Alternatives to CPAP: Oral Appliances, Inspire, Positional Therapy, Medication and Surgery

Before switching: is CPAP fixable?

Many problems that make people quit CPAP, such as mask fit, dryness, pressure discomfort or claustrophobia, can be solved. It is worth working through these with your sleep team before moving on. That said, alternatives are legitimate options, and for some people they work better simply because they will be used.

Oral appliance therapy

A mandibular advancement device is a custom mouthguard-like appliance that moves the lower jaw forward to keep the airway open. The AASM and the American Academy of Dental Sleep Medicine recommend oral appliances for adults with obstructive sleep apnea who cannot tolerate CPAP or prefer an alternative. They recommend a custom, adjustable device fitted by a qualified dentist, and a follow-up sleep test to confirm it is working.

Oral appliances are often most effective in mild to moderate sleep apnea. Side effects can include jaw discomfort and changes in bite.

Hypoglossal nerve stimulation (upper airway stimulation)

This is an implanted device, best known under the brand name Inspire, that stimulates the nerve controlling the tongue during sleep so the tongue does not block the airway. In 2023, the FDA expanded its approved labeling to adults 18 and older with moderate to severe obstructive sleep apnea (AHI 15 to 100) who cannot use or do not benefit from CPAP, and raised the body mass index (BMI) limit in its labeling warnings to 40.

Candidates typically need a drug-induced sleep endoscopy to check how their airway collapses, since certain collapse patterns are not suitable. It requires surgery and a recovery period.

Positional therapy

If your sleep apnea happens mainly when you are on your back, devices that encourage side sleeping can help. These range from wearable devices that vibrate when you roll onto your back to special pillows and backpacks. Your sleep study report shows whether your apnea is position-related.

Weight loss and tirzepatide

Excess weight is a major risk factor. In a well-known study, a 10% weight loss predicted about a 26% reduction in AHI. On December 20, 2024, the FDA approved tirzepatide (Zepbound) for moderate to severe obstructive sleep apnea in adults with obesity, alongside a reduced-calorie diet and increased physical activity. It was the first medicine approved for this use.

In the SURMOUNT-OSA trials, average AHI dropped by about 25 to 29 events per hour over a year with tirzepatide, compared with about 5 with placebo. Many participants still had sleep apnea afterwards, so tirzepatide is not automatically a replacement for CPAP. Talk to your clinician before stopping CPAP.

Surgery

Surgical options include nasal surgery to improve airflow, procedures on the soft palate and throat such as uvulopalatopharyngoplasty (UPPP), and maxillomandibular advancement, which moves the jaws forward. In children, removing enlarged tonsils and adenoids is often the first-line treatment. Results vary depending on anatomy, so careful evaluation by a specialist is important.

Lifestyle measures

Avoiding alcohol and sedatives near bedtime, treating nasal congestion, regular physical activity and good sleep habits help alongside other treatments. Myofunctional therapy (exercises for the tongue and throat) has some evidence but is generally not enough alone for moderate or severe sleep apnea.