CPAP machines/Shabbos

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I have been asked several questions about the use of CPAP machines for sufferers from OSA (obstructive sleep apnea) on Shabbos. Let me summarize what these machines are and how they are used and why they are needed.

Many males and a smaller proportion of females suffer from irregular breathing while sleeping at night, often accompanied by heavy snoring. Since they actually stop breathing for a moment or longer many times each night, they are at risk of sudden death (very rarely), constant tiredness resulting in care accidents etc., high blood pressure, slower metabolism and therefore obesity, and many other things. They also tend to have lower blood oxygen levels during the night, and this gradually strains the heart and the hemodynamic system generally leading to early heart disease and many other problems. You can read all the details about OSA and its symptoms, the simple tests to see if someone is likely to have it and the elaborate polysomnography sleep test which confirms it on many web sites (for instance http://www.sleepquest.com/s_osa.html)

It is treated with a machine called a CPAP, which is attached with a hose to the person's nose while sleeping and which forces regular air flow through the nostrils, so that the breathing is no longer interrupted. When all works well, the person then leads a full normal active life, as if they had never had OSA.

Several questions arise, this is an electric device which is used in people who may or may not be classified as choleh sheyesh bo sakana. It can apparently be attached to a timer to go on when the person goes to sleep. By the way the Shaarei Tzedek web site has a brief mention of this sheyla in which Rabbi Halpern advises asking the physician how serious a case it is and then asking a Moreh Horaah.

 

Here are some questions:

1. If a person uses the more sophisticated automatically adjusting CPAP is there a problem of Makeh BePatish, since it is being recalibrated constantly by his breathing? Is it preferable for a SHomer Shabbos to ask for a traditional CPAP rather than an APAP?

Answer--- If someone is suffering from frequent apneas and hypopneas pehaps over 30 an hour, or very long apneas, there is probably an immediate potential sakana, therefore it is probably permitted to do melacha and may even switch on the machine on Shabbos. Certainly the person does not need to worry that the breathing they do anyway causes the machine to reclibrate and adjust. If someone is only receiving treatment because of lower oxygenation, or because their partner cannot endure their snoring, then it is a gradual build-up of ill health not greatly affected by one night and therefore this sheyla might be applicable. Probably a spontaneous adjustment like this is not considered a Tikkun maneh, but it might be like the use of a digital thermometer which seem feel is a problem, but the thermometer is only used to print out a temperature, whereas here the device is primarily to pump air into the patient.

Another question I was asked is can a person connect the CPAP for a Shabbos afternoon nap, there is little concern with how soundly they sleep since this is an extra nap anyway, and there is little concern with lower oxygenation since this is for a short time. Can the person connect a timer-controlled CPAP just for comfort, to sleep without interruptions?

 

Another question: Many of these machines are used in conjunction with a humidifier, which ensures that the air pumped by the CPAP has a higher moisture content. Can the humidifier be used on Tisha b'Av and Yom Kippur or is it considered like drinking, or like bathing since it coates the inside of the nose with moisture? Since the CPAP could be used without the humidifier, and would just cause dry mouth and discomfort, is it considered as a chashash issur, without a direct medical need, and therefore should be forbidden at least on Yom Kippur.

One should perhaps not compare this to using a humidifier in a room on Yom Kippur since there it is dissipated into the air of the room, whereas here it is piped directly into the person's nostrils.

Nevertheless, it is clearly not "Derech Shtiyah Beckach" and not "Derech Rechitzah/Sichah" so at the most a chashash derabanan, and even that is very questionable since one can argue that it is just making the air comfortably moist and inhaled as normal air.

Therefore it seems to me that it is permitted.

I look forward to hearing your responses

Rabbi Avrohom Marmorstein

moderator medicalhalacha

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Another issue that occurred to me about CPAP on Shabbos. I understand
that a lot of people need to use a machine with a heated humidifier.
Heating the water on Shabbos seems to be bishul even when started with
a timer. No-one permits cooking with a timer on Shabbos, although there
are some intricate questions regarding when a timer removes the staus
of a melacha and when we say that even with a timer something is still
considered melacha. Furthermore, the heated moisture is definitely for
comfort and not medically necessary. But on the other hand it is
reported that many people are so uncomfortable without the heated
humidifer that they cannot bear to use the CPAP without it, and thus
may come back to the initial issue of chashash sakana. This seems to me
to be a difficult question which should be evaluated on a case by case
basis. (Can one use the humidifier and turn off the heating element
before Shabbos? I need more input from someone familiar with these
devices.)