Inspire Upper Airway Stimulation
Upper Airway Stimulation Device: Image via fda.gov

CPAP alternatives for sleep apnea

CPAP compliance is a big issue, so what are the alternatives?

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If you can’t face wearing a mask every night, 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.

What is CPAP?

CPAP stands for Continuous Positive Airway Pressure. Invented by Professor Colin Sullivan and his team  in 1981, the treatment involves the use of a CPAP machine, sometimes called a sleep apnea machine.

CPAP treatment for OSA works by supplying a constant mild air pressure to your airway whilst asleep, thus preventing your airway from collapsing. The CPAP machine delivers a flow of compressed air via a flexible hose to a mask or a sleep pillow. An important distinction is that it is the air pressure, and not the flow of the air, that prevents the airway from collapsing.

Benefits of CPAP

CPAP is the best non-surgical treatment for obstructive sleep apnea. It has a great success rate and some patients notice a marked improvement after just one night of use. Successful CPAP therapy will greatly reduce the symptoms of sleep apnea such as insomnia and daytime sleepiness. As well as restoring your normal sleep patterns, you should also experience an improvement in work-related productivity, concentration, memory and alertness. CPAP treatment also greatly reduces the effects of snoring, one of the biggest symptoms of sleep apnea sufferers.

Downsides of  CPAP

Unfortunately, CPAP isn’t suitable for everyone.  CPAP is effective only if you use it on a daily basis. Initially, it may cause discomfort and may take time to get used to.Some people find it uncomfortable or claustrophobic wearing a CPAP mask all night.

Other complaints include dry nose/throat, skin irritation, nasal problems, chest discomfort, nasal congestion, morning sneezing, runny nose and  and even nightmares.  These and other problems make mask rejection a common problem for  many OSA sufferers.

You can reduce the side effects of CPAP machine adjusting your mask or changing the mask size, material, or shape. Make sure that there are no air leaks in the mask or tubing. A nasal spray or dehumidifier can help to reduce nasal irritation and drainage.

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 4  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 belts, cushions and body pillows .

Whilst studies have shown  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 alternative to CPAP treatment.

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 sleep apnea surgery 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 rate  with relatively low risk of complications for patients with severe and persistent OSA symptoms.

UPPP (uvulopalatopharyngoplasty)

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.

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.

Upper-airway stimulation

A relatively a new, FDA approved technology called upper-airway stimulation is starting to be used for treating sleep apnea in patients who haven’t been able to stick with a CPAP program.

Upper-airway stimulation works in a similar way to a pacemaker. A small device is surgically inserted into the chest area with two insulated leads  – the first  is a breathing sensor lead and detects a person’s breathing patterns.

These breathing patterns then trigger the second, a stimulation lead, which is placed on a special nerve in the upper neck region). When stimulated, this nerve activates the muscles in the neck region, which in turn induces the breathing tube to open up.

 

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 (AASM)  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 study  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.

>> Read More: Can Acupuncture Help Insomnia?

Two separate clinical studies (1, 2)  by Brazilian sleep scientists 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.