CPAP Alternatives – Is There Sleep Apnea Treatment Without CPAP?
CPAP therapy is still considered the “gold standard” among the nonsurgical therapies of obstructive sleep apnea syndrome (OSAS). CPAP stands for “continuous positive airway pressure” and was first used in the year 1983. During the night, positive air pressure coming out of a compressor is led into the airways of the individual that is affected by sleep apnea through a nose- or face mask in order to keep them open and to prevent breathing interruptions (apneas) from occurring. CPAP-therapy does not represent a cure for OSAS, but rather has to be continued for life.
The cornerstone of an effective OSAS-therapy is in many cases a change of lifestyle. Weight reduction, avoiding alcohol, nicotine and sleeping pills, as well as a correct sleep hygiene should certainly be given a shot. There is more to read about healthy sleep hygiene in our tips about how to fall asleep.
The key part of the CPAP device is an electrically operated compressor, which generates an adjustable overpressure – meaning a pressure that is stronger than atmospheric pressure (1,013.25 hPa (approx. 1 bar)). A hose connects the compressor to a mask made of plastic material, which has to be worn during sleep. There are a number of sleep masks that vary in form and material. Those that are used the most are nasal masks – referred to as nCAP (nasal CPAP). With the help of these masks, the overpressure coming out of the respirator is transferred to the patient’s airways.
The problem with obstructive sleep apnea syndrome is the fact that the upper respiratory tract collapses in on itself as the muscles in the throat area start to relax, thus impeding the flow of air and forcing it to come to a halt. The stabilized positive pressure coming out of the CPAP-device prevents the airways from collapsing, therefore consequentially also preventing breathing stops during sleep. In that regard the term “pneumatic splinting” is used. The advantage that is gained from these devices is the fact that this only involves passive ventilation. This means that the patient continues to breathe on his own, in his own rhythm, while the instruments only make inhalation easier.
Nevertheless, overpressure is also maintained during the expiration phase, which makes it harder to exhale. To get rid of this issue, there are currently newer, modified CPAP devices available. Bi-level devices (=BIPAP) for example, are able to generate lower pressure during exhalation, which brings with it higher breathing comfort. The newest APAP models (=autoCPAP) are equipped with a sensor that registers every breath. This allows the device to automatically adjust the pressure that is needed for the next breath of air again and again.
When is CPAP ventilation reasonable?
A therapy with overpressure treatment is advisable to patients that suffer from obstructive sleep apnea syndrome with a moderate to high degree of severity. But also those who are a affected by a mild form of OSAS and concomitant associated symptoms (e. g. daytime sleepiness) or underlying cardiovascular problems, should receive CPAP –therapy. Diagnosis is made with the help of polysomnography (PSG). In the case of PSG, electrodes are used to acquire different parameters of body functions during sleep within the premises of a sleep laboratory. This includes heartbeat, brain activity, eye movement, respiratory activity and tensions affecting the muscles. The apnea-hypopnea index (AHI) indicates the average amount of breathing pauses (apneas) and episodes with reduced breathing activity (hypopneas) within an hour. With an apnea-hypopnea index (AHI) of 15 respirative occurrences per hour and more, it is reasonable to make use of positive pressure ventilation.
CPAP-therapy is a permanent form of treatment, which means that the mask has to be worn on a life-long basis every night without exception in order to permanently prevent apnea phases from occurring. This type of treatment promises marked relief of OSA symptoms, but it cannot cure the patient of his sleep apnea syndrome. As a consequence, if you suspend treatment, you will be in the same situation as before.
Even though CPAP-therapy also resolves snoring, it is very rarely applied to treat habitual snoring. On the one hand, statutory health insurance plans do not take over the costs in this case, on the other hand, only few patients put up with the in part unpleasant side effects of CPAP-therapy, “just” to come to grips with snoring.
How do the different variants of CPAP-ventilation look like in detail?
For CPAP-therapy, there are a range of different mask ventilation systems available, through which the positive air pressure coming out of the CPAP device is transferred to the airways. The most obvious method is the use of full-face masks, which cover both the nose and the mouth. They are fixed to the head with the use of straps and their form reminds one of the breathing masks used by Jet pilots. With CPAP devices it doesn’t matter whether you breathe through the nose or the mouth. They are often regarded as uncomfortable, however.
The masks that are applied the most are nasal CPAP masks. These are available in two different versions.
- The standard nasal CPAP masks are simply pulled over the nose and fixed to the head with the help of straps.
- Nasal pillow CPAP masks are clamped under the nose, whereas mostly two small tubes are put in the nostrils. This method causes less pressure marks on the skin – a disadvantage of traditional nasal masks as well as full-face masks. The hose is mostly led upwards vertically along the nasal bridge and over the forehead.
A common issue in conjunction with nasal masks is that patients unconsciously switch to mouth breathing while asleep. Then they may begin to snore in spite of wearing the sleep mask. To prevent this from happening, you can use a chin strap for instance, which squeezes the jaws together, thus preventing oral respiration. Oral screens, such as the anti-snore mouthpiece somnipax, are suitable for that purpose. These are curved plastic plates that are inserted in the oral vestibule, meaning the area between the gums and lips, before going to sleep. They also prevent the mouth from opening at night.
In particularly severe cases of sleep apnea syndrome with a very high apnea-hypopnea index (AHI), it is sometimes necessary for patients to wear a protrusion splint in addition to the use of CPAP-ventilation. In their case, the respiratory tract’s collapse is often so severe that even the excess pressure generated by the CPAP device is not strong enough to handle it.Mandibular protrusion splints force the lower jaw to protrude forward by a few millimeters and that way make sure that the base of the tongue is unable to fall back during night’s rest. This effect facilitates artificial respiration to a notable extent.
General undesirable side effects of CPAP-therapy
The adverse effects of CPAP-therapy should also be brought up. 96 percent of all patients state that they suffer from at least one of the numerous – although not severe – side effects. The by far most common ones are problems that derive from wearing the mask, which include pressure marks, aches or allergic skin reactions. That’s why it is essential that you find a snoring mask that fits best for you and causes the least complaints. Aside from that, permanent excess pressure on the nose and the mucous membranes of the mouth can lead to mouth dryness, rhinorrhea (runny nose) or dry eyes. Occasionally, hearing loss, feeling of pressure on the ears or headaches, may also arise.
The most difficult part for most patients is – especially at the start of the therapy – getting used to sleeping with the mask of the CPAP device put on. The noise that the compressor emits, which can reach up to 30 dB depending on the device used, is often considered a disturbing factor. 30 to 40 percent of patients discontinue CPAP-therapy or undergo treatment only on a non-regular basis, because they cannot cope with it or since they mistakenly believe to have been cured. If you come to terms with the device, however, and determinedly follow through with the therapy, then CPAP currently represents the most promising nonsurgical treatment option against OSAS.
Noninvasive alternatives to CPAP-therapy
There is a new, noninvasive alternative to CPAP-ventilation for dealing with obstructive sleep apnea syndrome on the market and it is called Provent.
Provent is the term for a new therapeutic approach. With this approach, your own exhaled breathing air is used to keep the respiratory tract open by creating positive air pressure in the airways during the expiration process.
Provent basically consists of two small round plasters that incorporate a membrane and a micro clap. Both plasters are fixated under the nose before going to bed, such that each nostril is densely masked off. The adhesive used is hypoallergenic and comparable to that of a traditional strip. In the morning you simply pull off Provent and dispose of it – since Provent is a disposable product.
The micro clap works like a valve. During nasal inhalation the valve opens up, such that air can stream through the subjacent membrane. The valve closes during exhalation. Only through a small hole in the valve can the air escape at this point. As resistance increases, there is also a rise in pressure within the respiratory tract during expiration, thus preventing the nasopharynx from collapsing.
With the help of this treatment method, it is hoped that an effective way to fighting OSAS has now been found. A study has shown that Provent can reduce the apnea-hypopnea index and alleviate daytime sleepiness as well as snoring issues. Therefore it can be considered as an interesting alternative to CPAP-therapy, which is often not tolerated well by patients.
Surgical alternatives to CPAP-therapy
As of recently, there are promising alternative invasive forms of therapy available for patients suffering from obstructive sleep apnea syndrome (OSAS). Invasive means that these systems require surgical treatment in order to implant them into the body.
The Inspire system consists of three pieces that are implanted underneath the skin. A sensor on the chest measures the patient’s breathing rhythm and forwards this information to a small generator – similar to a cardiac pacemaker – that is located underneath the collarbone. From there, a thin wire leads to an electrode placed at the suprahyoid musculature beneath the chin.
Once the sensor recognizes that the breathing rhythm has changed, the pacemaker will send a mild electrical impulse to the electrode. The electrical conductor in turn stimulates the suprahyoid muscles, thus preventing the throat area from collapsing. The airways are therefore kept open during sleep. The system is activated prior to going to sleep by using a remote control and is turned off each morning.
This new approach is intended for OSAS patients that cannot cope with CPAP-therapy or that seem to have no positive effect from this non-surgical from of treatment. A medical study conducted on the Inspire system has shown that the system reduces phases of apnea by approximately 68%. Daytime sleepiness and snoring could also be alleviated.
The Revent system is recommendable for OSAS patients who suffer from a respiratory obstruction caused by the tongue base falling back into the pharyngeal cavity. In the course of a minimally invasive surgical procedure, the system is embedded into the base of the mouth and the tongue through the skin.
The system comprises 1 to 4 rod-shaped implants made of flexible silicone, which include two loops, one at each end. After implantation is complete, their purpose is to facilitate ingrowth and fixation. Prior to surgical treatment, the implants are coated with a material that is fully metabolized by the body after several weeks. As a result thereof, the rods contract and thus prevent the tongue base from falling back into the throat area. Due to the implants’ elasticity, standard tongue movements are not affected.