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Side-eects associated with
https://t.me/medicina_free
continuous positive airway
pressure
Bertien Buyse, Alexandros Kalkanis and Dries Testelmans
Side-eects are a cause of suboptimal treatment adherence. Patient education and
regular follow-up for troubleshooting of side-eects are therefore very important
(figure 1). This chapter highlights the following side-eects associated with CPAP: air
leakage; mask side-eects due to local pressure; pressurised air-related side-eects;
ocular complications; and other side-eects.
Air leakage
Leakage-related side-eects are regularly seen. Leakage around the mask or through
the mouth is associated with annoying consequences: mask strap pain (due to an
appropriate mask tension in order to prevent leakage), ocular irritation, oral dryness,
nasal congestion and sleep fragmentation. Air leakage also produces noise which can
disturb the sleep of the bed partner.
The following factors contribute to unintentional air leakage:
• Older age, characterised by changes in facial morphology due to loss of teeth, changes
in skin elasticity or a decrease in subcutaneous fat, interfering with mask fitting.
• Nasal obstruction, which forces the patient to open their mouth.
• Obesity, especially in cases of central fat distribution, and COPD–OSA overlap
syndrome, characterised by higher airway resistance, which increases the work of
breathing and promotes mouth opening.
Key points
• Air leaks remain a challenge and are not always solved by using an oronasal
mask or pressure modification modalities such as automatic CPAP or
expiratory pressure relief, without assessment of the clinical context.
• Intranasal steroids appear useful to reduce rhinitis symptoms due to CPAP,
especially in patients demonstrating rhinitis symptoms before the start of
CPAP; steroids should be used over a prolonged period.
• Heated humidification reduces nasopharyngeal symptoms, making routine
use favourable. However, not all patients need humidification and the
decision should be based on patient preference and tolerance.
• Barotrauma due to CPAP is rare but should be considered in cases of tympanic
membrane rupture, (pneumo)parotitis, pneumothorax, pneumocephalus and
ocular complications.
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Others
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Ocular
complications
Aerophagy
Consider lowering the
pressure level
Ocular irritation
Consider a better-fitting
size or type of mask
(oen a change to nasal
pillows should be made)
Claustrophobia
Start graded exposure
TECSA
Use heated humidification
in case of nasolacrimal
valve incompetence
Side-eects associated with CPAP
Further discussed in
chapter 8.6 of this
Handbook
side-eects
Pressurised air related
Mask side-eects due to
Nasopharyngeal side-
local pressure
Skin marks
Air leakage
Around the mask
eects (especially rhinitis)
Consider prolonged use
of topical steroids,
especially in patients
1) Consider a better-
fitting size or type of
mask (including nasal
pillows in case of nose
Consider a better-fitting
size or type of mask
with rhinitis symptoms
before commencing
CPAP
Add heated
humidification
Barotrauma (rare)
bridge problems)
2) Use barrier cream
and mask liners
3) In case of mask strap
marks: consider a
change of mask and
Through the mouth
1) Check for the presence
of nose obstruction and
treat this initially
2) Add a chin strap (if
there is no nasal
Consider an alternative
treatment for OSA
strap type or replace
with a cloth strap
Dental or skeletal cranial
obstruction)ORChange to an oronasal
changes
Try using dierent masks,
including nasal pillows
mask (especially in case
of large leakage and/or
persistent nasal
obstruction)
Figure 1. Troubleshooting clinical side-eects of CPAP – an overview.
175ERS Handbook: Respiratory Sleep Medicine
Side-eects associated with CPAP
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Treatment options
Data downloaded from CPAP devices show the level of leakage, but there is no
threshold for clinically significant leakage, expressed in L·min−1, related to patient
adherence. Therefore, the need to address leakage is only indicated where there is a
complaint from the patient or from the bed partner. It is important to try to make a
distinction between mask and mouth leakage.
A (limited) role for customised masks
Masks can be customised (with or without the use of three-dimensional printing),
designed to optimally adapt to the patient’s face, but such customisations are
complex. A multitude of commercial models of nasal, oronasal and nasal pillow masks
are available, allowing proper mask fitting in the majority of patients.
The role of oronasal masks or chin straps
To reduce mouth leaks, an oronasal mask is oen used. Surprisingly, oronasal masks
are associated with higher leaks compared to nasal masks or nasal pillows. Moreover,
the clinician should be aware that use of oronasal masks can result in a paradoxical
induction of hypopnoeas and apnoeas and a higher therapeutic pressure. The
underlying mechanisms are partial obstruction due to a pressure-induced backward
displacement of the tongue, and/or a backward (and downward) shi of the mandible
due to the increased mask strap tension oen needed to prevent leakage around the
bigger oronasal mask. Nevertheless, in some cases, especially with persistent nasal
obstruction, an oronasal mask can be an eective treatment of oral leakage.
Use of a chin strap also decreases mouth leakage, but fails if a high level of leakage is
present: a chin strap keeps the jaw, but not the lips, closed, and may not counteract
the mouth opening when this is due to nasal obstruction.
The role of pressure modification modalities and humidification
Automatic CPAP results in reduction of the mean pressure overnight, and consequently
might modulate leakage. According to the results of the available randomised
controlled trials (RCTs), there is only a nonsignificant marginal eect. Moreover, to
date, there is a lack of evidence that expiratory pressure relief (using EPR or C-flex)
decreases leakage significantly.
RCTs on heated humidification could not demonstrate any impact on leaks, although,
in a study in patients with nasal symptoms, there was a trend towards a decreased
time with mouth leakage.
Mask side-eects due to local pressure
Skin marks, rashes, sores and ulcers
The mask may leave marks on the patient’s skin if it does not fit properly, especially
along the bridge of the nose.
Barrier creams and mask liners, such as a so microfibre tissue which creates a
comfortable barrier between the face and the mask, can help. Silicone gel sheeting
can be used to prevent hypertrophic scarring. Better-fitting mask options should be
reassessed, and in case of severe abrasion of the nose bridge, temporary relief of
pressure should be attempted using nasal pillows.
The mask strap can induce irritation; (allergic) contact dermatitis has been described.
Changing the type of strap or replacement with a cloth strap can help.
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Side-eects associated with CPAP
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Dental or skeletal cranial changes
Sustained pressure on the teeth has the potential to cause (gum) pain, induce tooth
movement and even skeletal cranial changes. The latter phenomenon, called midfacial
hypoplasia, characterised by facial flattening and maxillary retrusion, is reported in
children using CPAP.
Dental changes are rare in adults, but retrusion of the maxilla and inward tipping
of the maxillary anterior teeth have been described. Nasal pillows may reduce
this risk.
Pressurised air-related side-eects
Nose, pharynx and vocal cord problems
A substantial number of patients suer from nasopharyngeal symptoms. Rhinitis
symptoms – nasal dryness (even epistaxis), rhinorrhea and nose congestion – are
very common, and an obstructed nose favours open-mouth breathing and results in
complaints of mouth dryness and a sore throat. Moreover, mouth leakage increases
the blood flow of the nasal mucosa, which in turn further increases nasal congestion,
creating a pathological vicious circle. Furthermore, nasal congestion can be a reason
for unintentional removal of the mask during the night. Less frequently reported are
mild vocal changes (e.g. hoarseness).
Nasopharyngeal side-eects are related to dierent mechanisms
It has been shown that CPAP-flow reduces the mucosal airway surface liquid supply,
alters ciliary function and impairs nasal mucociliary clearance. Compression applied
by CPAP on the nasal mucosa triggers local inflammation.
Treatment options
RCTs in unselected patients who started CPAP did not show a dierence in nasal
symptoms (or adherence) between patients treated with anti-inflammatory nasal
topical steroids versus patients without steroids or treated with placebo aer a short
(4-week) follow-up. However, an RCT in selected OSA patients (with at least one
symptom of rhinitis at baseline before CPAP) followed over a longer (90-day) period,
showed a significant reduction of rhinitis symptoms (and a significantly higher CPAP
adherence with an average increase of 60 min per night).
Dierent meta-analyses show that heated nasopharyngeal humidification improves
symptoms to a major extent. But, to date, no dierence in CPAP adherence has
been shown.
CPAP is a rare source of barotrauma
It is important to mention that there is no eect of post-operative CPAP use on
anastomotic leakage aer bariatric surgery.
It has been proven that pressure delivered by the CPAP machine is transmitted to
the middle ear through the Eustachian tube, resulting in an increase in middle-ear
pressure, but, to date, no deleterious eect on hearing has been noted. Nevertheless,
tympanic membrane rupture has been reported.
Pneumothorax has also been described. The underlying mechanical hypothesis is
that a sustained (albeit mild) increase in regional transmural pressure causes alveolar
inflammation and overdistension with subsequent rupture of the alveoli.
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Side-eects associated with CPAP
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CPAP can precipitate or worsen pneumocephalus and cerebrospinal fluid leakage in
cases of head trauma and in the context of trans-sphenoidal surgery (important to
consider in patients with acromegaly, a disorder strongly associated with OSA).
Cases of (pneumo)parotitis due to insuation of (infected) air into the Stensen’s duct
in patients wearing oronasal masks (which could be solved by using nasal masks) have
been described.
Ocular complications
CPAP is associated with ocular irritation
Ocular irritation includes dryness or epiphora (overflow of tears) and, very rarely,
bacterial conjunctivitis.
A prospective study showed ophthalmologically proven significant increases in signs
of ocular irritation, tear evaporation and metaplasia of the conjunctiva aer starting
CPAP compared to pre-treatment values. In contrast, others reported, aer longlasting application of CPAP, a more stable tear film and even a decline in severity of
the floppy eyelid syndrome. They attributed these findings to the necessity of sleeping
in the supine position, during CPAP therapy, to prevent mask displacement, which
prevents the mechanical eects of eye rubbing in the case of a more prone posture,
with contact of lid and palpebral conjunctiva to the pillow.
Micro-organisms delivered to the eye may invade conjunctival tissue, especially
if it lacks its full ability to act as a barrier against bacterial penetration. Bacterial
conjunctivitis (endophthalmitis) is described in patients who are suering from pellucid
degeneration (a local peripheral corneal thinning pathology) and in patients who have
undergone surgery for glaucoma consisting of the creation of a subconjunctival pocket
which acts as a reservoir to be shunted to prevent ocular hypertension.
Dierent mechanisms might play a role
Mask leakage permits airflow across the eyes. Malposition and pressure of the
mask or strap might impair the function of the lower eyelids. Moreover, the impact
of CPAP-associated retrograde airflow through the nasolacrimal duct might be
underdiagnosed. The nasolacrimal system serves as an outflow tract for the passage
of secretions from the eye to the nose and retrograde flow is prevented by valves, but
CPAP might overcome the resistance of these valves. These patients can complain of
air escape from the region of the medial canthus, with an audible hiss and even flutter
of the eyelids. When placing saline drops at the medial canthus during CPAP usage, air
bubbles can be detected at the canalicular punctae.
Guidelines to overcome ocular complications
Masks should be optimally fitted (and a change to nasal pillows should be considered).
Theoretically, humidification can help, as CPAP tends to dry the nasal mucosa, which
may contribute to nasolacrimal valve incompetence.
The link between CPAP and elevated intraocular pressure: a matter of debate
It has been documented that CPAP can induce an increase in intraocular pressure
(IOP). CPAP has been suggested to leads to an elevated intrathoracic pressure, which
in turn gives a pressure elevation in the venous circulation, which may reduce the
outflow of aqueous humour through the episcleral veins. In other studies, no eect
on IOP was noted at all. Higher quality prospective studies are necessary to clarify the
association between CPAP and IOP (and glaucoma).
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Side-eects associated with CPAP
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Other side-eects
Aerophagy
Aerophagy occurs when the pressurised air is swallowed and becomes trapped in the
gastrointestinal system. This causes abdominal discomfort, excessive burping and/or
flatulence. There is a link with gastro-oesophageal reflux. CPAP-induced aerophagy
might precipitate reflux, but patients with reflux are also prone to develop aerophagy.
Reduction of the pressure helps to alleviate the problem.
Claustrophobia
A claustrophobic reaction when starting CPAP is possible even in individuals without
an overt anxiety/panic disorder. Graded exposure therapy may be helpful.
Small weight increase
Treatment with CPAP is associated with an average weight gain of 500 g. Mechanisms
include a (small) reduction in basal metabolic rate (because of the resolution of OSA,
resulting in less sympathetic activity) and an increased energy intake (associated with
a change in leptin/ghrelin balance). More recent studies focused on the reversal of
OSA-associated nocturia and demonstrated an increase in weight due to less fluid
loss. The underlying mechanism is not completely understood.
Treatment-emergent CSA
The term treatment-emergent CSA (TECSA) has been introduced to describe OSA
patients who develop central apnoeas under treatment with CPAP. This topic is
discussed further in chapter 8.6 of this Handbook.
Further reading
• Chen N, et al. (2017). Is middle ear pressure aected by continuous positive airway pressure
use? Laryngoscope; 127: 2443–2445.
• Drager LF, et al. (2015). Eects of CPAP on body weight in patients with obstructive sleep
apnoea: a meta-analysis of randomized trials. Thorax; 70: 258–264.
• Fauroux B, et al. (2005). Facial side eects during noninvasive positive pressure ventilation in
children. Intensive Care Med; 31: 965–969.
• Ghadiri M, et al. (2020). Clinical side eects of continuous positive airway pressure in patients
with obstructive sleep apnoea. Respirology; 25: 593–602.
• Herculano S, et al. (2021). Weight gain induced by continuous positive airway pressure in
patients with obstructive sleep apnea is mediated by fluid accumulation: a randomized
crossover controlled trial. Am J Respir Crit Care Med; 203: 134–136.
• Kennedy B, et al. (2019). Pressure modification or humidification for improving usage of
continuous positive airway pressure machines in adults with obstructive sleep apnoea.
Cochrane Database Syst Rev; 12: CD003531.
• Lebret M, et al. (2017). Factors contributing to unintentional leak during CPAP treatment:
a systematic review. Chest; 151: 707–719.
• Lee SSY, et al. (2022). Sleep and eye disease: a review. Clin Exp Ophthalmol; 50: 334–344.
• Patil SP, et al. (2019). Treatment of adult obstructive sleep apnea with positive airway pressure:
an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE
assessment. J Clin Sleep Med; 15: 301–334.
179ERS Handbook: Respiratory Sleep Medicine
Side-eects associated with CPAP
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• Rotty MC, et al. (2021). Mask side-eects in long-term CPAP-patients impact adherence and
sleepiness: the InterfaceVent real-life study. Respir Res; 22: 17.
• Segsarnviriya C, et al. (2021). Eects of intranasal steroids on continuous positive airway pressure
compliance among patients with obstructive sleep apnea. Sleep Breath; 25: 1293–1299.
• Westho M, et al. (2015). Obstructive sleep apnoea and non-restorative sleep induced by the
interface. Sleep Breath; 19: 1317–1325.
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Adherence to continuous
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positive airway pressure
treatment
Alexandros Kalkanis, Bertien Buyse and Dries Testelmans
Definitions
According to the World Health Organization (WHO), treatment adherence is ‘…the
extent to which a person’s behavior – taking medication, following a diet, and/or
executing lifestyle changes – corresponds with the agreed recommendations from
a healthcare provider,’ while compliance refers to conforming to medical advice and
taking treatment as prescribed. In CPAP treatment, adherence refers to the continued
use of CPAP over time, while compliance demonstrates the use of CPAP for a certain
amount of time per day.
Adherence to CPAP therapy is a crucial health outcome parameter that can be
compromised by problems with acceptance and tolerance – the main limitations of
CPAP treatment. Using a non-adherence criterion of <4 h of nightly CPAP usage on
70% of nights, CPAP non-adherence has been estimated to be 29–83% in dierent
studies. In a recent French database, overall rates of CPAP therapy termination
aer 1, 2 and 3 years were 23.1%, 37.1% and 47.7%, respectively. Another recent
cohort from Belgium showed higher compliance and a lower discontinuation ratio of
14.7% aer 1 year, presumably due to the integration of multidisciplinary care and a
structured approach to the management of patients.
There is evidence of a dose–response association between the duration of nocturnal
CPAP treatment and the alleviation of EDS, as well as a decrease in arterial hypertension.
Previously, the accuracy of PAP adherence estimates was restricted by self-reporting
– adherence was frequently overestimated by ∼1 h. Nowadays, data extracted from
the newer generation of PAP machines can objectively document the cumulative time
Key points
• Poor adherence to CPAP is widely recognised as a significant limiting factor in
treating sleep apnoea.
• Risk factors for non-adherence should be continuously assessed.
• Optimisation of the physical and psychosocial aspects of the treatment should
be attempted from the start.
• Technology can help with optimisation of the treatment, monitoring and
active patient engagement.
181ERS Handbook: Respiratory Sleep Medicine
Adherence to CPAP treatment
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that the PAP device works at an adequate pressure. Therapeutic eects are considered
optimal when CPAP is used for ≥6 h every night. That said, the general principle in
sleep apnoea treatment is: the longer the duration of the use, the better the result.
This chapter will present the latest knowledge regarding determinants of CPAP
adherence and will discuss the dierent interventions we could use to improve it.
Determinants of adherence
The initial severity of daytime sleepiness has been linked to enhanced CPAP usage,
and an ESS score of >10 has been shown to be an independent predictor of longterm CPAP use. The patient’s perception of symptoms, as well as improvements in
sleepiness and daily functioning, also appear to be essential factors in determining
compliance. The severity of the sleep apnoea itself, as measured using the AHI at
diagnosis, has not been recognised as a reliable predictor of CPAP adherence. However,
a higher residual AHI in the first week of treatment seems to aect the perception of
improvement and lead to reduced CPAP use.
Pre-treatment demographic and anthropometric factors – age, BMI, sex and marital
status – have not been consistently related to CPAP adherence. However, a recent
sizeable telemonitoring study investigated specific subgroups and showed substantial
variability in the pattern of use, with lower adherence in adult women <30 years of age.
There is evidence in the current literature that African-Americans tend to have lower
CPAP adherence. The causes of this disparity are unknown; however, it may primarily
be due to dierences in socioeconomic background. Unfortunately, because of the
scarcity of relevant data, further research is needed regarding the eect of race and
socioeconomic factors.
While the presence of a partner and support at home has an important positive
influence on CPAP compliance, it is also possible that CPAP may bother the patient’s
partner, leading to reduced intimacy, interference with their sexual relationship and
non-adherence. Involvement of the family should be strategically encouraged by the
sleep physician from the start, and discussion with the patient’s partner about the
possible eect of treatment on the other person’s sleep quality can improve social
support and influence adherence.
The patient’s personality has been shown to play a role not only in self-perception of
symptom severity and the eect of treatment but also in a more realistic approach
to the benefits of CPAP, better coping skills with regard to side-eects and better
adherence. Adherence can be regarded as the interplay between self-ecacy,
treatment expectancy and risk perception in the patient.
Despite the eect of these psychological elements, depression and anxiety, as
evaluated by questionnaires and scales, do not appear to have a substantial influence
on CPAP adherence. However, claustrophobic tendencies can be aggravated by the
material of the treatment itself and can aect both compliance and adherence.
Interventions: adaptations to CPAP in order to improve adherence
The initial period of treatment with CPAP is considered the ‘golden phase’. This is
a topic of interest for interventions, as the successful early adoption of CPAP use
has been associated with long-term adherence. The utilisation of CPAP treatment
within 1–3 months aer its initiation was associated with long-term CPAP treatment
continuation.
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Adherence to CPAP treatment
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In general, treatment-emerging side-eects have not been shown to impact
adherence, but some of them, such as frequent awakenings and dry mouth,
can reduce the use of the CPAP and increase the early drop-out rate. As a result,
interventions that target patient comfort have been investigated.
Nasal side-eects are commonly reported and could result in reduced adherence to
CPAP therapy or discontinuation of treatment. Topical nasal steroids are widely oered
as a treatment option for nasal symptoms caused by CPAP therapy. Administration of
nasal steroids in the first month of CPAP titration in unselected OSAS patients has
been shown to have no beneficiary eect on either nasal congestion or compliance.
In contrast, the addition of a humidifier decreased the frequency of nasal symptoms;
however, compliance and quality of life remained unaltered. These results have been
challenged elsewhere: in small studies, the use of a humidifier has been shown to
make a relatively small improvement to compliance, ranging 0.2–0.5 h, but no eect
was seen on the quality of life or sleepiness. Humidification of the inspired gas can
improve inflammation and airway resistance, thus enhancing the comfort of nasal
breathing; however, no significant improvement in the compliance of unselected
patients has been noted.
The use of specific pressure algorithms that are designed to address pressurerelated discomfort, such as expiratory pressure-relief technologies and the ramp
feature, has shown no objective benefit regarding adherence to treatment.
However, in patients requiring high levels of therapeutic pressure (>10 cmH2O)
and reporting side-eects with conventional CPAP, the use of auto-titrating
CPAP has been associated with a reduction in the mean applied therapeutic
pressure, greater comfort and improved adherence. However, in unselected
patients, comparison of auto-titrating CPAP systems with regular CPAP units has
shown comparable adherence. When it comes to other modes of delivering PAP,
no dierence has been noted between CPAP and BPAP. Furthermore, no substantial
dierence has been noted between CPAP and auto-CPAP in adults with moderateto-severe sleep apnoea who are beginning PAP therapy.
Another intervention that has delivered mixed results in the improvement of
compliance and adherence is the addition of a sedative-hypnotic drug early on in CPAP
initiation. It has been shown that patients receiving eszopiclone for the first 14 nights
are less likely to discontinue CPAP and will use CPAP for more nights and for more
extended periods per night than patients receiving placebo. Other studies on the use
of Z-hypnotics, though, have failed to show consistent improvement in adherence.
This medication could be considered in patients with concomitant insomnia that
aects their total sleep time and their CPAP compliance and adherence.
Education/support
Although results reported in the literature are inconsistent, CPAP adherence can
be optimised with labour-intensive approaches, such as detailed support and
education. These strategies include detailed training and coaching during titration,
regular nursing visits and follow-ups. Visits also add to the patient’s sense of
accountability, thereby improving the eect of education alone. Scheduled followups are largely determined by the healthcare service of the relevant country, in order
to control compliance in the framework of reimbursement. While structured followup improves treatment adherence, the optimal follow-up type and frequency are yet
to be established.
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