How to Treat Sleep Apnea Without CPAP
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Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a common sleep breathing disorder in clinical practice, characterized by intermittent apnea and reduced ventilation during sleep, mainly manifested as snoring at night, daytime sleepiness, fatigue and weakness, etc. The repeated intermittent hypoxia and ischemia caused by the intermittent apnea and hypopnea during sleep can cause a variety of complications involving multiple systems such as cardiovascular and cerebrovascular, nervous, endocrine, urogenital, digestive, and blood. OSAHS is the source of many diseases and has many complications, which seriously affect the quality of life of patients and even threaten their lives. Therefore, early and effective treatment of OSAHS can significantly improve health status.
When discussing treatment for obstructive sleep apnea, the first option often recommended is a CPAP machine. While CPAP therapy is effective for most cases of OSAHS, it is not the most comfortable or practical solution for everyone. Many people find sleeping with a mask awkward and uncomfortable or find the noise of the machine disturbing. Continuous positive airway pressure (CPAP) therapy can be expensive. The good news is that there is a range of alternative treatments or regular treatments that are needed for all patients, whether or not they are using CPAP and sleep apnea can be treated in ways that without CPAP.
These non-CPAP sleep apnea treatments offer natural and non-invasive ways to help people with sleep apnea symptoms. While they may not replace CPAP for those with severe sleep apnea, these alternative sleep apnea treatments are effective for mild to moderate cases.
Let’s look at some other treatments that may cure sleep apnea without the use of CPAP.
General Treatment
The general treatments for OSAHS mainly include postural therapy, weight loss, and exercise, which have a certain effect on mild OSAHS and can be used as an auxiliary treatment for moderate to severe OSAHS. After using general treatments, mild OSAHS can be treated for sleep apnea at home without the use of CPAP.
1.Postural Therapy
Sleeping in the side-lying position can prevent the tongue from falling back and improve the collapse of the pharynx. Studies have found that 53% of OSAHS patients suffer from positional sleep apnea-hypopnea, and their supine sleep apnea-hypopnea index (AHI) is more than twice that of non-supine AHI. Another study reported that 65% to 87% of mild to moderate OSAHS are positional OSAHS, and patients sleeping in the side-lying position can significantly reduce or eliminate the number of apneas and hypopneas.
Jackson et al. found that after 4 weeks of lateral sleep therapy, the lateral sleep group spent significantly less time in the supine position than the control group, and their AH1 was significantly improved compared with the control group. This change was particularly significant in OSA patients with AHI>20. SCARLATA et al. put tactile alarm devices on the necks of 20 patients with positional OSAHS to avoid supine sleep. The results showed that the average AHI dropped from 16.8/h to 4.4/h, the average oxygen depletion index (ODI) dropped from 13.7/h to 3.8/h, and the average respiratory disorder index (RD1) dropped from 20.0/h to 5.2/h.
Some studies have suggested that prone sleep can also help alleviate sleep apnea and hypopnea. BIDARIAN-MONIRI et al. included 14 OSAHS patients in the study. After 4 weeks of using the prone position (MPP) with a pillow at the end, the patients’ supine time was reduced from 128 min to 10 min, the average AHI was reduced from 26/h to 8/h, and the average ODI was reduced from 21/h to 7/h. The patients had good compliance and there was no significant reduction in total sleep time. AFRASHI et al. used a simple prone position (Ppp) to treat mild to moderate OSAHS patients, mainly by counteracting the effect of gravity on the upper airway and reducing the collapse of the upper airway. The AHI and blood oxygen saturation of 29 patients who received treatment were less than 90% of the time. It can be seen that changing the sleeping position has a certain effect on the treatment of OSAHS patients, especially those with positional OSAHS.
2.Lose Weight
Being overweight is one of the important risk factors for OSAHS. Being overweight leads to fat metabolism disorders, excessive fat accumulation in the pharynx and neck, causing hypertrophy of the upper airway soft tissue, narrowing of the pharyngeal cavity, and reduced upper airway compliance, which can easily lead to airway collapse. For every standard deviation increase in body mass index (BMI), the risk of OSAHS increases by 4 times.
Studies have shown that for every 3kg decrease in body weight, the distance from the Pleiotrophic Isthmus to the epiglottis can increase by 1-2 mm on average. Reducing body weight can help reduce upper airway collapse and improve sleep apnea and hypopnea.
Weight loss mainly includes two methods: diet and surgery. Diet is the simplest way to lose weight, but OSAHS patients often find it difficult to stick to it and give up halfway. For severely obese patients, surgical weight loss may be an option. A meta-analysis of 69 studies involving 13,900 OSAHS patients showed that more than 75% of OSAHS patients improved their apnea and hypopnea through weight loss surgery. Bariatric surgery is a feasible option for obese OSAHS patients to slow down their condition.
3.Exercise
On the one hand, exercise can help you lose weight, reduce airway collapse by reducing the quality of sleep, and improve sleep apnea and hypopnea.
On the other hand, some studies have reported that exercise can also reduce sleep apnea and hypopnea without significant changes in body weight. IFTIKHAR’s meta-analysis included 11 studies, including 129 OSAHS patients. The results showed that compared with before exercise, the patient’s AHI, daytime sleepiness symptoms, sleep efficiency, and cardiopulmonary function after exercise were significantly improved, while the patients’ BMI did not change significantly.
Exercise may have a certain improvement effect on patients with any degree of OSAHS. In addition, OSAHS is a disease affected by lifestyle habits, so avoid smoking and drinking. Regular work and rest, maintaining good living habits and an optimistic attitude can all help improve sleep apnea and hypopnea.
4.Quit Smoking and Avoid Alcohol
Smoking and drinking can worsen the symptoms of sleep apnea. Therefore, patients should quit smoking and drinking to reduce airway inflammation and edema and improve breathing. Alcohol and certain drugs (such as sleeping pills, sedatives, etc.) can inhibit respiratory reflexes and relax muscles. Avoiding or minimizing the intake of these substances can reduce the occurrence of apnea events.
Oral Appliance Treatment
Oral appliances are a simple, non-invasive, low-cost conservative treatment method, mainly suitable for patients with mild to moderate OSAHS, including tongue guides, palatal actuators, mandibular advancement appliances, etc. Oral appliance treatment can reduce the AHI of OSAHS patients, improve hypoxia, relieve subjective discomfort symptoms, and improve the quality of life. During use, attention should be paid to toothache, gingivitis, dry mouth, excessive salivation, and other discomfort reactions.
Upper Airway Stimulation (UAS) Therapy
At present, the pathogenesis of OSAHS is still unclear. However, some studies have found that the pharyngeal muscle tension and nerve activity of OSAHS patients during sleep are significantly lower than those when awake, suggesting that the decline in pharyngeal muscle and nerve activity plays an important role in the pathogenesis of OSAHS patients, which provides a new idea for the treatment of OSAHS. STROLLO et al. implanted a nerve stimulation device in the upper airway of 126 OSAHS patients who were unwilling to accept or could not tolerate CPAP treatment through surgery, and carried out UAS treatment for 12 months. The results showed that AHI decreased by 68%, ODI decreased by 70%, and the adverse reactions related to treatment were less than 2%.
A phase II clinical trial study showed that UAS treatment can improve the subjective discomfort symptoms and objective evaluation indicators of patients with moderate to severe OSAHS, and has fewer adverse reactions. Currently, UAS treatment is still in the clinical trial stage, and large-scale, multi-center trials are needed to reflect its long-term efficacy and adverse reactions.
Surgery Treatment
Surgical treatment of OSAHS is to remove the cause of upper airway obstruction from the source. Different surgical methods are selected depending on the location and degree of obstruction.
Nasal surgery can reduce the negative pressure in the airway during inspiration, but it cannot solve the actual obstruction of the upper airway. Therefore, it is difficult to treat OSAHS by nasal surgery alone. It can be tried in patients with mild OSAHS or OSAHS patients who have relieved pharyngeal obstruction. The main surgery for the velopharynx is suspended velopharyngeal plasty (UPPP), which is the most classic procedure for treating OSAHS. It is reported that the effectiveness is 40% to 80%, but its long-term effect is lower than the short-term effect.
Surgeries at the glossopharyngeal level mainly include gentioglossus advancement, hyoid bone suspension, tongue root suspension fixation, etc., which are mainly used to solve the narrowing or obstruction of the airway in the posterior epiglottal area.
Orthognathic surgery mainly includes genioplasty, mandibular advancement, bimaxillary advancement, etc., which are suitable for OSAHS patients with micrognathia, mandibular retrusion, or mandibular arch stenosis. Endotracheal intubation and tracheotomy play an irreplaceable role in the treatment of critically ill OSAHS patients.
Surgical treatment is an invasive treatment method. There are certain risks before, during, and after the operation, and there are many adverse reactions and complications. The surgical indications should be strictly controlled and the patient’s wishes should be fully respected.
Drug Treatment
There is currently no drug that can definitely treat OSAHS. Drug therapy, as an important part of sleep apnea syndrome management, is widely used when CPAP therapy is ineffective or cannot be tolerated. Studies such as ED-WARDS have shown that acetazolamide may help improve ventilatory instability and the severity of OSAHS. Studies such as NUSSBAUMER-OCHSNER have shown that when CPAP therapy cannot be used in high altitude areas, acetazolamide can stimulate ventilation to improve oxygenation, improve patients’ respiratory disorders and sleep quality.
Drug therapy can play a positive role in the following aspects:
- Adjunctive CPAP therapy: In cases where compliance with CPAP therapy is not possible or the CPAP device cannot be tolerated, medications may be given to relieve symptoms.
Mild and moderate sleep apnea syndrome: For mild and moderate patients, drug treatment may be an effective alternative.
Patients with specific phenotypes: Different patients may respond differently to different types of drugs, so treatment can be individualized based on phenotype when necessary.
Commonly used drugs and their mechanisms of action
1.Respiratory stimulants
Respiratory stimulants mainly act directly or indirectly on the respiratory center to increase the sensitivity of brainstem chemoreceptors, thereby improving normal respiratory rhythm. The most commonly used respiratory stimulants in clinical practice include theophylline drugs (such as aminophylline) and recombinant human Leptin-1 (rhlL-1).
Theophylline drugs can promote diaphragmatic contraction and bronchial dilation by inhibiting adenosine receptors, effectively improving nocturnal hypoventilation events. And rhlL-1 increases the sensitivity of respiratory oxygen receptors and blood oxygen concentration by regulating brainstem gastrointestinal peptide production, gastrointestinal peptide synthesis and transport.
2.Improvers of the function of the upper tongue nerve muscle
The improvers of the function of the upper tongue nerve muscle can enhance the contraction force of the maxillary anterior muscle, thereby promoting the forward movement of the hyoid bone and increasing the stability of the patient’s pharyngeal airway. Drug options include dopamine receptor agonists (such as pramipexole) and 5-hydroxytryptamine receptor agonists (such as ranitidine).
These drugs can stimulate the recurrent laryngeal nerve endings to produce effective contraction, thereby reducing the frequency of hypoventilation events and apnea.
3.Metabolic drugs
Metabolic drugs mainly improve sleep apnea syndrome by improving sleep quality and alleviating nighttime symptoms. Commonly used metabolic drugs are:
Folic acid: As a dietary adjuvant therapy, it can improve sleep quality and reduce cardiovascular and cerebrovascular risks associated with sleep apnea syndrome.
Vitamin D: Vitamin D is involved in multiple physiological processes, including regulating immune function and maintaining the normal function of the nervous system. Reasonable supplementation of vitamin D helps improve the symptoms of sleep apnea syndrome.
Coenzyme Q10: Coenzyme Q10 plays an important role in the body’s metabolism. It can reduce nocturnal hypoventilation events by improving mitochondrial function and antioxidant capacity.
Conclusion
The etiology and lesion sites of OSAHS are complex, and there is no method that can treat all OSAHS patients. Endotracheal intubation and tracheotomy have excellent therapeutic effects, but they are very traumatic and few patients can accept and benefit from them. The therapeutic effect of CPAP is more significant than other methods and is easily accepted by most OSAHS patients, but the efficacy of surgery and oral appliances cannot be ignored. For OSAHS patients, maintaining continuous general therapy and improving lifestyle will benefit them greatly. Losing weight and maintaining exercise, quitting smoking and limiting alcohol intake are always part of the treatment of sleep apnea syndrome.
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