Over the past few years, the number of adults living with obstructive sleep apnea (OSA) has steadily increased. If you’re not familiar, OSA is a sleep-related breathing disorder that impacts one’s ability to breathe during sleep. Across the world, it’s predicted that at least a billion people have this condition, with 25 million estimated to have OSA just in the United States alone ,.
Alarmingly, it’s also predicted that 80 percent of all sleep apnea patients remain undiagnosed . This statistic is disturbing, especially considering the consequences associated with this common condition. If left untreated, sleep apnea can lead to serious health conditions, including high blood pressure, type 2 diabetes, and stroke – and it some cases, it can even be fatal.
Why are there so many undiagnosed OSA patients?
The sleep community is worried that the number of undiagnosed OSA patients has consistently remained so high. It is especially concerning since sleep apnea is highly treatable. There are many options out there for patients to consider. When trying to wrap our heads around this health issue, it comes down to analyzing the circumstances that perpetuate a failure to diagnose.
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With sleep apnea specifically, one important obstacle for diagnosis is patient fear. Fear not just of the sleep apnea diagnosis itself, but of the treatment options available. Many people have seen or are aware of CPAP devices, the main way sleep apnea is treated, and have decided that it is not for them.
A new generation of therapy
Unfortunately, these fears are rooted in past misconceptions of sleep apnea. Because of this, many OSA patients are stopping their care journeys before they even begin. What many people don’t realize is that sleep apnea therapy options have come a long way over the past several decades. Now, there are multiple solutions that have been uniquely designed using a patient-centric approach.
Newer solutions offer improved comfort, ease of use and support increased mobility for sleep apnea patients – all to ensure that patients stay adherent to their treatment plans. Instead of being afraid of treatment, patients need to give themselves a chance to find the best solution for their unique needs.
As with most chronic conditions, there are a million questions that go through a patient’s mind after an initial sleep apnea diagnosis. As sleep experts, it’s our job to work with OSA patients to determine the best treatment plan for both their specific condition and their lifestyle.
Even in patients who do seek a diagnosis, we can face barriers with treatment. Unfortunately, patients can struggle to adhere to some prescribed treatments. This is because some therapies are uncomfortable and interfere with sleep habits.
But sleep apnea therapy has changed.
Not your father’s CPAP
Traditionally, the gold standard for sleep apnea therapy has been Continuous Positive Airway Pressure (CPAP). CPAP machines work by sending a constant flow of air pressure to the patient’s throat during sleep. This keeps the airway open and thereby treats the pauses in breathing associated with sleep apnea. As an additional benefit, many patients stop snoring, breathe regularly, and get a restful night of sleep with CPAP therapy.
However, people can find it difficult to adjust to sleeping with their CPAP equipment. Patients will sometimes complain about difficulty moving around in their sleep. They struggle with the pressure in their nose and airway. Some even struggle to comfortably watch TV before bed because of their masks.
Thankfully, there are new advancements in sleep technology that are paving the way for new options for more comfortable yet equally reliable treatment. No longer the bulky machines of the past, modern CPAPs, and their accompanying masks are:
- smaller and quieter
- offer greater ease of movement during sleep
- provide precise pressure control at the lowest effective pressures
Newer CPAP mask designs even include cushion options for additional comfort. Some have open-face masks that allow for the ability to comfortably wear glasses, read and simply relax in bed. In addition, other options and alternatives continue to present themselves.
Related Content: How Your Dentist Can Help with Sleep Apnea [Author’s note: click the link to learn more about Mandibular Advancing devices (MADs) which are effective therapeutic options for OSA.]
Positional therapy: non-invasive and just as effective
Even with these new innovations that offer more freedom and comfort for CPAP users, sometimes CPAP therapy just doesn’t just fit in with a patient’s lifestyle. For patients living with a certain subset of sleep apnea, there is another option for successful treatment: positional therapy.
Patients with positional OSA primarily experience disruptions in breathing when sleeping on their backs. In fact, it’s estimated that up to 47% of all sleep apnea cases are positional . In the past, these patients have gone to extreme efforts to avoid sleeping on their back – with some resorting to sleeping with a tennis ball sewn into the backs of their pajamas to encourage sleeping on the side.
As an alternative method to CPAP therapy, positional therapy wearables like Philips NightBalance work by encouraging users to remain off their back with gentle vibrations. As one of the most non-invasive sleep apnea therapy methods, positional devices are lightweight, portable, and easy to use. Like CPAP, they have also been proven to reduce the snoring that is typically associated with sleep apnea.
As an additional perk, positional therapy devices have demonstrated high adherence rates. A recent study in the Journal of Clinical Sleep Medicine found that short-term adherence with positional sleep apnea devices jumped from 75 to 95% when compared with other sleep apnea therapy methods ,. A clinical trial also found that these positional devices are effective in reducing Apnea–Hypopnea Index (AHI), an indicator of the severity of a patient’s OSA , .
Surgery is for sleep apnea is an option
Some patients seek a solution that will fix or cure their sleep apnea so that ongoing therapy is not required. One such option is surgery of the upper airway.
-Surgery to enlarge the airway
Most such procedures are aimed at enlarging the airway in the area behind the palate and tongue. This is generally accomplished by removing tissue or rearranging the tissue in such a way that the airway remains open during sleep when the pharyngeal muscles relax.
However, it must be realized that these procedures do not work in everyone and an examination of the airway under general anesthesia is often required to determine in whom such procedures will work and which procedure would be best for each patient.
-Hypoglossal nerve stimulation
A new approach to OSA therapy called hypoglossal nerve stimulation (HGNS) has emerged over the last 4-5 years. This therapy involves the placement of a nerve stimulator under the skin on the chest which is connected to the nerve that controls a muscle under the tongue which opens the airway.
This device is turned on at night and, in many patients, can effectively treat OSA . However, it only works in patients with very specific characteristics such as only a moderately elevated body mass index (BMI) and those not collapsing at certain places in the airway. Because of this, as described above, an examination of the airway under general anesthesia is usually required.
Solutions like positional therapy and HGNS give me a great sense of hope for the future of sleep apnea diagnosis and treatment. Through years of research, sleep therapy companies have begun to develop patient-centric therapies that are fundamentally changing the way patients live with sleep apnea.
Another hope for the future is drug therapies for OSA. Although there are currently no FDA-approved therapies to treat sleep apnea, studies suggest that this may well be possible. 
As a result of these advances, people suffering from this chronic condition no longer have to fear diagnosis or treatment plans. Instead, they can move forward on a path to living more healthy and restful lives.
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 Benjafield A, Ayas N, Eastwood P, et al. Estimation of the global prevalence and burden of obstructive sleep apnea: a literature-based analysis. Lancet Respir Med 2019, Aug 7(8):687-698.
 Heinzer, R. et al, Prevalence and Characteristics of Positional Sleep Apnea in the HypnoLaus Population-based cohort, Sleep Medicine 2018; 48:157-162
 Long-term effectiveness and compliance of positional therapy with the Sleep Position Trainer in the treatment of positional obstructive sleep apnea syndrome. van Maanen JP, de Vries N. SLEEP 2014;37(7):1209-1215.
 Benoist, L., de Ruiter, M., de Lange, J., & De Vries, N. A randomized, controlled trial of positional therapy versus oral appliance therapy for position-dependent sleep apnea. Sleep medicine. 2017 34, 109-117
 Berry R, Uhles M, Abaluck B, et al. NightBalance Sleep Position Treatment Device versus Auto-Adjusting Positive Airway Pressure for Treatment of Positional Obstructive Sleep Apnea. J. Clin Sleep Med. 2019 July 15:15(7):947-956.
 Eijsvogel, M. M., Ubbink, R., Dekker, J., Oppersma, E., de Jongh, F. H., van der Palen, J., & Brusse-Keizer, M. G. (2015). Sleep position trainer versus tennis ball technique in positional obstructive sleep apnea syndrome. Journal of clinical sleep medicine, 11(02), 139-147.
 Strollo P, Soose R, Maurer J, et al; STAR Trial Group. Upper airway stimulation for obstructive sleep apnea. New Engl J Med. 2014 Jan 9;370(2):139-49.
 Taranto-Montemurro L, Messineo L, Sands S, et al. The Combination of Atomoxetine and Oxybutynin Greatly Reduces Obstructive Sleep Apnea Severity: A Randomized Placebo-controlled Double-Blind Crossover Trial. Am J Respir Crit Care Med. 2019 May 15;199(10):1267-1276.
Editor’s note: Although the author is employed by Philips Sleep and Respiratory Care and they could benefit from this article, we have accepted it for publication because it contains valuable information for our readers. This post has not been sponsored by Philips.
David P. White, MD
Dr. David White, Chief Scientific Officer, Philips Sleep & Respiratory Care, graduated from Emory University Medical School and completed training in Internal Medicine and Pulmonary Disease at the University of Colorado Health Sciences Center. He has held a number of positions at various universities over his career and is currently a Professor of Medicine at the Harvard Medical School and works heavily with both Philips Respironics and Apnicure. Some of Dr. White’s major accomplishments include being President of the American Academy of Sleep Medicine, Chairing the Task Force to write the research plan addressing sleep and its disorders for the National Institutes of Health, and being the Editor-in-Chief of the Journal SLEEP. He was also on the test writing committees for the American Board of Internal Medicine for both Pulmonary Disease and Sleep Medicine.Finally, his principle research interest has been the pathophysiology of disorders of breathing during sleep about which he has published over 200 original papers.
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