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CPAP: A First-Line Sleep Apnea Therapy Fit for a President

Sleep doctor highlights reasons most patients should try machine for treatment first

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Written by Debra Melani on August 28, 2023
What You Need To Know

A growing number of people are being diagnosed with sleep apnea in the United States, including, it was recently revealed, the president. A sleep doctor talks about the disorder, which causes lapses in breathing, and its first-line treatment: CPAP therapy.

President Joe Biden recently joined the likes of basketball great Shaquille O’Neal, “Saturday Night Live” star Amy Poehler and Grateful Dead legend Jerry Garcia – he went public with his sleep apnea disorder.

Given away by the telltale head-strap imprints on his cheeks from his CPAP machine setup, the president’s secret was outed this summer by observant reporters. Biden joins an estimated 30 million Americans with sleep apnea, a number that rises as a nation grows older and wider (see sidebar).

Risks of OSA

  • Excess weight (obesity greatly increases the risk)
  • Large neck circumference
  • A narrowed airway
  • Being male
  • Being older
  • Family history
  • Use of alcohol or sedatives
  • Smoking

Like Biden, most patients sleep with a CPAP (continuous positive airway pressure) machine – the gold standard therapy for moderate to severe obstructive sleep apnea (OSA), the most common form.

“Even with all of the advancements, changes in technology and new therapies, CPAP still remains by far the most effective therapy that we have to treat sleep apnea,” said Katherine Green, MD, medical director of the University of Colorado Sleep Center at the CU Anschutz Medical Campus. “If you can wear a CPAP machine that’s been properly set and optimized for your airway, CPAP is always going to be 100% effective at eliminating sleep apnea.”

In people with OSA, muscles controlling the airway overly relax during sleep, causing the airway to collapse and restrict or completely block airflow. CPAP machines work by providing continuous pressure that keeps the airway open, reducing oxygen deprivation and numerous awakenings throughout the night.

For millions of CPAP users, the therapy has freed them of life-long fatigue, headaches and brain fog and potential serious health effects, such as strokes, diabetes and heart attacks.

CU Anschutz Today talked with Green, assistant professor in the Department of Otolaryngology - Head and Neck Surgery at the CU School of Medicine, about the disorder and how CPAP works.

Q&A Header

Can you start by defining OSA?

The way I always explain it to my patients is that the throat is really just a tube of muscle, and so when those muscles relax, just like when the muscles of the rest of the body relax during sleep, some areas of the throat become floppy, collapsing in and blocking breathing.


  • Excessive daytime sleepiness

  • Loud snoring often punctuated by gasping

  • Morning headaches that may persist for hours

  • Dry mouth upon awakening

  • Restless sleep with periods of wakefulness

  • Increased need to urinate at night

  • Irritability or frustration

  • Reduced focus

We define the severity of sleep apnea based on how frequently we see pauses in breathing that are significant enough to cause dips in oxygen. We grade that based on the apnea hypoxia index (AHI), and anything less than five events per hour is considered normal. Five to 15 events per hour is mild sleep apnea. Fifteen to 30 events per hour is considered moderate sleep apnea, and if you are having anything on average of 30 events per hour or more throughout the night, that’s considered severe.

How effective is CPAP therapy?

It is the single best thing that we can do to treat those obstructive events, no matter how mild or severe your events are. If you can wear a CPAP machine that’s been properly set and optimized for your airway, CPAP is always going to be 100% effective at eliminating sleep apnea. CPAP technology has also continued to improve and evolve. The newer CPAP machines are smaller, lighter, smarter and more efficient than they used to be, and there are more mask options available.

How prevalent is sleep apnea?

Sleep apnea affects upward of 10 to 14% of the general population, and there are certain subsets of the population where sleep apnea is present in upward of 60% to 70%.

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For instance, patients with heart failure or atrial arrhythmias, obese populations, patients with some underlying congenital syndromes such as Down syndrome, and some geographic and ethnic populations (black, Native American and Hispanic) have significantly higher rates of sleep apnea. And sleep apnea is probably one of the most under-diagnosed conditions in our country still.

How accepted is CPAP therapy?

Some people can put on a CPAP mask, sleep comfortably with it, and notice that benefit right away. But I think with the majority of patients, there’s definitely a transition period.


  • Car accidents from drowsy driving

  • Cardiovascular diseases

  • Metabolic disorders, including type 2 diabetes

  • Pulmonary hypertension

  • Thinking problems, such as impaired memory

  • Mood disturbances, such as depression

  • Nonalcoholic fatty liver disease

  • Anesthesia-related complications

It’s something new in the sleep environment that your body needs to get used to, so some have trouble working through that transition. There are a lot of studies looking at the compliance with CPAP, and if you just hand someone a CPAP that’s set to factory settings and give them an out-of-the-box mask and send them on their way, there’s only about 20% compliance. When working with experts in sleep medicine clinics, adjusting the settings on the machine and customizing the mask, about 70% of people are able to get to the point where they are really able to use it and get that benefit.

Does the sleep test discourage some people from seeking treatment?

Yes, people have been telling me for years that the idea of doing the sleep study was just not something that they were interested in doing.

But today, home testing is pretty easy to do. And most patients are going to qualify to start with a home sleep test. Our home sleep testing has gotten much more sensitive and much more detailed and can be all many patients need. There are certain indications for which a home may not give us the detail we need, but for 80% to 90% of patients, a home sleep test can be enough.

Are most of your patients generally happy after they get treatment?

It is life-changing. And it is so foundational to so many other downstream consequences. I’ve seen people whose migraines, diabetes, high blood pressure, depression all became easier to manage because their sleep quality improved. What I often hear from my CPAP patients is: ‘I should have done this years ago.’

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Katherine Green, MD