What are the alternatives to CPAP for treating sleep apnea?


CPAP is by far the most common form of treatment for patients with moderate to severe obstructive sleep apnea (OSA). Often referred to as the 'gold standard', CPAP (continuous positive airway pressure) works by delivering a steady air pressure in order to keep the patients breathing airway open. It's a very safe treatment and has a high success rate for patients who stick to it.

However, CPAP isn't suitable for everyone. Some people find it uncomfortable or claustrophobic wearing a CPAP mask all night. Other complaints include dry nose/throat, skin irritation, nasal problems and even nightmares.1 . These and other problems make mask rejection a common problem for  many OSA sufferers. Thankfully there are other alternatives when CPAP doesn't fit the bill.

Other PAP devices

BiPAP (bi-level positive airway pressure) machine works in a similar way to CPAP but it allows air to be delivered at two alternating levels. Commonly used to treat central sleep apnea, BiPAP allows for easier exhaling making it also suitable treatment for patients with heart and respiratory. VPAP devices are even more sophisticated enabling a variable airflow which can react to spontaneous breathing episodes.

While these alternative devices differ slightly , they do little to eliminate the main objections that CPAP users face. Many patients are looking for something completely different and more beneficial than the traditional masks and CPAP machine setup.

Positional therapy

An estimated 1 out of 42 sleep apnea patients have what is called positional OSA. In other words, the symptoms occur more frequently when the patient is supine ie lying on their back. Such patients can help to reduces their symptoms by learning how to sleep on their sides.

positional therapy

Positional therapy cushion prevents rolling onto your back

The traditional method involves attaching a sock or pocket to the back of a shirt or pyjama top and placing a tennis ball inside. These days there's a whole range of specially designed products to encourage side sleeping, including body beltscushions and body pillows .

Whilst studies have shown3 that positional therapy can be a valuable form of therapy for mild to moderate cases of obstructive sleep apnea, it cannot be considered as an effective treatment for more severe cases, where the airway collapses no matter what position the patient assumes.

However as a low cost, non-invasive solution for mild cases of OSA, snoring and other sleep related breathing disorders, learning to sleep on your side can often be an effective form of alternative to CPAP treatment.4

Surgery

If you've tried PAP treatment without success and are looking for a permanent solution to your OSA symptoms, there may be a surgical alternative. There are many different options for surgical treatment and they should be tailored to the individual patient's needs. Using surgery as an alternative to CPAP is sure to be an attractive option for many but it is also a drastic one with a number of risks. The two most common surgical procedures for obstructive sleep apnea treatment are:

Maxillomandibular advancement:

Maxillomandibular advancement is a complex, delicate process that expands the size and capacity of the airway by changing the structure of the skeletal framework around it. By doing so, patients are given the ability to take in air more easily but it also means a permanent physical change - with jaws being relocated by up to 12mm. Although it is an invasive treatment with a long recovery period, it has a high success rate5 with relatively low risk of complications for patients with severe and persistent OSA symptoms.

Uvulopalatopharyngoplasty, or UPPP:

This is the most common surgery for OSA and has been used for decades to treat snoring and other sleep related breathing disorders. Compared to the above operation, a uvulopalatopharyngoplasty is less intrusive and problematic.

Surgery for sleep apnea

Image:Wikipedia Commons

This procedure attempts to increase the width of the airway and improve the movement and closure of the soft palate. It involves removing the excess tissue and reinforcing the area to keep it open and unobstructed. The removed tissue may include the uvula (the soft flap hanging down at the back of the mouth), the soft palate, tonsils and adenoids.6.

The downsides to UPPP is that it is one of the most painful surgical procedures for treating OSA and recovery can take several weeks. Success rates are between 50%-65%.

Surgery is always a serious undertaking and both of these procedures come with the risk of dangerous complications, a long stay in hospital and some inconvenient after effects. No procedure is guaranteed to be 100% successful, so you need to be fully aware of every aspect of your treatment and recovery before you consider a surgical solution for obstructive sleep apnea.

Oral appliances

Oral appliances for sleep apnea

Image:Dear Doctor Inc

Dental appliances are another option if you're looking for an CPAP alternative. These oral devices look like mouth guards, the difference being they move the tongue or lower jaw forward, opening the airway making it easier to breathe. Although not suitable for patients with severe OSA, when used correctly, this form of treatment is safe and relatively reliable.  The American Academy of Sleep Medicine (AAoSM)7 endorses oral appliance therapy as a a CPAP alternative for patients who have mild to moderate OSA symptoms.

 The most common type of oral appliance for sleep apnea is called a mandibular repositioning appliance, or mandibular advancing device.  This devices uses the same principles as surgical treatment, but instead of a permanent realignment, a removable mouth appliance is worn at night to maintain the lower jaw in a protruded position during sleep, opening the airway by indirectly pulling the tongue forward.

Provent

Provent CPAP alternative

Provent EPAP therapy

Provent is one of the most recent options available to OSA sufferers, doing away with all of the bulky equipment that comes with CPAP machines. Provent consists of a small patches with two plugs that fit into the nostrils. When you inhale a valve opens, allowing air to flow freely. When you breathe out , however, the valve closes and air is forced out through a smaller channel. This creates back pressure  which in turn keeps the breathing airway open.

In a study8 of over 250 OSA sufferers, Provent, a nasal EPAP (expiratory positive airway pressure) device, was found to be successful in reducing apnea events and improving daytime sleepiness in patients with mild to severe symptoms.

Provent has rapidly become one of the most popular alternatives to CPAP, with millions of units shipped out to sufferers. The biggest drawback is the cost, which works at around $2 per night, more expansive than CPAP in the long run.

Acupuncture

The final procedure in this guide to alternatives to CPAP is a treatment that will be familiar to many but perhaps not widely associated with sleep apnea. Researchers in Brazil have been studying the potential of acupuncture as a viable, affordable substitute for CPAP treatments. Unlike most Western countries, in Brazil acupuncture plays a major role in mainstream healthcare.

Two separate clinical studies910 by Brazilian sleep scientist have demonstrated that both single and repeated treatments can be effective at reducing sleep apnea events for patients with moderate symptoms. The researchers hypothesize that the improvement is due to acupuncture’s anti-inflammatory  and serotonergic effects.

Although the evidence suggests that acupuncture could be a beneficial aid in managing sleep apnea, like positional therapy it is more likely to be perceived as a complementary rather than a stand-alone treatment until more research is undertaken and wider markets accept it as a viable alternative to CPAP.

Summary

Victoria Thon, Ph.D., a member of the ASAA board of directors, is quoted as saying that "it jeopardizes the health of an OSA patient to dismiss CPAP therapy, which has been extensively studied and in use for 25 years".

However, OSA sufferers who can't face wearing a mask at night needn't despair as there is a growing body of research into alternatives to CPAP for treating obstructive sleep apnea.

  1. Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea WebMD []
  2. Prevalence of Positional Sleep Apnea in Patients Undergoing Polysomnography Chest 2005;128;2130-2137 []
  3. Positional therapy for obstructive sleep apnea patients: A 6-month follow-up study. Laryngoscope. 2006 Nov;116(11) []
  4. Positional Treatment vs Continuous Positive Airway Pressure in Patients With Positional Obstructive Sleep Apnea Syndrome CHEST 1999; 115:771–781 []
  5. Maxillomandibular advancement for persistent obstructive sleep apnea after phase I surgery in patients without maxillomandibular deficiency. Laryngoscope. 2000 Oct;110(10 Pt 1):1684-8. []
  6.  Obstructive sleep apnea - Surgery University Of Maryland Medical Center []
  7.  Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances: An Update for 2005 AA0SM Report SLEEP, Vol. 29, No. 2, 2006 []
  8. A Novel Nasal Expiratory Positive Airway Pressure (EPAP) Device for the Treatment of Obstructive Sleep Apnea: A Randomized Controlled Trial Sleep. 2011 April 1; 34(4): 479–485 []
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  10. Immediate effect of acupuncture on the sleep pattern of patients with obstructive sleep apnoea. Acupunct Med. 2010 Sep;28(3):115-9. doi: 10.1136/aim.2009.001867. Epub 2010 Jun 15 []