Is treatment-emergent sleep apnea on Continuous Positive Airway Pressure (CPAP) predictive of treatment-emergent sleep apnea on Inspire (Upper Airway Stimulation) therapy?

Treatment-Emergent Central Sleep Apnea on CPAP as a Predictor for Treatment-Emergent Central Sleep Apnea on Inspire

Treatment-emergent central sleep apnea (TECSA) on CPAP therapy is likely predictive of TECSA on Inspire upper airway stimulation therapy, although direct evidence specifically comparing these two scenarios is currently limited in the medical literature.

Understanding Treatment-Emergent Central Sleep Apnea

Treatment-emergent central sleep apnea (TECSA) is characterized by:

• The emergence or persistence of central apneas during treatment for obstructive sleep apnea (OSA) 1
• Occurs in approximately 10% of OSA patients during CPAP titration studies 2
• May resolve spontaneously over time in some patients (55.1% transient cases) but persists in others (25.2%) 2

Pathophysiological Mechanisms of TECSA

Several mechanisms contribute to the development of TECSA, which would likely apply regardless of therapy type:

• Ventilatory control instability 1
• Low arousal threshold 1
• Activation of lung stretch receptors 1
• Prolonged circulation time 1
• Increased tidal volume potentially via inspiratory pressure increments 3

TECSA on CPAP vs. Inspire

While there is no direct evidence comparing TECSA on CPAP versus Inspire therapy, several factors suggest a correlation:

• Both therapies alter upper airway dynamics and respiratory drive, which are key factors in the development of central apneas 1, 4
• Patients who develop TECSA on CPAP have specific characteristics (older age, higher residual AHI) that would likely persist with other therapies 2
• The underlying pathophysiology that leads to TECSA on CPAP would theoretically remain present during Inspire therapy 1

Management Considerations

For patients with TECSA on CPAP who are considering Inspire therapy:

• TECSA on CPAP may be a risk factor for treatment failure or suboptimal outcomes with Inspire 2
• Patients with TECSA are at higher risk of therapy termination compared to those without TECSA 2
• Alternative approaches may be needed for patients with persistent TECSA 1

Clinical Implications

When considering Inspire therapy for patients with history of TECSA on CPAP:

• Careful screening and monitoring is warranted 5
• Patients should be informed about the potential risk of developing TECSA with Inspire therapy 1
• Alternative therapies such as adaptive servo-ventilation may be necessary if TECSA persists 1

Evidence-Based Approach

Recent research has shown:

• TECSA can be resolved by reducing inspiratory positive airway pressure in CPAP users 3
• Different TECSA trajectories exist (transient, persistent, emergent), suggesting different clinical phenotypes 2
• Early identification of TECSA through monitoring could facilitate timely intervention 2

Conclusion

While direct comparative studies are lacking, the underlying pathophysiological mechanisms suggest that patients who develop TECSA on CPAP would likely be at increased risk for developing TECSA on Inspire therapy. Careful monitoring and potentially modified treatment approaches should be considered for these patients.