CPAP Alternatives Clinic

CPAP Overview

Most people with sleep apnea try a continuous positive airway pressure (CPAP) machine for relief. This sleep apnea treatment works for some, but about half of all the people who try CPAP don’t see an improvement in their sleep apnea. Sometimes the mask causes discomfort or claustrophobia. In other cases, someone may tolerate wearing the mask but just not find it to be effective.

For these patients, we’ve created the Penn CPAP Alternatives Clinic to identify the causes of each patient’s sleep apnea and provide the optimal treatment.

When CPAP Doesn’t Help

People who have not had success with CPAP may find relief for their sleep apnea through Penn Ear, Nose, and Throat’s CPAP Alternatives Clinic. Led by Director Raj C. Dedhia, MD, MSCR and his team, the clinic uses a thorough diagnostic protocol to determine the cause of a patient’s sleep apnea and then develop a treatment plan tailored to the patient’s anatomy. Whether you need non-invasive treatment or sleep apnea surgery, the CPAP Alternatives Clinic can provide the treatment and follow-up care you need.

Meet Our CPAP Alternatives Clinic Surgeons

Director of the Penn CPAP Alternatives Clinic

Head shot of Raj Dedhia Dr. Dedhia is one of the first physicians in the United States trained in both sleep medicine and ENT. He brings the CPAP Alternatives Clinic a deep understanding of the pathophysiology and the anatomical aspects of obstructive sleep apnea (OSA).

As one of the country’s foremost experts on sleep apnea, Dr. Dedhia offers in-depth diagnostic protocols in order to help him determine which sleep apnea treatment will offer you the best results.

Because he is trained as both a sleep medicine specialist and an ENT, he performs the most advanced surgeries for sleep apnea, including advanced palatal surgery, hypoglossal nerve stimulation and maxillomandibular advancement. He has a strong surgical track record with high-risk patients, including people with obesity and cardiac problems.

Learn more about Dr. Dedhia

CPAP Alternatives Diagnosis & Treatment

There are five main areas that can contribute to sleep apnea:

Nose/nasal cavities
Soft palate (the area at the back of the throat)
Tongue
Side walls of the throat
Epiglottis (cartilage at the top of the voice box)

Some common problems in these areas that can be fixed with surgery include:

Small upper airway
Recessed chin
Small jaw
Overbite
Large tongue, tonsils, or uvula
Large neck size

Our CPAP Alternatives Clinic has a process for diagnosing and treating obstructive sleep apnea that is more comprehensive than traditional sleep apnea exams. The process may require multiple steps, but our team is equipped to guide you through each one in order to restore your air flow and allow you to sleep better throughout the night.

It begins with a physical exam to identify the site and severity of any obstructions in your airway that could be causing your sleep apnea.

STEP 1
Nasal exam performed
1. Obstruction identified
  - No, proceed to step 2
  - Yes, move on to treatment
2. Surgical treatment & CPAP retrial
  - Relief provided
  - No relief provided, proceed to next step 2
The exam starts by checking your nasal cavity. If you have an obstruction, sleep apnea surgery for the nasal cavities may be needed to correct this problem. Once surgery is performed, you can then retry CPAP.

If no obstruction is identified or CPAP retrial doesn't provide relief, proceed to step 2.
STEP 2
Review past sleep study, & jaw, throat and tongue exam performed
1. Positional OSA identified
  - No, positional OSA is not identified. proceed to step 3
  - Yes, move on to treatment
2. Positional Therapy trial
  - Relief provided
  - No relief provided, proceed to next step 3
The next step is an in-depth review of your past sleep study. This involves a thorough review of the report as well as an analysis of your overnight raw data related to airflow and oxygen saturation. We will also review your medical history and conduct a supine nasolaryngoscopy, which is a quick and painless procedure that uses a flexible scope to examine your jaw, throat and tongue for physical abnormalities.

If an obstruction is identified during this exam, you might benefit from positional therapy, which involves the use of foam or plastic devices to keep you off your back during sleep.

If positional OSA is not identified or positional therapy doesn’t provide relief, proceed to step 3.
STEP 3
Review past sleep study, & jaw, throat and tongue exam performed
1. Obstruction identified
  - No, proceed to step 4
  - Yes, move on to treatment
2. Surgery performed
  - Relief provided
  - No relief provided, proceed to next step 4
If you have a BMI over 40, you may be referred to the bariatrics team at this time.

If positional OSA is not identified, or it is but positional therapy doesn’t alleviate your sleep apnea, there are several surgical treatment options available depending on the location of the obstruction including sleep apnea surgery for the jaw and sleep apnea surgery for the throat and tongue.

If no specific obstruction is identified, proceed to step 4.
STEP 4
Drug Induced Sleep Endoscopy (DISE) PAP test performed
1. Obstruction identified
  - Yes, move on to treatment
2. Surgery performed
  - Relief provided
If the nasolaryngoscopy exam doesn’t reveal a clear problem (like a large tongue, large tonsils, or a small jaw) and positional or behavioral therapy or other treatment isn’t effective, you may benefit from a secondary test called a Drug-Induced Sleep Endoscopy (DISE) to determine the exact cause of your sleep apnea.

If no apparent problems are spotted, you might benefit from non-surgical treatment or advanced testing.

Drug Induced Sleep Endoscopy (DISE) PAP Test

Penn physicians administer a revolutionary new version of DISE unique to Penn called a DISE PAP, which provides additional information about the severity of your sleep apnea.

In this procedure, you receive a sedative administered by an anesthesiologist. While you are sleeping, a thin flexible endoscope is passed through one side of the nose and down the throat to look for potential blockages in the palate and tongue regions. Then, a CPAP mask is placed over your nose, which pushes a steady stream of air through the nose. Different from a traditional CPAP device, this mask has the endoscope built into it which allows the physician to see exactly how your airway reacts while using the CPAP. The pressure is slowly increased over time which allows us to measure how much pressure your airway needs to open and more precisely identify the potential causes for your apnea. People with a high pressure requirement typically need a more advanced surgical treatment than people with a lower pressure requirement and are more likely to have suboptimal outcomes from CPAP and other non-surgical treatments.

Candidates for trans-oral robotic surgery (TORS) and hypoglossal nerve stimulators will need to have DISE PAP first.

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