CPAP ALTERNATIVES FOR MILD-MODERATE OBSTRUCTIVE SLEEP APNEA AND SNORING
Continuous Positive Airway Pressure (CPAP) is the MOST EFFECTIVE treatment for CPAP and is recommended as first line therapy. The following are less effective alternatives which may be useful in specific circumstances. This is not a comprehensive list but contains the most commonly used alternative treatments.
Mandibular Advancement Device/Oral Appliance (made by dentist)
An “oral appliance”/”mandibular advancement device” is a retainer-like device worn on the upper and lower teeth which pushes the lower jaw forward to create more space in the back of the throat. The improvement in sleep apnea with an oral appliance is only partial at best (versus a complete “cure” with CPAP). Additionally, some patients have no improvement or even worsening of their apnea. There are very few long-term studies of oral appliances but some of these suggest that oral appliances lose their efficacy over time and the sleep apnea ultimately returns. It is common for patients, even with mild sleep apnea, to start using CPAP and report that they “feel SO much better”. Patients using an oral appliance rarely report such a dramatic improvement.
The other main problem with oral appliances is that after years of nightly use they ALWAYS cause bite changes which can be of little consequence but can also lead to jaw pain and chewing difficulties. Usually by the time a patient is aware of these changes they are already quite severe. Experienced sleep dentists may be able to reduce these changes if they follow patients closely, but there is little research available to guide them.
An oral appliance can be a nice alternative to CPAP for “sometimes” use, like with travel, camping, new bedpartner, etc.
To find a dentist who can make an oral appliance, visit www.aadsm.org/FindaDentist.aspx
Positional Therapy
Sleep apnea tends to be worst when sleeping on your back. Changing positions during the night, however, is part of normal sleep and it is impossible to fully “train” oneself to entirely avoid back sleeping.
Some patients can successfully avoid back sleeping by getting creative with pillow positioning (putting pillows behind them and/or using a body pillow).
The “tennis ball method” has been around for years and consists of sewing a tennis ball on the back of your shift to make it uncomfortable to stay off your back. In practice the method is often poorly tolerated and over time you learn to either sleep on the tennis ball or push it to the side and still back sleep. Nevertheless, there are a bunch of over the counter products designed to work in a similar way. Some of the best seems to be “slumberBUMP”, “Rematee” and “Zzoma”.
Elevating the head of the bed slightly with a wedge pillow can also be helpful in reducing sleep apnea severity.
There are also devices called “positional trainers” which are designed to vibrate when the person wearing them lies on his/her back, causing him/her to shift to a different position. Some patients develop muscle and back soreness with a positional sleep trainer due to lack of appropriate changes in body position. Positional trainers currently on the market include “NightBalance”: http://www.nightbalance.com/; “NightShift”: http://nightshifttherapy.com/ and “Snore Coach”: https://www.snoretrack.com/
BongoRX
BongoRX is a reusable silicone nasal insert you can wear at night to improve airflow during exhalation, reducing the severity of OSA in some people.
iNAP One Sleep Therapy System
iNAP is a negative intra-oral pressure device that delivers intermittent suction inside the oral cavity, moving the tongue forward and away from the airway. The intermittent negative airway pressure can reduce sleep apnea severity in many people. iNAP can be paired with an oximeter and smartphone so you can monitor the efficacy of treatment.
Myofunctional Therapy to Strengthen Oropharyngeal Muscles
Myofunctional therapy is physical therapy to strengthen the muscles of the oropharynx.
Research shows that myofunctional therapy can reduce the severity of both sleep apnea and snoring by as much as 50% (see Carrasco-Llatas M, O’Connor-Reina C, Calvo-Henríquez C. The Role of Myofunctional Therapy in Treating Sleep-Disordered Breathing: A State-of-the-Art Review. Int J Environ Res Public Health. 2021 Jul 8;18(14):7291. doi: 10.3390/ijerph18147291. PMID: 34299742; PMCID: PMC8306407).
There are many different ways to do myofunctional therapy and the exact duration and frequency of each therapy session is not well established. Typical recommendations are to do myofunctional therapy exercises daily for 3–6 months, then reduce the frequency.
How can you tell if myofunctional therapy is working? The best way to track your progress is by downloading a snore-tracking app on your phone such as SnoreLab. Once your snoring is resolved or no longer improving you should get a repeat home sleep test to assess how much your sleep apnea has improved.
Here are some options for how to do myofunctional therapy:
- Work 1:1 with a speech therapist. You can find a local therapist here: https://www.myofunctionaltherapists.com/. In Marin county we often recommend NORTHBAYSPEECH.COM
- Use a product called Zura https://tryzura.com/
- Use the app “Soundly” (download from app store)
- Watch free videos from this website http://www.myofunctionaltherapy.blogspot.com/
- Learn the didgeridoo (visit https://didgeproject.com/sleep-apnea/the-5-most-effective-practices-to-treat-sleep-apnea-with-the-didgeridoo/)
ExciteOSA
eXciteOSA is an electrical stimulator therapy used while awake on the tongue. After regular daily use, the muscle changes are claimed to reduce snoring and treat mild obstructive sleep apnea.
Weight Loss if Snoring and/or Apnea developed in the setting of Weight Gain
Extra body weight is the most common cause of Obstructive Sleep Apnea. Even many patients with a Body Mass Index (BMI) in the normal range will notice that their snoring started after weight gain. Losing weight will almost always reduce sleep apnea severity and can sometimes resolve it. Weight loss seems to be most effective as a treatment method in patients who have a normal to slightly elevated BMI (BMI ❤0). Your final weight goal should be the weight at which you were before your symptoms developed. Typically we recommend using another treatment option while you try to slowly lose weight (no faster than 1lb per week), then repeating the sleep study once your weight has stabilized.
Cessation of Alcohol
Alcohol relaxes the muscles in the throat and dilates the blood vessels in the nose, both of which can worsen sleep apnea and snoring significantly. It can take up to 1 month after stopping alcohol completely for these changes to completely reverse. Regardless of how much you normally drink, consider abstaining from alcohol for an entire month and see if your snoring improves or resolves by the end of the month.
Dietary Changes
A high sugar diet and a diet high in ultraprocessed foods exacerbates nasal congestion and snoring. In some people, dairy can also cause nasal congestion and increased airway mucus, exacerbating snoring. Consider a 1 month trial of avoiding dairy, sugars and/or ultraprocessed foods and see if your snoring improves.
Aggressive Management of Nasal Allergies (done by a good allergist)
This can significantly reduce snoring and improve breathing at night. The local allergists we like best are Dr. Anita Carmen Choy, Dr. Joann Blessing-Moore and Dr. Nancy Cummings (but there are many other good allergists in the area as well). Contact their offices to arrange an appointment.
Snoring Reduction Devices
There are a number of over the counter devices to reduce snoring. These devices can sometimes reduce sleep apnea severity slightly, but they typically do not fully correct it. Snoring, however, can be disruptive to sleep quality and sometimes eliminating it can result in subjective benefit to the patient and bedpartner.
Smart Nora
Smart Nora is an anti-snoring “nearable” that uses an inflatable balloon, inserted into the user’s pillow, to reduce snoring.
Sleep Apnea Surgeries
Procedures to surgically correct sleep apnea are typically not fully effective and carry significant risks. Most sleep apnea surgeries are not currently recommended, though they may be appropriate under special circumstances.
Hypoglossal Nerve Stimulation
Inspire and LivaNova THN Sleep Therapy are Hypoglossal Nerve Stimulators which are being aggressively marketed directly to consumers as an alternative to CPAP. Both products work by sending electrical pulses to the nerves supplying the tongue, causing the tongue to move forward with each breath, opening up the airway. Both products require a battery pack to be implanted under the skin of the chest (similar to what is required for a cardiac pacemaker) which then connects to wires which wrap around the nerves in the neck that control the tongue. Hypoglossal nerve stimulation is not as effective as CPAP and carries significant surgical risks. Additionally, the nerve stimulator cannot be turned on while awake or it will cause pain, so you have to manually activate the stimulator at bedtime and it will start to fire after a delay to give you time to fall asleep. Each time you awaken you must turn the stimulator off, then back on. This process means that the device ends up only being active for part of the night, reducing the efficacy even further. Patients with very severe sleep apnea or significant obesity are not currently eligible for either device. I do not recommend either device at this time and recommend that my patients use CPAP or BiPAP instead.
