Treating obstructive sleep apnoea using alternatives to CPAP – understanding the professional guideline
Who is this document for and what is it about?
This document explains the recommendations in the European Respiratory Society (ERS) clinical guidelines for the treatment of obstructive sleep apnoea using therapies other than continuous positive airway pressure (CPAP). It is aimed at people with obstructive sleep apnoea, or their carers.
What are clinical practice guidelines?
Clinical guidelines are produced after a scientific process used to gather and evaluate the latest evidence in the field. Guidelines also consider the opinions of leading experts and the priorities of patients and carers who have experience of a condition. Clinical guidelines are aimed at healthcare professionals. They use them as a ‘best practice’ document in how to diagnose, manage and treat specific conditions.
What does this document include?
This document summarises the key points from the clinical guidelines. It explains them in a way that is more easily understood by people who do not work in a medical field. It will cover what obstructive sleep apnoea is and how it can be treated. By providing this information in an accessible way, this document aims to help people with sleep apnoea understand more about treatments that are available and help them to feel informed when making decisions about care.
What is obstructive sleep apnoea?
Obstructive sleep apnoea syndrome (OSAS), commonly known as obstructive sleep apnoea or OSA, causes abnormal breathing during sleep. Someone with the condition is briefly unable to breathe due to a temporary blockage of the airway in the throat.
When we are asleep, our muscles are relaxed. In some people, the tongue and the relaxed muscles in the throat can cause a narrowing of the airway. This restricts breathing and can stop it for a short time. This is called an apnoea. If this happens, the brain briefly wakes the person up which reopens the airway and restarts breathing. Waking up several times at night can damage the quality of sleep, and lead to excessive daytime sleepiness.
Each apnoea is accompanied by a rise in heart rate and blood pressure. Eventually the increased blood pressure carries on even when you are awake. This increases the risk of a heart attack or a stroke.
What is CPAP?
Continuous positive airway pressure (CPAP) is the gold standard treatment for moderate-to-severe obstructive sleep apnoea. CPAP machines work by creating an air stream that keeps the upper airway open while a person is asleep. The air stream travels through a mask to the back of the throat. The devices are used at home during sleep for as long as they are needed.
This type of treatment focuses on reversing the narrowing of the upper airways. While it is the most effective form of treatment, some people with sleep apnoea find it difficult or uncomfortable to use. Research into the causes of sleep apnoea has grown in recent years. New therapies and treatment options now exist that use different ways to improve sleep apnoea symptoms. This guideline assesses a range of options, comparing them to CPAP, and makes recommendations on whether healthcare professionals should propose them to their patients.
Jaw advancement surgery (maxillo-mandibular osteotomy)
This form of surgery moves the upper jaw and the lower jaw forward to make the airway bigger. It can benefit all people with moderate-severe obstructive sleep apnoea and particularly people who have a jaw deformity. This kind of surgery has some risks involved and a longer recovery time than other procedures.
Maxillo-mandibular surgery is an effective form of treatment. Research has found it to be as effective as CPAP. The decision on whether to have the surgery is an individual choice. Some people may prefer CPAP because it does not involve such a big procedure. However, for others who do not like CPAP or have not seen any improvement in their symptoms, this surgery is an effective alternative.
Hypoglossal nerve stimulation
Nerve stimulation is a type of surgery that involves placing a small device inside the body. For people with obstructive sleep apnoea, this form of surgery focuses on the hypoglossal nerve. It is found in the throat and controls the movement of the tongue. The inserted device electrically stimulates the hypoglossal nerve, which activates the muscles in the tongue. This helps to move the tongue forward, preventing any blockage of the airway.
This form of surgery should not be the first option for treating obstructive sleep apnoea. There is limited evidence to show whether it is effective and therefore other treatment options, such as CPAP or Mandibular Advancement Devices (covered later in this document), should be used first.
This surgery should be considered as an option for people who:
- do not get an improvement in their symptoms after treatment with other options,
- who have a relatively high number of obstructive apnoeas each night, and
- are not very obese (a body mass index (BMI) of less than 32).
Weight loss surgery
Between 6 and 9 out of 10 people with obstructive sleep apnoea are obese. Obesity is the most common risk factor for obstructive sleep apnoea in adults. Being very big bodied can lead to an increase in fat around the throat, causing obstructive sleep apnoea. Losing weight can help improve, or sometimes completely remove, symptoms.
Weight loss surgery, known as bariatric surgery, is used as a treatment for people who are very obese. There are different types of weight loss surgery, including gastric band surgery or a gastric by-pass. The different surgeries aim to restrict the amount a person can eat, to aid weight loss.
When a person has not been able to lose weight, despite taking part in a reduction programme to help them lose weight, then weight loss surgery should be considered. Weight loss surgery is a major operation. A person’s values and preferences, alongside whether they have any other conditions, should all be taken into account and discussed before they make any decisions.
There is not a lot of research into the effectiveness of this treatment for people with obstructive sleep apnoea.
Carbonic anhydrase inhibitors
Carbonic anhydrase inhibitors are a kind of medicine used to treat conditions such as glaucoma and epilepsy. They have not yet been approved for treating obstructive sleep apnoea. Yet, some studies have found they can reduce apnoeas in people experiencing heart failure. The reason why they work is not yet fully understood but it is thought the drugs have an impact on the breathing system.
These drugs should only be used as a treatment option during a controlled study. A person would need to be taking part in a trial of the drugs that aimed to assess the benefits of the treatment for obstructive sleep apnoea.
Custom-made dual-block mandibular advancement device
Mandibular Advancement Devices (MAD) are worn in the mouth and fit over the teeth. They aim to hold the jaw and tongue forward, making more space to breathe.
CPAP is more effective at reducing the number of pauses in breathing during the night than a MAD. However, some people prefer wearing a MAD compared to a CPAP machine. A MAD may be preferable for people with mild-moderate obstructive sleep apnoea where it is less urgent to reduce the apnoea experienced each night, as it is still effective at improving quality of life and daytime sleepiness.
Myofunctional therapy or face and tongue exercises
Myofunctional therapy or face and tongue exercises work to correct any problems with the position of the tongue. After being trained by a healthcare professional in how to perform the exercises, people with sleep apnoea can practice them regularly at home. The aim is to change the way the tongue and upper airways work to reduce the symptoms of sleep apnoea.
CPAP is a better option for treating obstructive sleep apnoea compared with these exercises as there is not much research looking at how well they work. Research does suggest myofunctional therapy could improve sleepiness. But it was not as effective at reducing the number of apnoeas a person experiences during the night compared with CPAP. It could be useful for someone who is looking for an alternative to CPAP therapy, although there is also a lack of qualified speech and language therapists with training in sleep apnoea.
Some people with sleep apnoea experience more disturbances during sleep when they are lying on their back, compared to their side. Positional therapy involves keeping a person in a side-sleeping position. Different devices are available to help with this. They include wearable belts with foam inserts that prevent rolling from the side to the back and also vibration devices that vibrate when a person rolls onto their back and continues until they move.
Positional therapy devices that vibrate are recommended for people who have sleep apnoea that is worse when sleeping on their back. These devices are better than other kinds of positional therapy devices as research shows that people continued to use them more than others. Research suggests they are not quite as effective as CPAP for improving symptoms but that some people prefer them to wearing a CPAP machine.
This guideline was produced by the European Respiratory Society and the European Lung Foundation. You can find out more about these organisations and access the full professional guideline using the links below:
Full clinical guideline – published in the European Respiratory Review in December 2021.
Further resources for patients and carers:
- European Lung Foundation – CPAP factsheet: https://europeanlung.org/en/information-hub/factsheets/continuous-positive-airway-pressure-cpap/
- European Lung Foundation – Sleep apnoea factsheet: https://europeanlung.org/en/information-hub/factsheets/sleep-apnoea/
The European Respiratory Society (ERS) is an international organisation that brings together physicians, healthcare professionals, scientists and other experts working in respiratory medicine. It is one of the leading medical organisations in the respiratory field, with a growing membership representing over 140 countries. The ERS mission is to promote lung health in order to alleviate suffering from disease and drive standards for respiratory medicine globally. Science, education and advocacy are at the core of everything it does. ERS is involved in promoting scientific research and providing access to high-quality educational resources. It also plays a key role in advocacy – raising awareness of lung disease amongst the public and politicians. www.ersnet.org
The European Lung Foundation (ELF) was founded by ERS to bring together patients and the public with professionals. ELF produces public versions of ERS guidelines to summarise the recommendations made to healthcare professionals in Europe, in a simple format for all to understand. These documents do not contain detailed information on each condition and should be used in conjunction with other patient information and discussions with your doctor. More information on lung conditions can be found on the ELF website: www.europeanlung.org