Adverse Events Associated with Continuous Positive Airway Pressure and Related Positive Airway Pressure Devices: A Narrative Review and Rationale for Closer Monitoring

Background: Continuous positive airway pressure (CPAP) remains a principal treatment for obstructive sleep apnea because it maintains upperairway patency through pneumatic splinting.Fixed CPAP, auto-adjusting positive airway pressure (APAP), bilevel positive airway pressure (BPAP), adaptive servo-ventilation (ASV), and variable expiratory pressure systems are not interchangeable, however, and each requires appropriate patient selection.Although most adverse effects are mild and manageable, uncommon device-or pressure-related complications can be clinically important.Objective: To synthesize the adverse events described with CPAP and related PAP modalities and to identify situations in which closer clinical surveillance is warranted.Evidence summary: Frequently reported problems include mask pressure injury, dermatitis, nasal dryness or inflammation, epistaxis, air leak, conjunctival irritation, and aerophagia.Evidence regarding infection is mixed: Observational studies have not consistently shown higher rates of respiratory infection among CPAP users, yet poorly maintained equipment has been implicated in individual cases of Pneumocystis jirovecii pneumonia, nocardiosis, and Legionella pneumonia.Rare pressure-related events include pneumothorax, pneumocephalus, and cerebrospinal fluid leakage, particularly in patients with pulmonary disease, cranial defects, or recent skull-base surgery.Long-term mask pressure may affect midfacial growth in children.Treatment-emergent central sleep apnea (TECSA) may require repeat titration or a different PAP mode, whereas ASV requires particular caution in patients with heart failure and reduced ejection fraction.Degradation of polyester-based polyurethane (PE-PUR) sound-abatement foam in recalled devices has added concerns regarding particulate and chemical exposure, although spontaneous device reports do not establish causality.Conclusion: The therapeutic benefit of PAP generally exceeds its risk, but safe long-term use depends on correct device selection, proper interface fitting, manufacturer-directed cleaning, review of residual events, and timely investigation of new respiratory, neurologic, ocular, gastrointestinal, or dermatologic symptoms.Follow-up should be individualized and may require collaboration among sleep medicine, pulmonary medicine, cardiology, otolaryngology, ophthalmology, dentistry, and orthodontics.