CPAP Isn’t Working for Me - What Are My Options?
By Lily - Registered Respiratory Therapist
Sleep Apnea and CPAP Therapy
Obstructive sleep apnea (OSA) affects more than 25 million adults in the US, according to the American Academy of Sleep Medicine. Sleep apnea occurs when soft tissues in the back of the airway collapse during sleep, resulting in less (or no) airflow to the lungs.
This decrease in airflow causes oxygen levels to drop, which leads to the activation of the sympathetic nervous system and the “fight or flight” response. Heart rate and blood pressure increase, and the body produces stress hormones, such as cortisol and catecholamines.
Cortisol helps the liver release more glucose into the bloodstream, which is why untreated sleep apnea is a problem for those with diabetes. You may also experience a dip in your oxygen saturation (SpO2), depending on the extent of airway obstruction. Left untreated, this can take a toll on your cardiovascular health, especially if you have other heart conditions.
The gold standard of treatment for OSA is CPAP therapy. However, CPAP therapy requires an adjustment period that can take weeks and even months. Poor mask fit is a common problem that plagues many CPAP users, and those who struggle with claustrophobia brought on by CPAP masks have the hardest time adjusting.
Q: What happens if you have sleep apnea and don't use CPAP?
A: Untreated OSA can cause serious health issues and diagnoses.
This article outlines alternatives to CPAP therapy that may be an answer. Please bear in mind that there are limitations to alternative treatment options, and sleep physicians generally will not prescribe alternative treatments unless CPAP has been tried first.
Q: Are CPAP alternatives effective?
A: This is a question you need to have with your doctor. Your doctor knows what is best for you to treat your OSA diagnosis.
Q: Can you treat sleep apnea without a CPAP machine?
A: We suggest speaking to your doctor regarding the most effective way to treat your OSA. CPAP is golden standard but a Mandibular Advancement Device, BONGO, and positional therapy can assist with treating mild cases.
Q: What are CPAP alternatives for travel?
A: Please speak to your doctor before making a decision not to take your CPAP along while traveling or using an alternative device for treatment.
Q: What are some of the maskless sleep apnea treatments?
A: BONGO, Philips Night Balance, Mandibular Advancement Device.
Positional therapy is often recommended by physicians to patients with mild to moderate OSA who are hesitant to try CPAP. It’s really just a fancy way of telling you to avoid sleeping in the supine (on your back) position.
Sleeping on your back increases the likelihood of breathing events because you have gravity working against you, pulling the soft tissues of your oropharynx down and narrowing the airway. Research shows that more than half of sleep apnea patients have their most severe breathing events when they are sleeping supine.
Many positional therapy devices are available for those looking to give this a try. They range from the simple to the technological, and most require a prescription. The simplest prescription-free positional therapy device is the DIY tennis ball t-shirt. You sew a tennis ball to the back of a t-shirt and wear it to bed.
As strange as this sounds, it works because the tennis ball makes sleeping on your back uncomfortable so you will roll onto your side instead. Essentially you are training yourself to avoid sleeping on your back.
If you prefer a more technologically advanced approach to positional therapy, you may want to look into the NightBalance. The NightBalance is a small palm-sized device that you wear in a belt across your chest. It monitors your sleep behavior and gently introduces vibrations during your sleep, encouraging you to move from the supine position.
The device tracks how long you sleep, how many times you slept on your back, and how well you are responding to therapy. It also comes with an app so you can have access to your therapy data at all times.
Oral appliances, or mandibular advancement devices, are another alternative to CPAP therapy for those with mild to moderate OSA. They pull the lower jaw forward, which prevents the base of the tongue from falling back and blocking the airway.
If you are interested in having an oral appliance made, you need to see a sleep specialist and a dentist who specializes in oral appliances. The dentist will decide if you are a good candidate for oral appliance therapy and make an appliance based on the impression they take from your teeth.
The process will require several visits to the dentist, and further adjustments may need to be made to the appliance for optimal therapy. These are an alternative for those who cannot tolerate CPAP therapy, but can cost more than a CPAP machine and may not be covered under your dental insurance. Please contact your insurance provider prior to having an oral appliance made to avoid any unpleasant surprises.
EPAP devices/valves have become increasingly popular over recent years as an alternative to CPAP therapy. Unlike in CPAP therapy, there is no positive pressure on inspiration when you use an EPAP device. Positive pressure is instead generated on expiration when you exhale through the EPAP valve situated in your nose.
The EPAP valve partially closes on expiration which increases resistance and creates back pressure. This back pressure is the positive pressure that helps splint the upper airway open to prevent airway obstruction.
Research shows that EPAP devices are effective at reducing AHI (apnea hypopnea index or the number of breathing events) by as much as 50% for patients with mild to moderate OSA.
While CPAP therapy is still the gold standard of treatment for OSA, EPAP is a good alternative for those who struggle with CPAP. Some people find CPAP masks claustrophobic and have difficulty adjusting to the pressure on inhalation.
For those who struggle with CPAP, an EPAP device that lowers AHI from 20 events/hr to 10 events/hr still provides a better outcome than a CPAP machine which lowers AHI to less than 5 events/hr but is only used for 2 hrs a few times per week.
EPAP devices are small, portable, and do not require electricity. The Bongo, for instance, is an FDA approved EPAP device that is made of reusable silicone and comes in a starter pack which is good for a year.
Some CPAP patients choose to use the Bongo when they are on vacation because it is much smaller than a CPAP machine, and there’s no need to pack accessories, either. If you are interested in trying an EPAP device, please consult your physician to see if it is right for you. EPAP devices are recommended for treatment of mild to moderate OSA.
Uvulopalatopharyngoplasty (UPPP) is the most common surgical treatment for OSA. The goal is to open up the upper airway by removing all or part of the uvula, part of the soft palate, and tissues surrounding the airway. Tonsils and adenoids may also be removed if they are still present.
UPPP requires general anesthesia and an overnight stay at the hospital. Recovery time is 2 to 3 weeks, and patients will need to watch their diet (no solid foods) during the recovery period. The long term success rate for UPPP is around 50% with beneficial effects decreasing over time. You will need to see an ear, nose, and throat specialist for UPPP surgery.
Hypoglossal Nerve Stimulation Therapy
Hypoglossal nerve stimulation therapy (HGNS) is a sleep apnea treatment developed by Inspire Medical Systems and approved by the FDA in 2014. The hypoglossal nerve innervates muscles of the tongue, allowing the tongue to retract, protrude, and change shape.
HGNS therapy involves sending electrical impulses to the hypoglossal nerve which then stimulates the tongue to move forward and relieve airway obstruction. The stimulation is synchronized to the patient’s breathing with the impulse generated at the end of expiration and lasting throughout inspiration.
HGNS therapy, commonly referred to as Inspire, involves implanting a device (impulse generator) that is similar in size to a pacemaker beneath the skin of the clavicle. The impulse generator has two tunneled leads - one that travels up to the hypoglossal nerve and the other down between the internal and external intercostal muscles.
The lead that travels down to the internal and external intercostals is a pressure sensor that detects breathing. The patient will be able to turn the device on and off using a remote control placed over the skin above the implant.
HGNS is suitable for adults (age 22 and above) with moderate to severe OSA (AHI 15 to 65 events/hr) who have difficulty adhering to CPAP therapy and have BMI < 33 kg/m2.
Potential patients will be screened by drug induced sleep endoscopy (DISE) to rule out concentric (complete) collapse of the upper airway during sleep. Inspire is not indicated for patients with concentric upper airway collapse since moving the tongue forward in this instance does not help relieve airway obstruction.
If you have central apneas, please be advised that Inspire is contraindicated for those with central/mixed apneas > 25% of their total AHI.
If you are interested in HGNS therapy, please consult your sleep doctor for more information. The estimated cost of HGNS including surgery is approximately $28,000 based on a 2019 study conducted by Dr. Vathi and colleagues.
HGNS is covered by Medicare and some insurance providers. However, insurance coverage is on a case by case basis and may require an appeal.