I am often asked the question of whether or not nasal dilator strips (NDS), most commonly seen on the noses of NFL players, provide any benefits to patients with OSA/UARS. Most people are perplexed when without reservation I affirm that NDS therapy is not only effective in its own right, but also adds to the effectiveness of PAP use. The disbelief so many people, patients or otherwise, show regarding nasal strips may hinge on the lack of attention paid to nasal breathing in general. As described in our Nasal Breathing video series, it is common to normalize nasal breathing even when suffering from chronic congestion. As a result, the chronic congestion is discounted as just an everyday occurrence of life. Only when congestion clearly affects something, like your sleep, will someone seek a remedy, yet even then there is little sense about how much treatment to pursue, because most people do not establish a standard for normal nasal breathing.
When patients aggressively pursue nasal treatments like steroid or antihistamine nasal sprays or various OTC medications, it is easy to achieve some improvement, and most people recognize the change from congestion to clearer breathing. For PAP users, we hold a zero-tolerance policy and routinely encounter patients in which we either hear the congestion during a clinic appointment or see the congestion on nasal airway exam despite the patient’s denial of any such symptoms. We explain the importance of going forward with aggressive therapies, and nearly all patients over time appreciate the value of maximizing their nasal hygiene regimens.
NDS therapy is a mainstay at our center, because it can be used in at least three distinct ways to help OSA/UARS patients. The first and most obvious way is to help someone suffering from acute or chronic congestion when the problem interferes with sleep. As above, many people do not routinely apply a nasal hygiene regimen that would prevent congestion in the first place. Therefore, their treatment model is to address the symptom when something goes wrong. Individuals may put 2 and 2 together when they wake up in the middle of the night with dry mouths and needing to blow their noses. If the congestion is acute like a cold or chronic say from allergies, they may try all sorts of OTC remedies to unclog the passageways. Eventually, they may hear about or notice in the allergy medication aisle of the drugstore a small box of nasal dilator strips. When all else fails or works poorly, “why not?” says the congested person. Other individuals, including children, adolescents, and adults may come across NDS therapy for related factors such as a history of trauma to the nose, an obvious deviated septum, and chronic rhinitis of various types that leave the nose stuffy or runny nearly all the time yet not necessarily congested with mucus.
In this first example, the users are unlikely to stick with NDS therapy on a regular basis, but some might when the condition crops up literally every night and benefits are reliable. These are the types of patients who for whatever reasons can endure more symptoms than other people and therefore their threshold for taking action is very high.
A second group of individuals, who are much more likely to use the nasal strips every night are those who seek specific sleep relief. Usually, these individuals are trying to quell their snoring, but there seems to be a substantial number of other people who simply and clearly perceive that NDS therapy yields better sleep. This latter group represents the types of patients with whom we conducted a study a decade ago and showed NDS therapy provides a multitude of benefits in many different variables of sleep (1). The study was a randomized controlled trial in which the treatment group used the nasal strips every night, and the control group received some basic education about sleep without receiving any specific treatment steps. About 40 people completed the study in each group. And, we collected extensive data every day on all the patients during a 4-week period.
The study was designed to look at the effects of NDS therapy on two main factors: insomnia and sleep quality. We recruited individuals who presented with symptoms suggesting they suffered from sleep-disordered breathing but not severe OSA. Instead, we wanted patients who were more concerned about their insomnia symptoms but also had at least one indicator of a sleep breathing condition. As the best examples, someone with insomnia who snored was enrolled in the study, but others were precluded if the insomnia was accompanied by reports of loud snoring or breathing stoppage during sleep.
At the 4-week mark, the results were quite astonishing in comparison to what we expected, because although we knew from clinical experience that nasal strips were beneficial, we thought the most remarkable finding would be some small improvements in the treated patients’ sleep quality. And, while sleep quality improvements were common and statistically significant, the surprise was that 75% of the patients reported clear-cut improvements in their insomnia while using the nasal strips. In fact, in the treatment group, scales measuring insomnia severity or time spent awake in the middle of the night averaged a 30% improvement. In this group we also demonstrated their nasal passages increased in cross-sectional area from the strips, which theoretically would have permitted greater airflow through the nose. Using a technique known as acoustic rhinometry to measure changes pre- and post-nasal strips, we documented a nearly 50% increase in nasal airflow (1).
Despite the dramatic findings in the study, the research was not well-received in part because we were not able to conduct sleep studies on these patients beforehand and thus could not know for sure whether they suffered from OSA or UARS. As such, we could also not declare why the nasal strips made things better. Still, to this day, our sense is that the research was not embraced, because sleep researchers and clinicians simply do not believe NDS therapy could be so potent. Moreover, at the time, less than a handful of studies were reporting on the relationships between insomnia and sleep-disordered breathing, so for many sleep professionals the rationale remained unclear on how nasal strips would be a useful addition to the treatment regimens of OSA or UARS patients.
Nonetheless, from that point (2005) forward, whenever we have been confronted by a patient reluctant to initiate PAP therapy or even a dental device, we strongly encourage him or her to initiate NDS therapy for a period of months or longer as the most conservative and worthwhile step in addition to any other relevant nasal hygiene steps. The NDS pathway has proven a godsend to many of our anxious patients, because not only might they receive some degree of improvement in sleep, but more importantly by virtue of the nasal strips changing their sleep for the better, the entire process validates the existence of the sleep breathing disorder. Eventually, these patients return and almost all of them say words to this effect, “…the nasal strips clearly showed me I had a sleep breathing problem and as grateful as I have been in gaining benefits from them, I realize now it’s time to use something more powerful…”
This last point brings us to the use of NDS therapy as an adjunctive tool used in combination with PAP therapy. This area has gone untapped regarding research studies or even the emergence of any conventional wisdom on nasal strips; and, yet in our clinical experience, we routinely ask our patients to consider a trial of nasal strips with their PAP masks to see whether additional benefits could be garnered. In my own personal experience, I have been using NDS therapy for almost a decade, even in the early going when I was using a nasal pillow mask. Subsequently, with over the nose masks and now with full face masks, I continue a nightly ritual of placing the nasal strip on before putting on my mask.
There may be no research on the topic of routine use of nasal strips with PAP therapy. Clearly, people complaining of obvious congestion or upper respiratory infections may use the strips as needed. But, now we are talking about using the NDS therapy every night when there is no obvious congestion. Why then would we make this recommendation? Simply put, do you recall the change in cross-sectional volume described above? Nasal strips increased the airway space, technically described as the “nasal-valve” area, which therefore suggests a greater volume of area can pass through the nose.
But, that simple change in dimension is only one potential benefit from using a nasal strip. Another possibility relates to turbulence that occurs when anyone uses a PAP device. When air is pushed through the nasal or oral cavities, there is always a risk for turbulence in the airflow, because there will always be the potential for some degree of obstruction just because of the way the anatomy of these air spaces developed over time. One of the more obvious examples of this phenomenon is that most people’s tongues grow in size as they age. As you might imagine, the larger the tongue, the more potential for obstruction in the back of the throat; and, therefore not only might there be more severe sleep apnea but also pressurized airflow may lead to more turbulence, perhaps more so because in such a case higher pressures would be needed.
Turbulence is a tricky issue and again not one regularly discussed or researched in the field of sleep medicine, but we have always suspected that turbulence, especially as experienced by more sensitive patients, leads to more difficulty adapting to the PAP device. Whatever the issues that drive most people to use NDS therapy, it is revealing how so many patients report easier use of the PAP device with rather than without the nasal strip. In my own personal experience, I have had the rare experience in which I forgot to put the strip on at night. Within a few hours of awakening in the morning, I noticed I was a little bit more tired or sleepy than my normal response. Right around the same time, I would suddenly notice or recall I had not removed a nasal strip in the morning and realized I had not worn one that night. Of course, this point is only anecdotal information, not proof of the point I am suggesting.
More research on NDS therapy is warranted. Many anecdotal or case series have described subjective improvements in sleep. Very little data are available to show objective improvements beyond the findings of increased airflow when the nasal valve space is expanded. In contrast, one study claimed to designate nasal strips as an appropriate placebo device, because it yields subjective improvements in sleep without concomitant changes in objective airflow (2). The main weakness of this particular study was the failure to measure upper airway resistance in any of the patients, yet UARS is the most plausible condition likely to be affected by NDS therapy; whereas, standard apneas or hypopneas might be less affected due to their greater severity of 50 to 100% drop off in airflow.
Though currently there is no firm scientific basis for coupling NDS therapy with PAP therapy, this fact alone does not prevent the added use of the nasal strips. It simply means the research evidence is lacking. Yet, many of our patients, including myself, report highly favorable results when using the two interventions together. You must be your own judge of whether or not it helps you to more easily use PAP therapy or helps improve your results with the device or in my experience, both!
Last, although some knock-offs have been designed based on the original nasal dilator strip, I personally and professionally have never observed any product superior to that sold as Breathe Right® nasal strips, which is manufactured by a company (GSK) for which, regrettably, I own no stock!
Originally posted as: Using Nasal Dilator Strips Independently or in Combination with PAP Therapy to Treat OSA/UARS