Still can't sleep on CPAP?

If you're on CPAP and still lying awake, it may be insomnia as well as apnea. Between a third and a half of people with sleep apnea have insomnia symptoms too. CPAP keeps your airway open, but the insomnia, with habits and worries of its own, often needs separate treatment.

Why can't I sleep with CPAP?

Bad nights on CPAP usually have more than one cause. After years of broken sleep, waking up can become a habit, and you start to expect it. The mask takes getting used to, with the feel of it on your face, the pressure, the noise, a dry mouth. Lying awake in a mask can feel confining too, and some nights you pull it off half asleep and wake up without it.

Getting used to the mask

Tell your sleep clinic or equipment supplier exactly what's bothering you, like air leaking from the mask, a blocked nose, a bloated stomach from swallowed air, or pressure that feels too strong to breathe out against. A leak or a setting that's off can wake you on its own, and they can see both in your machine's data. Humidity and a slow start, which many machines call ramp, can usually be adjusted.

Some people find it helps to wear the mask with the air on for a while in the evening, on the sofa watching TV or reading, so it feels familiar before you sleep in it. A behavioral sleep specialist can help with this too. Ask about CPAP desensitization.

Keep using it while you sort things out, and talk to your clinic before you stop, because untreated apnea can leave you sleepy in the day. Don't drive when you're drowsy. If CPAP really doesn't suit you, there are other treatments to ask about.

The insomnia side

Treating the insomnia helps, and it can help with CPAP too. In a trial of 145 people with insomnia and moderate or severe apnea, those who had four sessions of CBT-I with a psychologist before starting CPAP used their machine about an hour longer each night on average, and their insomnia improved more. Other trials haven't all found the extra CPAP use, but CBT-I has usually helped the insomnia, including in people already on CPAP.

A few CBT-I habits fit alongside CPAP. Keep a steady get-up time. When you're lying awake and getting frustrated, take the mask off and get up for a while, with a night light on the way so you don't trip on the hose. Go back to bed as soon as you're sleepy and put the mask back on, so you don't doze off in a chair without it. If you're unsteady at night or you've taken something to help you sleep, sit up in bed instead, and put the mask on before you lie down.

If you find the mask has come off in the night, put it back on, even close to morning. The more of the night it's on, the more it helps.

Full CBT-I usually cuts back your time in bed for a few weeks, which can make you sleepier at first. If you try that part, do it with a clinician who knows about your apnea, and don't drive while it's making you sleepy.

When to call your doctor or clinic

If you wake short of breath, with chest pain, or with your heart pounding and it won't settle, get help straight away.

Call your doctor or clinic if:

• you're still sleepy in the day even though you use CPAP most of the night.
• you get drowsy when you drive, or you've nodded off or had a near miss at the wheel. Don't drive until you've talked to them.
• you can't keep the mask on for most of the night.
• the snoring comes back, you wake up gasping, or someone sees you stop breathing again.
• your weight has changed a lot since your pressure was set.
• you're thinking about taking something to help you sleep, even from the pharmacy. Some sleep aids can make apnea worse, and so can a drink at bedtime.
• you've had insomnia three or more nights a week for three months. Ask about CBT-I, cognitive behavioral therapy for insomnia, ideally with a clinician who also knows sleep apnea.

What your ring can't tell you

If you wear a ring, it can't tell you whether your apnea is under control, so go over your machine's own data with your clinic. Goodmorrow is a wellness app, not a treatment, and it isn't CBT-I. We don't read or change anything on your CPAP. We coach sleep habits like a steady get-up time, one at a time, and leave out the time-in-bed part of CBT-I.