What are the treatment options for central sleep apnea (CSA)?

Treatment Options for Central Sleep Apnea

The treatment of central sleep apnea (CSA) should be individualized based on the underlying etiology, with continuous positive airway pressure (CPAP) suggested as first-line therapy for most forms of CSA, including primary CSA, CSA due to heart failure, medication-induced CSA, treatment-emergent CSA, and CSA due to medical conditions. 1

Understanding Central Sleep Apnea

Central sleep apnea is characterized by a lack of respiratory drive for at least 10 seconds during sleep, resulting in:

• Sleep disturbances and sympathetic nerve activation 2
• Excessive daytime sleepiness and increased cardiovascular risk 2
• Various clinical presentations depending on the underlying cause 1

Treatment Approach Based on Etiology

CSA Due to Heart Failure (Cheyne-Stokes Respiration)

• First-line: Optimize heart failure treatment - Treatment of underlying congestive heart failure may improve breathing abnormalities 3
• Second-line options:
  • Low-flow oxygen therapy (conditional recommendation, low certainty) 1
  • CPAP (conditional recommendation, low certainty) 1, 4
  • Important caution: CPAP may increase mortality in the first 2 years of treatment in some CHF patients 3
  • Adaptive servo-ventilation (ASV) should be used with caution in heart failure with reduced ejection fraction (HFrEF) and limited to centers with experience 1

Primary (Idiopathic) CSA

• First-line: CPAP therapy (conditional recommendation, low certainty) 1, 4
• Alternative options:
  • Bilevel positive airway pressure (BPAP) with backup rate 1
  • Adaptive servo-ventilation (ASV) 1
  • Oral acetazolamide (conditional recommendation, low certainty) 1
  • Transvenous phrenic nerve stimulation (TPNS) for refractory cases 1

Medication or Substance-Induced CSA

• First-line: Address underlying medication use - Particularly opiates, which can depress upper airway tone 3
• Treatment options:
  • CPAP therapy (conditional recommendation, low certainty) 1
  • BPAP with backup rate 1
  • Acetazolamide (conditional recommendation, low certainty) 1

Treatment-Emergent CSA

• First-line: CPAP therapy (conditional recommendation, low certainty) 1
• Alternative options if CPAP fails:
  • BPAP with backup rate 1
  • ASV therapy 1, 4

High-Altitude CSA

• First-line options:
  • Low-flow oxygen (conditional recommendation, very low certainty) 1
  • Oral acetazolamide (conditional recommendation, very low certainty) 1

Specific Treatment Modalities

Positive Airway Pressure Therapies

• CPAP: Standard recommendation for most CSA types 1, 4
• BPAP with backup rate: Suggested when CPAP is ineffective 1
• BPAP without backup rate: Not recommended for CSA 1
• Adaptive servo-ventilation (ASV):
  • Effective for many CSA types 1, 4
  • Caution: Use carefully in HFrEF patients with close monitoring 1

Pharmacological Options

• Acetazolamide:
  • May reduce AHI from 54 to 34 events/h 3
  • Can lower PaCO2 from 37 to 34 mmHg 3
  • Conditional recommendation for multiple CSA types 1
• Oxygen therapy:
  • Decreases AHI from 49 to 29 events/h in some studies 3
  • Standard recommendation for CSA related to CHF 4
  • May worsen cardiac function at supernormal amounts 3

Invasive Options

• Transvenous phrenic nerve stimulation (TPNS):
  • Suggested for primary CSA and CSA due to heart failure 1
  • Should be considered after other treatments due to invasiveness and cost 1

Monitoring and Follow-up

• Assess treatment response through:
  • Resolution of symptoms (daytime sleepiness, insomnia, fatigue) 3
  • Improvement in quality of life 1
  • Reduction in AHI on follow-up sleep studies 1
• Persistence of central events should prompt re-evaluation of underlying risk factors 1

Important Considerations

• CSA in heart failure may be a compensatory mechanism in some patients 3
• The SERVE-HF trial showed increased mortality with ASV in HFrEF patients 3
• Prioritize optimizing therapy for underlying conditions rather than solely focusing on eliminating breathing events 1
• Treatment decisions should be based on expectations of symptomatic or quality-of-life improvement 1