Looking for CPAP ALTERNATIVES that really work? 

Here's a quick guide to CPAP and other options. Check the effectiveness of sleep masks, mouth devices & surgery in comparison to positive airway pressure machines. Make the best choice to reduce your snoring and finally get the rest you need!

PAP: Positive Airway Pressure

These devices are the most reliable non-invasive treatment option for sleep apnea. All of them deliver pressurized air through a hose into a sleep mask (nasal or full face). This air prevents your airway from collapsing and keeps it free of obstructions as you sleep. You can breathe freely and will experience fewer or no apnea events. Added comfort can be achieved by adding a humidifier.   

CPAP: One Set Pressure

Continuous Positive Airway Pressure. The “gold standard” of sleep apnea treatments. The CPAP machine is calibrated or “titrated” during a sleep study to blow air at one specified pressure into your airway at a constant pressure to keep your breathing passages open. This prevents apnea events by keeping your airway from relaxing too much.  

Success with CPAP use depends on, well, using it. So, for greater comfort while you are falling asleep, many machines now have a “ramp” feature. The pressure starts off lower for better comfort while you are falling asleep. It builds up to the prescribed setting and stays there for the rest of the night.

With newer machines, CPAP users can collect their sleep data on an SD card or a cloud. You can read the data via software or even a mobile app. This data might include number of hours used, number of apnea events or AHI, mask leak and mask off events, and more.

There are a couple of CPAP alternatives, close cousins that give you more control over the air pressure for more comfort: APAP and BiPAP.

APAP: Best Pressure Within A Set Range

Automatic Positive Airway Pressure. It’s basically the same as a CPAP machine, but CPAP can only be set to one pressure. APAP is set up with a low range setting and a high range setting. It uses algorithms to sense changes in your breathing while you sleep and automatically adjusts itself between the ranges moment by moment.

• It can sense when you roll to your side (you need less pressure) or your back (more pressure)
• During REM sleep, which is when you are most relaxed, it will switch to the higher pressure – this is the pressure a CPAP is usually set up with
• It will adjust when you have congestion due to allergies or a cold
• If your needs change (such as weight loss/gain) a CPAP machine may need a new titration study but an APAP will adjust to the change
• You can switch most of them over to straight CPAP if you want to
• You can get it with a CPAP prescription

Unlike CPAP machines, these machines are not standardized from one manufacturer to another, so finding your “sweet spot” on the settings may take some experimentation. APAP is also more expensive than CPAP.

BPAP or BiPAP: Different Pressures For Inhaling And Exhaling

Bilevel Positive Airway Pressure. One problem with CPAP machines is that some patients find it difficult to exhale against the constant incoming air pressure. It’s especially difficult for those using high pressure strengths.

A BiPAP device is set up with two pressure settings. The prescribed pressure (ipap) is set for inhaling and a lower pressure (epap) is set for exhaling. It can also be set to time your breathing. If it senses you missed a breath it can temporarily increase the pressure to force you to breathe. 

• You need a prescription specific to BiPAP because it needs both the ipap and epap numbers.
• Good for people who have failed with CPAP
• Good for people who need high pressure settings or have low oxygen levels
• Good for people with some neuromuscular disorders, lung disorders, congestive heart failure, cardiopulmonary disorders

ORAL AND DENTAL APPLIANCES

Dental sleep medicine has become a specialty because the level of non-adherence for CPAP therapy has remained high. More and more, sleep physicians are referring patients for oral appliance therapy as an alternative to CPAP rather than for throat surgery which is often less effective.

OAT (Oral Appliance Therapy)

You are custom-fitted with a device that is much like an orthodontic retaining mouthpiece or a sports mouth guard. It’s worn during sleep. It pushes your lower jaw forward to help open your airway. If you are lucky, this alone will improve your sleep, buff up your health, and give you back your vitality and alertness.

This form of therapy is considered to have a level of effectiveness close to that of PAP, though it is still being studied. It is much easier to comply with.

• Quiet
• Portable
• Comfortable and easy to wear
• Easy to care for
• But expensive

MADs (Mandibular Advancement Devices) or OAm (Oral Appliance – Mandible)

A dental sleep device or oral appliance opens your airway by holding your lower jaw (mandible) forward while you are wearing it. Your tongue is attached to your lower jaw behind your chin, so this gadget also moves your tongue forward. Presto! Better airway.

Avoid the “boil and bite” versions from the internet or department stores. A dental appliance should be fitted by your dentist in consultation with your doctor. 

SURGERY

The only 100% effective solution for sleep apnea is a tracheostomy. You probably don’t want to do that. Here are some other surgery options, depending on the cause of your sleep apnea.

Uvulopalatopharyngoplasty (UPPP or UP3)

UPPP, the most common surgical treatment for sleep apnea, is the removal or altering of tissues in your throat. These removed or altered bits could be your tonsils, your adenoids, part of your soft palate, your uvula (the hanging down squiggly thing). Or your uvula might get sewn to your soft palate. 

It’s important to remember that CPAP always works if you use it. Surgery such as this only has a 25% to 30% success rate. The most severe cases of sleep apnea are the least likely to be cured with this surgery, according to studies.

But here is a success story: Cleveland Cavaliers forward Anthony Bennett, NBA #1 draft pick in 2013. Sleep apnea and asthma had left him with his "hands on hips, shoulders rolled, head down, mouth-breathing like a freshly hooked bass," according to sports writer Janson Concepcion. Bennett said in 2014, “Since [having] my tonsils out, my adenoids, I have a lot more room to breathe.” 

Bariatric Surgery

Bariatric surgery uses a gastric band or removal of part of your stomach to make your stomach smaller. 

The problem with CPAP treatment is low patient acceptance and adherence, and poor tolerance for being hooked up to a machine every night wearing a mask. The comparative efficacy of the more tolerable acknowledged alternative, oral appliances (OAm or MAD), is still being studied.

An article published by Dr. Olivier M. Vanderveken in the Journal of Dental Sleep Medicine discusses these issues. Dr. Vanderveken, a professor in medicine at University of Antwerp, is a specialist in sleep medicine and in dental appliances. He suggests that obese patients with severe OSA who have bariatric surgery may then require lower CPAP pressures, which may then snowball into better adherence to CPAP treatment. His article also calls for more research into this solution.

It is well-known that losing weight is one of the most effective treatments for OSA. Losing 10% of your body weight may cause OSA to go into complete remission. While the weight stays off.

VOAT Procedure (Ventral Only Ablation Of Tongue)

One cause of OSA is that the base of a patient’s tongue is larger than normal. This has no connection to obesity. Radiofrequency ablation (RFA) has been used for 15 years to reduce the size of the base of the tongue. Tissue is removed by heat coming from a radio wave.

Dr. David Dillard, an ENT specialist, has finessed this at the Sleep and Sinus Centers of Georgia. His procedure “denatures” the proteins in the tongue tissues, causing scarring. Scarring is apparently the helpful part because it reduces the amount of tissue but also pulls the tongue away from the airway. Here are some comments from happy patients. 

SLEEP TESTING

If your doctor thinks you have sleep apnea, they will send you to a sleep specialist or sleep clinic to determine if you should undergo sleep testing. This testing will determine what kind of sleep apnea you have. (Here are some tips from Alaska Sleep Education Center on choosing a sleep clinic).

Types Of Sleep Apnea Testing

Medical professionals disagree on which is the better of two types of sleep testing – PSG or HST. 

Polysomnograph (PSG)

• Performed in a lab
• Sleep technicians monitor the patient throughout the night
• Equipment records measurements of 16 body signals (also called channels) including brain activity, movements, breathing

Pros:

1. Measures more body functions than HST, giving the doctor more information
2. If a sensor comes loose, technicians can replace it – test doesn’t have to be repeated
3. If CPAP is used, technicians can adjust it during the night

Cons:

1. Inconvenient, expensive
2. You’re not sleeping in a familiar environment during the test so the results may not be true

Home Sleep Test (HST)

• For home sleep testing, you are given portable monitoring (PM) equipment and shown how to attach it; you do the testing at home
• In 1994, the American Sleep Disorders Association laid out four levels of sleep testing: 

1.  PSG is the benchmark, Type 1, and the rest are PM equipment
2.  You need at least a Type 3 device for diagnosis – it records a minimum of        four channels: heart rate, snoring, airflow, oxygen
3.  Type 2 records a minimum of seven channels: brain waves, eye                      movement, chin movement during REM, heart rate, airflow, oxygen, snoring  (click here for an example from Advanced Brain Monitoring)

• Results are interpreted by a professional

Pros:

1. Convenient and less expensive than PSG
2. More likely to have a typical night’s sleep for truer results

Cons:

1. Measures fewer body signals, giving the doctor less information
2. No human monitoring – if equipment is not on correctly, if sensors coming loose, if CPAP needs adjusting, test may have to be repeated
   

If you have central sleep apnea, the primary treatment approach will be to treat the underlying cause, such as heart failure. If you have the most common kind of sleep apnea, obstructive sleep apnea (OSA), you will be advised to lose weight if you are overweight, and to change other lifestyle factors that contribute to OSA.

For both types, you will probably also be advised to use a positive air pressure (PAP) machine every night. There are several types of these:

• CPAP (continuous positive air pressure)
• APAP (automatic positive air pressure)
• BiPAP or BPAP (Bilevel Positive Airway Pressure)

These devices need a prescription and will be fitted and calibrated by your sleep professional (this is called “titration”).

SLEEP APNEA

Sleep apnea is a serious sleep disorder. Your breathing stops suddenly and then starts again. The stopping may wake you up. But that’s not all. You’re not getting enough oxygen. If you suffer from daytime sleepiness after a full night of sleep, or if you snore loudly, you may have sleep apnea and should get tested.

Three types of sleep apnea:

•  Obstructive sleep apnea (OSA), by far the most common – when you sleep, your airway relaxes too much or is obstructed by fatty tissues inside your airway (soft palate, base of tongue)
• Central sleep apnea – your brain isn’t sending the right messages to your breathing muscles during sleep
• Complex sleep apnea – is a combination of both

When your doctor sends you to the sleep clinic or specialist, they give you a sleep test at home or in the lab. Equipment will take readings while you sleep. One of those measurements is your AHI (Apnea Hypopnea Index). It indicates the number of apnea and hypopnea events you experience during each hour of sleep. Events that last for at least 10 seconds and are associated with a decrease in blood oxygen level will be recorded.

The drop in blood oxygen levels and poor sleep can lead to many health complications, some very serious (including death). Aside from health problems, the dangers of untreated sleep apnea include poor performance at work and causing car accidents. Don’t look at this as just a snoring problem. 

BOOSTING CPAP ADHERENCE

CPAP is considered to be the “gold standard” treatment for sleep apnea. The only treatment with a higher therapeutic success rate is a tracheostomy. However, for CPAP to work you have to use it. Studies have found that as many as 46% to 83% of patients with OSA are non-adherent to the treatment. That’s a lot of PAP machines sitting in closets.

There are several reasons why people stop using CPAP, use it less often or for shorter periods than they should, can’t get past the first week, or can’t try it at all.

• Mask is uncomfortable, causes marks and rashes
• Mask makes them feel claustrophobic
• Discomfort from pressurized air going into their nose
• Side effects: nasal discomfort, dry mouth, sore eyes (from mask leaks)
• Machine is noisy, keeping them or their partners awake
• Inconvenience
• Not enough early education on how to use the gear
• Psychosocial reasons:

1. low health literacy – poor understanding of the health problems caused by OSA
2. the mask and gear are embarrassing and not romantic
3. not enough family or partner support

Better outcomes with CPAP can be achieved:

The right mask for you, properly fitted, with the right cushions, and maybe a chin strap to keep your mouth shut. (some claustrophobic people find the full face mask less claustrophobic than the nasal mask)

• Keeping the mask clean will improve the seal and reduce some side effects
• Adding a humidifier, especially heated, will reduce side effects
• Better training on using the gear and better education about the health risks of OSA
• Talking to fellow sufferers online on how to deal with “embarrassing and not romantic”
• Involving your partner in your discussions with your doctor
• Using a quieter and smaller machine
• Using a CPAP with the “ramp” feature, or having more control over air pressure by using APAP or BiPAP

Sleep clinics are now able to offer patients effective alternatives for CPAP.

Studies into the efficacy of dental appliances, for example, are showing encouraging results.

And this article in Sleep Review analyzes nine new treatments and alternative treatments for sleep apnea, including a digital alternative for the tennis-ball-sleep-shirt.

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