From the Guidelines
Central sleep apnea is a sleep disorder characterized by repeated stops and starts in breathing during sleep due to the brain's failure to send proper signals to the muscles that control breathing, and it is closely linked to heart failure with reduced ejection fraction (HFrEF) as the most common cause and type of sleep-disordered breathing in this population. This condition is distinct from obstructive sleep apnea, which occurs when throat muscles relax and block the airway. Common symptoms of central sleep apnea include pauses in breathing during sleep, gasping for air, difficulty staying asleep, excessive daytime sleepiness, morning headaches, difficulty concentrating, and mood changes. It can be caused by heart disorders, stroke, brain tumors, opioid medications, or high altitude 1. The diagnosis of central sleep apnea may involve overnight polysomnography or advanced home testing equipment that can distinguish between types of sleep apnea. Treatment depends on the underlying cause and may include addressing medical conditions, adjusting medications, using continuous positive airway pressure (CPAP) machines, adaptive servo-ventilation (ASV) devices, or supplemental oxygen 1. However, the use of ASV in patients with HFrEF and predominantly central sleep apnea is not recommended due to the increased risk of cardiovascular mortality, as shown in the SERVE-HF trial 1. In contrast, CPAP has been shown to reduce the frequency of episodes of apnea and hypopnea, and improve left ventricular ejection fraction (LVEF) and 6-minute walk test distance in patients with heart failure-related central sleep apnea, but it did not improve prognosis or the rate of heart failure-related hospitalizations 1. Overall, central sleep apnea is a serious condition that requires proper diagnosis and treatment to reduce the risk of complications such as heart problems, fatigue, and other health issues. Key considerations in the management of central sleep apnea include:
- Identifying and addressing the underlying cause of the condition
- Using CPAP or other treatments to reduce symptoms and improve quality of life
- Avoiding the use of ASV in patients with HFrEF and predominantly central sleep apnea due to the increased risk of cardiovascular mortality
- Monitoring patients closely for signs of complications and adjusting treatment as needed 1.
From the Research
Definition and Characteristics of Central Sleep Apnea
- Central sleep apnea (CSA) is characterized by intermittent repetitive cessation and/or decreased breathing without effort caused by an abnormal ventilatory drive 2.
- CSA can be primary (idiopathic) or secondary in association with Cheyne-Stokes respiration, drug-induced, medical conditions such as chronic renal failure, or high-altitude periodic breathing 2.
- The occurrence of central apnea initiates a cascade of events that perpetuates breathing instability, recurrent central apnea and upper airway narrowing 3.
Types of Central Sleep Apnea
- Primary Central Sleep Apnea (CSA): recommended treatment includes a trial of Positive Airway Pressure (PAP), acetazolamide, or zolpidem 4.
- Central Sleep Apnea Due to Cheyne-Stokes Breathing Pattern in Congestive Heart Failure (CSR-CHF): recommended treatment includes PAP devices such as continuous positive airway pressure (CPAP) or adaptive servo-ventilation (ASV) 4.
- Central Sleep Apnea due to High-Altitude Periodic Breathing: recommended treatment includes descent from altitude or supplemental oxygen, and acetazolamide may be used when descent or oxygen are not feasible 4.
- Central Sleep Apnea due to Drug or Substance: recommended treatment includes a trial of CPAP, and if not successful, treatment with ASV 4.
Treatment Options
- Positive Airway Pressure (PAP) therapy is a standard treatment for central sleep apnea 3, 5.
- Adaptive Servo-Ventilation (ASV) is indicated for the treatment of CSAS related to CHF, but is contraindicated in patients with central sleep apnea who had heart failure with reduced ejection fraction 3, 5.
- Supplemental oxygen, phrenic nerve stimulation, and pharmacologic therapy are also treatment options for central sleep apnea 3, 5.