CPAP Alternatives: Sleep Apnea Treatment Without CPAP

Continuous positive airway pressure (CPAP) machines are commonly prescribed for people with breathing conditions like obstructive sleep apnea (OSA). OSA is a sleep disorder where your upper airway—nasal cavities, oral cavity, throat, and voice box—narrows and restricts your breathing, causing reduced airflow and lower blood oxygen levels.

While CPAP machines are very effective, they may not be the right choice for everyone. Some people may find sleeping with a CPAP mask uncomfortable. Luckily, there are many CPAP alternative treatments for sleep apnea. Here, our Reviews Team walks you through some of the other effective options.

Insurance coverage for sleep apnea treatments

To get insurance coverage for your OSA treatments, CPAP machine, or other devices (like a portable oxygen concentrator for supplemental oxygen therapy during the day), you must get an official diagnosis from a health care provider. If treatment or therapy is deemed medically necessary, your insurance should provide some amount of coverage. Private insurance and Medicaid coverage vary by state and plan.

Medicare coverage depends on the treatment type. Medicare Part B covers durable medical equipment (DME)ⓘ Medical equipment expected to last at least three years, prescribed for in-home use for a medical reason. if it’s prescribed by your doctor. To learn more, read our guide to Medicare coverage for CPAP machines and supplies.

Table 1 Comparison of CPAP vs. other therapies

^[1]Akashiba T, et al. Respiratory Investigation. January 2022. Sleep Apnea Syndrome (SAS) Clinical Practice Guidelines 2020. Found on the internet at https://www.sciencedirect.com/science/article/pii/S2212534521001556?via%3Dihub ^[2]Centers for Medicare & Medicaid Services. Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea – Policy Article. April 7, 2022. Found on the Internet at https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52467 ^[3]Sleeper G, et al. Sleep Medicine. August 2022. Comparison of Expiratory Pressures Generated by Four Different EPAP Devices in a Laboratory Bench Setting. Found on the internet at https://www.sciencedirect.com/science/article/pii/S1389945722001824 ^[4]Centers for Medicare & Medicaid Services. Oral appliances for obstructive sleep apnea – policy article. Aug. 8, 2021. Found on the internet at https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52512 ^[5]Centers for Medicare & Medicaid Services. Billing and coding: Surgical treatment of obstructive sleep apnea (OSA). Aug. 27, 2023. Found on the internet at https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=56905

CPAP alternatives

CPAP remains the gold standard for treating moderate to severe OSA, but there are many other sleep apnea treatments to consider, from CPAP alternative devices to natural solutions. ^[6]Francis C, et al. Pulmonary Therapy. June 2021. Mandibular Advancement Devices for OSA: An Alternative to CPAP? Found on the internet at https://link.springer.com/article/10.1007/s41030-020-00137-2

Weight loss, diet, and exercise

Obesity and higher weight are strongly associated with OSA, according to practice guidelines laid out by the American Thoracic Society. ^[7]Hudgel D, et al. American Journal of Respiratory and Critical Care Medicine. Sept. 15, 2018. The Role of Weight Management in the Treatment of Adult Obstructive Sleep Apnea. An Official American Thoracic Society Clinical Practice Guideline. Found on the internet at https://www.atsjournals.org/doi/10.1164/rccm.201807-1326ST Approximately 40% of adults with obesity have OSA. ^[8]Bailly S, et al. Journal of Clinical Medicine. Nov. 22, 2022. Impact of a Weight-Loss Rehabilitation Program on Sleep Apnea Risk and Subjective Sleepiness in Patients with Overweight/Obesity: The Diet Sleep Study. Found on the internet at https://www.mdpi.com/2077-0383/11/23/6890 Studies have shown weight loss and exercise are effective at reducing the symptoms and severity of OSA. ^[9]Kuna S, et al. American Journal of Respiratory and Critical Care Medicine. Jan. 15, 2021. Effects of Weight Loss on Obstructive Sleep Apnea Severity. Ten-Year Results of the Sleep AHEAD Study. Found on the internet at https://www.atsjournals.org/doi/10.1164/rccm.201912-2511OC Recent research found study participants reduced their OSA symptoms by 50% after losing weight. ^[9]Kuna S, et al. American Journal of Respiratory and Critical Care Medicine. Jan. 15, 2021. Effects of Weight Loss on Obstructive Sleep Apnea Severity. Ten-Year Results of the Sleep AHEAD Study. Found on the internet at https://www.atsjournals.org/doi/10.1164/rccm.201912-2511OC

“Weight loss can be achieved through a combination of a healthy diet, regular physical activity, and, in some cases, bariatric surgery,” said Chester Wu, MD, a psychiatrist and sleep specialist in Houston.

Weight loss surgery isn’t for everyone, but it can be an effective solution. The American Thoracic Society recommends gastric bypass surgery in people with a body mass index (BMI)ⓘ Body mass index (BMI) measures body fat based on height and weight. of 35 or higher to improve OSA. A recent study showed bariatric surgery, which is a procedure removing the portion of your stomach producing the hormone ghrelin—which signals hunger to your brain—improved OSA and caused remission in 65% of patients. ^[10]Oweidat K, et al. Sleep and Breathing. May 5, 2023. Bariatric surgery and obstructive sleep apnea: a systematic review and meta-analysis. Found on the internet at https://link.springer.com/article/10.1007/s11325-023-02840-1

According to the National Institutes of Health (NIH), drinking alcohol and smoking are also risk factors for sleep apnea. ^[11]National Institutes of Health. Sleep apnea: causes and risk factors. March 24, 2022. Found on the internet at https://www.nhlbi.nih.gov/health/sleep-apnea/causes Alcohol relaxes the muscles of your tongue, which can fall back, obstruct your windpipe, and cause restricted airflow while you’re sleeping. Smoking also affects your breathing and airway, which increases your risk of OSA. Lessening the amount you drink or smoke can improve your OSA and overall health.

Oral appliances

The American Academy of Dental Sleep Medicine recommends oral appliance therapy—devices worn while sleeping to help you breathe better—for OSA. ^[12]American Academy of Dental Sleep Medicine. Oral appliance therapy. Found on the internet at https://www.aadsm.org/oral_appliance_therapy.php These devices can look like mouth guards or orthodontic retainers and can decrease apnea events while you sleep.

“These dental devices are intended to reposition the lower jaw and tongue to maintain an open airway. They are better tolerated than CPAP and are more effective for mild to moderate OSA,” said Jennifer Silver, DDS, at Macleod Trail Dental in Alberta, Canada.

Some appliances can be purchased in stores or online, while others may have to be custom-fitted by your dentist. Some devices include:

• Mandibular advancement devices: These devices protrude your jaw and expand the passageway in your throat to improve breathing. A study found sleep apnea events reduced by at least 50% in nearly all patients wearing the custom-made device. ^[6]Francis C, et al. Pulmonary Therapy. June 2021. Mandibular Advancement Devices for OSA: An Alternative to CPAP? Found on the internet at https://link.springer.com/article/10.1007/s41030-020-00137-2
• Mandibular advancement splints: These devices separate the upper and lower teeth and move the tongue forward to improve breathing. ^[13]Ng J, et al. Sleep Medicine Clinics. March 2019. Oral Appliances in the Management of Obstructive Sleep Apnea. Found on the internet at https://www.sleep.theclinics.com/article/S1556-407X(18)30092-4/fulltext In a small study of 69 people, 47 of the participants had an improvement in their breathing with the splint. ^[14]Chan A, et al. Thorax. August 2010. The Effect of Mandibular Advancement on Upper Airway Structure in Obstructive Sleep Apnoea. Found on the internet at https://thorax.bmj.com/content/65/8/726.long
• Tongue-retaining devices: These devices hold the tongue in place using suction. Research from multiple studies has concluded these devices reduce apnea events by 53%. ^[15]Chang E, et al. American Journal of Otolaryngology. May–June 2017. Tongue Retaining Devices for Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. Found on the internet at https://www.sciencedirect.com/science/article/pii/S0196070916304197?via%3Dihub

Physical therapy

Physical therapy is another way to mitigate OSA by improving the tension, stiffness, and responsiveness of the tongue and the muscles controlling the mouth to prevent the collapse of the upper airway.

“Our approach typically involves providing education and training on exercises aimed at improving posture and airway control. We employ a variety of exercises targeting the jaw, mouth, and tongue muscles,” said Nick Voci, a physical therapist at Manchester Physical Therapy in Manchester, Vermont.

“Additionally, we collaborate closely with other health care providers, such as dentists, to ensure proper fitting of oral appliances,” Voci adds.

Positional therapy

Silver also recommends positional therapy to reduce sleep apnea events, especially for people whose events primarily occur when they sleep in specific positions, typically on their back.

“Positional therapy encourages people to maintain a side-sleeping position, which helps prevent the relaxation of throat muscles and tongue that can block the airway and lead to sleep apnea events,” Silver said.

“This approach can involve using special pillows designed to support the head and neck for side-sleeping, wearable devices that detect and alert you when you roll onto your back during sleep, or even shirts or vests with built-in mechanisms that make sleeping on your back uncomfortable,” she added.

Alternate pressurized sleep apnea treatments

If you prefer machine therapy, consider these types of pressurized air machines.

• Automatic positive airway pressure (APAP): APAP machines offer greater flexibility than other devices by automatically adjusting as you breathe and responding to your specific needs and breathing patterns. APAP can detect snoring or airway obstruction and automatically increase or decrease the pressure.
• Bilevel positive airway pressure (BiPAP): BiPAP machines introduce positive pressure into your upper airway and lungs to keep your airway open and prevent it from narrowing or collapsing. BiPAP machines can be set to different pressures for breathing in and out.
• Expiratory positive airway pressure (EPAP) therapy: EPAP machines work by using air pressure resistance when the person exhales to improve OSA symptoms. Instead of a mask, the EPAP attaches to the nostrils using valves. ^[3]Sleeper G, et al. Sleep Medicine. August 2022. Comparison of Expiratory Pressures Generated by Four Different EPAP Devices in a Laboratory Bench Setting. Found on the internet at https://www.sciencedirect.com/science/article/pii/S1389945722001824

Surgery

You and your health care provider may consider surgery if other noninvasive therapies do not work. According to the University of Michigan Health, some surgical treatments for sleep apnea are: ^[16]University of Michigan Health. Surgical alternatives to CPAP. Found on the internet at https://www.uofmhealth.org/conditions-treatments/brain-neurological-conditions/surgical-alternatives-cpap

• Transoral robotic surgery (TORS): This procedure may involve trimming the epiglottis—a flap of cartilage sitting under the tongue at the back of your throat—because it falls into your airway during sleep. Research has found this procedure can reduce apnea events by 40%. ^[17]Vicini C, et al. The World Journal of Otorhinolaryngology – Head & Neck Surgery. June 13, 2017. Transoral Robotic Surgery for Obstructive Sleep Apnea Syndrome: Principles and technique. Found on the internet at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5683592/
• Hypoglossal nerve stimulation: This procedure involves implanting a device in the chest to stimulate the tongue using a pulse generator to keep the upper airway open while the person is sleeping, according to the American Thoracic Society. ^[18] American Thoracic Society. Upper airway stimulation/hypoglossal nerve stimulator [PDF]. Found on the internet at https://www.thoracic.org/patients/patient-resources/resources/upper-airway-stimulation.pdf A review of 12 studies found this procedure had a surgical success rate of 55% to 76.9% at 12 months. ^[19]Costantino A, et al. Sleep and Breathing. June 2020. Hypoglossal Nerve Stimulation Long-term Clinical Outcomes: A Systematic Review and Meta-analysis. Found on the internet at https://link.springer.com/article/10.1007/s11325-019-01923-2
• Uvulopalatopharyngoplasty (UP3): This procedure removes excess tissue in the throat to widen the airway and allow air to move through the throat more easily. Multiple studies found that this procedure can result in a more than 50% reduction in respiratory disturbances for some patients. ^[20]Rosval B, et al. The Laryngoscope. May 12, 2017. Is Uvulopalatopharyngoplasty Effective in Obstructive Sleep Apnea? Found on the internet at https://onlinelibrary.wiley.com/doi/full/10.1002/lary.26631
• Lateral pharyngoplasty: This procedure is a variation of the UP3. Excessive tissue in the back of the throat is reconfigured to expand the airway, and tonsils are usually removed. The uvula—the small piece of flesh hanging in the back of the mouth—is also reshaped or removed. In a study where 133 people underwent this procedure, 69% of patients saw a significant reduction in sleep apnea symptoms. ^[21]Oh H, et al. Scientific Reports. Feb. 7, 2020. The Clinical Efficacy of Relocation Pharyngoplasty to Improve Retropalatal Circumferential Narrowing in Obstructive Sleep Apnea Patients. Found on the internet at https://www.nature.com/articles/s41598-020-58920-9
• Lingual tonsillectomy: This procedure is performed on people with an obstruction at the base of the tongue. The tissue typically causing this obstruction is called the lingual tonsil, which sits on top of the base of the tongue muscle and creates excess volume in a tight space. In an analysis of 151 tonsillectomies for OSA, 47.6% of patients had their symptoms reduced by at least 50%. ^[22]Sjöblom H, et al. European Archives of Oto-Rhino-Laryngology. March 2022. Treatment of Sleep Apnoea with Tonsillectomy: A Retrospective Analysis Using Long-term Follow-up Data. Found on the internet at https://link.springer.com/article/10.1007/s00405-022-07350-6
• A palatal z-plasty: This procedure is for people with an elongated soft palate—the fleshy roof of the mouth—and uvula. The procedure shortens the palate and eliminates the vibration of the uvula and palate. Research published in 2017 found that the procedure reduced sleep apnea symptoms in 68% of patients with severe sleep apnea. ^[23]Pavwoski P, et al. Neurology Clinical Practice. February 2017. Treatment Options for Obstructive Sleep Apnea. Found on the internet at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5964869/

Drawbacks of CPAP therapy

CPAP machines, while effective, may not be the first choice treatment for everyone. Some people may have a hard time adjusting to wearing them nightly. Some uncomfortable symptoms and side effects of CPAP usage can include: ^[24]Ghadiri M, Grunstein RR. Respirology. June 2020. Clinical Side Effects of Continuous Positive Airway Pressure in Patients With Obstructive Sleep Apnoea. Found on the internet at https://onlinelibrary.wiley.com/doi/full/10.1111/resp.13808

• Claustrophobia
• Dry eye and floppy eyelid
• Dry mouth
• Ear pressure or pain
• Excessive swallowing, which can lead to gas
• Infection, if parts are not cleaned regularly
• Nasal congestion and nosebleeds
• Skin irritation from CPAP mask
• Tooth chipping
• Voice changes

If you experience any of these symptoms regularly when using your CPAP machine, talk with your health care provider to see if you can find a solution.

Choosing the right CPAP alternative

People with OSA have many options to choose from when considering treatment, therapy, or surgery. Consulting your primary physician and sleep specialists should be your first step.

Factors to consider when choosing an alternative treatment

The severity of your OSA may influence which treatment is best for you. Those with mild to moderate OSA could benefit from noninvasive options like oral appliances. For people with moderate to severe OSA, your provider may recommend surgery. ^[25]Gambino F, et al. Internal and Emergency Medicine. June 2022. Treatment Options in Obstructive Sleep Apnea. Found on the internet at https://link.springer.com/article/10.1007/s11739-022-02983-1

Comfort is another factor to consider. Some people find PAP masks uncomfortable, dislike traveling with a machine, or are disturbed by the noise. In those cases, smaller oral devices or natural treatments like weight loss or physical or positional therapy may be preferred.

Cost and insurance coverage can also be key to determining if a treatment is right for you. CPAP machines can cost several thousand dollars, as can surgeries or oral appliances. Contact your insurance provider to see what therapies and treatments your plan covers.

Consulting a sleep specialist

If disrupted sleep regularly interferes with your daily activities, you should seek professional help to get a diagnosis. Your primary care provider may refer you to a sleep specialist. Sleep specialists can have different backgrounds: They are neurologists, pulmonologists, or psychiatrists specifically trained in sleep medicine. During a consultation, they will ask about your sleep patterns and perform a medical exam. A sleep specialist may suggest you participate in an overnight sleep study—a test monitoring your breathing, oxygen levels, and heart rate—to diagnose OSA.

Bottom line

Getting an official diagnosis is the first step to getting help for sleep apnea. CPAP therapy is an effective treatment option, but it may not be right for everyone. APAP, BiPAP, and EPAP therapies are other devices to consider. Alternative therapies, like surgery or oral appliances, and lifestyle changes like weight loss, exercise, and physical or positional therapy can also ease OSA symptoms.

Once diagnosed, check with your insurance provider to see what types of sleep apnea treatment your plan covers. The right option for you depends on your preferences, comfort level, and price. Talk with your health care provider if you’re unsure which alternative treatments to consider.

Have questions about this review? Email us at reviewsteam@ncoa.org.

Sources

1. Akashiba T, et al. Respiratory Investigation. January 2022. Sleep Apnea Syndrome (SAS) Clinical Practice Guidelines 2020. Found on the internet at https://www.sciencedirect.com/science/article/pii/S2212534521001556?via%3Dihub
2. Centers for Medicare & Medicaid Services. April 7, 2022. Positive Airway Pressure (PAP) Devices For the Treatment of Obstructive Sleep Apnea – Policy Article. Found on the internet at https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52467
3. Sleeper G, et al. Sleep Medicine. August 2022. Comparison of Expiratory Pressures Generated by Four Different EPAP Devices in a Laboratory Bench Setting. Found on the internet at https://www.sciencedirect.com/science/article/pii/S1389945722001824
4. Centers for Medicare & Medicaid Services. Oral Appliances for Obstructive Sleep Apnea – Policy Article. Aug. 8, 2021. Found on the internet at https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52512
5. Centers for Medicare & Medicaid Services. Billing and Coding: Surgical Treatment of Obstructive Sleep Apnea (OSA). Aug. 27, 2023. Found on the internet at https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=56905
6. Francis C, et al. Pulmonary Therapy. June 2021. Mandibular Advancement Devices for OSA: An Alternative to CPAP? Found on the internet at https://link.springer.com/article/10.1007/s41030-020-00137-2
7. Hudgel D, et al. American Journal of Respiratory and Critical Care Medicine. Sept. 15, 2018. The Role of Weight Management in the Treatment of Adult Obstructive Sleep Apnea. An Official American Thoracic Society Clinical Practice Guideline. Found on the internet at https://www.atsjournals.org/doi/10.1164/rccm.201807-1326ST
8. Bailly S, et al. Journal of Clinical Medicine. Nov. 22, 2022. Impact of a Weight-Loss Rehabilitation Program on Sleep Apnea Risk and Subjective Sleepiness in Patients with Overweight/Obesity: The Diet Sleep Study. Found on the internet at https://www.mdpi.com/2077-0383/11/23/6890
9. Kuna S, et al. American Journal of Respiratory and Critical Care Medicine. Jan. 15, 2021. Effects of Weight Loss on Obstructive Sleep Apnea Severity. Ten-Year Results of the Sleep AHEAD Study. Found on the internet at https://www.atsjournals.org/doi/10.1164/rccm.201912-2511OC
10. Oweidat K, et al. Sleep and Breathing. May 5, 2023. Bariatric Surgery and Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. Found on the internet at https://link.springer.com/article/10.1007/s11325-023-02840-1
11. National Institutes of Health. Sleep apnea: Causes and Risk Factors. March 24, 2022. Found on the internet at https://www.nhlbi.nih.gov/health/sleep-apnea/causes
12. American Academy of Dental Sleep Medicine. Oral Appliance Therapy. Found on the internet at https://www.aadsm.org/oral_appliance_therapy.php
13. Ng J, et al. Sleep Medicine Clinics. March 2019. Oral Appliances in the Management of Obstructive Sleep Apnea. Found on the internet at https://www.sleep.theclinics.com/article/S1556-407X(18)30092-4/fulltext
14. Chan A, et al. Thorax. August 2010. The Effect of Mandibular Advancement on Upper Airway Structure in Obstructive Sleep Apnoea. Found on the internet at https://thorax.bmj.com/content/65/8/726.long
15. Chang E, et al. American Journal of Otolaryngology. May–June 2017. Tongue Retaining Devices for Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. Found on the internet at https://www.sciencedirect.com/science/article/pii/S0196070916304197?via%3Dihub
16. University of Michigan Health. Surgical Alternatives to CPAP. Found on the internet at https://www.uofmhealth.org/conditions-treatments/brain-neurological-conditions/surgical-alternatives-cpap
17. Vicini C, et al. The World Journal of Otorhinolaryngology – Head & Neck Surgery. June 13, 2017. Transoral Robotic Surgery for Obstructive Sleep Apnea Syndrome: Principles and technique. Found on the internet at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5683592/
18. American Thoracic Society. Upper airway stimulation/hypoglossal nerve stimulator [PDF]. Found on the internet at https://www.thoracic.org/patients/patient-resources/resources/upper-airway-stimulation.pdf
19. Costantino A, et al. Sleep and Breathing. June 2020. Hypoglossal Nerve Stimulation Long-term Clinical Outcomes: A Systematic Review and Meta-analysis. Found on the internet at https://link.springer.com/article/10.1007/s11325-019-01923-2
20. Rosval B, et al. The Laryngoscope. May 12, 2017. Is Uvulopalatopharyngoplasty Effective in Obstructive Sleep Apnea? Found on the internet at https://onlinelibrary.wiley.com/doi/full/10.1002/lary.26631
21. Oh H, et al. Scientific Reports. Feb. 7, 2020. The Clinical Efficacy of Relocation Pharyngoplasty to Improve Retropalatal Circumferential Narrowing in Obstructive Sleep Apnea Patients. Found on the internet at https://www.nature.com/articles/s41598-020-58920-9
22. Sjöblom H, et al. European Archives of Oto-Rhino-Laryngology. March 2022. Treatment of Sleep Apnoea with Tonsillectomy: A Retrospective Analysis Using Long-term Follow-up Data. Found on the internet at https://link.springer.com/article/10.1007/s00405-022-07350-6
23. Pavwoski P, et al. Neurology Clinical Practice. February 2017. Treatment Options for Obstructive Sleep Apnea. Found on the internet at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5964869/
24. Ghadiri M, Grunstein RR. Respirology. June 2020. Clinical Side Effects of Continuous Positive Airway Pressure in Patients With Obstructive Sleep Apnoea. Found on the internet at https://onlinelibrary.wiley.com/doi/full/10.1111/resp.13808
25. Gambino F, et al. Internal and Emergency Medicine. June 2022. Treatment Options in Obstructive Sleep Apnea. Found on the internet at https://link.springer.com/article/10.1007/s11739-022-02983-1

Lauren Evoy Davis Author

Lauren Evoy Davis is a health journalist with expertise in cancer and other chronic conditions. Lauren holds an MA in Journalism from American University and a BA in English from Elon University. Her work has been published by the American Society of Clinical Oncology, Legacy, Health Central, WebMD, Verywell Health, Patient Power, and Verizon.

Elizabeth U. Lyda Medical Reviewer

Elizabeth Lyda, RRT, holds a bachelor of science degree from Empire State College and associate of science degree with a certificate in Respiratory Care from Mansfield State University, and has been a respiratory therapist since 1983. She was named Respiratory Therapist of the Year in 2007 from the University of Rochester and remains licensed in the state of New York.