Sleep Apnea

CPAP Machine Alternatives: Behavioral Therapies, Lifestyle Changes, Oral Appliances, and Surgery

Do you have obstructive sleep apnea (OSA)? If you’re reading this article, you’re likely to have received a diagnosis already from a sleep medicine physician. Or maybe you snore and have the other symptoms of apnea and have taken the STOP-Bang questionnaire at your doctor’s office or online.

Your score is telling you, based on your symptoms, neck circumference, weight/BMI, blood pressure, gender, and age that you’re likely to have OSA. You may be thinking, “OK. But do I really need to use a CPAP machine to treat my apnea?”

Not necessarily. About 22 million Americans are believed to have sleep apnea, according to the American Sleep Apnea Association. Most apnea sufferers do choose to manage their OSA with CPAP or another form of PAP therapy because these therapies are the gold standard for treating apnea.

The steady, pressurized air from CPAP or other PAP machines keeps your airway open when you sleep, clearing fatty obstructions that cause you to snore, choke, and stop breathing.

However, not everyone can tolerate CPAP therapy. Some people find PAP therapy to be uncomfortable and disruptive to sleep. Others may deal with claustrophobic responses to the mask and air pressure. Some individuals find that they remove the apnea mask during the night, or that it falls off when they toss and turn.

If you’re among the minority of apnea sufferers who fall into this category, and if you have mild to moderate apnea, you do have other options. You can try behavioral therapy, lifestyle changes, dental appliances, or surgery. Some of these approaches are more effective than others.

This article will present some of the current alternatives to CPAP therapy for obstructive sleep apnea. Remember: if you want to be healthy, ignoring your sleep apnea is not an option. Do something—choose the most effective therapy or therapies you can tolerate. Ultimately, the best therapy for your apnea—the one with the best shot at improving your condition—is the therapy you will stick with.

Positional Therapy

This behavioral approach to treating apnea changes your sleep position. Many people who snore or suffer from apnea have positional apnea—apnea that responds positively to a change from “supine” (on your back) sleeping to side sleeping.

If you’re a back sleeper, gravity pulls down on your tongue and on the loose, untoned tissue in your throat; when these fall to the back of your throat, they create a flap or obstruction that prevents you from breathing easily.

The idea behind positional therapy is that sleeping on your side will prevent the tongue and loose tissue from falling back in such a way that they fully block your airway.

Studies have shown that for people with positional apnea, side sleeping can reduce apnea events by 50% or more. A simple change in position can greatly reduce the severity of your apnea, improving your oxygen levels and therefore your health.

Of course, we choose our sleep positions based on what feels natural to us, and in most cases, people have been sleeping a certain way their entire lives. Changing from being a back sleeper to a side sleeper isn’t easy. Also, you can’t control when you shift positions in your sleep.

Because of this, positional therapy relies upon wearing a therapeutic device, usually wrapped around your middle, to prevent you from rolling from your side back onto your back. This device can be as simple as securing a tennis ball to your back using a pair of pantyhose.

You can also opt for vibrating devices worn around your neck or abdomen. These devices track your sleep position and vibrate when you try to roll onto your back, just enough to stop you from changing position (but not enough to wake you—theoretically).

The upside of positional therapy: it’s helpful if you stick with it. The downside: people tend to quit using this approach after a while, either because they prefer to sleep on their backs and can’t get used to sleeping on their sides or because they continue to experience some snoring and apnea events, even with the therapy.

Provent Sleep Apnea Therapy

Provent is the brand name for an FDA-approved apnea therapy available with a prescription. It’s a disposable nasal device that adheres to the inside of your nose using hypoallergenic tape. Each device contains a tiny valve to control the flow of air and out of your nose.

According to the manufacturer, “Provent uses a proprietary MicroValve design that creates pressure when you exhale to keep your airway open.” How it works: The valve allows you to inhale without resistance but creates slight resistance when you exhale.

This resistance keeps air in your airway a bit longer than is typical, which increases pressure and acts as a sort of splint to keep your airway open (similar to what a CPAP machine would do). This pressure allows more oxygen to get through when you take your next breath.

Provent has been rigorously tested and it can improve OSA if you have mild to moderate apnea and cannot tolerate CPAP. However, if your apnea is severe or if you have other breathing issues, CPAP is still the recommended choice, as it has more evidence of success in preventing cardiovascular events.

Another consideration: if you are a mouth breather, Provent probably won’t work for you—the device depends on exhaling through your nose to create air pressure. Some people who don’t mouth breathe may even begin doing so in response to wearing the device, which defeats the purpose of the therapy.

The upside to Provent: if you can’t tolerate CPAP, this nasal device is another way to create airway pressure, and it’s portable, which makes for easy travel. The downside: severe OSA probably won’t respond sufficiently to this therapy, and if you exhale through your mouth (as many people who snore do), the therapy won’t work at all.

Surgery

Some people with apnea consider surgery to trim away the excess tissue in the throat. The most common surgical response to apnea is a procedure called a uvulopalatopharyngoplasty or UPPP. However, this procedure is a last resort, not the first line of defense. It’s normally considered only if the apnea patient cannot tolerate CPAP therapy.

Though effective to some degree, UPPP surgery is no guarantee that your apneas will stop completely. According to one study published by the Mayo Clinic, only about 1 out of 4 patients were able to achieve an AHI (apnea hypopnea index) score of less than 5 —indicating no or very mild apnea—after surgery.

However, patients who still had residual apnea after treatment were able to reduce the air pressure settings on their CPAPs.

Other, less common procedures include removal of nasal polyps, the Pillar Procedure (inserting implanted rods into the soft palate), hyoid, tongue, or lower jaw advancement (surgically moving a bone in your throat, a part of your tongue, or your jaw forward), tongue base reduction (to decrease the size of the tongue), or tracheostomy (creating a hole in the trachea to bypass the upper airway).

Although some of these surgeries have become less invasive in recent years, nearly all carry some risk. Most doctors will recommend non-invasive PAP therapy or an oral appliance before mentioning surgery as an option for sleep apnea.

Oral Appliances

Oral appliance therapy (OAT) treats mild to moderate sleep apnea through the use of a custom-fit dental device you wear in your mouth when you sleep. The device slides your lower jaw forward just enough to create additional space at the back of the throat, opening the upper airway. OAT good for upper airway soft tissue obstructions or tongue position obstructions.

It is FDA-approved as a first-line therapeutic approach for mild to moderate obstructive sleep apnea. An oral appliance can be an effective therapy if your apnea is not severe. Compliance is quite high with this treatment, and many people like it because it’s “low maintenance” and portable as compared to CPAP therapy. However, if you number over 30 apnea events per hour, CPAP is still the recommended treatment.

Weight Loss

Some overweight or obese individuals may see an improvement or even complete elimination of their apnea if they drop excess weight and reduce their BMIs. Losing weight may mean losing neck circumference and excess fatty tissue in the throat.

Because a healthy BMI has such a beneficial impact on many aspects of your wellness, losing weight is a good idea—but there’s no guarantee that burning fat and getting slimmer will cure your apnea. Plenty of thin, physically fit people have OSA. While losing weight may be a positive lifestyle change that helps your health in other ways, weight loss alone may not resolve your apnea.

Inspire Therapy (hypoglossal nerve stimulation)

This therapy is another alternative for those who cannot tolerate CPAP or use an oral appliance. If you’re a good candidate (an adult with moderate to severe apnea, not severely overweight), a surgeon will implant a device under your skin during an outpatient procedure. At bedtime each night, you activate the device via remote control. While you sleep, the implanted device stimulates nerves and muscles to keep your airway from collapsing.

Inspire (the brand name for the therapy) received FDA approval in 2014. According to the official website, snoring and apnea events see significant improvement, and 81% of patients use the treatment every night, all night. However, it’s important to note that the product’s clinical trial showed improvements in sleep apnea: reductions in the number of apnea events per hour (about 68% improvement, from 29 to 9 events per hour).

Though this is a substantial improvement, it represents a change from moderate apnea (bordering on severe) to mild apnea. You may still experience sleep apnea after the implantation procedure. Though symptoms and quality of life are likely to improve, the apnea may not completely resolve without the addition of other methods.

Summary

Numerous alternatives to CPAP machines exist for treating obstructive sleep apnea, but with the exception of oral appliance therapy for mild to moderate apnea, most are reserved for patients who have a proven intolerance for CPAP therapy.

Talk to your doctor about the method that will be most effective for you, based on the severity of your apnea and any special considerations that may affect your ability to stick with your therapy.

2 Comments

  1. Thank you so much for the good tips! I particularly liked the one about holding the mask out and letting it fill with air before seating it. I also liked your list of alternatives such as the Provent. I am going to look into right away.

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