What are the management options for central sleep apnea?

Management of Central Sleep Apnea

The optimal approach to central sleep apnea (CSA) treatment should incorporate clinical features, comorbid conditions, and polysomnographic findings in an individualized manner, with priority given to optimizing therapy for underlying conditions contributing to central apneas rather than solely focusing on eliminating disordered breathing events. 1

Types of Central Sleep Apnea

Central sleep apnea is not a single disease but represents a final pathway in heterogeneous disorders that can be classified into several categories:

• Primary (idiopathic) CSA
• CSA due to heart failure (Cheyne-Stokes respiration)
• CSA due to medication or substance use
• Treatment-emergent CSA
• CSA due to medical conditions or disorders
• CSA due to high altitude

First-Line Management Approaches

1. Treat Underlying Conditions

• Heart Failure: Optimize heart failure management according to current guidelines 2
• Medication-induced CSA: Consider adjusting or discontinuing opioids or other medications that may contribute to CSA
• High-altitude CSA: Acclimatization or descent to lower altitude when possible

2. Positive Airway Pressure Therapies

• CPAP: Suggested as first-line therapy for most forms of CSA (conditional recommendation, low certainty) 1

  • Effective for primary CSA, CSA due to heart failure, medication-induced CSA, and treatment-emergent CSA

• BiPAP with backup rate: Suggested when CPAP is ineffective (conditional recommendation, very low certainty) 1

  • Particularly useful in patients with opioid-induced CSA

• Adaptive Servo-Ventilation (ASV):

  • Suggested for primary CSA, medication-induced CSA, and treatment-emergent CSA (conditional recommendation, low certainty) 1
  • CAUTION: ASV is contraindicated in patients with heart failure with reduced ejection fraction (HFrEF) as it causes harm 2
  • The SERVE-HF trial demonstrated increased mortality with ASV in HFrEF patients 2

Second-Line and Alternative Therapies

1. Oxygen Therapy

• Low-flow oxygen: Suggested for CSA due to heart failure (conditional recommendation, low certainty) 1
• Also suggested for high-altitude CSA (conditional recommendation, very low certainty) 1

2. Pharmacological Approaches

• Acetazolamide: Suggested for various forms of CSA including primary CSA, CSA due to heart failure, and high-altitude CSA (conditional recommendation, low/very low certainty) 1
  • Typical dosage: 250 mg daily 2
  • Caution: May disturb electrolytes or induce laryngeal spasm during sleep 2

3. Advanced Interventions

• Transvenous Phrenic Nerve Stimulation (TPNS): Suggested for primary CSA and CSA due to heart failure (conditional recommendation, very low certainty) 1
  • Consider only after other treatments have failed
  • Requires an invasive procedure and is associated with high costs
  • Risk of serious adverse effects in approximately 10% of patients 2

Management Algorithm Based on CSA Etiology

For CSA due to Heart Failure:

1. Optimize heart failure management (GDMT) 2
2. Consider CPAP trial
3. If ineffective, consider low-flow oxygen
4. Consider acetazolamide in selected cases
5. AVOID ASV in patients with HFrEF due to increased mortality risk 2

For Primary/Idiopathic CSA:

1. CPAP trial
2. If ineffective, consider BiPAP with backup rate
3. Consider ASV if CPAP/BiPAP ineffective
4. Consider acetazolamide as adjunctive therapy

For Medication/Opioid-Induced CSA:

1. Consider medication adjustment if possible
2. CPAP trial
3. If ineffective, consider BiPAP with backup rate
4. Consider ASV if CPAP/BiPAP ineffective

For High-Altitude CSA:

1. Acclimatization or descent when possible
2. Low-flow oxygen
3. Consider acetazolamide

Monitoring and Follow-up

• Reassess treatment efficacy with follow-up sleep studies
• If central events persist despite therapy, reevaluate underlying risk factors and consider alternative treatment options 1
• Monitor for treatment-related adverse effects

Important Considerations

• CSA treatment should focus on improving patient-reported outcomes and quality of life, not just reducing the apnea-hypopnea index 1
• Prior to initiating ASV, patient-provider shared decision-making is recommended 1
• Treatment with ASV in heart failure patients should be limited to centers with experience, along with close monitoring 1
• The comparative study of therapeutic approaches showed response rates of 42.2% to CPAP, 20.3% to CPAP+O2, and 28.1% to BiPAP, with 9.4% of patients (mostly with heart failure) being non-responsive to all approaches 3