CPAP has long been the gold standard for treating obstructive sleep apnea (OSA). OSA is one of the main reasons many patients come to The Insomnia and Sleep Institute of Arizona. Today, implants are available for some patients who are considered CPAP intolerant. What exactly, however, does that phrase mean?
Adherence to CPAP therapy remains notoriously low, but that doesn’t necessarily mean a person is CPAP intolerant. For example, bad sleep hygiene, challenges with the upper airway, and barriers that can actually be broken down are not “CPAP intolerance.” (1) Unfortunately, the term is often overused and misunderstood.
Why CPAP Intolerance Is Often Misunderstood
In the vast majority of cases, so-called CPAP intolerance is actually a set of barriers that can be overcome. OSA is rarely a patient’s only sleep issue, and other disorders or habits may interfere with CPAP use.
One of the most common problems is poor sleep hygiene. These behaviors interfere with falling and staying asleep and, in turn, interfere with CPAP therapy. For example, some patients say they can’t put on their CPAP mask because they need their glasses on to watch TV in bed,even though screen time right before sleep is known to disrupt sleep. (1).Ideally, all screens should be avoided for at least two hours before bedtime. (2).
You might be surprised to learn just how common this struggle is, even among people you’d least expect. NBA legend Shaquille O’Neal, one of the most physically dominant athletes in sports history, was diagnosed with severe sleep apnea after undergoing a study at Harvard Medical School, which revealed that he stops breathing 72 times per hour. His words after getting treatment? “I feel good, the weight is good, got a lot of energy, the relationship is good at the house. Everything is working.” (3). If a 7-foot, 325-pound superathlete had to face and overcome the challenges of sleep apnea therapy, you are absolutely not alone in finding it difficult.
Insomnia, RLS, and OSA
Insomnia is another very common sleep disorder, and OSA can actually contribute to chronic insomnia. Patients may also be compensating for OSA, knowingly or not, by doing things like drinking too much caffeine during the day, taking naps longer than 20 minutes, and smoking (1). All of these things also feed insomnia, and a vicious cycle begins. There are some patients with insomnia who are diagnosed with OSA who say that CPAP makes their insomnia worse (1). This is where cognitive behavioral therapy for insomnia (CBT-I) can help, and we have an expert on site who provides this therapy. Having trouble going to sleep or staying asleep isn’t in itself CPAP intolerance, but rather it may be insomnia which is exacerbating CPAP non-adherence.
Restless Legs Syndrome and CPAP Challenges
Restless legs syndrome (RLS) is another commonly-identified sleep disorder that may occur alongside insomnia and OSA. Patients with RLS often complain that CPAP equipment does not stay in place and may even blame CPAP for their symptoms (1).
However, the amount of movement associated with untreated RLS can interfere with any sleep equipment. (1). Treatment options for RLS often improve CPAP adherence significantly. Many patients have multiple sleep disorders, and some go undiagnosed for years.
What Really Gets in the Way of CPAP Adherence
Conditions such as sleepwalking or other parasomnias can disrupt sleep patterns and make treatments harder to follow. Irregular sleep patterns are strongly linked to lower CPAP adherence, showing how closely sleep behavior and therapy success are connected. (4)(5)
CPAP machines also appear frequently in pop culture, from sitcom jokes to everyday characters using them as part of their routine, reflecting how widespread sleep apnea truly is. (6)
Fans of The King of Queens may remember Doug’s CPAP machine being used as a joke. In The Big Bang Theory, Howard’s mom can be heard using one in several scenes. And in The Office, Angela uses her CPAP like part of her normal routine, which helps show that women can have sleep apnea too (7). The fact that CPAP keeps showing up on our screens is not a coincidence.It reflects how widespread these challenges truly are.
Medications and Medical Factors That Affect CPAP Tolerance
Also bear in mind that medications like antidepressants, stimulants, and antihistamines can affect CPAP adherence (1). Talk to your medical team about how pharmaceuticals may be interacting with your sleep (and CPAP usage).
Upper airway problems, such as rhinitis, can result from improper mask fit or poor cleaning habits, such as algae buildup in humidifiers. Additives like essential oils can also be problematic (1). If a patient has GERD, this can cause excess mucus production and upper airway challenges (1).
CPAP therapy works for the vast majority of patients but it often requires collaboration, adjustment, and customization to find the right fit.
Dr. Gerard Meskill, a board-certified sleep specialist and medical reviewer at SleepApnea.org, explains it well: “Many times non-compliant CPAP stems from one or more treatment variables being wrong, rather than from lack of will power. The initial pressure at the beginning of the night, the pressure range throughout the night, the mask type and fit, the humidifier settings, and the exhalation relief setting can all impact a patient’s ability to tolerate CPAP therapy. These devices aren’t just plug and play, and you cannot ‘just get used to it’ if the settings are incorrect.” (8)
This is echoed by Dr. Carlos Nunez, Chief Medical Officer at ResMed, one of the world’s leading CPAP manufacturers, who put it plainly: “We don’t have to run more clinical trials to prove that sleep apnea is bad and that CPAP works. We are 40 years into this journey. We now have to encourage people to be more aware of sleep health and deal with the stigma around CPAP therapy.” He even compared using a CPAP to wearing glasses for nearsightedness or insoles for flat feet, which are simple, matter-of-fact corrections for how your body is built (9). There is no shame in needing a tool to breathe properly at night.
Tragically, the consequences of ignoring sleep apnea can go far beyond feeling tired. NFL legend Reggie White — twice named NFL Defensive Player of the Year and a Hall of Famer — died in 2004 at only 43 years old. His death was attributed to a heart attack compounded by complications from sleep apnea (10). A man in peak physical condition, taken too soon — in part because a sleep disorder went undertreated. This is not a condition to manage lightly.
Signs CPAP May Not Be Working for You
CPAP should reduce apnea events and improve sleep quality. If that is not happening, adjustments may be needed.
Common signs include:
- Ongoing daytime sleepiness
- Frequent nighttime awakenings
- Waking up unrefreshed
- Continued snoring or breathing pauses
- Mask leaks or dry mouth
- Nasal congestion
- Pressure that feels too strong or too weak
- Removing the mask during sleep without realizing it
Data from the CPAP machine can provide useful insight. A high apnea-hypopnea index (AHI), leak alerts, or inconsistent usage hours often indicate that therapy needs optimization.
Who Qualifies for CPAP Alternatives Like Inspire Therapy?
CPAP alternatives are considered only when a patient is unable to use CPAP consistently despite proper adjustments and support. This typically means the patient has tried multiple masks, pressure settings, and addressed other sleep-related issues but still cannot tolerate therapy.
Inspire therapy is one option for select patients with obstructive sleep apnea. Candidates are typically adults with moderate to severe OSA who are not benefiting from CPAP. Evaluation includes a detailed sleep study, airway assessment, and overall health review.
Not every patient qualifies. Factors such as body weight, airway structure, and the type of apnea all play a role in determining eligibility. A sleep specialist will assess whether the airway collapses in a pattern that can be treated with Inspire.
The goal is to find a treatment that the patient can use consistently. Proper evaluation ensures that alternatives are only recommended when CPAP is no longer a workable option. Contact us.
Dr. Ruchir P. Patel Shares His Own Personal CPAP Journey
In this short teaser from the Dr. Ruchir P. Patel: The Real Sleep Doc podcast, Dr. Patel opens up about his own experience with CPAP therapy. Listen to the rest of the episode here.
Stay tuned for more insights in upcoming episodes!
References
- Watenpaugh, D. (2023, May 9). ‘CPAP Intolerance’ Is a Sweeping, Misused Phrase. Sleep Review. https://sleepreviewmag.com/sleep-treatments/therapy-devices/cpap-pap-devices/cpap-intolerance-misused-phrase/
- Bobby. (2022, March 13). Screen Use Disrupts Precious Sleep Time – National Sleep Foundation. National Sleep Foundation. https://www.thensf.org/screen-use-disrupts-precious-sleep-time/
- Did You Know These 6 Famous People Use a Sleep Apnea Device? – CPAP.com Blog. (2026). Cpap.Com. https://www.cpap.com/blogs/sleep-apnea/famous-people-use-sleep-apnea-device
- Howell, M. J. (2012). Parasomnias: An Updated Review. Neurotherapeutics, 9(4), 753–775. https://doi.org/10.1007/s13311-012-0143-8
- Gupta, R., Das, S., Gujar, K., Mishra, K., Gaur, N., & Majid, A. (2017). Clinical Practice Guidelines for Sleep Disorders. Indian Journal of Psychiatry, 59(5), 116. https://doi.org/10.4103/0019-5545.196978
- Sawyer, A. M., King, T. S., Sawyer, D. A., & Rizzo, A. (2014). Is Inconsistent Pre‐Treatment Bedtime Related to CPAP Non‐Adherence? Research in Nursing & Health, 37(6), 504–511. https://doi.org/10.1002/nur.21631
- Overmyer, B. (2025, February 25). Sleep Apnea in Pop Culture: How Movies and TV Get It Right (or Wrong!). CPAPnation; CPAPnation. https://www.cpapnation.com/blogs/news/sleep-apnea-in-pop-culture-how-movies-and-tv-get-it-right-or-wrong
- CPAP Compliance | SleepApnea.org. (2024, June 27). SleepApnea.Org. https://www.sleepapnea.org/cpap/cpap-compliance/
- forsythe. (2025, October 21). “Not Your Grandfather’s CPAP”: Improving Sleep Apnea Therapy Adherence With Emerging Technology – IEEE Pulse. IEEE Pulse. https://www.embs.org/pulse/articles/not-your-grandfathers-cpap-improving-sleep-apnea-therapy-adherence-with-emerging-technology/
- Airing. (2017, June 16). Airing. https://www.fundairing.com/journal/2017/6/15/19-celebrities-with-sleep-apnea
Disclaimer: The information provided in this blog post is for educational and informational purposes only and is not intended as a substitute for professional medical advice, diagnosis, or treatment. Always consult with a licensed healthcare provider for recommendations specific to your individual health needs.
