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 produce 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 seal is a common problem that plagues many CPAP users, and those who struggle with claustrophobia, have facial hair or wear dentures tend to have a hard time finding a good fitting mask.
This article outlines alternatives to CPAP therapy that include mask free options. Bear in mind that there are limitations to alternative treatment options, and sleep physicians generally do not prescribe alternative treatments unless CPAP has been tried first.
Positional Therapy
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 on your back.
Sleeping on your back increases the likelihood of breathing events because you have gravity working against you. Gravity pulls the soft tissues of your oropharynx down and narrows the upper 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 Philips NightBalance Positional Sleep Therapy Device. The NightBalance is a small, palm-sized device that you wear on a belt strapped across your chest. It monitors your sleep behavior and gently introduces vibrations during 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 Appliance
Oral appliances, also known as mandibular advancement devices, provide an alternative to CPAP therapy for individuals with mild to moderate OSA. These devices function by pulling the lower jaw forward, thereby preventing the base of the tongue from falling back and obstructing 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 evaluate whether you’re a good candidate for oral appliance therapy and create an appliance based on an impression from your teeth.
The process requires several visits to the dentist and further adjustments may need to be made to the appliance for optimal therapy. While these devices offer an alternative for individuals who cannot tolerate CPAP therapy, they can be more expensive than a CPAP machine and may not be covered by your dental insurance. We recommend contacting your insurance provider prior to having an oral appliance made to prevent unexpected expenses.
EPAP Valve
EPAP devices or valves have gained popularity in recent years as an alternative to CPAP therapy. Unlike with CPAP therapy, when using an EPAP device, no positive pressure is applied during inhalation. Positive pressure is generated during exhalation, as you breathe out through the EPAP valve located in your nose.
The EPAP valve partially closes on expiration which increases resistance and creates back pressure. This back pressure assists in keeping the upper airway open, thereby preventing airway obstruction.
Research shows that EPAP devices are effective at reducing AHI (apnea-hypopnea index or the number of breathing events per hour) by as much as 50% for patients with mild to moderate OSA.
While CPAP therapy remains the gold standard treatment for OSA, EPAP valves present a viable alternative for those who find CPAP challenging. Some individuals find CPAP masks claustrophobic and have difficulty adjusting to the pressure during inhalation. For these individuals, an EPAP device that reduces the AHI from 20 events/hr to 10 events/hr provides a better outcome than a CPAP machine which, while designed to lower the AHI to fewer than 5 events/hr, might only be used for 2 hours a few times per week due to discomfort or inconvenience.
Some people appreciate how EPAP devices are small, portable, and do not require electricity. The Bongo, for instance, is an FDA-approved EPAP device that is reusable and small enough to fit in a shirt pocket. There’s no need to pack accessories for it either.
If you are interested in trying an EPAP device, please consult your physician to see if it is right for you. Remember, EPAP devices are only recommended for the treatment of mild to moderate OSA.
Surgery
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 the 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.
Sources:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3065258/
https://www.thoracic.org/members/assemblies/assemblies/srn/sleep-matters/2019-10-28.php
https://www.sleepfoundation.org/sleep-apnea/treatment/hypoglossal-nerve-stimulation
https://aasm.org/rising-prevalence-of-sleep-apnea-in-u-s-threatens-public-health/