Rebreathing during CPAP therapy and its implications in obstructive sleep apnea

Elevated environmental CO2 levels can have important health impacts, including increased anxiety, impaired high-level cognitive performance, reduced sleep quality, and decreased next-day alertness, especially in children.Bedrooms, where people spend a third of their lives, are often poorly ventilated, further exacerbating CO2 exposure during sleep.These symptoms may be of particular concern for individuals with obstructive sleep apnea (OSA) treated with continuous positive pressure (CPAP) as a result of CO2 trapping within the mask, which is dependent on environmental levels, and circuit CO2 rebreathing.Additionally, lower inhaled oxygen concentrations may be encountered when exhaled gases are rebreathed from the circuit.Low expiratory PAP, high ventilation levels (e.g., in large individuals or at altitude), and small exhaust valves increase rebreathing risk, which can self-propagate due to patient attempts to compensate by increasing tidal volume.Elevated environmental CO2 may further exacerbate the clinical consequences of rebreathing, including reduced CPAP adherence.While strategies including higher expiratory PAP or larger exhaust valves help mitigate CO2 buildup, they can also lead to increased noise which may potentially affect adherence.With this work, we review the available evidence on the thresholds and effects of classroom, office, bedroom and rebreathed CO2 levels, in healthy and OSA individuals, both adults and children.Importantly, we provide the often-overlooked link between environmental CO2 concentrations and circuit rebreathing for OSA patients, underscoring the need to optimize current indoor ventilation standards and thresholds for mask-based CO2 inhalation, as well as CPAP technology to maximize adherence, abate CO2/hypoxic exposure, and improve health outcomes.