Unfortunately, CPAP (Continuous Positive Airway Pressure) is not well tolerated by many people. When adherence is defined as at least 4 hours of use per night it is estimated that 29 to 83 percent of people are non-adherent. This may be due to disappointment because daytime symptoms persist, discomfort, and difficulty with using the mask or the overall unaesthetic appearance.
If you are finding the mask uncomfortable it may just be that the mask is not right for you. There are many different types of masks currently available. A visit to your local equipment supplier to try various masks would be the best option. Generally, the smaller the mask such as nasal pillows and nasal masks, the fewer issues tend to arise.
There are many reasons why daytime symptoms persist despite CPAP adherence. For some people, it is because CPAP is not the right treatment option for them. Below are some of the alternatives to CPAP therapy. Not every option is suitable for every patient. Talk to your doctor about what alternatives best suit you.
Automatic adjusting PAP (APAP) therapy
The APAP machine has a low and high range pressure number that automatically adjusts as you sleep in response to obstructive apneas that may be occurring. The patient is given the ideal pressure when needed at a given moment rather than the constant fixed pressure of CPAP. When the machine detects apnea events occurring, the pressure is raised. Once the apnea events have reduced or ceased, the pressure decreases.
Bilevel or BiPAP (Bilevel PAP) therapy
Bilevel machines have a lower exhale pressure than both CPAP and APAP machines. The patient has greater comfort and will find it much easier to breathe. Patients will feel less resistance to breathe against the incoming airflow overcoming the issue of the pressure being too high.
Bilevel therapy is also used for patients who may have low oxygen levels as well as to treat central sleep apnea (CSA). CSA is where you have no obstruction in your upper airway, however, you stop breathing. It occurs because your brain doesn't send proper signals to the muscles that control your breathing.
The bilevel machine is very smooth and it is a natural feeling when breathing. Your breathing can be in sync with the machine. Many patients may find that the bilevel machine offers better comfort, therapy, and sleep quality than a CPAP machine. Further, recent medical research shows that patients are sleeping 20% longer with a bilevel machine than when they were using a CPAP machine. Talk to your sleep medical specialist about this treatment option and whether it is suitable for you.
Alternatives to using PAP machines
1. Oral Appliances
Two common oral devices are the Mandibular Advancement Device/Splint (MAD/MAS) and Tongue Retaining Device (TRD). The MAD/MAS is a special “mouth guard” made specifically for you by sleep apnea dentists. They work by pushing the bottom jaw forward by up to 10mm. By doing so, the airway is opened and less likely to collapse causing snoring and obstructive sleep apnea events. The TRD can either reposition the tongue or pulls the tongue forward to prevent the tongue from collapsing.
The MAD/MAS needs to be properly fitted by a dentist trained in Dental Sleep Medicine otherwise the patient may end up with soreness and a permanent change in the position of the jaw and teeth.
See videos below for more for more information.
A number of cheaper ‘boil and bite’ products are available over the counter and online. These are not recommended as they are poorly adapted to your teeth and can cause gum, tooth, and jaw problems. They also cannot advance your jaw far enough to be effective in opening the airway. If you have tried one and it did not help your sleep, you cannot compare the outcome to that of a MAD/MAS which is a custom made to measure appliance made by a dentist trained in Dental Sleep Medicine.
2. Positional Therapy
Positional therapy works for patients who have positional sleep apnea ie: they only snore or have apnea events when they sleep on their backs. This isn’t common but for those that do, positional therapy is a simple and effective treatment option. There are sleep products available to assist you to stay on your side. Some people find sewing a tennis ball inside a sock to the back of their pyjamas is a great cost saving way to keep from sleeping on their back.
3. Sleep Apnea Implants (Hypoglossal nerve stimulation)
This treatment involves the insertion of a pacemaker like device that monitors breathing patterns. These devices work inside your body while you sleep. When you’re ready for bed, you click the remote control to turn the device on. It is activated during sleep to stimulate the hypoglossal nerve, which controls muscles in the upper airway, to keep airways open so you can breathe during sleep.
There are a number of surgical procedures including the removal of tonsils, adenoids or excess tissue at the back of the throat. The type of surgery available to you will depend on the structures that are causing the blockage in your breathing during sleep.
While not all children with OSA are suitable for surgery, adenotonsillectomy (removal of both the adenoids and tonsils) along with weight normalisation, is considered the first line of therapy for most children and adolescents with OSA.
5. Weight Loss
Weight loss can be very effective to help reduce the severity of sleep apnea and in some cases even cure sleep apnea. While weight loss may not cure all cases of OSA healthy weight loss and ongoing management will improve overall health and quality of life, will lead to higher energy levels, a more positive mood and will reduce the risk of associated health conditions. Research has shown it has a greater benefit on cardiovascular risk than CPAP.
6. Expiratory positive airway pressure (EPAP) device
This device fits inside the nostrils and is held in place by adhesive. The device works on maintaining positive airway pressure when you are exhaling. It is thought to work due to a belief that airway collapse and resulting sleep apnea are most likely to occur when you are breathing out.
Other possible alternatives to CPAP include iNAP. This is an oral negative pressure therapy (OPT) designed for patients suffering from mild to moderate OSA and other sleep related disorders. The iNAP eliminates the need for a CPAP mask, humidifier, and pressurised air and instead uses a discreet soft oral interface with a pocket-sized console. Also, the Buteyko Breathing Method. This method looks at retraining your breathing so that you breathe slower and reduce the amount of air that you are breathing. The training teaches you to breathe through your nose rather than through your mouth and to reduce hyperventilation. Doing so will increase a patient's oxygen levels. This breathing method can be considered in mild to moderate cases of obstructive sleep apnea up to 15 to 20 events per hour.
Whilst not an alternative to CPAP, consider using a CPAP pillow which may help you to sleep better with your mask. These pillows are designed to reduce the pressure of the mask against your face and reduce mask leaks.
Avoid alcohol as it relaxes muscles and may worsen apnea, as may sleeping tablets which depress the drive to breathe. Try to maintain a regular sleeping pattern. Caffeine and eating late at night should also be avoided. Post updated to include a link to our post "Struggling with CPAP". Click here for 12 Tips to CPAP Success from someone with nearly 30 years of experience.
Written by Michelle Chadwick and Steve Sue Yek. EDIT: 24 Feb 2021 Dentist Dr Damian Teo was live during the Sleep Apnea Awareness Day 2020. In this video presentation, Dr Teo explains what a MAS appliance is and how it works. How much they cost and what the pros and cons are between over the counter oral appliances vs custom made (by a dentist) and more.
Further update: This talk was given at our Sleep Health & Wellbeing Expo in April 2022 by Dr Adam Teo. It is an overview of Mandibular Advancement Splint (MAS) treatment for OSA as an alternative to CPAP.
• Adherence to Continuous Positive Airway Pressure Therapy. Terri E. Weaver and Ronald R. Grunstein, American Thoracic Society 2008
• A systematic review of CPAP adherence across age groups: clinical and empiric insights for developing CPAP adherence interventions. Sawyer AM, Gooneratne NS, Marcus CL, Ofer D, Richards KC, Weaver TE, Sleep Med Rev 2011.
• Monash Lung and Sleep Institute, State of the Art 2017
• Acute Upper Airway Responses to Hypoglossal Nerve Stimulation during Sleep in Obstructive Sleep Apnea. Schwartz AR, Barnes M, Hillman D, et al. American Journal of Respiratory and Critical Care Medicine 2012.
• Obstructive Sleep Apnea In Children. Marianna Sockrider, Carol L. Rosen,
Harold J. Farber, et al. American Thoracic Society 2017.
• Nasal Expiratory Positive Airway Pressure Devices (Provent) for OSA: A Systematic Review and Meta-Analysis. Riaz, Muhammad et al, Sleep Disorders 2015.
• SAVE Trial Shows no Benefit of CPAP Therapy on Cardiovascular Events. American College of Cardiology 2016.
• CPAP for Prevention of Cardiovascular Events in Obstructive Sleep Apnea
R. Doug McEvoy, Nick A. Antic, Emma Heeley, Yuanming Luo, Qiong Ou, Xilong Zhang, Olga Mediano, Rui Chen, Luciano F. Drager, Zhihong Liu, Guofang Chen, Baoliang Du, et al for the SAVE Investigators and Coordinators. 2016
• Your weight matters: obesity and sleep apnea. American Sleep Apnea Association 2017
• The effective rationale of a novel intra‐oral negative pressure device for obstructive sleep apnea, C.L. Liu, T.J. Liu, Y.P. Wang, Y.S. Leu. Journal of Sleep Research 2018