Expert David Rapoport Gives Advice on Sleep Apnea, CPAP, and Alternative Therapies


"I have seen 500-pound patients drop down to 450 pounds and notice significant improvements in their symptoms."(DAVID RAPOPORT)

David Rapoport, MD, is director of the Sleep Medicine Program at the NYU School of Medicine and director of research at the NYU Sleep Disorders Center at Bellevue Hospital. He is the founder and president of the Foundation for Research in Sleep Disorders, and a editorial adviser.

Q: I just started using my CPAP machine and have noticed a big improvement in my sleep. Do I need to use it every night?

A: Absolutely. Studies have shown that the moment you remove your continuous positive airway pressure (CPAP) mask, obstructive sleep apnea returns. While you may be able to get away with one or two nights without the machine, the symptoms will eventually come back. It's simple: If you don't wear the mask, you will have sleep apnea episodes.

Q: But I don't want to depend on a machine for the rest of my life. Are there any lifestyle changes I can make?

A: Studies show that sleep apnea is associated with a person's weight. For overweight people, especially those with mild cases of sleep apnea, losing weight may reduce sleep apnea symptoms and, in some cases, the symptoms may completely disappear.

It's not necessarily about getting back to a 'normal' weight. I have seen 500-pound patients drop down to 450 pounds and notice significant improvements in their symptoms. Overall, 100% improvement is very rare, but losing weight is definitely worth trying.

Apneas also tend to be worse when sleeping on the back, since gravity makes it more likely for the tongue to fall back over the airway and for the airway muscles and other tissues to collapse and block the airway. Sleeping on your side may reduce the frequency of apneas.

If you're looking for less conventional treatment options, you may be interested in a study published in 2006: Swiss researchers suggested that playing a didgeridoo, an Aboriginal instrument, improves (but doesn't cure) sleep apnea symptoms. While the study was quite small and more investigation is needed, it does suggest that exercising the upper airways may help relieve apnea.

Q: I use my CPAP at night but have trouble falling asleep. Is it safe to take sleeping pills?

A: If you're using your CPAP, taking a mild sleeping pill to deal with mask discomfort and help you fall asleep is safe, as long as you keep the mask on. However, if you remove the mask—say, you get up in the middle of the night and, because you've taken a sleeping pill, you're groggy and inadvertently forget to put the mask back on—your sleep apnea will worsen.

[ pagebreak ] Q: I've been using a CPAP for several months and have noticed that my mouth has gotten extremely dry. Am I doing something wrong?

A: Dry mouth is one of the most common complications of CPAP use, and it's usually due to air leakage out of the mouth and there are two easy fixes. The first is to increase the humidity of your CPAP system. Most CPAPs have humidifiers with various levels (either built in or sold separately), and increasing the humidity usually does the trick. You can also use a chin strap, which is designed to hold the mouth closed in order to prevent air from leaking out.

Q: Normally I use a CPAP every night, but just came down with a cold. Should I continue using the mask?

A: If you are able to use the CPAP and breathe through your nose, the mask may actually be good for your cold because the heated, moist air (produced by an optional humidifier, sold separately) is similar to that of vaporizers. But if your nose is completely blocked, the CPAP will not be able to work properly, so there's a good chance you will go untreated. Still, I recommend patients use the CPAP through a cold, possibly with a decongestant medication. It might be helpful despite nasal blockage. If not, it's no worse than not wearing it at all.

Q: I was at the mall and saw a pillow advertised to improve mild sleep apnea and snoring. But it was over a hundred dollars! Will this really work?

A: Many of these pillows encourage you to lie on your side rather than your back, which may improve your sleep apnea symptoms. Overall, these nonprescription products are more effective for snoring but less so for apnea. However, they work differently for each individual, and as long as your mild apnea doesn't require immediate attention, there's nothing wrong with trying it.

Q: I've tried using the CPAP for months now and it's incredibly uncomfortable. Are there any alternatives?

A: There are ways to make the CPAP more comfortable. First, make sure your mask fits correctly. There are many types available and each mask needs to be properly fitted to an individual's face. Secondly, it's important that you use learn to use the mask correctly. Patients often try to alleviate mask discomfort by tightening the device, which actually makes it worse. Similar machines, called bi-level positive airway pressure (BiPAP) and auto-titrating positive airway pressure (APAP) devices, might make the air flow more tolerable.

CPAP is the most effective treatment for sleep apnea, but about 25% of patients are unable to tolerate the device. If a person has tried using it and is at his/her absolute wit's end, there are other, less-reliable treatments. A surgical treatment that involves the removal of tissue from the back of the throat has about a 30% success rate. There is also an oral breathing device that helps keep the airway open, this is recommended for those with mild sleep apnea.

However, both options have low success rates and with both treatments, you have to pay for them before you find out if they work. There is a lot of research being done in the field and within the next few years, there will likely be other treatments available. But as of now, no treatment works as well and is as predictable as CPAP.

[ pagebreak ] Q: Both of my parents suffer from sleep apnea. Is it hereditary? And is there anything I can do to prevent sleep apnea?

A: If you have family members with sleep apnea, you may be at an increased risk. The same goes for those people with a family history of obesity, since that is a very strong risk factor for sleep apnea. If you have a history of either condition in your family, maintaining a healthy weight is critical to preventing complications.

Q: I am overweight and was diagnosed with sleep apnea last year. Since then, I've lost 25 pounds. Will this cure my sleep apnea?

A: Not always, but often. If you are overweight, losing weight is by far the best treatment for sleep apnea. And even if it doesn't improve your condition, there are many other health benefits you'll reap that make losing weight worth doing.

An individual's medical history needs to be taken into account. If you were thin, didn't snore, and didn't have apnea—but have now gained 100 pounds, snore, and have apnea—there is a much higher chance you'll be cured after losing weight, compared to someone who has snored their entire life, recently became overweight, and now has significant apnea. Someone with a predisposition for apnea may not be affected by weight loss.

Q: I've been taking medication for hypertension and depression, and lately, I've been fatigued all the time. Could this be sleep apnea?

A: Many blood pressure and depression medications have side effects of fatigue and lack of energy. However, people who have sleep apnea often have hypertension and usually also have a type of fatigue that mimics depression, which can lead to misdiagnoses. Look for the signs and symptoms of sleep apnea: severe snoring, the weight association, and the gasping and choking during sleep.

Q: I am 25-year-old female, fairly healthy, and I don't snore. But I've been waking up at night, gasping for air. Could this be sleep apnea?

A: Probably not. Women are less likely to have sleep apnea, and the fact that you don't snore is a good sign—although we have seen people with severe apnea who don't snore at all. The gasping for air could also be associated with asthma, insomnia, or anxiety. Ultimately, undergoing an overnight sleep study at a sleep center is the definitive way to diagnose apnea.

[ pagebreak ] Q: My ear, nose, and throat doc says he can cure my apnea with surgery. What can I expect, and will it definitely work?

A: Your doctor is overstating the case. While it is possible that the surgery may cure your sleep apnea, it's not definite. The success rate is anywhere from 25% to 50%; however, the majority of sleep researchers are disappointed that the rates aren't higher. That said, most sleep apnea surgeries are relatively safe and benign procedures that are worth considering if you're desperate and really do not want to use CPAP. Surgery is irreversible, while there are no downsides or side effects to using CPAP. My recommendation is to always try CPAP first and then use surgery as a last resort.

Q: Even with the CPAP machine, I still don't sleep well and I'm always tired during the day. Are there any medications I can take to help me stay alert?

A: First, check with your sleep specialist to make sure that your CPAP is functioning properly; if you're using the mask correctly, your sleep should go back to normal. If you're still sleepy during the day, there are some medications that may help, provided you're regularly using the CPAP properly.

Provigil (generic name modafinil) is a wakefulness-promoting drug that's similar to caffeine—however, medications should not be used as a CPAP substitute. Drugs can trick you into thinking you've been cured while your apneas remain untreated.

Q: My wife thinks I might have sleep apnea, but I don't want to travel to a sleep lab for a study. Is there any other way I could be diagnosed?

A: "Unattended" home sleep tests are available; they involve the use of a portable-monitoring system that you wear as you sleep in your own bed. The American Academy of Sleep Medicine has strict guidelines as to who should use home tests, and recommends that if you have an unattended home test, you do so only in conjunction with seeing a certified sleep specialist.

An attended overnight sleep study at a sleep disorders center is still the standard testing method, because it can detect all levels of sleep apnea along with many other sleep disorders—information you would not be able to obtain from a home sleep test. Working with a trained specialist at a clinic will also ensure that you receive the most detailed information about your sleep as well as a specific treatment plan.