With the CPAP recall announcement by Phillips in June 2021 and ResMed’s struggles with getting the component parts for their PAP machines, demand for CPAP is outpacing supply. Sleep apnea doesn't take a holiday. In fact, diagnosis of sleep apnea where I practice has been picking up over the last year after COVID-related shutdowns delayed diagnosis for those pending in lab testing.

Let's say you happen to be one of the lucky people who got a new diagnosis of sleep apnea over the last six months. You want to see if treating your sleep apnea can help your symptoms so maybe – just maybe – you can start to feel better.

But there's a problem.

Your machine is on back order. You've waited weeks – perhaps months – and you still have no idea where your CPAP set up day will be.

What are your options? What can you do to do something while you wait?

I don't have all the answers to that question. It is a question I wanted to investigate a potential answer for because I think a lot of people are finding themselves in this situation right now. There are others facing the question of what to do without CPAP – not because of the machine shortage – but for other reasons. Travel without electricity. CPAP failure or preemptive failure.

Treating obstructive sleep apnea

CPAP works by using air to hold open a relaxed and obstructing airway. Without this “air splint,” efforts to inhale are abnormally difficult, resulting in all sorts of symptoms and associated health issues.

For some people this therapy works like a dream. For others, just the thought of it sounds like a nightmare because of the mask for air delivery and the air delivery itself.

But what if a person could use the air they already have to help prop up their oral airway, get rid of snoring, and treat their obstructive sleep apnea?

I'm not talking fairy tales here. I'm talking about expiratory positive airway pressure therapy or EPAP.

The history of EPAP in the 2010s

When I entered practice in Sleep Medicine in 2011, the only “EPAP” was the one that went with BPAP and used a mask and machine. It was CPAP but with more bells and whistles.

By the mid 2010s we had Provent therapy. Per my experience, it was the first of its kind to harness the power of one's own breath to treat obstructive sleep apnea. The same manufacturer made a sister product for snoring, Theravent. While the two add different designs (Provent was two sets of stickers while Theravent was just one larger sticker to go over the nose), the foundation was the same: adhesive vents (like band-aids) covering the nose to allow normal air intake on inhalation. On exhalation, the vents would slow exploration, thereby keeping the airway open. According to marketing materials, Provent and Theravent came in differing strengths offering more or less resistance based on patient preference and tolerability. The vents were disposable and designed for single night use.

If Provent was something a person wanted to stick with, we had the ability to do a sleep study in the lab to make sure it was getting the job done well enough.

To be a candidate for Provent a person needed to be able to breathe only through their nose and have no significant underlying lung or heart issues. Needing supplemental oxygen is a deal breaker for this therapy. Really low blood pressure or severe heart failure would also take a person out of the running. If I had a patient with shortness of breath problems, Provent is not a therapy I would offer.

I had a handful of patients who tried Provent and the ones who returned in follow up were generally pleased with their experience with it.

The need for a new set of vents each night meant it was an ongoing, revolving cost for the patient. It had no way to monitor use (like CPAP does with downloads), which could be a bonus or a drawback depending on how you look at it.

Bye, Bye EPAP

In June 2020 the manufacturer of Provent sleep apnea therapy announced that they were ceasing production due to high manufacturing costs and the COVID-19 pandemic.

As of the time of this writing Provent and Theravent are essentially unobtainable. If it can be found online, all the listings say it is out of stock. If I remember correctly, the cost was $2-3 per night.

EPAP in the 2020s

I've been around the Sleep Medicine world long enough to have figured out that there are a lot of gimmicky things out there. Something new comes along and makes hopeful promises which usually don't amount to much in the end. A volunteer patient or two tries them and provides feedback which helps me to steer the next person toward or away from it.

Provent is an example of an OK option for good candidates. It didn't work for everyone who tried it, but nothing does. Mask liners offered a fix for poor mask fit, but usually weren't much help (because you can't get a bad fitting mask to fit better just by adding a liner). Gel pads for the bridge of the nose would slip and slide and most of my patients didn’t find them all that helpful either. I could go on, but I'll spare you.

I get a lot of my best gossip and information from the CPAP users I have met. With the manufacturing death of Provent, I thought manual EPAP was gone forever until an acquaintance asked me about Bongo RX.

This EPAP technology is reusable, made from silicone, washable and does not involve adhesive pads like Provent.

I didn't have any patients in the pipeline who would be candidates. I didn't know anyone who had tried it either. With the mounting CPAP supply issues, I thought now would be a good time to obtain a starter kit and have someone with mild to moderate sleep apnea (and no nasal congestion, lung or heart issues) take a spin with them. The candidate I approached had a machine CPAP that was on back order and delivery wasn't expected for another month. He was miserable with his untreated sleep apnea. What did he have to lose?

Bongo RX

In November 2021, standard pricing for Bongo RX starter kit is about $200 USD. A single replacement set of Bongos (you order the size you need moving forward) run about $100. Since there's no adhesive, size matters. Too small and it won't seal. If it doesn't seal, it won't work.

After cleaning all the sizes in the starter kit, the instructions say to start with the smallest size and place it just inside the nostrils. It doesn't need to go too far up. To see if it fits properly, cover the vents and exhale through the nose. If any air leaks around the nostrils, the user is supposed to go to the next size up and repeat the process until no air escapes on the blow test.

Our experimental candidate used the large Bongos for two nights. His bed partner noted that on the first night, he did not snore and he seemed to sleep more still. He did have some lip puffing, which means that air was going out of his mouth rather than out of the Bongo vents. In the morning, he reported having significant dry mouth – not an unexpected finding with oral leak. Following his first night of use of the Bongo RX, our volunteer did not wake up with a headache. He did not remain headache free that day.

On the second night of this Bongo trial, quite a bit of snoring was noted by the bedpartner, as was ongoing mouth breathing. There was no subjective difference for this person with or without the Bongos other than the addition of dry mouth, due to mouth breathing.

By the third night, the patient's CPAP machine had been delivered and he switched over to that mode of therapy.

My Take on Bongo RX

I had the opportunity to try on the Bongo RX, even though I don't have sleep apnea myself. I needed the extra-large size Bongos because the large size leaked for me. The extra-large seemed a little bit too big. It did seal well but I don't think it would have been a reasonable long-term solution for me because I think it would have made my nose very sore with ongoing use.

Part of the way the Bongos works, is to hold air in the airway when breathing out. This means that it takes much longer than normal to breathe out. I found this to be uncomfortable after a couple of breaths. The predecessor to the Bongos had different strengths of expiratory positive airway pressure therapy in a single size. The Bongos has multiple sizes but only one strength of EPAP.

Good candidate selection is likely to improve success rates if someone wants to try this therapy. If I were to try it with a motivated clinic patient and that patient planned to continue using it long-term, I would want to confirm it was working, at least by checking overnight oximetry with it in place. To do a diagnostic sleep study with these in place, the sleep lab would have to have special monitoring equipment to accommodate for Bongo RX. One of the primary sensors in any formal sleep test to measure an apnea is the nasal airflow sensor. This tells us whether or not air is moving in and out of the person's nose/mouth. This was available with Provent. I am not certain that it is available with Bongo RX.

Like CPAP, it has to be used to work. Like a nasal mask or mouth guard, mouth breathing makes it ineffective, or less effective.

For folks without electricity, such as hikers or people on sailboats, it could have utility.

Because there's no way to monitor adherence, it would not be a good option for someone who requires a DOT medical exam (truck drivers or bus drivers) because medical examiners usually need some sort of objective measure supporting the person's use of therapy and its effectiveness. We get this information from a person's CPAP download data. The same reasoning holds true for airplane pilots, though The FAA rules are a little different and not do recognize manual EPAP therapy in their medical examiner guidelines for people with OSA.

For those of you who want to ditch your CPAP therapy and try this, I would encourage you to discuss it with your health care team first. I would say the same to any sleep apnea patient who isn't on CPAP but wants to see if something like this could benefit their version of sleep disordered breathing, as it comes in various flavor combinations. Whether we're talking Provent or Bongo RX, it is difficult to find good candidates for manual expiratory positive airway pressure therapy.

It also is by prescription only.