More than a century after sleep apnea was first described in literature, and decades after it was first recognized as a clinical disorder, treatment finally caught up. In 1981, Australian physician Colin Sullivan pioneered continuous positive airway pressure (CPAP), a device, fitted using a mask, that keeps the airway open during sleep. It remains the gold standard in sleep apnea care today. But not everyone can tolerate it, and a new wave of technologies is expanding treatment options beyond one-size-fits-all.
“The issue with CPAP is not that they don’t work—they do—but adherence,” says Joerg Steier, adjunct professor of respiratory and sleep medicine at King’s College London. Studies show CPAP can reduce overall mortality and cardiovascular risk “quite substantially,” he says.
Many people, though, struggle to sleep with a mask strapped to their face or find it claustrophobic. One study found that three months in, just 38 percent of patients were using CPAP for the minimum required hours. Another showed that two years after starting treatment, only 45 percent were considered “high adherence.” But untreated sleep apnea raises the risk of hypertension, heart disease, stroke, and dementia, not to mention the daily toll of chronic exhaustion.
Obstructive sleep apnea (OSA) affects nearly one billion people worldwide, including potentially more than 80 million adults in the US, of whom around 80 percent remain undiagnosed. As clinicians identify more patients—with widely varying anatomy and symptoms—it is becoming clear that a single treatment is unlikely to work for everyone.
This need has led Steier to develop ZeusOSA, a device worn under the chin at night that delivers mild electrical pulses to stimulate the hypoglossal nerve. The aim is to counteract the loss of muscle tone that occurs during sleep and causes the airway to collapse. He’s going to start recruiting for a clinical trial around July.
Early proof-of-concept studies suggested patients with slimmer necks responded particularly well, “presumably because we were coming closer with the device to the muscle,” Steier says. That could make it a promising option for women, who often present differently from men and whose breathing interruptions are more likely to fully wake them during sleep, making it harder to tolerate CPAP. The upcoming multicenter trial will recruit men and women on a one-to-one basis.
There are also mechanical alternatives to CPAP already in use. Custom-made mandibular advancement devices (MADs), worn like mouthguards, gently pull the lower jaw forward to reduce airway collapse. They are recognized as an evidence-based treatment, but access remains limited. While doctors oversee care, only specially trained dentists can fit them, and they cost between $1,500 and $4,500 in the US. They don’t work for everyone—pulling the jaw forward won’t always open the airway enough, or the airway collapse happens at a different part of the throat—and are mostly effective for mild to moderate OSA.
Ama Johal, a consultant orthodontist at Barts Health NHS Trust and clinical lead at 32Co, a health care technology company that trains dentists to deliver sleep-related treatments, says the gap leaves patients stranded. “What do you do with a patient who is very symptomatic and can’t tolerate CPAP? We’re not giving them anything, actually.”
Sonia Szamocki, founder and chief executive of 32Co, says dentistry has a specific role. “Dentists are the only people that are allowed to prescribe it. So you need to have someone look in the mouth and custom-make this for you for it to be effective.” But she is clear the goal is not to displace CPAP. “We’re not saying everyone should come off CPAP and use a mandibular advancement device. It really comes down to what patients can tolerate, and patient choice.”