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Alternatives to CPAP Therapy

Quick Overview

Obstructive sleep apnea (OSA) is a serious condition which causes people to temporarily stop breathing while they sleep. Treatment is necessary for anyone with sleep apnea, as it has serious effects both in the short term and the long term.

The most popular treatment for OSA is the use of a continuous positive airway pressure (CPAP) machine. However, adherence rates for CPAP therapy are low, and some people can’t tolerate the use of a CPAP machine at all. Fortunately, alternative sleep apnea therapies are available.

There are a wide range of CPAP alternative therapies, each of which is more appropriate for some OSA sufferers than others. Some, such as positional therapy, are minimally invasive and work best for those with mild to moderate OSA. Other treatments, like surgery or implantable devices, may work for those with more severe sleep apnea.

If you’re curious about non-CPAP OSA treatments, speak to your care team. They will help guide you through your options and find the best choice for your health.

Why Do Some People Need CPAP Alternatives?

Invented by an Australian doctor in 1980, continuous positive airway pressure (CPAP) therapy is considered the best available treatment for sleep apnea. CPAP machines generate positive air pressure, which is then funneled into the user’s airway through a hose and mask system.

This air pressure then acts like air inside an inflatable tube, keeping the airway open throughout the night and reducing (or eliminating) the number of breathing interruptions.

While CPAP therapy works exceedingly well in many cases, it is not always well-tolerated for a variety of reasons. In addition to the problem of treatment adherence, there are other reasons why some people may need a CPAP alternative, either some or all of the time.

CPAP Adherence Problems

The primary problem with CPAP therapy is low rates of adherence. Between 46-83 percent of sleep apnea patients may not be adhering to their therapy (defined as more than four hours of CPAP use each night), making it far less effective in treating both the symptoms and long-term effects of OSA. It is possible that a majority of CPAP users either abandon the therapy or do not use it long enough per night to see the beneficial effects.

There is some indication that patients who do not adhere to CPAP therapy are more likely to have large tonsils and nasal conditions (such as a deviated septum) which may cause worsened side effects. However, the high rates of CPAP non-adherence show that these are not the only concerns.

Common reasons given for lack of adherence include:

  • Skin irritation
  • Nasal discomfort and congestion
  • Severe nosebleeds
  • Mask leaking and other technical problems
  • Swallowing air
  • Air pressure problems of the inner ear
  • Claustrophobia
  • Oral health problems such as dry mouth, halitosis, and gingivitis

While machine adjustments or equipment changes can address some of these issues, their prevalence has made CPAP alternatives an appealing prospect for many sleep apnea sufferers.

Lack of Access to Electricity

Since CPAP therapy requires the use of a machine, alternatives are often of interest to people who do not have regular access to electricity. Some people may only be without electricity for a short while (such as when camping or in emergencies), while others require an OSA treatment which allows them to go without power for longer periods.

One avid backpacker, for example, was able to resume trail-hiking due to being fitted with an implantable upper airway stimulation (UAS) device. These developments in CPAP alternatives show great promise for people who live, work, or travel in areas with poor access to electricity.

Cognitive Challenges

Early research shows that treating OSA in people with dementia may help slow cognitive deterioration and help them remain independent for longer. However, CPAP adherence is probably less likely among people who struggle with cognitive challenges. This may also be true for OSA sufferers with Down syndrome or other developmental disorders.

While some CPAP alternatives require equipment and regular (or nightly) routines, others need only regular check-ups. This may allow for greater independence while ensuring their sleep apnea is treated.

Alternative CPAP Therapies

Weight Loss

Excess weight can cause or worsen sleep apnea by enlarging tissue in the throat. Fat tissue also secretes proteins called adipokines which may interact with muscles in the upper airway. It is well known that obesity is a risk factor for OSA, with up to 50 percent of obese patients showing signs of sleep apnea.

As weight is one of the few changeable factors contributing to OSA, many OSA treatment plans include weight loss. In some cases, significant weight loss can even resolve sleep apnea in some patients.

There are three types of weight loss which may be used to treat OSA:

  • Behavioral methods include dietary and weight-loss programs, controlled diets, exercise, and other patient-focused methods of losing weight.
  • Pharmacological methods involve the use of medication which may aid in weight loss, though these are untested for use with sleep apnea.
  • Surgical methods include laparoscopic adjustable gastric banding (LAGB), Roux-en-Y gastric bypass (RYGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic biliopancreatic diversion. While effective, these procedures have potential complications, and behavioral weight loss methods are likely to be used before doctors consider surgery.

Of course, losing weight can be difficult. This is particularly true for OSA sufferers, as sleep apnea causes elevated levels of leptin and ghrelin. These hormones help control hunger and satiation, so their imbalance can make it harder to lose weight.

Because of this, while weight loss provides an effective alternative to CPAP therapy in the long run, use of a CPAP device in the short term can help OSA sufferers lose weight.

Positional Therapy

One trait shared by up to 60 percent of OSA patients is that they are ‘supine-predominant’, meaning that their sleep apnea is partially based on their sleep position.

Researchers have known for a long time that sleeping on your back (the supine position) can make OSA worse. In one early study, sufferers who slept in the supine position had twice as many apnea events in a night as those who slept on their side. Non-obese patients even had their breathing fall within normal parameters when no longer sleeping on their back.

For supine-predominant patients, particularly those who are not obese, positional therapy may provide an effective alternative to CPAP. This therapy involves wearing a device — these range from a strap with a tennis ball at the back to more sophisticated alarms — which alerts the wearer whenever they roll onto their back during sleep.

People with mild to moderate OSA can see good results from positional therapy, particularly when using one of the more advanced alarm devices. This may be due to the mechanisms of sleep apnea, as sleeping in the supine position can cause collapse of the airway on multiple levels, versus only one level when sleeping on the side.

As positional therapy works best for supine-predominant OSA sufferers, deciding to use it as a primary treatment may require a sleep study first. Speak to your care team, who will help you determine if it will work for you.

Dental Appliances

For patients with mild to moderate sleep apnea, dental appliances can provide an effective alternative to CPAP therapy. These are generally available in two styles:

  • Mandibular advancers look like a mouthguard and snap onto the upper and lower teeth, with a hinge between allowing the lower jaw to be brought forward. This opens up the airway by allowing for more room behind the jaw.
  • Tongue-stabilizing devices are splints which keep the tongue forward in the mouth, preventing it from collapsing back against the airway.

    A mandibular advancer used to open the airway during sleep. Source: Wikimedia Commons.

Mandibular advancers are generally more common, with tongue-stabilizing devices prescribed primarily to patients who lack the number of teeth needed for a mandibular advancer.

Side effects are generally not serious but can include jaw pain, excess salivation, and dental tenderness. The advice appears to have little effect on the temporomandibular joint, and side effects usually go away after an initial adjustment period.

Dental appliances have around a 52 percent success rate for sleep apnea patients, making them less effective than CPAP therapy. However, high adherence rates have made dental appliance treatment a promising choice for some people.

Research indicates that patients for whom dental appliances are successful tend to be younger, with lower body weight and smaller neck circumference. These traits are not universal, so older or heavier patients should not be discouraged from looking into this treatment option.

Nasal Expiratory Positive Airway Pressure (EPAP) Devices

Since being approved by the FDA in 2010, EPAP devices are increasing in popularity among sleep apnea sufferers. They consist of a disposable pair of one-way valves which are held in each nostril by a temporary adhesive. This creates resistance and increased air pressure when exhaling through the nose, holding the airway open until the next inhalation.

As with CPAP therapy, the increase in air pressure (and resultant opening of the airway) has been shown to decrease the number of apnea events during sleep. Patients undergoing EPAP therapy also seem to spend a dramatically increased amount of time in sleep stages three and four, resulting in improved sleep quality and a decrease in daytime sleepiness.

More research needs to be done to show the long-term success rates of EPAP therapy, but initial studies indicate that the treatment may work well for people with mild to moderate sleep apnea. As the devices are small, disposable, and work without electricity, they are also a good temporary alternative to CPAP for people who are traveling or without access to electricity.

There are currently no guidelines on who makes the best candidate for EPAP therapy, though high nasal resistance (such as from a deviated septum) may lead to treatment failure. Patients for whom EPAP works well appear to have high rates of adherence to the treatment, possibly due to the relative lack of side-effects and ease of use.

Surgery

Surgery is one of the standard treatments for childhood sleep apnea and can be effective in adults as well. There are two primary areas which surgeons target for OSA treatment:

  • Nasal: While sinus problems in and of themselves do not cause sleep apnea, they can interfere with treatment and make it more difficult to use a CPAP machine. In this case, surgery is less an alternative to CPAP therapy and is instead intended to make it more effective.
  • Upper Airway: Surgery of the oropharynx (an area at the back of the throat) is usually intended to reconstruct muscles in the soft palate or remove excess tissue (sometimes including the tonsils).

Surgery may also involve the tongue, jaw, and throat.

There are multiple studies which show that nasal surgery can improve CPAP adherence, but patients without sinus problems are unlikely to benefit.

The effectiveness of upper airway surgery is highly dependent on the position of the patient’s palate and the size of their tonsils. Those with a specific combination of these factors had a success rate of 80.6 percent, while success rates in other groups were only 37.9 or even 8.1 percent.

In another study, the success rate (defined as symptom improvement, not a cure) of upper airway surgery was 66.4 percent overall. This was paired with a complication rate of 14.6 percent. While serious complications are rare following OSA surgery, side effects can include bleeding and infections.

Patients who are curious about surgical OSA treatment should speak to their care team. They will help determine whether you may be a candidate for surgery, as well as explaining the benefits and drawbacks of each type.

Upper Airway Stimulation (UAS) Devices

One of the newest forms of sleep apnea treatment (the first was approved in 2014) are upper airway stimulation devices.

The device is implanted surgically and consists of an impulse generator, a breathing sensor, and a stimulation lead attached to the nerve which controls tongue protrusion. Once switched on (via remote control or wearable patch), the UAS device uses electrical impulses to push the tongue forward in the mouth.

The most common side effect is tongue discomfort (seen in one-third of patients), though this is usually resolved by adjusting the stimulation or wearing a dental guard.

Although UAS is a new form of treatment, early research results are promising. One study found a greater than 50 percent reduction in apnea events, with complications occurring in only 6 percent of patients. In another review, 94 percent of physicians saw improvements in their patients, and 90 percent of the patients were more satisfied with UAS than CPAP therapy.

Blood tests also show that blood oxygen saturation levels improve significantly, with the lowest levels reading 90 percent rather than the 79 percent seen before treatment.

UAS devices can be implanted in patients over 22 years old who have a BMI of less than 33 and have moderate to severe OSA. Some research indicates that older patients have a greater likelihood of success, though the reason for this is currently unknown.

Like any surgery under general anesthetic, the implantation of a UAS device has associated risks. However, procedure-related complications occur in only 2 percent of patients, lower than that of other sleep apnea surgeries.

Final Thoughts

Obstructive sleep apnea is a serious condition, but its most widely-prescribed treatment — CPAP therapy — has low rates of adherence. For sleep apnea sufferers who can’t tolerate CPAP, or those who have other reasons for wanting an alternative treatment, there are both new and established treatment options available.

Weight loss is considered one of the few ways to “cure” sleep apnea in some patients. The process can be challenging, but those who succeed can see real improvement in their OSA symptoms.

Positional therapy and dental appliances are both treatments which may work well for people with mild to moderate sleep apnea. Not everyone the right candidate for these therapies, but people with the right OSA characteristics may find them to be an ideal CPAP alternative.

Nasal EPAP therapy is a relatively new treatment option which has shown promising results. People with mild or moderate sleep apnea might find relief solely through using EPAP devices, while others find them useful on a temporary basis.

There are a variety of surgeries available for OSA patients, but two of the most common forms are nasal surgery (to improve CPAP use) and upper airway surgery (to remove excess tissue or reconstruct tissue). Rates of serious complications are low, but sleep apnea surgery isn’t right for everyone.

Upper airway stimulation devices were approved in 2014 and are one of the more exciting new therapies. The device is surgically implanted and uses sensors and electrical impulses to move the tongue forward during sleep.

With such a wide variety of treatment options, it’s possible that many people who can’t tolerate CPAP could find one which works well for them. If you’re curious about any of these treatments, speak to your care team to discuss your options.

 

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