Alternatives To CPAP: Options For Sleep Apnea Without A Mask

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Illustration for Alternatives to CPAP: Options for Sleep Apnea Without a Mask: a bed with a wedge pillow and a small case on a side table

The main alternatives to CPAP are oral appliances, positional therapy, weight loss and lifestyle changes, nerve stimulation, surgery and mouth exercises. CPAP is usually tried first because it has proved the most effective. The Sleep Foundation says it only works if you wear it most nights (Sleep Foundation). If you cannot use CPAP, other options exist, and each suits different people. All of them should be chosen with a doctor and checked with follow-up testing. Do not stop CPAP on your own. This guide is for education only and is not medical advice.

Struggling with the mask? Try how to get used to CPAP first.

Why Look For Alternatives To CPAP?

CPAP is the most proven option, but it is not easy for everyone. The Sleep Foundation says CPAP use may be as low as 50 percent among people who are prescribed it. If you do not wear the mask on most nights, it will not help (Sleep Foundation). Before giving up, ask about changes such as a humidifier, a different mask or a pressure adjustment (Sleep Foundation). NHLBI says that if you cannot tolerate CPAP, your provider may prescribe an oral device (NHLBI). For the full list of treatments, see sleep apnea treatment.

Sleep Apnea Treatment Without CPAP At A Glance

Option Who It May Suit Main Limit
Oral appliance Adults who cannot use CPAP; mild apnea or apnea only on the back (AASM guideline, Sleep Foundation) CPAP lowers breathing events more; needs a dentist and follow-up
Positional therapy People whose apnea is worse on the back (Cochrane review) CPAP works better; devices are not foolproof
Weight loss and lifestyle Mild apnea, or as support for any treatment (NHS) Rarely resolves severe apnea alone
Nerve stimulation Certain people with moderate to severe apnea who failed CPAP (Sleep Foundation) Strict criteria and a surgical implant
Surgery Selected cases, often after other treatments (MedlinePlus) May not fully cure it; risks
Mouth exercises Adults, alone or with other care (meta-analysis) Small, varied trials

Oral Appliances: Do Mouth Guards For Sleep Apnea Work?

Oral appliances, such as a mandibular advancement device, hold the jaw forward to keep the airway open. The American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine recommend that sleep physicians consider an oral appliance, rather than no treatment, for adults who cannot tolerate CPAP or prefer an alternative. They suggest a qualified dentist use a custom, adjustable device rather than a non-custom one, and that the dentist provides follow-up to watch for bite changes (AASM and AADSM guideline). They also suggest follow-up sleep testing to confirm the device works (AASM and AADSM guideline).

How well do they work? In that review, CPAP lowered breathing events by a mean of 6.24 events an hour more than an oral appliance, and oral appliances lowered them by a mean of 13.60 events an hour compared with no device (AASM and AADSM guideline). The Sleep Foundation says these devices work best for mild apnea or apnea that happens only on the back (Sleep Foundation). So an oral appliance helps, but CPAP is stronger.

Reported Drops in Breathing Events Three cards from different reviews. Oral appliances lowered the apnea-hypopnea index by a mean of 13.60 events per hour versus no device. Positional therapy lowered it by 7.38 versus control. Mouth exercises lowered it by 8.85 versus before treatment. Studies differ, so the numbers are not directly comparable. Events per Hour Lowered -13.6oral appliancevs no device -7.4positional therapyvs control -8.9mouth exercisesbefore vs after Different studies, so do not compare cards directly. Sources: AASM and AADSM, Cochrane, myofunctional meta-analysis.

Positional Therapy For Sleep Apnea

Some people have apnea mostly on their back. The Sleep Foundation says nearly 62 percent of people with obstructive sleep apnea have apnea that is worse on the back, and that experts recommend sleeping on your side (Sleep Foundation). The NHS and NHLBI also advise side sleeping (NHS, NHLBI). A Cochrane review found that positional therapy lowered breathing events by 7.38 an hour compared with a control, but that CPAP has a greater effect than positional therapy in positional apnea. The studies were short and small, so long-term effects are unknown (Cochrane review). Devices that alert you when you roll onto your back are not foolproof and do not always stay on (Sleep Foundation).

Weight Loss And Lifestyle Changes

The Sleep Foundation says losing weight can often reduce the severity of sleep apnea, in proportion to the amount lost. It rarely resolves it fully on its own, especially in severe cases, though some people improve enough that they may no longer need CPAP (Sleep Foundation). The NHS says lifestyle changes may be all you need if sleep apnoea is mild. These include weight loss, regular exercise, side sleeping, not smoking and cutting back on alcohol, especially before bed. It adds that sleeping pills can make sleep apnoea worse unless a doctor recommends them (NHS). Read about sleep apnea and weight gain and alcohol and sleep.

Hypoglossal Nerve Stimulation

The NHS describes this as a device that sends small electrical signals to the nerve that controls your tongue (NHS). It is implanted under the skin of the chest (NHLBI). The Sleep Foundation says the FDA indicates it for certain patients with moderate to severe apnea, with an AHI of 15 to 65, who have failed or cannot tolerate CPAP. Success is more likely with a BMI under 32, and every candidate should have a drug-induced sleep endoscopy to see how the airway collapses. It is not recommended in pregnancy. One year after implant, AHI fell by 68 percent in the study the Sleep Foundation cites (Sleep Foundation). Age, BMI and other rules vary by device label and insurer, so ask a sleep specialist whether you qualify.

Surgery For Sleep Apnea

MedlinePlus calls surgery often a last resort if other treatments did not work and you have severe symptoms. It may not fully cure sleep apnea and can have long-term side effects (MedlinePlus). The Sleep Foundation lists adenotonsillectomy, jaw advancement, UPPP and nerve stimulation, and says the evidence for efficacy is limited to small studies (Sleep Foundation). For UPPP, around half of people have significantly fewer breathing disruptions, and a complete resolution of symptoms is uncommon. Apnea can return over time. As many as one-third of patients develop swallowing or eating difficulties (Sleep Foundation). The NHS gives removing large tonsils as an example (NHS).

Mouth And Tongue Exercises

A review of 5 randomized trials in adults found that exercises alone lowered breathing events by 8.85 an hour compared with before treatment, and by 5.29 compared with control groups. Adding exercises to CPAP made no significant difference. The studies were small and varied, and the authors called for larger trials (meta-analysis). The NHS lists exercises for the mouth and facial muscles as an option (NHS).

How To Check An Alternative Is Working

You cannot judge it only by feeling better. The AASM and AADSM guideline suggests follow-up sleep testing for people fitted with an oral appliance, plus periodic visits (AASM and AADSM guideline). For the other options, ask your sleep specialist how your progress will be measured. Learn how results are read in how to read sleep study results, or see the home sleep apnea test.

Should You Stop Using CPAP?

Not on your own. The Sleep Foundation says to talk with your doctor or sleep specialist before changing or stopping therapy (Sleep Foundation). If you lose weight or try another treatment, retesting shows whether it is safe to change. See a sleep specialist to plan this, and read sleep apnea causes and risk factors to understand what you can change.

Quick Takeaways

  • CPAP is the most effective first treatment, but alternatives exist.
  • Custom oral appliances are the best-supported alternative, though CPAP lowers events more.
  • Positional therapy and exercises help some people, with limited evidence.
  • Nerve stimulation and surgery suit selected people only.
  • Every alternative should be chosen and checked with a doctor.

FAQs About CPAP Alternatives

Can I Use An Over-The-Counter Mouth Guard?

The guideline suggests a custom, adjustable device fitted by a qualified dentist over a non-custom one (AASM and AADSM guideline). Ask your doctor before buying one.

Is Positional Therapy As Good As CPAP?

No. A Cochrane review found CPAP has a greater effect on breathing events, even in positional apnea (Cochrane review).

Who Can Have Nerve Stimulation?

It is for certain people with moderate to severe apnea who cannot use CPAP, after a special airway exam (Sleep Foundation). A specialist decides.

Can Weight Loss Replace CPAP?

For some people it reduces the need, but it rarely resolves severe apnea alone (Sleep Foundation). Retest before any change.

Can An Operation Remove Sleep Apnea For Good?

Not always. MedlinePlus says surgery may not fully cure sleep apnea (MedlinePlus).

Sources