CPAP is the most common treatment for Obstructive Sleep Apnea (OSA). The CPAP machine consists of a face or nasal mask that is connected to a pump, providing a positive flow of air into the nasal passages in order to keep the airway open.
Although CPAP is a highly effective treatment, there is no benefit to a treatment that isn’t used and patient compliance remains an issue due to CPAP machine side effects. Compliance means that the patient is using their CPAP machine every night as recommended. Recently, Medicare released their requirement for CPAP compliance, which requires that the patient uses CPAP at least 70% of the time over a 30 day period, for at least 4 hours every night. Patients who do not meet these compliance rates must return their machine and find alternatives to CPAP. With proper care and monitoring by healthcare professionals, patients who refuse or cannot tolerate CPAP are able to get the treatment they need through alternative effective obstructive sleep apnea treatments.
According to the American Academy of Dental Sleep Medicine (AADSM) up to 50% of sleep apnea patients do not comply with or tolerate CPAP.(1) Other studies have shown much lower compliance rates.
In one study, almost half of patients rejected treatment before even trying CPAP or soon after pressure titration and trial. An additional 12-25% stop CPAP treatment within 3 years.(3)CPAP side effects and complaints affect between 30-70% of patients to varying degrees. Texas has more CPAP users in than any other US State, followed by California and Florida.Dr. Collin Sullivan, inventor of CPAP, spent three years studying bulldogs. Before testing his CPAP prototype on humans, he tested the results on dogs.CPAP devices cost anywhere from $500 to $4,000, and is usually covered by insurance.
Research has shown that compliance is low because of the discomfort and other side effects of the CPAP mask, the inconvenience of the tubing and the added bulk and burden while travelling with the CPAP machine.
There are ways to improve CPAP comfort and, if CPAP has been recommended, it should be attempted before switching to an oral appliance or other CPAP alternatives. A recent study has shown that patients who receive regular follow-up calls regarding their CPAP are 10% more compliant.(2) If patients are still uncomfortable and cannot tolerate CPAP, oral appliances are an approved, effective alternative to CPAP. Snoring Isn't Sexy recommends that patients who are currently compliant with CPAP continue using CPAP as their primary treatment method for sleep apnea.
While CPAP side effects appear to be the primary reason for low CPAP compliance, patients choosing to stop using CPAP list a variety of reasons including:
Noise: The CPAP machine is too noisy to allow sleep
Discomfort: Caused by straps and headgear or poor fit
Relationships: The fear of compromised relationships
Restrictions: Inability to move or change positions during sleep
Perceived Effectiveness: Lack of noticeable symptom improvement
Tooth Movement: Pressure on upper lip causing tooth related problems, including shifting in tooth position and tooth pain
Claustrophobia: Feeling of suffocation from the mask
Irritation: Mask irritations on the skin and nose
Air intake: Air trapped in the stomach or sinuses
Intolerance: Patients often report removing the mask during sleep without knowing it or general intolerance of the pressure
There are various sleep apnea treatment options for patients that can’t tolerate the CPAP machine side effects and are looking for effective alternatives to CPAP to treat snoring and sleep apnea.
In a 2-year randomized trial of 103 mild to severe obstructive sleep apnea patients, there was no statistical difference between the proportion of patients obtaining successful treatment from an oral appliance, termed Mandibular Advancement Splint in the study and CPAP. The study also did not find any statistical difference between the treatments in terms of Epworth Sleepiness Scale. (5)
In fact, the American Academy of Sleep Medicine recommends oral appliances as a primary or first line of treatment for mild to moderate obstructive sleep apnea:
Oral appliances (OAs) are indicated for use in patients with mild to moderate OSA who prefer OAs to Continuous Positive Airway Pressure (CPAP), or who do not respond to CPAP, are not appropriate candidates for CPAP, or who fail treatment attempts with CPAP or treatment with behavioral measures such as weight loss or sleep position change.
Source 1: American Academy of Dental Sleep Medicine Ins and Outs of OAT. http://aadsm.org/pdfs/insandoutsofoat.pdf
Source 2: Phone Support Improves CPAP Compliance http://www.hmenews.com/article/study-phone-support-improves-cpap-compliance-0
Source 3: Engleman HM, Wild MR: Improving CPAP use by patients with the sleep apnoea/hypopnoea syndrome (SAHS).Sleep Med Rev. 2003, 7:81–99.
Source 4: Kushida CA; Morgenthaler TI; Littner MR et al. Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances: An Update for 2005. SLEEP 2006;29(2): 240-243.
Source 5: Almeida FR. Long-term effectiveness of oral appliance versus CPAP therapy and the emerging importance of understanding patient preferences. SLEEP2013;36(9):1271-1272.
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