The Beginner's Guide to Starting CPAP
Why It's Harder Than You Expected (And What To Do About It)
Starting CPAP therapy can feel overwhelming at first, but most early challenges have practical, treatable solutions.
You would think getting diagnosed would be the hardest part. I'm not saying that process is easy. Scheduling appointments, dealing with insurance, completing the sleep study itself. Hoops and hoops to jump through, usually. But now you've been diagnosed with sleep apnea and prescribed this thing called CPAP.
The quality of instruction and support people receive after diagnosis varies tremendously. Some people leave their appointments feeling informed and supported. Others go home with a machine, a quick demonstration, and a lot of unanswered questions. And now you're expected to sleep every night with this wacky thing blowing pressurized air into your nose or mouth.
Given the hundreds of masks available on the market, there's often an annoying amount of trial and error involved in finding one that fits comfortably, doesn't leak, works well with your sleeping position, and has the right pressure and humidity settings.
Many people assume they have to stick with the first mask they're given.
You don't.
In fact, I encourage all of my clients to be a squeaky wheel with the durable medical equipment (DME) company if needed. If the first mask isn't comfortable, leaks excessively, or simply isn't a good fit, ask to try another one. And if that one doesn’t work, ask for another one. Keep bugging them until you have something that works for you.
But wait, there’s more. Then, once you’ve got the right mask, you might be dealing with gas, skin irritation, dry mouth, rainout, pressure adjustments, and all the other fun side effects.
Many early CPAP challenges are common and often have practical solutions. Identifying the specific problem is the first step toward making CPAP more comfortable and sustainable.
Oh, and I have to clean this thing how often?!
Great. Another #$^&@*% thing to do.
And then there’s the stigma some people feel about wearing one of "those Darth Vader machines." What if my partner no longer finds me attractive or my kids make fun of me? How am I going to date or travel with this thing?
Believe it or not, though, I've had many clients eventually describe their CPAP as "my best friend."
Once they get through those early obstacles—and yes, there are many—they become completely different people. They're finally getting restorative sleep for the first time in years. They have more energy. Their concentration improves. They're no longer falling asleep in meetings or while watching television. Their partners are commenting that they seem like themselves again.
Once all of those practical issues have been resolved, barriers can remain that don't get talked about nearly enough. They're less obvious than a leaking mask, but they often determine whether someone gives up on CPAP or successfully makes it part of their life.
Over my years of specializing in sleep disorders, I've noticed these challenges tend to fall into four broad categories. Once we know which barrier we're dealing with, the next steps become much clearer.
Before We Talk About the Barriers: Rule Out Mechanical Problems
I recommend addressing all equipment problems with your doctor and/or the DME company first. This includes mask fit, leaks, humidity, pressure settings, and other side effects. If you've addressed those issues and you're still struggling, one of the four barriers below may be what's keeping you from using CPAP consistently.
Most people don't adjust to CPAP overnight. Long-term success usually comes from addressing both equipment issues and the psychological barriers that can make treatment difficult.
The Four Hidden Barriers to CPAP Success
Barrier #1: The Mask Makes You Anxious
For some people, CPAP isn't just uncomfortable. It's threatening.
I eventually adjusted to this thing and had a great time in the ocean. The same gradual approach can help many people adjust to CPAP.
I remember the first time I went snorkeling. Once my face was in the water, I started hyperventilating. I felt like I couldn’t breathe. Except I knew I could breathe. I kept thinking, “I know I can breathe, so why can’t I breathe?” My brain just wasn’t getting the memo somehow because I was having to breathe through this unfamiliar device. Plus, I think open ocean is an unnatural habitat for a human like me who grew up on the plains of West Texas.
Restricted facial movement and unfamiliar air pressure can easily be perceived as threats by our brains. Couple this with the fact that this unnatural situation is happening at night when we naturally feel more vulnerable. And some people are just more inclined toward claustrophobia.
In Austin, a popular spot to hang out in the summer is Barton Springs Pool. The water temperature is 68-70 degrees year-round (this is cold for a Texan). There is a long-standing debate about the best way to get into Barton Springs. Some advocate jumping in all the way and tolerating that initial shock to the system. But that method doesn’t work for everybody. Some people ease their way in gradually and adjust little by little. We all end up in the pool no matter how we got in.
At Barton Springs, some people jump right in while others ease into the cold water a little at a time. Adjusting to CPAP often works the same way—gradual exposure can be more effective than forcing yourself through the discomfort.
We can do that with your CPAP mask. There is an established, step-by-step protocol for desensitizing you to wearing this device. If anxiety or claustrophobia is the main obstacle, the solution isn't forcing it.
It's gradual exposure, the same way we treat all other phobias.
Barrier #2: You Also Have Insomnia
So often, there is an assumption that if we just treat the apnea, the sleep will improve. And this might be true if apnea is the only condition we’re dealing with. But insomnia occurring alongside sleep apnea is common enough that it gets its own acronym: COMISA.
CPAP is ultimately a breathing treatment, not a sleep treatment. It uses pressure to keep your airway open so you don’t stop breathing in your sleep. That will do nothing to address any insomnia that has shown up along the way.
People with sleep apnea alone often fall asleep without difficulty but experience repeated brief awakenings caused by breathing interruptions.
Unlike sleep apnea, insomnia is characterized by prolonged periods of wakefulness and difficulty returning to sleep, requiring a different treatment approach.
In a person with only sleep apnea, their night tends to look like this: fall asleep quickly, have short awakenings throughout the night, able to return to sleep quickly after awakening, may or may not remember the awakenings.
In a person who also has insomnia, you’ll see long blocks of time awake either at the start of the night or over the course of the night. Further, someone with insomnia will develop a lot of anxiety about their sleep and exert a lot of effort to fix it.
None of the insomnia is happening because you stop breathing. It’s an entirely separate problem, and it needs an entirely separate treatment.
The gold standard treatment for insomnia is Cognitive Behavioral Therapy for Insomnia (CBT-I), which helps retrain the brain and body to sleep again. So long as insomnia is present, I don’t think we’re going to have any success wearing CPAP.
Barrier #3: You're Learning to Live With a Chronic Condition
Some people assume sleep apnea can be fixed. Maybe after surgery or losing weight. Some people do lose their apnea after surgery or weight loss, sure. But not everybody is a candidate for surgery and not everyone’s apnea is tied to their weight to begin with.
For many, sleep apnea is something you’ll manage rather than cure.
When you get strep throat, you take antibiotics to get rid of it. When you break a bone, it eventually heals. Those are acute illnesses. They have a beginning, treatment, and an end.
Chronic illnesses are different, and sleep apnea is probably better understood as a chronic illness. That means treatment focuses on managing the condition over time rather than permanently eliminating it.
CPAP isn't designed to cure sleep apnea. It's designed to manage it. It’s like glasses for nearsightedness.
That realization can bring up a surprising number of emotions. Some people feel relieved they finally have an explanation. Others feel frustrated. Some feel embarrassed. Some grieve the idea that they may need a machine for years to come. All of those reactions are normal.
Unfortunately, these emotional reactions often receive very little attention during busy medical appointments.
Acute vs. Chronic Illness
Understanding sleep apnea as a chronic condition—not an acute illness—can help explain why successful treatment focuses on long-term management rather than a one-time cure.
Here’s a way to think about the differences between acute and chronic health problems. Acute illnesses generally have a rapid onset, a predictable course, and are often curable. Chronic illnesses usually develop over time, have multiple contributing factors, and require ongoing management rather than a one-time cure.
For many people, obstructive sleep apnea fits much better into this second category. Recognizing that shift can help explain why adjusting emotionally to CPAP sometimes takes longer than expected.
Barrier #4: Part of You Wants to Use CPAP—and Part of You Doesn't
This is probably the barrier that surprises people the most. You can fully understand that CPAP is important...and still not want to use it. Those two things can both be true. Psychologists call this ambivalence. Ambivalence means wanting two things at the same time.
You feel these things:
Mixed feelings about CPAP are normal. You can genuinely want the benefits of treatment while also disliking parts of using the equipment. Recognizing that ambivalence is often the first step toward making intentional, long-term changes.
"I want to live longer."
"I want more energy."
"I don't want to snore anymore."
"I don't want to keep falling asleep during the day."
And also these:
"This thing is uncomfortable."
"I hate cleaning it."
"I don't want to wear this every night."
"What if I never get used to it?"
"How am I supposed to date with this thing?"
Neither cluster is true at the expense of the other. Both are trying to protect something important. The problem isn't that you're ambivalent. The problem is pretending you're not.
When people feel wrong for having mixed feelings, they often avoid using CPAP altogether. Instead, I encourage people to get curious. What are the advantages of using CPAP? What are the disadvantages? Let’s acknowledge that there are downsides to any “healthy” behavior. I’m middle-aged, and still don’t think vegetables taste good.
What do you hope your life looks like a year from now? What gets in the way of moving toward that future? Any significant behavior change comes with ambivalence. Once people understand both sides of their motivation, they're much more likely to make intentional decisions instead of reacting emotionally in the moment.
The Bottom Line
Most people think using CPAP successfully is simply a matter of discipline. In my experience, that's rarely the whole story. Sometimes the barrier is mechanical. Sometimes it's anxiety. Sometimes untreated insomnia is still getting in the way. Sometimes you're grieving the diagnosis of a chronic condition. Sometimes part of you simply isn't convinced the effort is worth it yet.
Each of those barriers has a different solution. The goal isn't to force yourself to "just use the machine." The goal is to identify what's actually standing in your way and address that specific problem. Once you do that, using CPAP often becomes much easier than trying to push through obstacles that no one ever acknowledged in the first place.
If this guide resonated with you and you are located in Texas, reach out to schedule a consultation. I offer support for people struggling to use their CPAP.
About the Author
Jessica Fink, LCSW-S, is a therapist in private practice in Austin, TX. She has 19 years of experience in the mental health field, and her practice specializes in sleep disorders and behavioral sleep medicine. She is a member of the American Academy of Sleep Medicine and the Society of Behavioral Sleep Medicine.