From the Guidelines
Central sleep apnea treatment should prioritize continuous positive airway pressure (CPAP) over adaptive servo-ventilation (ASV) due to the increased mortality risk associated with ASV in patients with heart failure with reduced ejection fraction (HFrEF) 1.
Treatment Options
- Positive airway pressure therapy: CPAP is the preferred treatment option for central sleep apnea, as it improves sleep quality and nocturnal oxygenation 1.
- Supplemental oxygen therapy: may help reduce central apneas, especially in patients with heart failure or those at high altitude.
- Medications:
- Acetazolamide (typically 125-250 mg twice daily) stimulates breathing by creating a mild metabolic acidosis and is useful for high-altitude or heart failure-related central sleep apnea.
- Theophylline (100-200 mg twice daily) may be prescribed but has limited use due to side effects.
Important Considerations
- Treating underlying conditions like heart failure, atrial fibrillation, or kidney disease is essential for managing central sleep apnea effectively.
- Lifestyle modifications such as avoiding alcohol and sedatives before bedtime, maintaining a regular sleep schedule, and sleeping with the head elevated can provide additional benefits alongside primary treatments.
- Adaptive servo-ventilation is associated with increased mortality in patients with HFrEF and central sleep apnea, and its use is not supported by current evidence 1.
From the FDA Drug Label
In a study assessing the respiratory-depressant effects of Xyrem (same active moiety as XYWAV) at doses up to 9 g per night in 21 adult patients with narcolepsy, no dose-related changes in oxygen saturation were demonstrated in the group as a whole. One of the four patients with preexisting moderate-to-severe sleep apnea had significant worsening of the apnea/hypopnea index during treatment In a study assessing the effects of Xyrem 9 g per night in 50 adult patients with obstructive sleep apnea, Xyrem did not increase the severity of sleep‑disordered breathing and did not adversely affect the average duration and severity of oxygen desaturation overall However, there was a significant increase in the number of central apneas in patients taking Xyrem, and clinically significant oxygen desaturation (≤55%) was measured in three patients (6%) after Xyrem administration, with one patient withdrawing from the study and two continuing after single brief instances of desaturation During polysomnographic evaluation (PSG), central sleep apnea and oxygen desaturation were observed in pediatric patients with narcolepsy treated with Xyrem. Prescribers should be aware that increased central apneas and clinically relevant oxygen desaturation events have been observed with sodium oxybate administration in adult and pediatric patients
Treatment options for centralized sleep disorders, such as central sleep apnea, may include sodium oxybate (XYWAV), but it is essential to note that this medication can impair respiratory drive and increase central apneas.
- Key considerations:
- Sodium oxybate may worsen sleep-disordered breathing in some patients.
- Clinically significant oxygen desaturation events have been observed in patients taking sodium oxybate.
- Prescribers should carefully evaluate patients for a history of sleep apnea and monitor them closely for signs of respiratory depression.
- Sodium oxybate is available only through a restricted program under a REMS due to the risks of central nervous system depression, abuse, and misuse 2.
From the Research
Treatment Options for Centralized Sleep Disorders
The treatment options for centralized sleep disorders, such as central sleep apnea, include:
- Positive Airway Pressure (PAP) therapy, which can be effective in treating primary Central Sleep Apnea (CSA) 3
- Adaptive servoventilation (ASV), which has been shown to be effective in treating central and complex sleep apnea syndromes 4, 5, 6
- Acetazolamide, which has been found to be effective in reducing the apnea-hypopnea index (AHI) in both obstructive sleep apnea (OSA) and central sleep apnea (CSA) 7
- Oxygen therapy, which may be effective in treating central sleep apnea due to Cheyne-Stokes breathing pattern in congestive heart failure (CSR-CHF) 3
- Bilevel positive airway pressure-spontaneous timed mode (BPAP-ST), which may be recommended for patients with central sleep apnea due to drug or substance use 3
- Average volume assured pressure support (AVAPS), which may be considered for patients with obesity hypoventilation syndrome or neuromuscular or chest wall disease 3
Specific Treatment Recommendations
The following are specific treatment recommendations for different types of centralized sleep disorders:
- Primary Central Sleep Apnea (CSA): trial of PAP, acetazolamide, or zolpidem 3
- Central Sleep Apnea Due to Cheyne-Stokes Breathing Pattern in Congestive Heart Failure (CSR-CHF): PAP devices such as CPAP or ASV, oxygen therapy 3
- Central Sleep Apnea due to High-Altitude Periodic Breathing: descent from altitude, supplemental oxygen, acetazolamide 3
- Central Sleep Apnea due to Drug or Substance: trial of CPAP, ASV, BPAP-ST 3
- Obesity Hypoventilation Syndrome: initial CPAP trial, BPAP, BPAP-ST, or AVAPS if CPAP is not effective 3
- Neuromuscular or Chest Wall Disease: early implementation of BPAP-ST, AVAPS 3
Effectiveness of Treatment Options
The effectiveness of these treatment options has been studied in various research papers, including:
- A study that found ASV to be effective in treating central and complex sleep apnea syndromes 4
- A study that compared the efficacy of NPPV and ASV in treating patients with centrally mediated breathing abnormalities, and found ASV to be more effective 5
- A study that found ASV to be an effective treatment for complex and central sleep apnea syndromes 6
- A systematic review and meta-analysis that found acetazolamide to be effective in reducing the AHI in both OSA and CSA 7