Continuous Positive Airway Pressure (CPAP) is the most common and effective treatment for Obstructive Sleep Apnea (OSA), a condition where the airway repeatedly collapses during sleep. The CPAP machine delivers a steady stream of pressurized air through a mask, acting as an air splint to hold the upper airway open. Despite its high efficacy, many people find the device cumbersome or restrictive and seek alternatives. Other therapeutic options exist for individuals who have modified the factors contributing to their OSA or those with milder forms of the condition. Any decision to stop or change CPAP therapy must be made in consultation with a healthcare provider or sleep specialist.
Lifestyle and Behavioral Adjustments
Lifestyle modifications offer a non-invasive approach to reducing OSA severity by addressing underlying causes. Weight management is a significant factor, as obesity, particularly increased neck circumference, predicts OSA. A 10% reduction in body weight can lead to a substantial decrease in the Apnea-Hypopnea Index (AHI). Losing weight reduces fat deposits around the upper airway, decreasing pressure on the throat and the likelihood of obstruction during sleep.
Positional therapy is effective for people with positional OSA, where disturbances worsen when sleeping on the back (supine position). Lying supine allows gravity to pull the tongue and soft palate backward, narrowing the airway. Sleeping on the side helps keep the airway more open. Specialized pillows or wearable devices can encourage and maintain a non-supine position throughout the night.
Avoiding substances that relax throat muscles is a helpful behavioral adjustment. Acute alcohol consumption near bedtime causes upper airway muscles to relax, increasing obstructive events. Sedatives and certain anti-anxiety medications similarly depress the central nervous system and worsen sleep apnea symptoms. Managing nasal congestion, such as treating allergies or sinus issues, also plays a role because a blocked nose forces mouth breathing, which can destabilize the airway.
Mandibular Advancement Devices and Other Oral Appliances
For people with mild to moderate OSA who cannot tolerate CPAP, Oral Appliance Therapy (OAT) provides a device-based alternative. These custom-fitted devices are worn during sleep and physically alter the position of the jaw or tongue to keep the airway clear. The most common type is the Mandibular Advancement Device (MAD).
A MAD fits over the teeth and gently pushes the lower jaw (mandible) forward. This movement pulls the soft tissues of the tongue and throat forward, increasing space for airflow in the pharynx. The American Academy of Sleep Medicine recommends MADs as a first-line treatment for mild to moderate OSA in selected patients.
The Tongue Stabilizing Device (TSD) is a less common but viable alternative. It holds the tongue in a forward position using a small suction bulb. TSDs are typically used by individuals who cannot use MADs, such as those with insufficient teeth to anchor the splint. Both MADs and TSDs must be custom-fitted by a dentist specializing in sleep medicine to ensure effectiveness.
Surgical and Minimally Invasive Procedures
Surgical intervention offers a way to physically restructure the airway for those with anatomical obstructions who have failed CPAP or oral appliances. Soft tissue procedures, such as Uvulopalatopharyngoplasty (UPPP), involve removing or repositioning excess tissue from the soft palate and uvula. While UPPP can improve the AHI, its success rate is variable and is often most effective when combined with other procedures.
More extensive options include skeletal procedures like Maxillomandibular Advancement (MMA), considered one of the most effective surgical treatments for OSA. MMA involves surgically moving the upper jaw (maxilla) and lower jaw (mandible) forward. This significantly increases the volume of the entire upper airway. This procedure is often reserved for severe cases and can achieve high success rates, sometimes exceeding 85%.
A modern, minimally invasive technique is hypoglossal nerve stimulation, also known as Upper Airway Stimulation (UAS). This involves implanting a device that monitors breathing and delivers a mild electrical impulse to the hypoglossal nerve, which controls the tongue. The stimulation causes the tongue to move forward rhythmically with each breath, preventing airway collapse during sleep. UAS is an option for people with moderate to severe OSA who cannot tolerate CPAP and meet specific anatomical criteria, such as a Body Mass Index (BMI) below 35 kg/m\(^2\).
Determining If CPAP is No Longer Necessary
Discontinuing CPAP must be based on objective medical evidence and the guidance of a sleep physician. Even after successful surgery or significant lifestyle changes, improvement in airway function must be confirmed. Symptom improvement alone is insufficient, as the underlying severity of sleep apnea could still pose long-term health risks if left untreated.
The only formal way to determine if CPAP is no longer needed is through a repeat diagnostic sleep study performed without the machine. This study, such as a Polysomnogram or Home Sleep Apnea Test (HST), accurately measures the new Apnea-Hypopnea Index (AHI). For adults, an AHI of less than five events per hour is generally considered the non-apneic range.
The sleep physician interprets the follow-up study results and formally recommends whether the patient can safely stop using CPAP or if pressure settings can be reduced. Relying on subjective feelings or consumer devices is not a substitute for this medical re-evaluation. The AHI provides the necessary data to assess cardiovascular and other health risks associated with untreated OSA.