More Than Oxygen: How CPAP Manages Symptoms But Misses Long-Term Solutions

The CPAP's never really intended to be a long-term solution. It should be considered a short-term solution to improve oxygenation while we come up with a long-term solution. A fix. When it comes to treating a sleep disorder, it's like anything else. There is management of the disorder and there is treatment of the disorder.

CPUP has long been called the gold standard treatment for sleep apnea. For many patients, it can be life-changing, but for others, it becomes frustrating, uncomfortable, or difficult to maintain long term. Today we're taking a balanced look at CPUP, why it remains so important in sleep medicine, where it works best, and why some patients need to explore additional or alternative approaches. Let's start with the fundamentals. Why has CPUP earned the reputation as a gold standard for treating sleep apnea?

Well, it's funny you use the term earned because I don't think it was actually earned. The CPAP was kind of the initial treatment that was created for sleep apnea. Because at one point it was essentially all we had. And in today's world, there's lots of alternatives. And I do not believe in today's world it should be considered the gold standard. We'll talk about that a little bit more in a little bit, but it just became the standard because at one point you had two options. You had the CPEP and you had surgical alternatives, and most people would just choose the non-surgical alternative of the CPAP.

When CPEP works well, what kinds of improvements uh do patients typically experience?

So one thing a CPAP does very well is improve oxygenation quickly. So when we have sleep apnea or a sleep disorder, one of the big problems is oxygen desaturation. So our oxygen drops below what it should be. And a CPAP is really good, really quick at reversing that problem. It's not good or quick at reversing the other problems that we have with sleep disorders, but it does improve the oxygen desaturations quickly.

Is the CPAP just essentially throwing air in? Is that what it is? Or is there something more specific about it?

Uh that's all it is. So, and this is a fundamental that people should understand. The CPAP is never really intended to be a long-term solution. It should be considered a short-term solution to improve oxygenation while we come up with a long-term solution effects. So when it comes to treating a sleep disorder, it's like anything else. There is management of the disorder, and there is treatment of the disorder. So let's look at a broken arm as an example. If I break my arm, setting the bone, putting a cast around it, is the treatment that fixes it, right? The pain meds that you take, the anti-inflammatories that you take manages the situation, but doesn't fix the situation if that's all you did, right? A CPAP manages a situation. While you are wearing it, it improves oxygenation. It doesn't fix your problem, and when you're not wearing it, it does nothing for your airway. So it falls under that classification of management, not treatment. So therefore, if we're managing a situation, we should ultimately be trying to find a solution, a treatment that fixes it. And a CPAP will never do that.

And what makes a CPAP such a reliable therapy from a medical standpoint?

How quick it improves oxygenation is the key factor with a CPAP. When you say what makes it successful, uh, I don't find most people being successful, quote unquote, with a CPAP. Many people don't even seek treatment for their sleep disorder because they believe it's their only solution. And so they don't even treat their sleep disorder. If you're given a CPAP, the a number of people who are actually treated successfully, and when I mean treated successfully, to your point, medically successfully treated, it's probably under 40% because you have to look at the entire symptoms and chief concerns of the patient. Okay, it's not just about the number of times you stop breathing, it's not just about the oxygen levels, it's about fragmented sleep, which we've talked a lot about, okay, it's about all those stages of sleep, it's about their chief concern of snoring. There's lots more to treating a patient than just the number of times they stop breathing. And if you can't address those other factors, are we really successfully treating them? If your concern is to prevent dementia and Alzheimer's, and statistically, most people's deep sleep gets worse with a CPAP. So deep sleep, as we've talked about, is the correlation between having a sleep disorder and developing dementia or Alzheimer's, right? So if your concern is to improve or prevent memory issues, dementia, Alzheimer's, then is a CPAP really the right solution for you? Because it makes your deep sleep worse in the majority of patients. Just the agitation of the mask, the hoses, and everything else keeps us out of deep sleep.

Yeah, yes, for a non-invasive form of symptom management, it's pretty invasive.

There's a term used in research. MDA mean disease alleviation, which means taking everything into account, what's the likelihood of something improving you? Right? Well, if we look at oil appliance therapy, for instance, old school appliance therapy has, I don't know, 46, 48% mean disease alleviation. What's the CPAP? Most doctors are going to say, oh, this is this gold standard. This is a standard of care. This is as good as you get, right? What is the MDA of a CPAP? I would think it's 54% or 56%. But let's look at some precision dental appliances that we have today. The mean disease alleviation is higher than a and better than a CPAP. Because you've got to take everything into account, right? Compliance is one of those things taken into account in MDA. Well, what's the compliance on a CPAP? You gotta wear it for medical purposes, you gotta wear it for somewhere between six and eight hours a night, 90% of the time. What's the average time that somebody wears a CPAP? It's a little over four hours a night. For insurance purposes, and for these research purposes, they used four hours in the study. Well, medically, we know four hours doesn't cut it. If you stop breathing sixty times an hour and you wear your CPAP for four hours and take it off, and now spend the next four hours without the CPAP. You just slept four hours stopping breathing sixty times an hour. So you gotta wear it for somewhere between six and eight hours to medically be relevant. Insurance purposes, you only gotta wear it for four. But medically, you gotta wear it for six or more.

That's a long time. I don't know anybody that can well, maybe one person that can actually tolerate a CPAP for that long every night.

Not many people can do it.

What are the most common reasons people have uh difficulty using it?

There's lots of reasons why people have difficulty using a CPAP. It could be claustrophobia, it can be allergies to resins, which the masks are made out of and causes irritation of their face. Uh just having the thing on their face. If you're a side sleeper and you sleep on your left side, your right side, or your stomach, you can't do that with a CPAP. You got to sleep on your back. Because a lot of people don't like to sleep on their back. And so if you can't sleep on your back, it makes it very difficult to comply with a CPAP, because as you roll over it, it's going to knock your mask off. Also, we got to look at anatomy. We're going to talk about that a little in a little bit, but your anatomy and what's causing your sleep disorder is not taken into account when you're given a CPAP mask. And some of those structural problems that is the root cause of your sleep disorder is not taken into account. And some of those things cannot be overcome by a CPAP.

Yeah, I remember you've mentioned a couple of times about how you had a patient that got a pillow or something, his apnea events reduced by like 90% or something. So if if he was to use a CPAP, then his problem wouldn't have resolved, right? Because he couldn't change positions.

Correct. If you if you have a positional component to your sleep disorder, which a significant amount of people do, whether better or worse in one position, left side, right side, their back, their stomach, then that can be simple treatment to alter that. Using a positional pillow. And you really can't do that when you're wearing a CPAP because you're stuck in one position.

How much of a CPAP intolerance is related to comfort versus underlying airway anatomy?

I think most of it is under underlying anatomy, which then leads to a lot of the other problems. Okay, so let's talk about, and again, let's go back to this concept of success. When you look at the research that says a CPAP is good for you, it improves cardiovascular disease, it reduces risk of heart attacks and strokes, right? But all those studies were done, and when you when you set a CPAP up, you set it at a certain pressure. And you can set these machines at a pressure which starts at four or five, let's say, and the pressure can go all the way up to ten, fifteen, twenty. Okay? So most of them are set somewhere between five and twenty. Now all the studies that show that a CPAP improves our health were all done with pressures between four and seven. When your pressure got to eight or above, they took those out of the study. So how many people and at a pressure of four to seven, to your point, who can tolerate it? At a pressure between four and seven, most people could tolerate the mask, that pressure. Okay, they might not tolerate the mask and the other stuff about it, but they can tolerate that pressure. When that pressure has to start going up, is when people can't tolerate it. Well, how many people can successfully be treated with a CPAP where the pressure does not go above a seven? It's not many. I see patients' compliance reports all the time from their CPAP machines. I I I haven't seen one in two years that their pressure does not go above an eight. Haven't seen one in two years. And I do 50, 70 consults a month. So if your pressure is going above an eight, now there's research that shows you actually increase your risk of heart attack and stroke, not decrease your risk. So if we're wearing a CPAP mask that the pressure has to go to 10 or 12 or 14, that one makes it intolerable to people. And secondly, you now have a risk factor that may be worse than your sleep disorder. So we were reminded during COVID about this topic of pressures, right? When you had people going on to the ventilators, right? A lot of people looked at somebody going on to a ventilator as a death sentence. Right? It was bad news when somebody had to go on a ventilator, right? Well, what was one of the things happening when people went on ventilators? They were having heart attacks. Well, that's what it was. They were having extreme pressure from the ventilator, which causes problems in our arteries. Well, that same problem happens with your CPAP when that pressure gets above an 8. So when you get to certain pressures on a CPAP, you actually increase your risk of heart attack and stroke, not decrease your risk. And in the 50-something years we've been using CPAPs, we have not curbed, altered the incidence of heart attacks and strokes. One iota. Not one bit. And this is why. Because the average person requires a pressure that gets above a seven. And it's between four and seven that improves our risk of heart attack and stroke. Well, how many people can be treated successfully with a pressure between four and seven? Not many. Not many at all. So when you talk about success, it's not very successful treatment. I would argue that a CPAP is probably successful, medically successful, in less than 30% of people. So seven out of ten people cannot be treated successfully with a CPAP. Yet it is considered the gold standard. For no reason, as I talked about in the very first question, for absolutely no reason.

That's so crazy that it's also such an old technology, but it doesn't seem to evolve in any form of way, right? It's still the same device and it works in the same way. Like it hasn't even improved or anything, and people have, and I mean, medicine has advanced so much. Technology has advanced so much, and it's still the same thing from 50 years ago.

It it hasn't changed. Um, keeping in mind the CPAP, as we've talked about this before, the CPAP wasn't even originally invented for a human, it was invented for a bulldog. And then just, you know, now we just started using it on humans, and it drives me nuts. I have a I have a little lecture I gotta do next month uh to some pulmonologist, and this is one of the points when I speak to these pulmonologists. This is one of the points I always make. If your patient as a pulmonologist goes and does anything outside of a CPAP, any treatment outside of a CPAP, I don't care if they do the Inspire sleep implant, they do an oral appliance, they see an ENT for a surgery. Whatever it is, you know what that pulmonologist says? Make sure you get your sleep test done afterwards to make sure it's working. Yet, these same doctors will give you a CPAP, send you off for 10 years, and never give you a sleep test to do at home to see if it's working. Never.

My dad has severe sleep apnea for 40, 50 years now, and he was he was recommended a CPU, and and he never got a sleep test. It's like take it home and that's it. There's no follow-up. That's your treatment, that's your solution. No more. There was an initial sleep test done, but then there has never been a follow-up.

And that's that and that's normal. It's sad. It's really sad. Because how do you know if something's working? You tested. How do you know if your blood pressure medicine is working? You test your blood pressure, right? How do you know if your diabetes medication is working? You test your blood sugar. How do you know if your own appliance is working to treat your sleep apnea? You do an updated sleep test. Well, why are we not doing sleep tests? Because I'm going to tell you right now, I do probably 20, 25 sleep tests a month on CPAP wares, and it's pretty rare that I find one that's successfully treating the patient. So it just drives me nuts that these people are not testing to confirm. Because some of these people need a CPAP for their oxygenation, et cetera, et cetera. But they could be doing co-therapies, other therapies that could actually treat. Remember, this is managing something, oxygenation. It's not treating it, it's not fixing it. So why don't we work on fixing it, correcting the root cause, so that one day we don't need a CPAP machine. But we're not. And it's sad, but you know, the CPAP business is a$7 billion a year business. And a lot of that comes from every three months, you gotta buy new hoses, new stuff, and blah, blah, blah. And it's just a repeat business.

And I feel like it's been like a sentence for people who have a sleep problem or sleep apnea for a long time, whether they give you pills or a SIPA, and that's your only treatment, and then you have to go home and just kind of uh accept that that's that's what it is. Like you're gonna manage it, but you're gonna prevent a heart attack, maybe, but you're not gonna feel rested, you're not gonna wake up with energy, you're not gonna sleep well. And I feel like that's the majority of people. Like they don't know that there's other options. And I and and I'm not sure that uh uh that most people even think that it's possible to actually overcome their sleep apnea or actually cure it.

Yeah, they don't they they don't think there's options out there, they think their only option is CPAP or a surgery, and and it's not the case, but that's what the majority of people think. That's why there's so many sleep apnea and sleep disorders in general are probably the most undiagnosed, untreated problem we have in medicine. And a lot of that is simply because the doctor says, hey, go get a sleep test, and the person doesn't even go get tested because in their mind, their only option is this mask that they don't want and will not wear, and they know it, so they don't even get diagnosed. They don't even start down that road because they believe that's the only option. We gotta change this.

No, absolutely. And and it's like, okay, I'm gonna get this mask that it's supposed to help me with my health, but it doesn't actually help me sleep. So I'm not gonna feel restored. And people don't want to prevent prevent other things from happening. They want to sleep well, they want to be able to feel rested. And CPUP does not provide that. It may prevent or it may be said to prevent certain things, but it doesn't provide the the restoration that sleep and deep sleep provide, right? Right. And do you see patients who technically use CPUP but still don't feel fully versed?

That's it's it's it happens all the time because again, let's think about what CPAP does. It improves oxygenation. What does it not do? It does not improve deep sleep in almost anybody. So you can still have very bad fragmented sleep. So you can sleep 10 hours, and your oxygen might be great. But if you have fragmented sleep, you still don't feel great, and you still have all the health confidence. Consequences. Blood pressure, blood sugar, cortisol, etc. Right? All the problems that come from fragmented sleep, bed wedding in kids, getting up to go pee four times a night for adults. This is all related to fragmented sleep and controlling hormones.

Oh, really?

Yes, and bed wetting in children. So bed wedding beyond the age that you're supposed to is usually caused by a sleep disorder.

How is that related?

Because you can't control hormones properly. Hormones are related to the to uh what causes us to feel the need to go to the bathroom. Okay. So there's uh there's uh certain hormones that cause us to resist the urge to go pee. Right. And we cannot control these hormones if we're not if we're in fragmented sleep, if we're not in the proper stages of sleep.

Interesting. And so CPEP supports breathing during sleep, but it doesn't change the airway structure itself. Why is that distinction important?

Because let's look at children, for instance, and I always use this term, you've heard you've heard me say this. Sick children lead to broken adults. So when you see a child walking around with their mouth open all the time, sleeping with their mouth open, you could put a mask on that child and improve their oxygenation when they're sleeping. But did you fix the airway? You did not. So now they remain mouth breathers. Well, what happens when we breathe through our mouth as a human while we're growing? We don't grow right. We grow asymmetrical, we grow narrow, our jaws don't develop, so we create severe orthodontic problems, and you're not stopping that by wearing a mask for four or five, six, seven hours a day. You have to fix the airway to treat somebody. A CPAP needs to be looked as as a temporary solution that's managing some symptoms. It's not treating anything. We need to find treatment. Fix root cause treat. Stop just managing symptoms.

And it feels so aggressive to tell a kid to use a CPAP to wear a mask at night. It's horrible. It's horrible.

It should never be done, actually. I'd I'd my mask should never be put on a kid. On a kid, you have to find solutions. Putting a mask on a child, um, I will argue all day, every day. It should never happen. You are you are severely affecting that child's growth and development, their long-term cognitive abilities, learning abilities, etc., uh, if you don't fix the airway in this child, and a CPAP mask cannot fix the airway.

And when might patients benefit from combining CPAP with other treatments?

Well, it's quite often. You know, as much as I talk negatively about a CPAP, and the reason why I do it is because I don't believe it should be looked at as a long-term solution. Because it is not long-term successful in most patients. And when you look at statistically how many people are given a CPAP and how many people are still wearing that CPAP in three years, it's very little. Okay? So we gotta find a better alternative. And there are lots of alternatives out there, right? But with that said, I oftentimes tell patients that dual therapy, which means CPAP temporarily while we're doing other stuff, is a good idea. And I oftentimes tell patients to wear a CPAP for a period of time while we're getting through their case, while while we are coming up with treatment that works. And so dual therapy is something I recommend quite often. But dual therapy has the point of having an endpoint where you're gonna one day get rid of this mask. And when you tell patients, hey, this is your solution, wear this mask, and then their mind, that is forever and ever, they're not interested, the majority of people. But when you say, hey, can you just do this for a year? almost all people will say yes. Almost all people will do everything they can to try it, knowing there's an endpoint coming. So patients that for the most part, I don't think have a problem with dual therapy. Because they know there's an endpoint. But to say this is your life sentence to wear this thing, they don't want it.

Yeah, no, absolutely. If it's gonna actually fix the problem, if it's if it's a process, if it's part of a treatment, if it's a temporary thing, then everyone would gladly do it because, hey, this is gonna get me better. But if I'm just gonna stay in the same situation forever and I'm gonna have to wear this uncomfortable thing forever and not ever feel rested, then that sounds like the worst idea. At least people prefer just to be able to move at night if if it doesn't guarantee to make them feel better, right? And what are some alternative or complementary approaches uh patients can consider if CPAP alone isn't working for them?

There's lots of alternatives. Um, you know, we focus primarily on oral appliance therapies, epigenetics. Uh the focus of epigenetics is the development and growth of the jaws in the airways uh to create kind of a permanent solution. Um there are laser procedures that can tone and tighten and shrink the tissues of the airway. Uh there are ear nose and throat ENT procedures that can be done to reduce the size of the soft palate. Uh if it's flabby, they can put little implants in to tighten up those tissues. Uh there are nasal surgeries, nasal procedures, radio frequency procedures that could be done to improve nasal breathing. There's lots of alternatives to a CPAP. And it's and most of the time, by the way, it's not a one thing. It's not a one doctor can fix you. If you have an airway problem, it goes back to the kink in the hose analogy that I always use, right? If I have a kink in the hose, then I have two options. One is to go one kink the hose. And that's what we do through our epigenetic and laser treatments. We're trying to get the airways opened up, right? Well, the other option I have is to leave the kink in the hose. And to go to the faucet and just turn up the pressure all the way. Force as much water through the kink as possible. That's what a CPAP mask is doing. It's forcing air down the airway and through the kinks. It's not fixing any kinks. Well, let's say I have three kinks in the host and I only get rid of one kink. I'm better, but I still have a problem, right? So the CPAP does not get rid of the kinks, any of the kinks. And so when you do dual therapy, you're working on getting rid of those kinks while you're temporarily improving oxygen with the mask.

And so, how should patients approach conversations with their providers if they're struggling with the CPAP?

It's difficult because unfortunately, their providers are unaware of a lot of these options. The majority, the vast majority of pulmonologists are completely unaware of the options I provide. They don't even know they exist. So it becomes difficult because when you talk to the provider about your CPAP mask, they tell you the only option is surgery. And we're going to talk about that soon, the inspire surgery, right? So they tell them that you do the inspire surgery or you wear the mask. And they're honestly they're not aware of the alternatives. And every time I give a lecture, every time I give a webinar to talk about these things, do you know who I never have in the audience? Ever? Pulmonologists. They're never there. I get ENTs, I get neurologists, I get physical therapists, I get dentists, I get primary care doctors, I get everybody else. I never have a pulmonologist in my audience.

Why is that? Why do you think that is?

Uh I have no idea. Uh I think they're just so ingrained in what they know and whatever they learned 15 years ago, 20 years ago, 30 years ago, and that is it. And they're just not open to learning about what's out there. I I don't know why. I don't I can't I don't understand it. Because for me, you know, I've been treating sleep for 25 years. How I treat sleep today is way different than how I treated sleep 25 years ago. So I I I I I'm a progressive person. I I I I want to do what's best for the patient. And when there's something that new that comes out that's better for my patient, I want to learn it. I would think these guys would and girls would want to learn this stuff. I don't know why. I can't honestly I can't answer that.

Dr. I we've reached the end of our episode. Is there anything else that would you would like to leave our listeners with today?

I think the main thing is it's gonna become on the patients to go to their providers and say, listen, you know, uh, I need an alternative. And it's gonna be for them to pay attention to their compliance reports on their CPAP machines, figure out where their pressures are at, what does their pressure get to? If it's getting above an eight, then you gotta talk to your provider. Uh this isn't new stuff. This has been this research on the and this studies on the pressures have been out for, I don't know, maybe four years now. This isn't brand new stuff. Uh so they need to point this out and get their doctors to start looking at this stuff and say, okay, if my pressure is getting above an eight, what can I do? And start looking for the alternatives. Start reaching out. Anybody can have their provider reach out to me. Uh I'll give a one-on-one webinar and just give some basic stuff on what we do to any doctor to help their patients.

Thank you for all the information you have given us today, Dr. Eck. CPAP remains a powerful tool in treating sleep apnea, but it's not the only path toward better breathing and restorative sleep. Understanding both its strength and its limitations help patients make informed decisions about their long-term health. If this episode resonated with you, share it with someone navigating sleep apnea treatment. To learn more about airway focused solutions, visit sleeptreatmentdirect.com. Better breathing, better sleep, better life.