Continuous Positive Airway Pressure (CPAP), pioneered in 1981, remains the gold standard treatment for sleep apnea, proven to reduce mortality and cardiovascular risk. However, widespread issues with patient adherence, due to discomfort and claustrophobia, have driven the development of new alternative therapies.
These emerging options include devices like ZeusOSA, which uses electrical nerve stimulation, and custom-made Mandibular Advancement Devices (MADs) that reposition the jaw. Another established alternative is Inspire therapy, an implantable hypoglossal nerve stimulator.
The central challenge is that obstructive sleep apnea affects a highly diverse global population, making a single treatment like CPAP ineffective for everyone. The expanding range of technologies aims to provide personalized care based on individual anatomy, symptoms, and tolerance.
Main Topics: Sleep apnea, CPAP treatment and adherence issues, alternative treatments (hypoglossal nerve stimulation, mandibular advancement devices).
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.”
Inspire therapy—a hypoglossal nerve stimulation implant—has been FDA-approved for more than 11 years, with over 100,000 patients treated across the US, Europe, and Asia. Ruchir Patel, Inspire’s senior medical director, says data show reductions in daytime sleepiness, a 79 percent drop in sleep apnea severity, and a 90 percent reduction in snoring. Early US data report average nightly usage of more than 6.5 hours. “This is an exciting time because there are more treatment options available than in the past,” he says.
Pharmaceutical approaches are also emerging. In 2024, the US Food and Drug Administration approved Zepbound (tirzepatide) for moderate to severe OSA in adults with obesity—the first weight-loss drug to carry a specific sleep apnea indication.
Meanwhile, Cambridge, Massachusetts–based startup Apnimed has developed a nightly pill targeting neuromuscular pathways that influence upper airway tone. Rather than mechanically splinting the airway open, the drug aims to stabilize it biologically.
“For a long time, OSA was understood primarily as an anatomical problem, so the logical solution was mechanical,” says John Cronin, chief medical officer at Apnimed. As understanding evolved, the question became: “Could we design a therapy that targets the biology of the condition directly, rather than relying solely on mechanical support?” The company has completed two phase three trials and plans to submit a New Drug Application to the FDA this year.
For all the innovation, Steier remains pragmatic. “I couldn’t be happier than finding someone who’s got typical sleep apnea and gets CPAP therapy,” he says. Modern machines automatically adjust pressure to airway resistance. “A single night can make all the difference.” Patients return re-energized, telling him they’ve got their lives back.
Sleep medicine is still relatively young, and research is only beginning to capture the diversity of the condition. That complexity also underpins efforts to improve CPAP use rather than abandon it.
Amanda Sathyapala, an associate professor at Imperial College London’s National Heart and Lung Institute, led the research showing 62 percent of patients were not using CPAP enough to make a meaningful health impact. Her team has studied the psychology of adherence, finding that factors such as understanding risk and confidence using the device shape long-term use.
Drawing on behavioral science, she developed CPAP Buddy, an app offering video-based behavioral therapy, peer support, and round-the-clock answers to patient questions. The project has received £2.2 million from the UK’s Medical Research Council, alongside backing from CPAP manufacturer Fisher & Paykel.
“CPAP is likely to be the most effective treatment that you can get because it's giving air directly into the airway,” Sathyapala says. “[CPAP] is always going to be the most efficacious once the person's using it, therefore it's worth trying to get people to use it.”
For her, the problem is not the machine but behavior. “I don't like to give up if we haven't tried the right things,” she says. Using CPAP, she adds, is no different from “losing weight, stopping smoking, starting up a long-term physical activity program—it's a behavior change.”
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