Sleep apnea treatment often involves using a mask and an air pump but a Mass General expert says there are many variations and options to consider.

Do I really need that mask for sleep apnea treatment? Let’s be honest: this is a common – and understandable – sentiment among those grappling with a new diagnosis of obstructive sleep apnea (OSA). It’s hard for some patients to accept that the gold-standard treatment involves strapping on a mask and hooking up to an air pump every night. Some may be inspired by a recent study in the Journal of Clinical Sleep Medicine showing that OSA patients treated with a mask “appear more alert, more youthful, and more attractive.” Knowing your options is always important, but before reviewing the alternatives to the mask, it’s worth reviewing some basics about the tried and true gold-standard.

What’s the difference between the sleep apnea treatment methods known CPAP, BiPAP and AutoPAP?
Each involves a mask and machine that uses purified, humidified room air to keep your airway from collapsing during sleep. The difference among these sleep apnea treatment methods is how this positive airway pressure (PAP) is delivered. The “C” of CPAP indicates that the airflow is continuous or constant – like a fan. By comparison, AutoPAP machines sense how much apnea is occurring in sleep and automatically adjust the pressure to your needs. Meanwhile, BiPAP machines sense your breath cycle and deliver a larger pressure while you inhale and a smaller pressure while you exhale. Ask your doctor which method is most appropriate for you.

It can be challenging to predict which patients will struggle and which will strike gold when it comes to tolerating PAP, and that’s why I urge all of my patients to try it before moving on to alternatives for sleep apnea treatment.

Who could stand wearing a mask?
A growing number of patients are successfully using PAP therapy. Improvements in technology are making the machines smaller, lighter and quieter. Finding the right fit is easier than ever with the wide selection of masks that cover the nose, the mouth or both. We prefer to have the first attempt at wearing CPAP occur during an overnight stay in the sleep lab, so our technicians can make the necessary adjustments to give each patient the best chance of success.

I have many patients who “never sleep without it” even if they were initially skeptical. It can be challenging to predict which patients will struggle and which will strike gold when it comes to tolerating PAP, and that’s why I urge all of my patients to try it before moving on to alternatives for sleep apnea treatment.

I couldn’t get used to sleeping with the mask.
The most common problems fall into three categories: wrong mask, wrong pressure and wrong machine. The mask is the easiest to fix. Many CPAP companies (and our own lab) offer mask-fitting resources for patients who need a little extra help. As for the pressure, I take a Goldilocks approach: too low and the breathing pauses will continue, too high and sleep can actually be worsened. I commonly find that the pressure is set too high for certain patients.

The idea is to reduce apnea, but preventing every last pause in breathing is not realistic. We consider up to five breathing pauses per hour of sleep to be normal. In other words, there is some wiggle room as we balance comfort and tolerance with keeping the airway open. Too much pressure can actually worsen breathing, a problem known as “complex apnea.” That brings us to the machine question. For some patients with complex apnea, we can’t get the pressure “just right” using CPAP or BiPAP. These patients may benefit from trying an adaptive servoventilator (ASV) machine specially designed to react to breathing patterns in real time and thus avoid the worsening that can occur with complex apnea.

I’ve tried everything to make the mask work. What else is there for sleep apnea treatment?
The main alternatives to PAP therapy are mouth guards, surgical treatments and position therapy. Mouth guards are custom-made by dentists and work by pulling your bottom jaw forward while you sleep. These devices work best for those with mild or moderate levels of OSA. One approach to surgical treatment involves ear, nose and throat surgeons removing part of the soft palate. Another is performed by oral surgeons and involves restructuring the jaw bones to move the jaw forward. Each of these strategies carries risks that should be reviewed with the surgeon. Finally, position therapy can be considered for patients who’s OSA occurs mainly when they sleep on their back, while breathing is more normal when they sleep on their side. Despite the appeal of this approach, the few studies out there suggest that the situation is complicated: some patients still roll onto their back during sleep despite the positioning device.

There is some emerging evidence for sleep apnea treatments such as palate stiffening implants or tongue retention devices.

Can’t I just lose weight?
Obesity is one of the major OSA risk factors. However, it is only one of many and accounts for only a small portion of the total risk for OSA. There are many compelling health reasons to lose weight. But it is hard to predict if you will be one of the fortunate ones who cure their OSA with weight loss. Patients who lose substantial weight should have another sleep study to re-assess their OSA severity. This is important, even if you feel great after losing weight and your bed partner says the snoring is gone. We know all too well from large studies that these clues are not accurate enough, and when it comes to OSA, it’s not worth taking any chances.

What about other sleep apnea treatment tricks I’ve seen advertised?
A simple Google search will reveal lots of tricks, ranging from breathe-right strips and special pillows to playing the didgeridoo. Although some small benefit is possible, they are generally not considered proven treatments. There is some emerging evidence for sleep apnea treatments such as palate-stiffening implants or tongue retention devices. As with any facet of medicine, it’s best to discuss with your physician anything that makes a medical claim that seems too good to be true!

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Matt T. Bianchi, MD, PhD, is director of Mass General’s Sleep Informatics Laboratory, whose specialties include sleep apnea treatment.