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

Treatment Options for Central Sleep Apnea

The optimal treatment for central sleep apnea (CSA) should prioritize addressing underlying causes while using specific therapies based on etiology, with continuous positive airway pressure (CPAP) being the first-line treatment option for most CSA subtypes. 1

First-Line Approaches Based on Etiology

• For CSA due to heart failure, optimize heart failure treatment as the primary intervention before considering respiratory support therapies 2
• For medication-induced CSA, particularly from opioids, address the underlying medication use as first-line therapy 2
• For overweight patients with CSA, weight reduction is recommended along with avoidance of alcohol and sedatives before bedtime 3
• CPAP therapy reduces apnea-hypopnea index (AHI) to fewer than 15 events/hour in approximately 45% of patients with CSA associated with heart failure 4

Positive Airway Pressure Therapies

• CPAP is suggested as first-line therapy for CSA due to primary CSA, heart failure, medication use, treatment-emergent CSA, and CSA due to medical conditions 1
• Bilevel positive airway pressure (BPAP) with a backup rate is recommended for primary CSA, medication-induced CSA, treatment-emergent CSA, and CSA due to medical conditions when CPAP is ineffective 1
• BPAP without a backup rate is not recommended for CSA treatment 1
• Adaptive servo-ventilation (ASV) is effective for many CSA types but should be avoided in patients with heart failure with reduced ejection fraction (HFrEF) due to increased cardiovascular mortality demonstrated in the SERVE-HF trial 4, 1

Oxygen and Pharmacological Therapies

• Low-flow oxygen therapy is recommended for CSA due to heart failure and high-altitude CSA 1
• Acetazolamide may be considered for primary CSA, CSA due to heart failure, medication-induced CSA, treatment-emergent CSA, and high-altitude CSA 2, 1
• Acetazolamide has been shown to reduce AHI from 54 to 34 events/hour and lower PaCO2 from 37 to 34 mmHg 2
• Other pharmacological therapies have not demonstrated sufficient efficacy for CSA treatment 4

Advanced Therapies

• Transvenous phrenic nerve stimulation (TPNS) is suggested for primary CSA and CSA due to heart failure when other treatments fail 1
• TPNS should be considered after other treatments due to its invasiveness, high costs, and risk of serious adverse effects in approximately 10% of patients 4, 1

Treatment Algorithm Based on CSA Type

• For CSA due to heart failure:

  1. Optimize heart failure treatment 2
  2. Try CPAP therapy 1
  3. Consider low-flow oxygen if CPAP is ineffective 2, 1
  4. Consider acetazolamide 1
  5. Consider TPNS if other options fail 1
  6. Avoid ASV in patients with HFrEF 4

• For primary CSA:

  1. Start with CPAP therapy 1
  2. If ineffective, try BPAP with backup rate 1
  3. Consider acetazolamide 1
  4. Consider ASV if other options fail 1
  5. Consider TPNS as a last resort 1

• For medication-induced CSA (particularly opioids):

  1. Address medication use if possible 2
  2. Try CPAP therapy 5, 1
  3. Consider BPAP with backup rate if CPAP fails 5, 1
  4. Consider acetazolamide 1

Monitoring and Follow-up

• Assess treatment response through resolution of symptoms, improvement in quality of life, and reduction in AHI on follow-up sleep studies 2
• If central events persist, re-evaluate underlying risk factors and consider alternative treatment options 2, 1
• Regular follow-up is essential to assess treatment efficacy and should include objective monitoring of treatment outcomes 3

Important Considerations and Pitfalls

• CSA in heart failure may be a compensatory mechanism in some patients, so treatment decisions should be based on expectations of symptomatic or quality-of-life improvement rather than solely focusing on eliminating breathing events 2, 1
• Benzodiazepines should not be prescribed for long-term treatment of CSA associated with heart failure 4
• Oxygen therapy decreases AHI from 49 to 29 events/hour in some studies but may worsen cardiac function at supernormal amounts 2
• ASV treatment in HFrEF patients showed worsened all-cause and cardiovascular mortality despite reduction in AHI, as seen in the SERVE-HF trial 4