What’s stopping the NHS from using alternatives to CPAP to treat sleep apnoea?

It’s a condition that should be treated promptly, as it can lead to more serious problems, such as high blood pressure and an increased risk of stroke and heart attack. Determining accurate OSA prevalence is challenging, but the latest analysis in 2020 estimated UK OSA prevalence at 8 million people. 

For most people, their first stop will be their GP, who will likely refer them to a specialist sleep clinic for tests, including finding out how severe their OSA is. OSA can range from mild (described by the National Institute for Health and Care Excellence as fewer than 15 episodes per hour where the patient stops breathing) to severe (more than 30 episodes per hour).

Sometimes, mild OSA can be addressed through lifestyle changes, such as losing weight, quitting smoking and reducing alcohol consumption. However, the next step for many adults with moderate to severe OSA will be a prescription for a continuous positive airway pressure (CPAP) machine – a machine that pumps air into a mask over the mouth or nose while the patient is sleeping, holding the airway open using air pressure.

But a CPAP machine is not suitable for every OSA patient. Studies have suggested CPAP non-adherence rates are around 34.1 per cent, while data from France has found CPAP termination rates of 47.7 per cent after three years.

Sometimes, mild OSA can be addressed through lifestyle changes, such as losing weight, quitting smoking and reducing alcohol consumption

The reasons why are wide-ranging, although common causes include patients finding the mask not fitting well, causing discomfort or irritation to their face; experiencing claustrophobia or panic attacks; and the nose and mouth drying out.

Tim Quinnell, lead consultant for Royal Papworth Hospital’s Respiratory Support and Sleep Centre, says clinical teams should first investigate possible alterations to the machine to make CPAP more tolerable, such as exploring a range of masks and using the pressure-modifying algorithms built into many modern machines. Remote telemonitoring can also help clinicians tailor their approach and advice for patients who are struggling with CPAP.

But he adds: “Despite considerable technological innovation over the years, a proportion of patients simply can’t sleep with CPAP. If it undermines sleep quality more than the [OSA], then the net effect is negative and adherence is likely to be poor.”

Alternative treatment options for OSA are available.

Among the most common, particularly for mild to moderate OSA, are mandibular advancement devices (MADs), which are mouthguard-like devices designed to reposition the tongue and jaw and hold airways open while sleeping.

However, MADs are not suitable for patients with tooth decay, while others can find them uncomfortable. Dr Quinnell also points out that, although NICE recommends MADs, availability on the NHS can be “patchy”. He says: “The reality is that this needs to improve before clinicians can follow guidelines in many areas of the UK.”

Dr Quinnell notes that other NICE-listed options include positional modifiers for when sleeping position worsens OSA and oropharyngeal surgery, but adds: “While NICE lists these as options, the weaker recommendations reflect the limited evidence base for both clinical and cost effectiveness. For many NHS sleep apnoea services, they remain off the menu.”

One of the other newer options for treating OSA is hypoglossal nerve stimulation (HGNS), also known as upper airway stimulation (UAS)

Further CPAP alternatives include weight-loss surgery when weight is a contributing factor to OSA and surgery to remove the tonsils if these are a problem, although this is more commonly an issue for child patients than adults.

Meanwhile, the growing use of anti-GLP-1 receptor agonist medication, such as Ozempic, may prove useful in addressing weight-related OSA.

One of the other newer options for treating OSA is hypoglossal nerve stimulation (HGNS), also known as upper airway stimulation (UAS). This uses a surgically implanted system to deliver mild, targeted stimulation in time with normal breathing to the nerves that control the tongue and muscles in the airway, allowing the airway to stay open while sleeping. Inspire Medical Systems makes such a device.

The system includes an implant and two silicone leads. The implant – which is roughly the size of two 50p coins – is inserted under the skin in the chest through a small incision to enable detection of the patient’s breathing through the sensing lead, with a second silicone lead placed under the chin to directly stimulate the hypoglossal nerve. Synchronising with respiration, this stimulation moves the tongue and opens the blocked airway. Taking place under general anaesthesia, the surgery lasts approximately two hours, and some patients can be discharged the same day. Approximately four weeks after the surgery, the patient returns to the hospital to have the device activated and individually adjusted.1

Once activated and after a titration phase, the only maintenance and preparation for sleep for the patient is using the Inspire remote to turn on the device before sleeping to start the stimulation.

The UK’s first implant was fitted by an NHS trust around three years ago, in 2022. However, the device has so far been more popular internationally, with many patients being treated since 2014 across countries such as the US, Germany, the Netherlands, France and Switzerland. Thilo Tuebler, medical director for Europe for Inspire, says about 100,000 patients have now been treated, adding the company – which fully focuses on the HGNS implant – also has more than 300 peer-reviewed studies for the device.

This May, Inspire announced the number of hospitals offering the implant would increase to eight by the end of the year, with a view to increasing access to the therapy across the whole of England.

The results for HGNS have so far been encouraging. A study published in 2018 in Otolaryngology—Head & Neck Surgery cited that follow-ups with patients after five years showed promising results, with less daytime sleepiness and improved quality of life2.

While this study also noted 6 per cent of patients needed further surgery to reposition the device, recent real-world data collected via Inspire’s global ADHERE registry demonstrates that with modern devices and techniques, the reported rate of revisions and implant removals was less than 2 per cent3. Inspire may be suitable for OSA patients for whom CPAP has not worked or is intolerable and who have moderate to severe OSA (an AHI between 15 and 65) with a low level of central apnoea2 – this apnoea being caused by a lack of impulse from the brain to the diaphragm muscles, which the implant does not address.

The vast majority of those who have received the treatment are happy with it, with 91 per cent saying they were satisfied or very satisfied with Inspire3. However, Dr Tuebler points out that some patients are put off by surgery and can be cautious about “having something in their body”. Other patients and doctors may be put off that it is not an “instant relief therapy”, requiring recovery time and time to get the device calibrated.

Dr Tuebler says part of the reason Inspire was founded was to address a “huge unmet medical need”. He points to studies which suggest a small level of uptake for second-line therapies for OSA, despite the high levels of non-adherence and termination for CPAP, adding: “You can imagine that there’s a whole bunch of people out there that are actually left with no therapy. And the worst thing is to have people with no therapy.”

This May, Inspire announced the number of hospitals offering the implant would increase to eight by the end of the year

Meanwhile, 92 per cent thought Inspire’s implant was better than their experience with CPAP3.

So, if the appetite and the need for a wider range of OSA treatments are there, what’s stopping them from being provided?

Dr Quinnell says access is a major issue. “Accessing the CPAP alternatives may be lengthy and complicated, and subject to capacity constraints, such that the referral process requires disproportionate per-patient resource input, that may simply result in a patient languishing on a new waiting list for a long period.”

Brendan Cooper, Association for Respiratory Technology & Physiology Sleep Apnoea Consortium chair and a consultant clinical scientist in respiratory and sleep physiology at University Hospitals Birmingham Trust, adds: “Since the covid pandemic, there has been an enormous backlog in [ear, nose and throat] services, so referral waits can be 18-24 months despite great efforts to improve patient services.”

Dr Quinnell also points to the lack of locations offering some CPAP alternatives, saying: “Patients may not want to travel beyond their local area to access treatment.”

However, Dr Tuebler says he thinks among the biggest reasons more doctors and patients are not using HGNS is that it is just “not well known”.

He encourages clinicians to do more to explore alternatives, adding: “The data is good; the patients are there. The attitudes just need to switch.”

HSJ asked NICE if they had somebody who could be interviewed for this feature, but a spokesperson said they were unable to help.

As a consultant physician at Royal Brompton and Harefield hospitals and co-president of the British Sleep Society, Alanna Hare sees a lot of OSA patients.

“It’s a growing problem,” she says. “We’ve got a population that is increasingly overweight and obese, and so we are going to continue to see more and more of these patients going forward.”

She’s also seen the problems with delivering OSA treatment when patients do not tolerate CPAP.

“CPAP has been around for a really long time,” she says. “It’s nice, simple technology, and it is very effective… But we’ve just always had this issue with the cohort of patients who just cannot get on with the device.”

Dr Hare adds: “For a long time, we’ve been trying to understand how can we better phenotype our patients, to understand what treatment strategy is going to be more effective… [HGNS] has started to speak to some of those issues around treatment.”

Yakubu Karagama, consultant ENT surgeon and laryngologist at Guy’s & St Thomas’ Foundation Trust, was the first surgeon in the UK to implant an Inspire HGNS device. He says: “It is a very, very exciting time for us, but most especially for the patients.”

He adds: “The patients’ stories and the histories that I hear in clinics is that how for a long time – a very long time – that they’ve suffered either silently or even they’ve asked for help, although that help wasn’t available because it’s just CPAP… So, my experience really demonstrated that this is the way forward for a lot of patients that cannot tolerate CPAP.”

Mr Karagama says that, in his experience, among the most common reasons patients cannot tolerate CPAP is claustrophobia.

He says other reasons for patients not tolerating CPAP include the mask leaking, some people being left with red marks across their face in the morning due to the tightness of the mask, the dry air sometimes causing eye and sinus infections, people not wanting to take the machine with them if they travel or fly a lot, and the machine waking patients’ sleeping partners.

Dr Hare adds: “It’s a big ask, when you think about it, to fall asleep with a mask blowing air at you every night… I think we’ve just got to be more understanding of that.”

Mr Karagama says he feels it is particularly important to find an effective OSA treatment because it is a condition that affects people “at night, when your body, your vital organs, are supposed to be recovering, be healing themselves”. He adds this lack of recovery could lead to “risk of heart conditions, [and] endocrine conditions, such as diabetes [and] thyroid issues”.

“[CPAP]’s nice, simple technology, and it is very effective… But we’ve just always had this issue with the cohort of patients who just cannot get on with the device.”

He also says the amount of nighttime waking OSA causes means “you wake up not feeling refreshed at all and it affects your concentration in the daytime”.

“I’ve had patients who cry their eyes out looking for help – their partners as well – and [tell me] how this has destroyed their lives, destroyed their relations, destroyed their work,” he comments.

Mr Karagama points out that, although the use of HGNS devices is relatively new in the UK, there is plenty of evidence of positive outcomes from those who have been treated in the US and Europe.

Meanwhile, Dr Hare says, although the patient cohorts for HGNS are relatively small compared to CPAP, the outcomes so far show “the device is clinically effective and well tolerated”.

Mr Karagama urges clinicians to research CPAP alternatives for OSA patients, pointing out that patients are becoming more and more knowledgeable and expect the same from those treating them.

He says: “Nowadays, everything is popping up online. Everything new that people publish… will be online. Patients will know about it. For the patient, when the person comes to you with a condition and they need help… they spend all their time looking for answers for that, so as the clinician, we will have a duty to listen to that. And if it is something new that we don’t know, then we have the obligation to understand it more.”

Likewise, Dr Hare says in HGNS’s early days, she had patients coming to her with articles they had cut out of newspapers about the Inspire device, asking if they could have it. She adds: “I always see that as a really positive thing. Because, in the early days, if you’re not aware of it as a practitioner, it triggers you to look into these things a little more… I think we should be really happy about empowering patients to approach us with new treatment strategies.”

But just as CPAP does not suit every patient, Dr Hare expresses neither will HGNS. She says some patients may be put off by surgery: “It’s not a huge surgical procedure, but… of course, like every surgical procedure, there are associated risks.” She also notes that, while the surgery does not have any major cosmetic impact, “some people just don’t want any outward signs of health conditions, which is completely understandable”.

“It’s really important that you carefully consider all of these things with your patients,” she adds. “Because the worst possible outcome is that you go ahead with a surgical procedure, you have a device implanted under [the skin in] your chest and onto your nerves, and then it doesn’t bring about the benefits you were hoping for in terms of improving your sleep and controlling your sleep apnoea.”

But Mr Karagama says the appetite for the treatment is there, and although some people are initially apprehensive about surgery, they usually feel more positive after he explains the pros and cons. “When they come here, they come here excited about this,” he adds.

Gerard Cowie and Matthias Winker are two of the first patients in the UK to have the Inspire device fitted.

Mr Cowie was diagnosed with sleep apnoea more than a decade ago, after an ENT appointment for a separate issue prompted his doctor to recommend he get tested. Despite having none of the “glaring symptoms”, it was found he had a “big case” of the condition.

Mr Winker’s symptoms, on the other hand, were more obvious, and he describes waking up from what should have been a good night’s sleep feeling unrefreshed and “like I had a hangover”.

Both were initially given a CPAP machine – “with all the hassle that comes with it,” says Mr Winker. Likewise, Mr Cowie recalls of his CPAP machine: “It was cumbersome”, adding he experienced challenges with getting the correct fit for the masks.

While participating in research at GSTT, Mr Cowie learned about the Inspire device and was asked if he would consider it. He had his implant fitted in February 2022.

Meanwhile, Mr Winker says he learned about the Inspire device through his own research and was particularly encouraged by the positive research on its safety coming out of the United States. When asked whether he was surprised that he had to proactively seek out the treatment, rather than having his clinician recommend it to him, he comments he was not given much aftercare with CPAP. He says he was told: “‘Here’s the machine. If you face any problems, just come back in’, so I didn’t experience any continuity of care. I was literally left to my own device.”

Mr Winker says that, after three to six months of having the implant, he had “got used to it, and since then the evening routine is very simple, with the remote, pressing one button and then activating the device”.

He notes that he’s “really felt a difference with the quality of sleep”, adding: “I feel it mentally and physically; I’ve got more energy during the day. I’m feeling more refreshed.” He also points out his sleep apnoea events have gone down from 40 events per hour to three or four very short episodes per hour.

While he’s happy with the device, Mr Cowie admits having the implant is not without its practical problems. As the treatment is newly available on the NHS in England, it is only offered by a handful of hospitals, although this is expanding quickly. Mr Cowie says he is “quite fortunate” to live near London, but he is aware of other patients who are “hundreds of miles away, and having an appointment [takes] up a whole day”. This situation is changing, however, with the treatment now being offered in more locations than just London.

But Mr Cowie notes the device’s newness to England also has its benefits. “Because it’s something so new here, we’re being fairly closely monitored,” he says. “If I have a problem, I could just email the doctor, and I’d hear back very quickly.”

When asked what he would say to somebody considering getting the implant, Mr Winker says he would “definitely recommend doing it if people can’t tolerate CPAP”.

Mr Cowie adds: “The technology is going forward. The health service needs to be universally ready for it.”

To answer what’s holding the NHS back, we must consider cost.

Patients who cannot benefit from CPAP may be eligible for Inspire. We must consider the costs of leaving a patient with moderate to severe OSA untreated – not only the long-term health consequences, but the significant economic impact.

Historically, alternatives have been limited. That’s changing, as several hospitals in England offer Inspire UAS – a proven therapy for people with moderate to severe OSA who can’t tolerate CPAP1.

After surgery and a titration phase, Inspire is, for most patients low-maintenance, discreet, and easy to use – no masks, straps, or bedtime routine of charging and cleaning. These design elements are well received by patients – evident through high patient satisfaction rates of 91 per cent3, and 94 per cent of patients likely to recommend Inspire to a friend or family member3. Adherence reflects this satisfaction, with average nightly use of 5.6 hours at 12 months3.

By offering another CPAP alternative, the NHS is transforming how OSA is treated. This is very much about a more responsive, patient-centred model of care, aligned with the NHS Long Term Plan’s focus on prevention and choice.

What’s most encouraging is how ENT and sleep medicine teams are listening to patients who are frustrated with the lack of choice. As more centres offer alternatives, the NHS is not just treating OSA; it’s preventing incidents of untreated OSA, helping patients stay well, independent, and in control.

Let’s keep that momentum moving. For patients who can’t use CPAP, access to proven alternatives like Inspire isn’t optional – it’s essential.

Read the wealth of clinical data through the latest Patient Experience Report.

Ed Holyoak, regional director – UK & Nordics

References

1. Inspire Medical Systems (2024). System Implant Manual. 200-276-010_EN Rev E.
2. Woodson BT, Strohl KP, Soose RJ, et al. Upper Airway Stimulation for Obstructive Sleep Apnea: 5-Year Outcomes. Otolaryngology Head Neck Surgery 2018; 159(1):194-202)
3. Suurna, V. Maria et al. The Laryngoscope 131.11 (2021) 2616-2624