What are the American Academy of Sleep Medicine (AASM) treatment guidelines for Central Sleep Apnea (CSA)?

From the Guidelines

The American Academy of Sleep Medicine (AASM) guidelines advise against using adaptive servo-ventilation (ASV) for the treatment of central sleep apnea (CSA) related to congestive heart failure (CHF) in adults with an ejection fraction ≤ 45% and moderate or severe CSA predominant, sleep-disordered breathing, due to increased risk of death in this population. When considering treatment options for CSA, it is crucial to prioritize the patient's underlying medical conditions and the specific type of CSA they are experiencing.

• For patients with CSA related to CHF, alternative treatments should be considered, such as positive airway pressure therapy, bi-level positive airway pressure (BPAP), or supplemental oxygen therapy, as these may be more effective and safer options 1.
• The AASM guidelines emphasize the importance of tailoring treatment to the individual patient, taking into account their specific needs and medical history.
• In general, treatment for CSA should focus on addressing the underlying causes of the condition, such as heart failure or opioid use, while also managing the sleep disorder itself.
• Close monitoring for treatment efficacy and potential side effects is essential, and a multidisciplinary approach may be necessary to effectively manage CSA and any underlying medical conditions. Key considerations in the treatment of CSA include the type of CSA, the patient's medical history, and the potential risks and benefits of different treatment options, as highlighted in the 2016 AASM guideline update 1.

From the Research

American Academy of Sleep Medicine (AASM) Treatment Guidelines for Central Sleep Apnea (CSA)

The AASM provides guidelines for the treatment of Central Sleep Apnea (CSA) based on various studies and evidence. The following are some of the recommended treatment options:

• Primary Central Sleep Apnea (CSA):
  • A trial of Positive Airway Pressure (PAP), acetazolamide, or zolpidem may be recommended based on thorough consideration of risks and benefits and incorporation of patient preferences 2
  • CPAP therapy may be considered for the treatment of primary CSAS 3
  • Acetazolamide has limited supporting evidence but may be considered for the treatment of primary CSAS 3
  • The use of zolpidem and triazolam may be considered for the treatment of primary CSAS only if the patient does not have underlying risk factors for respiratory depression 3
• Central Sleep Apnea Due to Cheyne-Stokes Breathing Pattern in Congestive Heart Failure (CSR-CHF):
  • PAP devices such as continuous positive airway pressure (CPAP) or adaptive servo-ventilation (ASV) may be recommended to normalize sleep-disordered breathing after optimizing treatment of heart failure 2
  • Oxygen may also be an effective therapy 2
  • CPAP therapy targeted to normalize the apnea-hypopnea index (AHI) is indicated for the initial treatment of CSAS related to CHF 3
  • Nocturnal oxygen therapy is indicated for the treatment of CSAS related to CHF 3
  • Adaptive Servo-Ventilation (ASV) targeted to normalize the apnea-hypopnea index (AHI) is indicated for the treatment of CSAS related to CHF 3
• Central Sleep Apnea due to High-Altitude Periodic Breathing:
  • Descent from altitude or supplemental oxygen may be recommended 2
  • Acetazolamide may be used when descent or oxygen are not feasible, or in preparation for ascent to high altitude 2
• Central Sleep Apnea due to Drug or Substance:
  • A trial of CPAP may be recommended, and if not successful, treatment with ASV may be considered 2
  • If ASV is ineffective or if nocturnal hypercapnia develops, bilevel positive airway pressure-spontaneous timed mode (BPAP-ST) is recommended 2
• Obesity Hypoventilation Syndrome:
  • An initial CPAP trial may be recommended 2
  • If hypoxia or hypercapnia persists on CPAP, BPAP, BPAP-ST or average volume assured pressure support (AVAPS) may be recommended 2
  • Tracheostomy with nocturnal ventilation should be considered when the above measures are not effective 2
  • Weight loss may be curative 2
• Neuromuscular or Chest Wall Disease:
  • Early implementation of BPAP-ST may be recommended based on thorough consideration of risks and benefits and patient preferences 2
  • AVAPS may also be considered 2
  • Close follow-up is recommended due to disease progression 2

Comparison of Therapeutic Approaches

Comparative studies have been conducted to evaluate the effectiveness of different therapeutic approaches for CSA:

• A study found that CPAP and BIPAP are the most effective therapeutic approaches to CSA in patients with histories of heart failure and opioid use, but CPAP + O2 could be reliable in some conditions as well 4
• Another study found that although the majority of patients needed treatment for central sleep apnea, a clear advantage in using ventilators when compared to oxygen therapy or drug therapy could not be found 5
• A review of the literature suggests that positive pressure therapy (PAP) remains a standard therapy for central as well as obstructive apnea, and other treatment options include adaptive-servo ventilation (ASV), supplemental oxygen, phrenic nerve stimulation, and pharmacologic therapy 6