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By: Rita Brooks on September 25th, 2017

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Pros & Cons of APAP Therapy

Sleep Disorders

As a sleep technologist, you already know the importance of a good night’s sleep. Sleep plays a vital role in well-being and health. It’s crucial to sleep well to protect both mental and physical functioning. When a patient doesn’t sleep well, it can be harmful over time. Lack of sleep can cause chronic health problems like stroke, heart disease, diabetes, kidney disease, and high blood pressure. It can also increase the risk of obesity.

According to the American Psychological Association, as many as 40 million Americans suffer from more than 70 different types of sleep disorders. In patients with sleep apnea, multiple health problems can occur if they can’t get quality sleep at night.

Below we look at the pros and cons of APAP therapy so that you’ll be able to speak to your patients in a knowledgeable and beneficial way about their sleep apnea treatment.

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What is APAP Therapy?

APAP is the shortened term for Automatic Positive Airway Pressure. It’s one of the three primary types of positive airway pressure that opens the airway during sleep. The APAP machine connects via a mask to a pressure generator.

As an analogy, APAP therapy works by the air pressure acting like a splint. It stops the throat from collapsing in on itself, thus allowing your patient to breathe freely throughout the night without experiencing sleep apnea events.

The majority of machines employ a set pressure that’s determined during a titration study in the sleep center. The APAP machine has two separate settings. One is low pressure; the other is high. These different pressures allow the machine to automatically adjust to your patient’s varying pressure needs throughout the night as they change sleeping positions or go through their various sleep stages.

The APAP machine increases automatically as needed to allow normal breathing during sleep. When the patient has an obstructive apnea, the APAP machine increases pressure just enough to return breathing to normal. The air pressure from the machine rises and falls throughout the night as needed to keep the airway open.


There are many different sleep apnea treatments on the market today. The most popular are APAP and CPAP machines. Choosing the correct treatment is crucial to managing your patient’s condition.

There are several differences between APAP and CPAP machines, but the main one is that CPAP machines offer one steady airway pressure (that must be set by a doctor or sleep specialist) and APAP machines have airway pressure that can adjust automatically based on your needs.

Let’s take a look at the differences between APAP and CPAP:

  • Multiple breathing changes. In general, patients who experience multiple changes in their breathing throughout the night tend to opt for APAP machines to manage and treat their sleep disordered breathing. People who have a pattern of continuous events over time usually opt for CPAP treatments. Some patients do very well in general with the continuous airway pressure delivered with CPAP. Others begin their treatment with a CPAP machine and find that that they cannot tolerate continuous airflow or that CPAP does not help them manage their symptoms enough, so they move on to an APAP machine. APAP machines have a built in algorithm that determines the amount of airway pressure a patient needs at any given time and adjusts accordingly.
  • Tossing and turning throughout the night. APAP machines are oftentimes better suited for patients who tend to toss and turn throughout the night. Because of gravity, patients in REM sleep or supine sleepers have the most respiratory events as opposed to people who sleep prone or laterally. The APAP machine automatically adjusts the air pressure higher during these periods when more severe events tend to occur. It also lowers pressure accordingly when the patient is in a sleeping position where respiratory events are reduced.
  • REM sleep. REM sleep is a deep stage of sleep that restores cognitive functioning and memory. Throughout this stage, breathing is irregular, temperature isn’t regulated and blood pressure can often spike. These changes are true for everyone, whether or not they have sleep apnea. For people who have REM related sleep apnea, the APAP device is ideal as it only increases pressure to compensate during this sleep stage.
  • Weight changes. CPAP machines don’t allow for physical changes in patients, such as weight loss, for example. It’s generally recommended that after a patient increases or decreases their body weight by ten percent, a CPAP patient should undergo an evaluation to see whether they need an increase or decrease in pressure. A CPAP’s constant pressure setting might eventually be too weak or too strong for the patient's needs. With an APAP machine, pressures adjust automatically to compensate for any weight loss or gain that may occur over a protracted time period.
  • Drinking alcohol. Drinking alcohol close to bedtime increases the severity of obstructive sleep apnea. CPAP pressure isn’t always enough to maintain an open airway under these circumstances. But, APAP is flexible enough to adjust to the level of airway resistance, so keeps the airway open.
  • Home sleep apnea test (HSAT). If your patient receives a diagnosis via a home sleep apnea test (HSAT) that is not followed up with an in-laboratory PAP titration, an APAP machine may be the best course of action. This is because HSAT is unable to determine sleep stages, and APAP can be used to determine the range of CPAP that’s needed throughout the night.
  • Comfort. CPAP therapy can be claustrophobic. Some patients, especially new ones, find that CPAP causes feelings of claustrophobia, particularly at high pressures. These feelings can be overwhelming when a patient attempts to exhale against high pressure and there is a continuous flow of air coming back at them. APAP is, however, adjustable and generally starts at low pressures which can help to overcome those experiencing feelings of claustrophobia with CPAP.
  • Pressure settings. CPAP machines can only be set to one pressure setting. The setting remains exactly the same throughout the night no matter how much pressure the patient needs to keep their airway open. A doctor must adjust the CPAP machine if there are any changes. Patients may find this inconvenient.

Pros of APAP Therapy

There are various positives of APAP therapy. These include:

  • Two different modes - two machines in one.  APAP machines offer continuous mode (CPAP) or auto adjusting mode. This allows patients to try out both CPAP and APAP without changing devices
  • Adapts pressure for different sleeping positions. Because the pressure can change throughout the night, patients can change sleeping positions and receive the amount of pressure they need.
  • Increased comfort. Patients typically require less pressure in lighter sleep stages, but APAP machines only deliver higher pressure when apnea events are occurring. Because they’re only getting the pressure they need, patients often report a more comfortable night's sleep using APAP. This is also why APAP therapy has better adherence rates than CPAP therapy.
  • Adapts to changing lifestyle/circumstances. If a patient loses weight or has allergies that cause congestion, they don’t have to have their APAP machine pressure setting adjusted by their doctor, because it will adapt to their changing needs. For example, if a patient has a stuffy nose or congestion, the APAP machine adjusts pressure accordingly to deliver just the right level of air pressure to allow them to breathe.

Cons of APAP Therapy

Although APAP therapy has many positives, there are a few potentially unfavorable aspects to consider. These include:

  • Cost. APAP machines are sophisticated devices. Because of this, they tend to be more costly than CPAP machines, and some insurance plans do not provide coverage for them.
  • Adjustments can be slow. When the machine adapts, sometimes it can be a little slow to make adjustments, and this can cause disturbances in sleep. If the machine makes several disturbing adjustments throughout the night, sleep quality can suffer.
  • Patients with certain health conditions should not use APAP. People with chronic heart failure or obesity hypoventilation syndrome are not appropriate candidates for this therapy.

Your patients need to get enough good quality sleep at the right times to help them function well throughout the day. When someone is sleep deficient, they’re consequently less productive. They take far longer than usual to finish tasks, make more mistakes, and have slower reaction times. After several nights of losing sleep, even with a loss of just a few hours per night, a patient’s ability to function suffers as if they’ve not slept even for a day or two.

It’s crucial to have all the facts before you suggest APAP to your patients. Remember that there are many treatments for sleep apnea on the market today. Work with your patients and their medical team to find the best route to getting a good night’s sleep. Choosing the correct device can make a huge difference to your patient’s overall quality of life.

To find out more, download our complimentary eBook, "Increase PAP Adherence," which was developed as part of AAST's mission to educate sleep technologists.

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