

Full face mask. This type of mask covers both the nose and mouth, forming a seal over both airways. A full face mask may be a good option for people with allergies or medical issues that make it difficult for them to breathe through their nose during sleep. It may also work for those who need a higher-pressure setting but find this more comfortable than a nasal mask, the AAST says. But the bulkiness may be a drawback for some folks.

Then, Ease Your Way In

It may take two to three weeks to get comfortable sleeping with CPAP and four to six weeks before you really begin to see a benefit, Rowley says.

A gradual introduction to CPAP works best for many people, Feinsilver says. Start by using your CPAP for 20 to 30 minutes before bed. “Put the mask on, turn the machine on, and watch TV or read a book,” he says. After a few days, try sleeping with the device. “If you don’t fall asleep within an hour, take if off and try again the next day,” Feinsilver says.

If you find that the mask that felt right during your fitting is uncomfortable after a few nights, or that it’s difficult to adjust, contact your sleep medicine doctor or the medical equipment provider. You may need advice on adjusting or a different style of mask.

Deal With Dry Mouth and Nasal Stuffiness

Here’s how to handle other common CPAP-related complaints:

Dry Mouth
An uncomfortably dry mouth can occur when a full mask fails to form a tight seal over your face or with a nasal mask or nasal pillows if you’re mouth-breathing, says James Rowley, M.D., medical director of the Detroit Receiving Hospital Sleep Disorders Center.

What to do: If you wear a full mask, have your sleep medicine specialist or sleep technician check its fit. For mouth-breathing, ask whether a chin strap can be added to your nasal mask or nasal pillow devices to hold your mouth shut during sleep.

Nasal Congestion
This can be the result of air being directed into your nose. 

What to do: Most newer CPAP machines come with a built-in humidifier—you can adjust the level of humidification so that it might ease nasal congestion. If that doesn’t help, talk to your doctor, Rowley says. “Most CPAP-related nasal congestion can be treated with an antihistamine or nasal steroid spray,” he explains.

Rash
Some CPAP users report redness, itching, or rash where the mask touches the skin. According to the AAST, an allergic reaction to a CPAP mask is rare and such skin problems are almost always related to improper mask hygiene.

What to do: “Wash the entire mask and humidifier chamber with soap and water at least once a week,” Rowley says. (Get more CPAP care tips here.) And while some researchers have theorized that CPAP might increase the risk of respiratory infections such as pneumonia, studies so far have failed to find a link. 

Still Having Trouble? Don't Give Up

And if after two to three weeks of giving it a good try, you feel that CPAP just isn’t working for you, “talk with your sleep physician about what else you can do, but don’t just quit,” Rowley says.

For some people, it may take additional time to adjust. David Levey, for instance, estimates that he spent two to three months to feel fully comfortable with his CPAP—and to switch from a side sleeping position to a back position to keep his device from slipping out of place.

“Getting used to sleeping on my back was the hardest part about adjusting to CPAP, but once I did I woke up feeling so much more refreshed,” he says.

Also, non-CPAP options are available, including mouth guards, called mandibular advancement devices, that help to keep your airway open, and surgically implanted devices that deliver electrical impulses to the nerve that controls the upper airway muscles.

If you’re overweight, shedding some pounds can help reduce sleep apnea severity, too.

And remember this: “Not only will addressing your sleep apnea help you sleep better, but you might live longer,” Feinsilver says.