What is the treatment approach for central sleep apnea (CSA)?

Treatment of Central Sleep Apnea: A Comprehensive Approach

The optimal approach to central sleep apnea (CSA) treatment should incorporate clinical features, comorbid conditions, and polysomnographic findings in an individualized manner, with continuous positive airway pressure (CPAP) being the first-line therapy for most CSA subtypes. 1

Initial Assessment and Classification

• CSA is characterized by apneic episodes during sleep with no associated ventilatory effort, often occurring alongside obstructive and mixed events 2
• Two basic mechanisms trigger central respiratory events: post-hyperventilation central apnea and central apnea secondary to hypoventilation (commonly with opioid use) 3
• Proper identification of central events during polysomnographic recording is mandatory before initiating treatment 4

First-Line Treatment Options

CPAP Therapy

• CPAP is recommended as the initial treatment for CSA due to primary CSA, heart failure, medication/substance use, treatment-emergent CSA, and CSA due to medical conditions 1
• CPAP therapy has shown the most positive results in patients with congestive heart failure (CHF) and ischemic heart disease (IHD) 5
• For patients with CSA and heart failure, CPAP should be targeted to normalize the apnea-hypopnea index (AHI) 3

Bilevel Positive Airway Pressure (BPAP)

• BPAP with a backup rate is suggested for primary CSA, CSA due to medication/substance use, treatment-emergent CSA, and CSA due to medical conditions 1
• BPAP has shown effectiveness particularly in patients with a history of opioid use 5
• BPAP without a backup rate is not recommended for CSA treatment 1

Second-Line and Alternative Treatments

Adaptive Servo-Ventilation (ASV)

• ASV may be used for primary CSA, CSA due to medication/substance use, treatment-emergent CSA, and CSA due to medical conditions 1
• ASV should NOT be used for CSA related to CHF in adults with an ejection fraction ≤ 45% and moderate or severe CSA predominant sleep-disordered breathing due to increased risk of death 6
• ASV can be considered for CSA related to CHF in adults with an ejection fraction > 45% or mild CHF-related CSA 6

Oxygen Therapy

• Low-flow oxygen is recommended for CSA due to heart failure 1
• Oxygen therapy can be effective when combined with CPAP in some patients (CPAP + O2) 5
• Low-flow oxygen is also suggested for CSA due to high altitude 1

Pharmacological Approaches

• Oral acetazolamide is suggested for primary CSA, CSA due to heart failure, medication/substance use, treatment-emergent CSA, and CSA due to medical conditions 1
• Acetazolamide has been shown to decrease central apneas during short-term use, though results have been variable with prolonged administration 2
• Acetazolamide is also recommended for CSA due to high altitude 1

Advanced Interventions

• Transvenous phrenic nerve stimulation (TPNS) may be considered for primary CSA and CSA due to heart failure when other treatments fail 1
• This approach requires an invasive procedure, is not universally accessible, and is associated with high costs, so other treatments should be considered first 1

Treatment Algorithm Based on CSA Etiology

For CSA Related to Heart Failure:

1. Optimize heart failure medical therapy
2. If EF > 45%: Try CPAP first, then consider ASV if CPAP fails 6
3. If EF ≤ 45%: CPAP or low-flow oxygen (DO NOT use ASV) 6
4. Consider acetazolamide if other therapies fail 1

For Primary CSA:

1. Start with CPAP therapy 1
2. If inadequate response, try BPAP with backup rate 1
3. Consider ASV if BPAP fails 1
4. Acetazolamide may be considered if PAP therapies are not tolerated 1

For CSA Due to Medication/Substance Use (especially opioids):

1. Consider CPAP or BPAP with backup rate 5, 1
2. ASV may be used if other PAP therapies fail 1
3. Address underlying medication use if possible 4

Monitoring and Follow-up

• Once therapy for CSA has been initiated, persistence of central respiratory events should prompt re-evaluation of underlying risk factors 1
• Treatment decisions should be based on expectations of symptomatic or quality-of-life improvement 1
• Treatment with ASV in patients with heart failure requires close monitoring and follow-up 6

Common Pitfalls and Considerations

• Focusing solely on eliminating disordered breathing events rather than improving patient-reported outcomes 1
• Using ASV in heart failure patients with reduced ejection fraction (≤45%), which increases mortality risk 6
• Failing to optimize therapy for conditions contributing to central apneas before initiating specific CSA treatments 1
• Not considering the typology of respiratory disturbances observed by polysomnography when selecting therapy 4