Treating obstructive sleep apnoea using alternatives to CPAP

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.

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).

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 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.

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 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.