From the Guidelines
The treatment approach for a patient with Cheyne-Stokes respiration and sleep apnea should prioritize continuous positive airway pressure (CPAP) therapy, as adaptive servo-ventilation (ASV) has been shown to increase mortality in certain patient populations, particularly those with heart failure with reduced ejection fraction (HFrEF) 1.
Key Considerations
- CPAP starting at 5-10 cmH2O may be used initially, especially if obstructive sleep apnea is also present.
- Oxygen supplementation at 2-3 L/min via nasal cannula can be beneficial, particularly for patients with heart failure, but its role is unproven and not recommended in HF guidelines 1.
- Medication management includes optimizing treatment for underlying conditions like heart failure (using beta-blockers, ACE inhibitors, and diuretics) or addressing neurological disorders.
- Lifestyle modifications are also important, including sleeping with the head elevated 30 degrees, avoiding alcohol and sedatives before bedtime, maintaining regular sleep schedules, and weight management if obesity is present.
Evidence-Based Recommendations
- The SERVE-HF trial demonstrated an increase in cardiovascular mortality in heart failure patients with a reduced ejection fraction using ASV compared to a control group 1.
- The 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure recommend CPAP, BiPAP, or ASV for patients with sleep apnea, but note that none of these interventions has been prospectively shown to be beneficial on major outcomes in HFrEF 1.
- The 2018 Journal of Clinical Sleep Medicine article suggests that CPAP may be beneficial in reducing AHI and improving LVEF, but notes that the evidence is not yet conclusive 1.
Treatment Effectiveness
- Treatment effectiveness should be monitored through follow-up sleep studies and clinical assessment of symptoms like daytime sleepiness, cognitive function, and quality of life.
- The goal of treatment is to improve morbidity, mortality, and quality of life, and to reduce the frequency and severity of Cheyne-Stokes respiration and sleep apnea episodes.
From the Research
Treatment Approaches for Cheyne-Stokes Respiration and Sleep Apnea
The treatment of Cheyne-Stokes respiration (CSR) with central sleep apnea (CSA) in patients with heart failure is a complex issue. Several studies have investigated the effectiveness of different treatment approaches, including:
- Adaptive servo ventilation (ASV) 2, 3, 4
- Continuous positive airway pressure (CPAP) 2, 3
- Noninvasive positive pressure ventilation (NPPV) with bilevel positive airway pressure (BiPAP) 5
- Oxygen therapy 3, 4
- Optimization of heart failure therapy 3, 6
Comparison of Treatment Outcomes
Studies have compared the outcomes of different treatment approaches, including:
- ASV versus oxygen therapy: ASV was found to be more effective in reducing CSA-CSR than oxygen therapy 4
- ASV versus CPAP: ASV was not found to be superior to CPAP in terms of sleep quality, cardiovascular outcomes, or quality of life 2
- NPPV with BiPAP: This treatment approach was found to improve cardiac function and reduce CSA-CSR in a patient with congestive heart failure 5
Importance of Optimization of Heart Failure Therapy
Optimization of heart failure therapy is considered the initial treatment approach for CSR-CSA in patients with heart failure 3, 6. This approach aims to improve cardiac function and reduce the severity of CSR-CSA. Additionally, it is essential to continue referring heart failure patients for sleep evaluation to discern obstructive sleep apnea (OSA) from CSR-CSA 2.