Why I Don’t Recommend CPAP as the Only Long-Term Solution 

Continuous Positive Airway Pressure (CPAP) is one of the most effective treatments for obstructive sleep apnea (OSA). It works by delivering positive airway pressure through a mask to keep the upper airway open during sleep. For many patients—particularly those with significant OSA—it can be highly effective and may substantially improve sleep quality and daytime symptoms.

So why, as an ENT and sleep surgeon, do I sometimes look beyond this solution?

The answer is simple: CPAP treats the airway obstruction while the patient is wearing the device. It does not necessarily correct the anatomical reason why the airway is collapsing in the first place.

For some patients, particularly those with an identifiable structural obstruction, I believe it is important to evaluate whether a more definitive or patient-specific treatment is appropriate.

1. It Is a Treatment, Not Always a Cure

The machine keeps the airway open by applying positive pressure during sleep. When the machine is stopped, the underlying tendency for the airway to obstruct can return.

This makes it an excellent ongoing treatment, but not necessarily the ideal definitive solution for every patient.

For example, a patient may have significant anatomical narrowing caused by:

• Enlarged tonsils
• Nasal obstruction
• Deviated nasal septum
• Enlarged turbinates
• Palatal or pharyngeal narrowing
• Tongue-base obstruction
• Other structural abnormalities

In such patients, an ENT evaluation can help determine whether correcting the underlying obstruction could reduce or eliminate OSA.

2. The Mask Can Be Difficult to Live With

Common problems include:

• Mask discomfort
• Air leakage
• Difficulty finding the right mask
• Claustrophobia
• Difficulty falling asleep with the mask
• Skin irritation
• Nasal congestion
• Dry mouth or nose
• Nosebleeds

These side effects are recognised problems and can often be improved by changing the mask, adjusting settings or using humidification.

Therefore, difficulty with using the device should not simply be accepted as inevitable. It should trigger troubleshooting and, where appropriate, consideration of other treatment options.

3. Long-Term Adherence Is Critical

A patient who owns the machine but cannot tolerate it, removes it during sleep or uses it inconsistently may not receive the full therapeutic benefit.

This is one reason why treatment should not end with simply prescribing a machine.

The patient needs:

Diagnosis → appropriate treatment selection → CPAP optimisation if indicated → follow-up → assessment of effectiveness and adherence.

4. Other Treatments for OSA

Treatment should be individualised according to the severity of OSA, anatomy, weight, associated medical conditions, patient preference and ability to tolerate treatment.

Depending on the patient, options may include:

Lifestyle and Weight Management

For patients who are overweight or obese, appropriate weight management can form an important part of OSA treatment.

Avoiding alcohol and sedating medications when medically appropriate, and addressing sleep position, may also help selected patients.

Oral Appliance Therapy

A custom, titratable mandibular advancement device can be an alternative for selected adults, particularly those who cannot tolerate CPAP or prefer an alternative treatment.

Surgery

Surgery may be appropriate when there is a significant anatomical obstruction that can be addressed surgically.