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Central sleep apnea

What's new

Added 2023 BTS, 2022 AHA/ACC, 2022 JRS, 2017 ERS, and 2016 AASM guidelines for the management of central sleep apnea.

Background

Overview

Definition
CSA is a sleep disorder characterized by intermittent cessation or reduction of respiratory effort during sleep due to a lack of respiratory drive from the brain.
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Pathophysiology
CSA can be idiopathic or associated with underlying disorders such as HF, stroke, opioid use, ESRD, and high-altitude exposure. The pathophysiology of CSA involves unstable ventilatory control during sleep, leading to periods of insufficient ventilation and compromised gas exchange.
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Epidemiology
The prevalence of CSA is estimated at 7.8% in males and 0.3% in females in the general population, and up to 25-40% in patients with HFrEF.
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Disease course
Clinically, CSA presents with symptoms such as frequent awakenings, nonrefreshing sleep, nocturnal dyspnea, snoring, difficulty staying asleep, and excessive daytime sleepiness. It can present with or without Cheyne-Stokes breathing.
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Prognosis and risk of recurrence
The prognosis of CSA can vary based on the underlying causes and associated comorbidities. However, with timely diagnosis and appropriate management, the QoL and clinical outcomes can be significantly improved.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of central sleep apnea are prepared by our editorial team based on guidelines from the British Thoracic Society (BTS 2023), the Heart Failure Society of America (HFSA/AHA/ACC 2022), the Oto-Rhino-Laryngological Society of Japan (ORLSJ/JADSM/JSSR/MHLW/JRS/JSPN/JCS/JSOH 2022), the European Respiratory Society (ERS 2017), and the American Academy of Sleep Medicine (AASM 2016; 2012)....
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Diagnostic investigations

Sleep evaluation: as per HFSA/AHA/ACC 2022 guidelines, consider obtaining a formal sleep assessment in patients with HF and suspicion of sleep-disordered breathing to confirm the diagnosis and differentiate between obstructive and CSA.
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Respiratory support

Positive airway pressure therapy: as per ORLSJ/JADSM/JSSR/MHLW/JRS/JSPN/JCS/JSOH 2022 guidelines, offer CPAP therapy for moderate-to-severe Cheyne-Stokes breathing associated with CVD, such as HF, remaining even after optimizing treatment of the underlying disease.
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More topics in this section

  • Adaptive servo-ventilation

  • Oxygen therapy

Medical management

General principles: as per ORLSJ/JADSM/JSSR/MHLW/JRS/JSPN/JCS/JSOH 2022 guidelines, treat underlying diseases associated with CSA, such as medical therapy for HF and pacemakers, including CRT.
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More topics in this section

  • Acetazolamide

  • Theophylline

  • Hypnotics

Specific circumstances

Pediatric patients: as per BTS 2023 guidelines, consider obtaining pulse oximetry as a first-line diagnostic test in pediatric patients with suspected sleep-disordered breathing. Consider obtaining a higher level of investigation, such as a cardiorespiratory sleep study, if the test result is inconsistent with the clinical picture.
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More topics in this section

  • Patients with ESRD

  • Patients with pulmonary hypertension

  • Patients with opioid-induced CSA

  • Patients with high altitude-induced CSA

  • Patients with treatment-emergent CSA