If you’ve been diagnosed with sleep apnea, your doctor may have asked you to use a continuous positive airway pressure (CPAP) machine at night—and you might not like it.
That’s what we learned when we interviewed several neurologists for a story in the American Academy of Neurology’s publication, Neurology Today. We’ve excerpted their comments to explain sleep apnea, why CPAP machines are the standard treatment, and other strategies that might help you get a good night’s rest.
Sleep apnea occurs when breathing stops and starts frequently during sleep, which reduces the amount of oxygen going to the brain and disrupts rest. This can cause daytime sleepiness and exacerbate, trigger, or increase the risk of neurologic conditions such as headaches, seizures, stroke, and memory problems, says Karin G. Johnson, MD, FAAN, professor of neurology at UMass Chan Medical School's Baystate Regional Campus in Worcester.
There are three types of sleep apnea. The most common is obstructive sleep apnea, in which the throat muscles relax and prevent air from flowing into the lungs. In central sleep apnea, the brain doesn't send correct signals to the muscles involved with breathing. A less-common form, called complex sleep apnea, or treatment-emergent central sleep apnea, occurs in people who have obstructive sleep apnea that switches to central sleep apnea when treated.
Most sleep specialists recommend a CPAP machine, especially for those with memory problems or headaches, says Dr. Johnson. Treating even mild cases of sleep apnea with these machines potentially can improve symptoms.
Using a CPAP device involves wearing a mask, which is connected via hose to a machine that delivers filtered, purified, pressurized room air to open the airways. Other positive airway pressure (PAP) machines include the bi-level PAP, which uses different pressures for inhalation and exhalation; the auto CPAP, which self-regulates and delivers different pressure levels; and the adaptive servo-ventilation, designed for people with central sleep apnea. The machine records how long a person is using it each night, how effective it is in keeping the airways open, plus any problems the user may have, such as mask leak, says James McGuirk, MD, assistant professor in the sleep division at Vanderbilt University in Nashville.
But not all people are willing to try a CPAP machine—or they may ask for alternatives after they've tried it. “A lot of times, there is hesitation,” says Raman Malhotra, MD, a neurologist specializing in sleep medicine at Washington University in St. Louis. “We are introducing something that looks different and in some sense is invading their bedroom, which is not something we typically do in medicine.”
Young and otherwise healthy people may be reluctant to adopt the device and all the equipment it involves, Dr. Malhotra says. They may feel embarrassed about it, have a bed partner who doesn’t like it, or find it impractical if they travel a lot, he adds. On the other hand, if they have friends or family members who’ve benefited from a CPAP machine, they may be eager to try it, Dr. Malhotra says. It helps that the machines have improved over the years; they have excellent tracking and are much quieter. Dr. Malhotra encourages people to keep an open mind before trying one. “If it is unsuccessful, we can look at other alternatives,” he says.
Dr. Johnson also encourages first-time users to give the treatment a go and notes that some of her patients have been pleasantly surprised that the machine was not as bad as they expected. “If it works and you tolerate it and you’re feeling better with it, I say stick with it,” she says. “If it’s not for you, stop. You’re not committed to it for life on day one, but sometimes I have patients who are experiencing headaches for years and trying 20 different headache medicines, and nothing works. Then we try CPAP, and it fixes everything.”
The first few weeks of using a machine might require adjustments, such as trying different mask sizes or changing pressure levels or humidity settings, Dr. McGuirk says. Whether you sleep on your back or side can affect which type of masks work best. Adjusting to using a CPAP machine takes time, says Douglas Kirsch, MD, FAAN, FAASM, medical director of sleep medicine at Atrium Health and clinical professor of neurology at Wake Forest University School of Medicine in Winston-Salem, NC. Data from his medical system suggest that about 70 to 75 percent of people who try CPAP adapt within 90 days.
People who feel exhausted because of sleep apnea tend to feel so much better after a good night's sleep that any sort of hesitation they have about using the device melts away, according to Dr. McGuirk. “I really do think CPAP is ultimately the best treatment,” he says. “If we've gone through everything and they just can't do it, then we do talk about other options.”
For some people, such as those who have had strokes, however, the physical demands of the machine can be overwhelming, says Dr. Kirsch. “If you've had a stroke and you can't put on a mask at night and you live by yourself, that's going to make use of a CPAP machine more difficult,” he says.
For those who cannot tolerate a CPAP machine, our sleep neurologists suggest exploring the following alternatives. The effectiveness and tolerance of these treatments may vary. Discussing these options with a sleep specialist will help to determine whether any are appropriate for you.
Sleeping position. Sleeping on your side helps keep your airways open. If you roll onto your back frequently, you may benefit from wearing a specially designed T-shirt with pockets for holding tennis balls that discourages that position, says Dr. Kirsch. Other items that encourage side sleeping include a wedge-shaped pillow placed behind the back and a palm-sized device worn across the chest that vibrates gently to encourage you to move if you roll onto your back.
Strips or mouthpieces. You can insert a retainer-type device on your top and bottom teeth that pushes your lower jaw forward and pulls your tongue forward, which keeps the back of the throat open for airflow, says Dr. Johnson. These are available over the counter, but custom-made prescription versions tend to work better, she says. Or you can place special strips outside your nostrils that increase pressure in your airways when you breathe out to prevent them from collapsing.
Surgery. Some people find relief after having their tonsils and adenoids removed. Others may need the tonsils, uvula, and part of the soft palate taken out, says Dr. Kirsch. Another surgery, maxillomandibular advancement, involves repositioning the jaw to relieve airway obstructions, according to Mayo Clinic. A fourth option is to have a quarter-sized device implanted in the chest wall with wires that connect to the chest muscles and the nerve that controls tongue movement. You use a remote to turn on the device at night, which sends a signal to the nerve to push your tongue forward as you breathe without waking you. You are eligible if you have at least a moderate amount of sleep apnea, have tried CPAP, and have a body mass index of 32 or lower, along with other criteria. The implantation takes about two hours, Dr. Johnson says, and most patients go home the same day.
Since obesity and tobacco and alcohol use are risk factors for obstructive sleep apnea, losing weight, exercising, quitting smoking, limiting alcohol consumption, and establishing a regular and adequate sleep schedule are also recommended for anyone who has obstructive sleep apnea. In the meantime, researchers continue to pursue other options for treating sleep apnea. “A lot of these other treatments are effective and can help patients,” Dr. Malhotra says. “We hope to have many other options in the coming years.”
