How to Treat Sleep Apnea Without CPAP

CPAP therapy is the gold standard for treating obstructive sleep apnea (OSA). It is highly effective and well-supported by research. But a significant number of people cannot use it comfortably or consistently. For those patients, effective alternatives exist. This article reviews the main non-CPAP options for treating sleep apnea, from lifestyle changes to devices to surgery.

Lifestyle Changes

For some people, lifestyle adjustments can meaningfully reduce OSA severity or even resolve it entirely.

Weight Loss

A higher body mass index is a major risk factor for OSA. Research has shown that losing approximately 15 kg can reduce the apnea-hypopnea index (AHI) to normal levels in people with mild OSA. Weight loss should be recommended for any OSA patient who is overweight.

Exercise

Exercise reduces OSA severity even without significant weight loss. A review of five randomized trials found that structured exercise programs reduced the AHI by as much as 6 events per hour, independent of changes in body weight.

Sleep Position

In some people, OSA is significantly worse when sleeping on the back. Avoiding the supine position can reduce breathing disruptions. Specialized pillows and vibratory feedback devices can help maintain a side-sleeping position throughout the night. A sleep study should confirm that the non-supine position resolves OSA before relying on this approach alone.

Alcohol and Medications

Alcohol worsens OSA by depressing the central nervous system and increasing the frequency and duration of breathing events during sleep. People with untreated OSA should avoid alcohol. Certain medications including benzodiazepines, opiates, and barbiturates can also worsen OSA and should be avoided when possible. Some antidepressants that cause weight gain may also contribute to OSA and are worth reviewing with a physician.

Oral Appliance Therapy

Oral appliances are devices worn in the mouth during sleep that move the lower jaw slightly forward to keep the airway open. They are a recognized treatment option for OSA, particularly for people who cannot tolerate CPAP.

The most effective oral appliances are custom-made by a qualified dentist and titratable, meaning the degree of jaw advancement can be adjusted over time. Prefabricated boil-and-bite devices are less effective. A tongue-retaining device is another option for people who cannot use a standard mandibular advancement device.

After fitting, the patient adjusts the device gradually over several weeks. Once an optimal position is found, a follow-up sleep study is conducted to confirm how well the AHI has improved. Ongoing visits with both the sleep physician and the dentist are recommended.

For people with mild to moderate OSA, oral appliance therapy achieves similar results to CPAP. For severe OSA, CPAP is more effective at reaching AHI targets, but oral appliance therapy is still preferred over no treatment at all for patients who cannot use CPAP. Adherence to oral appliances tends to be higher than adherence to CPAP, in part because the devices are smaller and easier to tolerate.

Common side effects include excess saliva, dry mouth, jaw discomfort, and minor tooth movement. These effects are usually manageable with adjustments.

Expiratory PAP (EPAP) Devices

Nasal EPAP is a small, disposable valve worn in each nostril during sleep. The valve allows air to flow in easily during inhalation but creates resistance during exhalation. This back-pressure acts as a pneumatic splint that helps keep the airway open at the most vulnerable point in the breathing cycle, right before the next breath begins.

Clinical trials have shown meaningful results. In a 3-month randomized controlled trial of 250 patients with untreated OSA, nasal EPAP reduced the AHI by a median of 52% compared to a sham device. At 12 months, patients using EPAP maintained a 71% reduction in median AHI with 89% full-night adherence.

EPAP is best suited for people with mild to moderate OSA without significant obesity or cardiovascular comorbidities. It requires nasal patency and may not be sufficient for severe OSA with significant oxygen desaturation. Side effects are generally mild and include nasal discomfort, difficulty with exhalation, dry mouth, and headache. EPAP is particularly convenient for travel, as no machine or power source is required.

Hypoglossal Nerve Stimulation

Hypoglossal nerve stimulation (HNS) is a fully implanted device that treats OSA by stimulating the nerve that controls the tongue. A breathing sensor detects each inhalation and triggers a mild electrical pulse that moves the tongue and surrounding muscles forward, keeping the airway open.

The device is implanted in a one-time surgical procedure under the collarbone, chest, and neck. It is controlled with a handheld remote and turned on at bedtime.

The five-year results from the pivotal STAR trial showed that HNS reduced the AHI by an average of 70%, bringing most patients into the mild OSA range. Overall, 85% of patients reported improved quality of life. Bed partners reported that snoring was eliminated or reduced to soft levels in 85% of cases. When directly compared to UPPP surgery in a matched group, HNS achieved surgical success in 100% of patients versus 40% for UPPP, with a much greater reduction in AHI.

HNS is indicated for adults with moderate to severe OSA who have not responded to CPAP. It is not appropriate for people with complete concentric collapse of the airway at the palate level, which is identified through a procedure called drug-induced sleep endoscopy (DISE) before implantation.

Surgery

Several surgical procedures target the upper airway structures that cause obstruction. The most common are uvulopalatopharyngoplasty (UPPP) and maxillomandibular advancement (MMA).

UPPP removes or reshapes soft tissue at the back of the throat including the uvula, tonsils, and soft palate. It reduces the AHI by about 33% on average. About half of patients achieve a 50% or greater reduction in AHI, but surgical cure (AHI below 5) is rare with UPPP alone. Results can also diminish over time if weight is regained.

MMA moves both the upper and lower jaws forward to physically expand the airway. It achieves higher success rates than UPPP, particularly in patients with lower baseline AHI. It is a more complex procedure but can be highly effective in the right candidates.

Bariatric surgery is an option for people with OSA related to severe obesity. Studies of over 13,000 patients found that bariatric surgery improved or eliminated OSA in approximately 75% of cases.

Surgical candidates are evaluated using drug-induced sleep endoscopy (DISE), which allows surgeons to directly observe where and how the airway collapses during sleep, guiding the choice of procedure.