Non-CPAP Treatments for Obstructive Sleep Apnea

by Jyotsna Sahni, MD

While PAP therapy has been considered the gold standard for the treatment of obstructive sleep apnea for many years, there are new treatment options available. Oral appliance therapy has been shown to be effective and preferable to CPAP in many patients and continues to gain popularity and recognition. In addition, many other effective treatments are emerging.

Positional Therapy

Since sleep apnea tends to be worse in the supine position where the patient’s tongue may fall backward due to gravity and occlude the airway. Simply shifting to the side may offer benefit for patients with positional sleep apnea. While it is simple to ask a patient to stay off their back during sleep, this may not be a practical suggestion without a tool to aid them.

Low tech mechanical devices that simply alert a patient to turn over is an option. This can be as simple as wearing a fanny pack around the waist stuffed with socks or sewing a tennis ball into the back of their night shirt. The lump which they feel every time they turn to their back serves as a signal to turn over onto their sides. There are “anti-snore backpacks” and some devices specifically designed for positional sleep apnea. These devices are easily available online, do not require a prescription, and are generally inexpensive.

A more sophisticated option to treat positional sleep apnea involves a light plastic collar worn around the neck during sleep. A small rectangular box is positioned against the nape of neck which contains a position sensor. The position sensor vibrates, like a cell phone, when the patient turns on their back. There are incremental increases of vibrational intensity that occur as the patient continues to maintain supine position. The device starts at a low level with a very gentle vibration and, based on the algorithm of the device, it will eventually reach a more intense level, if the patient has not turned over sooner. The device is charged through a USB port and a download can be obtained to look at its efficacy. This report shows how often the patient attempted to turn onto their back (“supine attempts“) and how often it was successful in thwarting those attempts. It also looks at percentage of the night that the patient spent snoring and overall duration of use during the night. Unlike the low-tech mechanical devices which can be unwieldy, this device only requires the neck collar to be worn. The rest of the body is free from encumbrances. Therefore, it is less intrusive and may be more acceptable to the patient. This device is significantly more expensive than the low-tech options and does require a prescription.

Treatment of Nasal Obstruction

Nasal congestion and allergies are very common and lead to worse snoring and obstruction. Avoidance of known allergens, nasal flushing, nasal steroids, oral antihistamines, or leukotriene receptor inhibitors (e.g. Montelukast) are conservative treatment options to help with nasal congestion and obstruction. Since many patients with nasal allergies also suffer from asthma, reducing nasal allergies may reduce asthma exacerbations which tend to worsen during the night and can lead to awakenings and hypoxia. While unlikely to be curative for sleep apnea alone, these measures may improve sleep apnea and allow other treatment options to work better, for example, notably oral appliance therapy for sleep apnea. When nasal congestion is more significant, ENT surgical procedures may be curative of sleep apnea. One such example is nasal turbinate reduction which may be accomplished with freezing or lasers and procedures to support an incompetent nasal valve.

Nasal dilators can prevent an incompetent nasal valve from collapsing during sleep and making it harder to breathe out of the nose. A common type of nasal dilator is an adhesive strip that is placed on the external nostrils at night and can reduce snoring and increase airflow through the nostrils. Unfortunately, the adhesive itself can be irritating to the skin. It is a single use product and can get expensive. Another example is a plastic or metal nasal dilator. For example, one such device is a small strip of plastic in the shape of a horseshoe that is placed inside the nostrils. Reusable and generally comfortable, it too, prevents the nasal valve from collapsing, reduces snoring, and increases airflow through the nostrils. There are a large number of nasal dilators on the market, fairly inexpensive, sold over the counter, and a variety of shapes and sizes, some of which may be more comfortable for one patient’s anatomy over another.

A new and innovative treatment for both nasal obstruction and sleep apnea is an airway stent (Alaxo Airway Stents, Alaxo USA, Inc.). Available in three depths, this device addresses nasal turbinate hypertrophy which can lead to congestion, snoring, and worsening of sleep apnea.

Reduction or Elimination of Certain Medications

Certain medications may worsen sleep apnea. For example, narcotics which suppress respiratory drive can lead to increased obstructive sleep apnea, central sleep apnea, and hypoxia. Muscle relaxants or drugs that have muscle relaxing effects such as Diazepam, a benzodiazepine, can worsen obstructive sleep apnea and hypoxia. Only the smallest, most effective dose of these drugs should be administered, and safer alternative drugs should be used preferentially.

There are a variety of surgeries that may benefit sleep apnea including bariatric surgery, ENT surgery, and hypoglossal nerve stimulation.

Devices that Exercise the Tongue

A small hand held device, recently was approved by the FDA for snoring and mild sleep apnea, provides neuromuscular electrical stimulation to the tongue and upper airway muscles. The goal is to strengthen the muscles to prevent significant loss of tone during sleep. The device is used daily for 20 minutes for 6 weeks initially, then just twice weekly after. It has been shown to reduce snoring and the severity of sleep apnea. It does require a prescription.

Negative Pressure Device

Unlike the oral appliance that brings the mandible and tongue forward to make more room in the airway, there is a device that directly targets the tongue. A small E-battery powered device essentially utilizes gentle vacuum suction positions the tongue forward in the mouth to prevent obstruction of the airway. This oral negative pressure device is worn during sleep and requires a prescription.

Weight Loss

Weight loss may be curative in mild cases of sleep apnea. By reducing extra tissue in the cheeks, palate, tongue, neck, and upper chest, it will frequently improve, although may not fully resolve more severe cases of obstructive sleep apnea.

Surgery

There are a variety of surgeries that may benefit sleep apnea. Frequently underutilized, bariatric surgery can be curative in less severe cases of sleep apnea, but may greatly decrease severity of sleep apnea in other patients. Gastric sleeve and gastric bypass are the most commonly performed surgeries.

Tonsillectomy and adenoidectomy is curative in approximately 80% of children with obstructive sleep apnea and is rarely performed in isolation in adults, because it is generally not effective. Uvulopalatopharngoplasty (UP3) is ENT surgery that greatly alters the anatomy of the oral cavity by removing excess tissue to open it up. Mandibular advancement surgery is major surgery that involves bringing the maxilla and mandible forward to create more space in the airway. Deviated septum repair can improve nasal breathing and therefore be adjunct therapy for the treatment of sleep apnea.

Hypoglossal nerve stimulation is a promising treatment modality for moderate to severe obstructive sleep apnea. It involves an outpatient procedure with two incisions. The first is where a battery is implanted in the upper right chest pocket. It is similar to a pacemaker battery and lasts approximately 11 years. The second incision is performed to place a wire in the vicinity of the hypoglossal nerve, the motor nerve of the tongue. When used during sleep, the device senses inspiration and delivers an electrical stimulus to the hypoglossal nerve which moves the tongue forward thereby enlarging the airway. One month after surgery, the patient is “activated.” The patient is given a remote control which is turned on at bedtime. Over the course of approximately three months, the patient calibrates the intensity of nerve stimulation to control sleep apnea. A final in-lab polysomnogram is performed to ascertain that the patient is optimally treated.