The use of a mask or nasal pillows at night is uncomfortable for some patients, even after they have tried every mask option available.
For others, it’s problems with adjusting to the pressure delivered from the machine, especially during exhale, that makes the therapy hard for them to tolerate.
CPAP has come a long way since it was first developed in the 1980s, and more people are finding it the perfect solution for their OSA problems, but for some, a different option may be the best way for them to treat their OSA.
While CPAP is frequently discussed as the first line of treatment for OSA, it is not the only sleep apnea treatment available to you. As a patient, you have a right to know what options are available to you so that you can make the best decision moving forward. If you have used CPAP unsuccessfully, you also have the option of seeking a different approach in order to be proactive about your OSA.
Considering the risks that one faces by not treating their OSA (heart problems, high blood pressure, diabetes, stroke, depression, etc.), it’s worth it for these patients to find what works best for them, regardless whether it is the “gold standard.”
Lifestyle changes alone will not cure OSA overnight, but they can certainly go a long way toward improving its severity. Lifestyle changes are often used with CPAP therapy to enhance the therapeutic experience and to show quicker results.
Losing just ten pounds can help shrink fat cells, and this bodes well for those overweight people with OSA.
No matter how much you way, everyone has a layer of fat across the neck area. Generally speaking, fat cells in these “pads” around the neck expand and shrink in tandem with changes to your body mass index. Therefore, if you are overweight, the fat pads below your chin will be larger and retain more fluid, both which exert pressure on the upper airway as you sleep, resulting in obstructed breathing patterns.
Making healthy dietary changes and getting more aerobic exercise daily will help shrink those fat cells, as well as improve the overall tone of your muscles in the upper airway. This can lead to less severe patterns of sleep apnea.
Enough weight loss (which depends upon each individual) can even eliminate some cases of OSA. Of course, this is a major commitment that requires time, discipline and patience; your sleep breathing problems will not disappear overnight just because you are trying to lose weight. However, weight loss for those who are overweight or obese is almost always a good strategy for preventing the onset of any chronic illness, OSA included.
Positional Therapy for Sleep Apnea
This is an old-school approach that has been shown to work for those who have mild OSA. Back sleeping is the position which leads to the worst snoring and the most severe problems with apnea. Training yourself to sleep on your right or left side while avoiding back sleeping may be all it takes to keep the upper airway from collapsing as you sleep at night.
There are special night shirts with tennis balls sewn into their backs that help to retrain you to avoid sleeping on your back. A new technology also exists in which the patient wears a sensor on the back of their neck which vibrates while they are supine until they finally move to either side.
2015 brought renewed interest in performing a series of tongue and throat exercises as a way to improve the tone of the muscles in the upper airway.
This ABC News video from last summer gives an animated demonstration of the exercises used in recent clinical research; a study reporting on research results published in CHEST last spring, includes a visual aid with instructions (see above). While these tactics are meant for snoring problems, they may also have some use for those with mild to moderate OSA.
As with weight loss, throat exercises will require a daily commitment of up to 10 minutes of repetitions over the long term (3 or more months) to show results, and there’s no certainty that such exercises will “fix” OSA, although they might alleviate its severity. If nothing else, they might make using CPAP easier down the line.
And speaking of CPAP… it is only one of a three positive airway pressure therapies (PAP) that you can use. Switching from CPAP to a different form of PAP may be the solution to your problem when your mask fit is still okay but you still can’t adapt to the pressure.
Bilevel positive airway pressure (BiPAP)
BiPAP is a form of PAP that provides split pressures for improved comfort—one preset pressure for inhalation, and a second different preset pressure for exhalation (learn more here). Sometimes the single fixed pressure offered by CPAP is not comfortable for some patients, whereas split pressures provided by BiPAP can provide better comfort for either the inhaling or exhaling segments of the breathing process.
Automatic positive airway pressure (APAP or AutoPAP)
APAP is a pressure delivery system preset for a range of pressures which adjusts based on the patient’s pressure needs in order to prevent obstructive breathing. For many patients, the “smart” adaptability and sensitivity of this technology makes it superior to CPAP, which is set on only a single fixed pressure. There’s less for the patient to adapt to with APAP; essentially, the put on the mask, turn on their PAP machine and let the delivery system to the rest of the work.
CPAP with C-Flex
For those with mild OSA, adding the C-Flex option might be all that’s necessary to improve the comfort level of incoming pressure. C-Flex is a kind of pressure relief setting that softens the exhale pressure like BiPAP, but at a much lower setting.
For some, OSA issues are a product of less-than-ideal physiology. Some people are born with naturally narrow nasal or sinus passages, or deviated septums, or an especially soft chin. Sometimes the problems with breathing occur due to allergies and other issues of tissue drainage (excessive postnasal drip, for instance) in the cavities above the airway. These patients may not be able to tolerate pressurized air as a therapy for keeping their airways clear.
Oral appliance therapy must be custom-built to fit your orofacial landscape by dentists with training in sleep dentistry and in conjunction with prescriptions from sleep physicians. The latest OAT devices are easy to adjust, often covered at least partially by insurance and very durable and long-lasting. They are often used while taking PAP therapy for those with more severe problems with OSA.
Mandibular advancement devices
These mouthguard-styled devices work by advancing the lower jaw; this, as well as a slight forward reposition of the tongue, leads to a more open airway. In the morning, the user swaps out the device for a jaw repositioning mouthpiece that helps to adjust the bite back to a normal position, in the event it shifts overnight
Tongue retaining mouthpieces
These are similar to MADs in that they are worn in the mouth with the goal of moving the tongue forward and away from the back of the throat. However, the device is placed on the tip of the tongue and rests outside the mouth, on the lips, rather than in the mouth.
For more severe cases of OSA, there are various outpatient, implant and surgical procedures that can help to prevent the collapse of the airway while sleeping.
Outpatient and implant procedures
These are considered simple, safe and minimally invasive procedures that help to change the way the upper airway functions while the patient is asleep.
Small woven inserts are implanted in the soft palate at the back of the throat under local anesthetic; these help to stiffen the soft palate, decrease tissue vibration and stabilize the airway.
This procedure is also known as temperature-controlled radio frequency, in which radio waves are targeted toward specific areas of extraneous tissue in the upper airway in order to remove them. The technology is precise and minimally invasive.
Upper Airway Neurostimulation
This newly introduced procedure involves the implanting of a neurostimulating device in the upper chest which sense breathing patterns and, as necessary, delivers gentle electrical impulses to key airway muscles in order to keep them from collapsing.
Surgical procedures for OSA
More invasive procedures may be the only options for some with severe OSA and other severe respiratory problems.
The most common form of upper airway surgery, UPPP describes the enlargement of the airway through reductions of the tissue (usually parts of the soft palate and the uvula, and sometimes including the tonsils).
Sometimes, the regular airway obstruction can be blamed on overlarge adenoids (tonsils); surgical removal of these can provide considerable relief for those with severe OSA.
Often the key problem with OSA can be caused by dysfunctional tissues and processes in the nose and sinus regions. Deviated septums, swollen turbinates, collapsed nasal valves can contribute to breathing problems; for those with severe OSA, surgery is often performed in addition to the use of CPAP therapy to help the patient with comfort issues.
Maxillomandibular advancement (MMA) surgery
Parts of the jawbone are repositioned during this surgical procedure to enlarge the space at the back of the throat to prevent obstructive events from occurring.
This was the only option patients with OSA had before PAP technology was developed. It involves the most extreme surgical procedure, in which the surgeon creates a permanent opening in the trachea (commonly known as the windpipe) inside which is inserted a valved breathing tube. The valve is opened at night to bypass obstructions in the throat so air to enter the respiratory system.
What to choose?
Ultimately, someone with OSA should seek out and commit to the therapy that best works for them. Even the most popular therapy is useless if the patient won’t comply with using it.
Choosing the right therapy should be part of a careful discussion that includes the advice of your sleep physician and other specialists, such as surgeons, sleep-certified dentists, otolaryngologists and others.
Considerations besides effectiveness and comfort when choosing from these alternatives should include risk-benefit considerations, overall costs, your qualifications as a patient (all of these alternatives to CPAP have risks and specialized criteria that need to be met), how choosing these options could impact your activities of daily living, and the availability of these treatments in your area.
As always, you are best advised to discuss all your options with your sleep physician, who has the best information and treatment alternatives suited to your situation.
Many patients who first start using CPAP struggle with it for a week or two, then give up. What they don’t realize is that it can take the brain and the body longer than that to adjust to the changes the body goes through while adapting to the physical use of the CPAP device as well as while receiving steady air pressure.
Sometimes the problem can be blamed entirely on using the wrong mask. Contacting your equipment provider to try out different masks can make a big difference.
For others, the solution might be to attend a support group where others are using the same CPAP equipment so that they can get tips from real-life users who’ve been on the therapy for some time.
Given all the sleep apnea treatment options available, it’s worth comparing their risks, costs and availability against the use of basic CPAP. It’s never a bad idea to try again if, at first, you don’t succeed. Many patients have false starts with CPAP, start over, and become lifetime evangelists. So don’t give up on CPAP. What may have at first seemed like a nuisance may actually turn out to be the best thing you ever did for yourself.