For a 52-year-old office worker in Tokyo, a diagnosis of obstructive sleep apnoea (OSA) was supposed to bring relief. Instead, it began a wait that has now stretched past 14 months. His doctor prescribed a continuous positive airway pressure (CPAP) machine in early 2024, but the hospital's sleep clinic told him the device would not arrive until late 2025. The patient, who asked to be identified only by the pseudonym Kenji Tanaka to protect his privacy, says he has been rationing the loaner mask he received — using it only every other night to make it last. “I wake up gasping, and my wife says I stop breathing,” he said through a translator in a phone interview. “I know the machine would help, but I have no choice but to wait.”

Tanaka is not alone. Across Japan, an estimated 5 to 10 percent of adults have moderate-to-severe OSA, according to epidemiological surveys cited by the Japanese Society of Sleep Research. Yet the waiting time for a CPAP device — the gold-standard treatment — now ranges from 18 to 24 months in many public hospitals and large clinics. The delay places Japan among the longest waiters in the Organisation for Economic Co-operation and Development (OECD) for a therapy that, when used consistently, can halve the risk of hypertension and stroke.

This feature examines why the bottleneck persists, what the evidence says about the harms of delay, and how patients and clinicians are coping — and why the status quo may be slow to change.

A Breath Held for a Year and a Half

The scale of the waiting list is difficult to pin down precisely because Japan does not publish a national registry of CPAP wait times. But interviews with sleep physicians at four major university hospitals and two prefectural medical centres, conducted in early 2025, all reported waits of 18 to 24 months for a new device. At one Tokyo hospital, the list of patients awaiting CPAP titration — the process of calibrating the machine's pressure settings — had grown to more than 400 names by November 2024.

Untreated OSA does more than disrupt sleep. A 2023 meta-analysis in the Journal of Clinical Sleep Medicine estimated that people with severe, untreated OSA have a 2.5-fold higher risk of developing hypertension and a 1.8-fold higher risk of stroke. The condition is also linked to atrial fibrillation, heart failure, and type 2 diabetes. Japanese guidelines recommend initiating CPAP therapy within three months of diagnosis, but the current reality falls far short of that benchmark.

Patients like Tanaka describe a system that seems unresponsive to their urgency. “I called the clinic every month for six months,” he said. “Each time, they told me to wait. They said the manufacturer was behind on production, and the hospital couldn't switch suppliers because of the reimbursement rules.” His experience echoes that of many others who spoke to me on condition of anonymity, fearing that complaining could jeopardise their place on the list.

Some patients have turned to buying used machines from online auction sites such as Yahoo! Auctions Japan and Mercari. A quick search in early 2025 showed dozens of listings for second-hand CPAP devices, often sold without a prescription or cleaning certification. Physicians warn that used machines may have inaccurate pressure settings, worn-out motors, or contaminated circuits, which can cause infections or ineffective therapy.

Another patient, a 45-year-old taxi driver from Osaka who also requested anonymity, described a different workaround. After waiting 16 months for a CPAP machine, he purchased a second-hand device from a seller on Mercari for ¥60,000 (about US$400). “I had no choice,” he said. “I was falling asleep at red lights. My doctor said I couldn't drive, but I have to earn a living.” He now uses the machine nightly, though he admits he never had it professionally calibrated. “It feels better than nothing,” he said.

Why the Bottleneck Persists

The root causes of the CPAP bottleneck are multiple and reinforcing. The most frequently cited is market concentration. One supplier — ResMed, an Australian-headquartered company — dominates Japan's CPAP market, with an estimated 70 to 80 percent share, according to industry analysts. A single Japanese distributor, Fukuda Denshi, handles a large portion of imports and servicing. When ResMed faced production delays during the global semiconductor shortage of 2021–2023, the ripple effects in Japan were severe and have not fully resolved.

Regulatory hurdles also slow the entry of competing devices. Japan's Pharmaceuticals and Medical Devices Agency (PMDA) requires foreign manufacturers to conduct local clinical trials or submit extensive documentation, a process that can take two to three years. In contrast, the U.S. Food and Drug Administration (FDA) and the European Medicines Agency (EMA) often accept data from overseas trials under mutual recognition agreements. “The PMDA is cautious, and that caution translates into fewer approved devices,” said Dr. Hiroshi Nakamura, a sleep medicine specialist at Keio University Hospital. “We have maybe five or six CPAP models available, compared to dozens in the US or Europe.”

Reimbursement policies further discourage new entrants. Japan's national health insurance system sets a fixed fee for CPAP device rental — roughly ¥5,000 to ¥8,000 (US$33 to $53) per month — which covers the machine, mask, and tubing. This fee has not risen in more than a decade, making Japan a less attractive market for manufacturers who might otherwise compete on price or features. “The reimbursement rate is too low for a company to justify the regulatory cost of entering the market,” said Dr. Nakamura.

Beyond device supply, a shortage of sleep-lab technicians creates a diagnostic bottleneck. In-lab polysomnography — the overnight test that confirms OSA and determines the required CPAP pressure — requires a specially trained technician and a dedicated bed. Japan has roughly 1.2 sleep-lab beds per 100,000 adults, about half the rate of Germany or Australia, according to a 2024 survey by the Japanese Society of Sleep Technologists. Home sleep testing, which can be done with a portable monitor, is available but underused: only about 20 percent of new OSA diagnoses in Japan use home tests, compared with more than 60 percent in the United States, according to a 2023 study in Sleep and Biological Rhythms.

What the Evidence Demands

Clinical guidelines from the Japanese Respiratory Society and the Japanese Society of Sleep Research recommend that CPAP therapy begin within three months of diagnosis. The rationale is grounded in evidence that early treatment improves adherence and reduces cardiovascular risk. A 2024 review in Chest pooled data from 12 randomised trials and found that patients who started CPAP within three months had a 40 percent lower rate of cardiovascular events over two years compared with those who waited six months or longer.

Adherence itself suffers when treatment is delayed. A study published in 2022 in Sleep Medicine followed 340 Japanese patients who received CPAP after a mean wait of 10 months. Those who waited longer than 12 months used the device an average of 3.2 hours per night at six-month follow-up, below the 4-hour threshold considered minimally effective. In contrast, patients who started therapy within three months averaged 5.1 hours per night. “The longer you wait, the harder it is to convince the patient that the machine is worth the hassle,” said Dr. Yuki Sato, a pulmonologist at Osaka University Hospital who co-authored the study.

Quality-of-life scores also deteriorate with delay. The same study found that patients who waited more than a year had significantly worse scores on the Epworth Sleepiness Scale and the Functional Outcomes of Sleep Questionnaire at the time of treatment initiation. “They've already adapted to a life of exhaustion,” Dr. Sato said. “They've changed jobs, stopped driving, withdrawn socially. The machine can't undo all of that.”

Home-based titration — where patients use an auto-adjusting CPAP machine at home for a week to determine the optimal pressure — could reduce the need for in-lab visits. The Japanese guidelines now endorse home titration as an alternative, but adoption remains low. A 2025 survey of 120 sleep clinics found that only 15 percent offered home titration as a standard option. The barrier is partly cultural: many Japanese physicians believe in-lab testing is more accurate, even though multiple international trials have shown home titration achieves equivalent clinical outcomes. Expanding home testing and titration could shorten the diagnostic queue, but it requires training more primary-care doctors to interpret results — a step that Japan has been slow to take.

How Other High-Income Systems Compare

Japan's CPAP wait times stand out among high-income countries. In the United Kingdom, the National Health Service (NHS) targets an 18-week referral-to-treatment standard for sleep apnoea, and most patients receive a device within 12 to 16 weeks, according to the British Sleep Society. In Australia, a device is typically supplied within 4 to 8 weeks of diagnosis, thanks to a combination of home testing, multiple suppliers, and a government subsidy scheme that encourages competition.

Germany dispatches CPAP machines after a single in-lab sleep study, with waits of 2 to 4 weeks common in urban areas. The country's health insurance system reimburses device rental at around €30 to €50 per month — comparable to Japan's rate — but the market includes at least 15 competing brands, keeping supply chains resilient. “Germany shows that a small market can support many players if the regulatory burden is low,” said Dr. Markus Weber, a sleep physician at Charité – Universitätsmedizin Berlin, in an email interview.

In the United States, Medicare covers CPAP after a 90-day compliance trial, during which the patient must use the device for at least 4 hours per night on 70 percent of nights. The device is typically provided within 2 to 4 weeks of the sleep study. Private insurers often have similar timelines. The US market benefits from a large number of durable medical equipment suppliers and a regulatory pathway — the FDA's 510(k) clearance — that allows new devices to reach the market relatively quickly.

Japan's wait times are among the longest in the OECD, comparable only to some Canadian provinces. In Ontario, for example, a 2023 study in the Canadian Journal of Respiratory Therapy reported median wait times of 12 to 18 months for a sleep study, with CPAP delivery following several months later. A 2024 report by the OECD's Health Committee noted that Japan's CPAP waiting list was “an outlier” among member states, though the country has not yet set a national maximum wait-time standard for sleep apnoea treatment.

Workarounds Patients and Clinicians Use

Faced with long waits, patients and clinicians have developed a range of stopgap measures. Some patients buy second-hand CPAP machines from online auctions, as mentioned earlier. Others purchase “travel” or “portable” models from overseas vendors on Amazon Japan or eBay, bypassing the domestic prescription system. These devices may not be covered by insurance, and patients pay out of pocket — typically ¥50,000 to ¥100,000 (US$330 to $660) — but they offer immediate relief.

Clinicians, for their part, often prescribe oral appliances — custom-fitted mandibular advancement devices — as an interim therapy. These devices, which reposition the lower jaw to keep the airway open, are covered by Japan's national insurance and can be fitted by a dentist within a few weeks. However, they are less effective than CPAP for moderate-to-severe OSA, and adherence declines over time. A 2023 study in the Journal of Oral Rehabilitation found that only 40 percent of Japanese patients continued using an oral appliance after one year, compared with 70 percent for CPAP.

Weight-loss programmes are also offered as a bridge. Many sleep clinics now refer patients to dietitians or bariatric surgery centres, since weight loss can reduce apnoea severity. But the effect is modest — a 10 percent weight loss typically reduces the apnoea-hypopnea index (AHI) by about 25 percent — and few patients achieve and maintain that degree of weight loss.

Positional therapy — using a special pillow or a vibrating device that alerts the patient when they sleep on their back — can help those whose OSA is position-dependent. Roughly half of OSA cases are worsened by supine sleep, according to a 2022 review in Sleep Medicine Reviews. But positional therapy alone is rarely sufficient for moderate-to-severe disease, and its long-term adherence is poor.

Few studies have examined the outcomes of these workarounds in the Japanese context. “We don't know if patients who use a second-hand machine or an oral appliance for a year have better cardiovascular outcomes than those who simply wait,” said Dr. Sato. “It's a gap in the evidence that we urgently need to fill.”

What Needs to Change

Addressing the CPAP bottleneck will require changes at multiple levels. The most immediate step is to expand home sleep testing. Japan's Ministry of Health, Labour and Welfare (MHLW) revised its reimbursement rules in 2023 to cover home sleep apnoea testing for patients with a high pre-test probability, but uptake has been slow. Training more primary-care doctors to interpret home test results could reduce the burden on sleep-lab technicians and shorten the diagnostic queue.

Regulatory reform is also needed. The PMDA could adopt a mutual recognition framework that accepts device approvals from the FDA or EMA, reducing the time and cost for new CPAP models to enter the Japanese market. The MHLW's Pharmaceutical Affairs and Food Sanitation Council has discussed this option since 2022, but no concrete timeline has been announced. However, critics warn that faster approvals could risk admitting devices with lower quality or less robust local data. “We need to balance speed with safety,” said Dr. Nakamura. “If we rush, we might end up with machines that don't work well in Japanese patients.”

Reimbursement rates must rise to attract more suppliers. The current rental fee of roughly ¥5,000–8,000 per month has not kept pace with inflation or manufacturing costs. A modest increase — to ¥10,000–12,000 per month — could make the market more attractive to companies like Philips, DeVilbiss, or Fisher & Paykel, which currently have limited presence in Japan. But raising reimbursement would increase healthcare spending, and the MHLW must weigh this against other priorities. “Every yen we spend on CPAP is a yen we don't spend on cancer drugs or dementia care,” said a ministry official who spoke on condition of anonymity. “It's a trade-off.”

Telemonitoring — where CPAP usage data is transmitted wirelessly to the clinic — can reduce the need for in-person follow-up visits, freeing up clinician time. Japan's national insurance began reimbursing telemonitoring for CPAP in 2020, but adoption remains low, partly because older patients are less comfortable with the technology. A 2024 pilot programme at Kyoto University Hospital found that telemonitoring reduced the number of in-clinic visits by 40 percent without compromising adherence. Yet scaling telemonitoring requires investment in digital infrastructure and training, which many smaller clinics lack.

Finally, Japan could set a national maximum wait-time standard for sleep apnoea treatment, similar to the NHS's 18-week target. The MHLW's Health Services Bureau has the authority to impose such a standard, but it has not yet done so. “Without a target, there is no pressure to improve,” said Dr. Nakamura. “The system will continue to muddle along.”