Many patients ask if CPAP is the only treatment option for obstructive sleep apnea.
Patients sitting across from a sleep specialist getting the news that they have sleep apnea, often envision nights wearing a mask connected to a large, loud, uncomfortable, and disruptive machine keeping themselves and their partner up at night.
If they’re honest, they’re also picturing an older uncle or their dad using one of the older CPAP models they saw and heard when they were growing up.
Admittedly, it’s not a sexy image. But CPAP treatment, from the machines to the masks, have come a long way.
CPAP (Continuous Positive Airway Pressure) is no longer the big boxy, loud machines of the past. CPAP has come a long way in design, technology, and function, and is still the most widely researched, and most effective treatment available for sleep apnea available today.
Sleep specialists and health care providers recommend CPAP treatment for sleep apnea unless the apnea is extremely mild, or for a number of different reasons CPAP treatment has failed. This is because CPAP is considered the least expensive and most viable treatment for the vast majority of the population.
For patients who struggle to stick to their treatment or have trouble using it consistently, adjustments to pressure, choosing a new mask, or adjusting the fit of their mask usually resolves any issues.
In rare cases, a CPAP alternative may be needed and thankfully, there are alternative treatments available for sleep apnea patients who struggle to use CPAP on a regular basis or don’t get the desired treatment results.
However, it’s crucial to note that CPAP alternatives are only truly viable for patients with very mild cases of sleep apnea or in extreme cases where CPAP has failed. We’ll take a look at some of those later, but let’s start by talking about CPAP, and why many patients may not use it as prescribed.
What is CPAP?
CPAP, or continuous positive airway pressure, is the most common treatment for sleep apnea symptoms.
CPAP therapy consists of the CPAP machine itself, as well as a mask that goes over either your nose, your mouth, or both, or nasal pillows which nestle into the nose. With these components, a continuous stream of air is provided, which gently holds your upper airway open and prevents airway obstruction while you sleep.
CPAP therapy treats and helps resolve sleep apnea symptoms, and helps reduce many of the associated health risks potentially worsened by sleep apnea. Health risks associated with sleep apnea include heart disease, diabetes, and chronic pain.
To date, alternative treatments for sleep apnea have not been researched or studied as thoroughly as CPAP. Multitudes of studies have proven CPAP to be the most effective treatment for obstructive sleep apnea (OSA). This is why CPAP is considered the best and most effective treatment for sleep apnea.
Why Many Sleep Apnea Patients Stop Using CPAP
Despite how effective CPAP is in treating sleep apnea and comorbidities, more than one-third of sleep apnea patients who try CPAP do not continue to use it.
There are any number of reasons patients may struggle to maintain CPAP treatment consistently which is why it’s important to work closely with your sleep center’s respiratory therapist.
The most common reasons patients avoid starting CPAP treatment for sleep apnea or struggle to continue CPAP treatment include:
- Initial difficulty tolerating and adjusting to the high flows and pressures
- The CPAP device is noisy or the sound makes it difficult to fall asleep
- Patients may find the CPAP mask uncomfortable
- The cost of the machine may seem expensive if insurance coverage is limited and may require strict compliance to provide any insurance discounts
- The CPAP machine is clunky or takes up a lot of space near the bed
Addressing CPAP Concerns Before Seeking Alternatives
CPAP is the most affordable and effective treatment for sleep apnea, which means a sleep professional will initially work with patients to address any concerns. Especially because of improvements to CPAP therapy thanks to advancements in technology over the past few years.
CPAP machines have come a long way from the noisy, bulky machines some patients remember their grandparents using. The misconception about CPAP being noisy often creates hesitation among patients, but despite the stigma, modern CPAP machines are now far more compact and run silently throughout the night.
Patients who try CPAP but give up on their sleep apnea treatment because of difficulties adjusting quickly to the treatment often fail to talk with their doctor about the initial difficulty.
Of course, developing new sleep habits can take time and effort to make it worthwhile, and your best option is to seek the support of a sleep professional.
As we mentioned above, the high flows and pressures of the CPAP machine can make it more difficult to sleep when first adjusting to CPAP. In fact, this is the number one reason patients seek alternatives to CPAP.
Fortunately, a helpful tool now exists that can help ease a new CPAP user into initial treatment more comfortably. This simple new addition called V-Com is added to your CPAP hose that connects the mask to the machine.
V-Com is essentially training wheels for your CPAP machine. It’s used to adjust the flow, without affecting treatment. The flow adjustment creates a more comfortable inspiratory flow that makes it easier for you to stick with your CPAP.
Ask your doctor about V-Com if you are having trouble adjusting to the airflow of your CPAP machine.
Despite the advancements, there are alternatives to CPAP therapy that can be discussed with a sleep specialist and in some cases may be necessary.
Alternatives to CPAP That Can Treat Sleep Apnea
CPAP is considered the gold standard in treatment for sleep apnea and obstructive sleep apnea (OSA). Depending on the severity of the disorder, and whether someone is able to handle treatment with continuous positive airway pressure with CPAP, there are alternatives to speak to your doctor or sleep specialist about.
Here are CPAP alternatives available to treat sleep apnea, and who they may work best for when treating OSA.
Note: Alternative therapies to CPAP only make sense in certain situations. Be sure to discuss your symptoms with a sleep professional to see if any of these treatments would be right for you.
An oral appliance looks similar to a mouthguard you might wear during sports, or to prevent oral damage if you grind your teeth. Oral appliances work by repositioning your tongue and your lower jaw. The repositioning prevents your tongue from falling back into your throat and the tissue in your upper airway from obstructing your breathing.
There are over 100 types of FDA-approved oral appliances for sleep apnea treatment. For best results, use a custom oral appliance that’s fitted to your specific measurements— a device that doesn’t fit can actually worsen sleep apnea and cause jaw problems.
Oral appliances work best for patients with mild sleep apnea to moderate sleep apnea— if you suffer from severe sleep apnea, you will need a more proactive treatment.
Follow-up treatment is important to ensure this option is working for you. Once you receive your sleep apnea mouth guard, your doctor should ask for a sleep study to evaluate how effective it is at treating your apnea.
However, there are two important caveats to consider here. The first is that oral appliances typically cost as much as or even more than CPAP does, and does not have the same track record of success. So if you’re looking for a more frugal option, this likely isn’t the best choice.
Again, your doctor will also need to schedule a sleep study to ensure that the appliance is working properly, which can amplify the costs as well.
Because of advances in CPAP machines, BiPAP therapy is rarely used and can only be considered if you have already failed to find success with your CPAP.
BiPAP, also known as bilevel positive airway pressure or bilevel PAP, is similar to CPAP because you use a machine that uses pressurized air to keep your airways open. However, BiPAP therapy uses two pressure settings, rather than the same consistent pressure from CPAP.
The pressure in BiPAP Therapy reduces as you exhale and increases as you inhale— making exhaling much easier for patients, especially if they experience other breathing difficulties from conditions like lung disease.
BiPAP therapy may be more effective for you if you have difficulty exhaling while using a CPAP machine.
However, BiPAP is seldom used anymore, except in patients with very severe sleep apnea— particularly central sleep apnea. This is because all modern CPAP machines have an expiratory relief setting, which is very similar to what BiPAP does.
It’s also much more expensive than CPAP and is generally not covered by insurance.
Surgery is only an option if CPAP has failed. The type of procedure you receive will depend on the source of your sleep apnea symptoms. Here are a few options that may be suggested, depending on the source of your apnea.
Your tonsils and your adenoids exist in the back of your throat and can obstruct your airways if they become enlarged or inflamed. Adenotonsillectomy, or the removal of your tonsils and adenoids, can remove these obstructions and help you breathe more easily.
However, this option is very expensive and works in less than 10 percent of patients. This is because you have to have a very specific factor causing your sleep apnea for this treatment to be effective— in this case, if your tonsils or adenoids are not contributing to your sleep apnea, this isn’t the correct treatment option.
On top of this, there’s currently no commercially available way to determine if there are any physiological issues causing your OSA, so there’s no way to know for sure if the surgery will be effective.
On the other hand, CPAP addresses all potential issues that may be causing your sleep apnea, so there’s no need to add any further stress or expense to dig any deeper.
Of course, surgery is a far more invasive method of treatment, and when the odds of it being an effective procedure are so low, an adenotonsillectomy is rarely worth it.
Remember— surgery is expensive. Comparatively speaking, CPAP is not.
Inspire (Hypoglossal Nerve Stimulation)
A special device is implanted into your chest and is connected to your hypoglossal nerve. This device works by controlling tongue movement— if you stop breathing during sleep, a sensor in the device stimulates your hypoglossal nerve to move your tongue out of your airway.
However, this surgery can cost up to $50,000 and may only be covered by insurance if you meet the following criteria:
- You have failed or are not a candidate for CPAP
- Have a body mass index (BMI) of 35 or less
- Have between 15 and 65 on the apnea-hypopnea index (AHI) in a recent sleep study
Many people who suffer from obstructive sleep apnea are overweight or obese. For obese patients, losing weight is one of the best ways to reduce the severity of their symptoms. Bariatric surgery is considered by many to be an effective treatment against morbid obesity and its associated comorbidities, including obstructive sleep apnea.
In a study published by The Journal of Sleep Medicine, researchers investigated the positive effects bariatric surgery provided to obstructive sleep apnea patients a year following their surgery. They found that the prevalence of OSA decreased significantly in patients— 78 percent of participants saw improvement in their symptoms, and 45 percent of patients saw full resolution of their symptoms.
However, 20 percent of patients still experienced moderate to severe OSA even after a year, which would require further cardiorespiratory monitoring.
While bariatric surgery can be effective in treating obesity and indirectly, sleep apnea, many people may not qualify for the surgery, or it is not covered by private insurance. If you feel like this is a good option for you, talk to your doctor or insurance provider to see what your options are.
If you decide to pursue bariatric surgery, your doctor will first want you to get a sleep evaluation and have you treated for sleep apnea. This is because there are significant concerns about using anesthesia on patients with untreated sleep apnea. Because of this risk, your doctor may require compliance with CPAP before they conduct the surgery.
OSA occurs when the upper airway collapses during sleep causing either a partial or complete obstruction in airflow. When lying on your back while sleeping the collapsibility of the upper airway increases, leading to an increased number of apneas (complete obstruction) or hypopneas (partial obstruction) per hour of sleep.
If you have fewer respiratory events when you’re not sleeping on your back (aka, the supine position), then you have what the American Academy of Sleep Medicine defines as positional obstructive sleep apnea.
According to some reports, approximately half of all patients with OSA have positional OSA. This percentage increases among mild to moderate OSA patients.
If you have positional obstructive sleep apnea (PT), positional therapy (PT) is may be offered as a secondary treatment option but typically only after other therapies have failed.
Positional therapy works by helping you sleep on your side and correcting your sleeping position if you accidentally sleep or roll over onto your back. This type of therapy may involve wearing a special band or device that makes sleeping on your back uncomfortable, encouraging you to sleep on your side.
In a study assessing the effectiveness and long-term adherence to PT published in the Journal of Clinical Sleep Medicine, positional therapy was successful for short-term use in 68% of patients. Long-term adherence to the PT treatment however was low, especially among patients with moderate positional OSA with 89% stopping their treatment.
While positional therapy isn’t as effective as CPAP therapy, it may be a temporary solution if you have positional sleep apnea and have failed and are unable to use CPAP for treatment. This is because in the grand scheme of things, sleeping on your side can reduce OSA symptoms, but it will not fully treat this disorder.
Let us say this again. Positional therapy can help with mild cases of sleep apnea, but it will not solve any long-term problems. On the contrary— without the proper treatment, OSA will worsen with age.
Medication is not a typical treatment for sleep apnea. In fact, as a whole, it’s less of an alternative treatment and more of a complementary one. However, one prescription, modafinil is often used to treat residual sleepiness for sleep apnea patients using CPAP.
One study from Flinders University found that combining reboxetine— an antidepressant, and butylbromine— an antispasmodic, helped prevent airway collapse during sleep.
Researchers observed 15 otherwise healthy participants with sleep apnea over two nights. Researchers monitored airflow, oxygen saturation, and heart activity.
Following the tests, the researchers found that the two medications rebalanced the electrical activity in the participants’ throats, which significantly reduced the number of breathing pauses they experienced at night.
However, more research is needed to examine the long-term effects of these and similar medications in treating obstructive sleep apnea.
The Bottom Line
CPAP is the most popular sleep apnea treatment for a reason— it works, but only as long as you use it as directed. However, if you require an alternative to CPAP for treating your sleep apnea, there may be potential alternatives.
Talk to your doctor or get evaluated by a sleep expert— they can help you find the right treatment option for your sleep-disordered breathing if you’re unable to maintain your CPAP treatment.
Sleep apnea is a serious and potentially dangerous sleep disorder— but you don’t have to worry as much about your symptoms if you receive the proper treatment. Contact us today at the Sleep Centers of Middle Tennessee to find the right treatment for you so you can get back to the good night’s sleep you deserve.
Rotenberg, Brian W, et al. “Trends in CPAP Adherence over Twenty Years of Data Collection: A Flattened Curve.” Journal of Otolaryngology — Head & Neck Surgery = Le Journal D’oto-Rhino-Laryngologie Et De Chirurgie Cervico-Faciale, BioMed Central, 19 Aug. 2016, www.ncbi.nlm.nih.gov/pmc/articles/pmc4992257/.
Peromaa-Haavisto P;Tuomilehto H;Kössi J;Virtanen J;Luostarinen M;Pihlajamäki J;Käkelä P;Victorzon M; “Obstructive Sleep Apnea: The Effect of Bariatric Surgery after 12 Months. A Prospective Multicenter Trial.” Sleep Medicine, U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/28549834/.
Clebak, Karl T., et al. “Positional Therapy for Obstructive Sleep Apnea.” American Family Physician, 1 Jan. 2020, www.aafp.org/afp/2020/0101/p16.html.
Lim, Richard, et al. “The Noradrenergic Agent Reboxetine plus the Antimuscarinic Hyoscine Butylbromide Reduces Sleep Apnoea Severity: A Double‐Blind, Placebo‐Controlled, Randomised Crossover Trial.” The Physiological Society, John Wiley & Sons, Ltd, 14 July 2021, physoc.onlinelibrary.wiley.com/doi/abs/10.1113/JP281912.