Management of Mild Central Sleep Apnea: CPAP vs BiPAP
For a patient with mild central sleep apnea (~8 central apneas per hour), start with CPAP as first-line therapy. 1
Initial Treatment Approach
CPAP is the recommended initial positive airway pressure modality for central sleep apnea, including primary CSA, treatment-emergent CSA, and CSA due to medical conditions, based on the 2025 American Academy of Sleep Medicine clinical practice guideline 1
The AASM provides a conditional recommendation for CPAP use in CSA with low certainty of evidence, but this represents the most current and authoritative guidance available 1
CPAP has demonstrated efficacy in reducing central apneas even in patients where obstruction is not the primary mechanism, with documented cases showing reduction of central apneas from 281 to 32 per night at low CPAP levels (7.5 cm H₂O) 2
When to Consider BiPAP
BiPAP with a backup rate should be considered if CPAP fails or is not tolerated 1
The AASM suggests using BiPAP with a backup rate (not without) for CSA, including primary CSA, medication-induced CSA, treatment-emergent CSA, and CSA due to medical conditions 1
BiPAP without a backup rate is specifically recommended against for central sleep apnea, as it lacks the respiratory rate support needed to prevent central events 1
BiPAP titration guidelines recommend starting with IPAP of 8 cm H₂O and EPAP of 4 cm H₂O, with adjustments based on persistent respiratory events 3
Critical Clinical Considerations
Optimize underlying conditions first: The optimal approach to CSA treatment must incorporate clinical features and comorbid conditions rather than solely focusing on eliminating respiratory events 1
Monitor for treatment-emergent issues: If central apneas persist or worsen on CPAP, this may represent treatment-emergent central sleep apnea (TECSA), which can sometimes be managed by reducing inspiratory pressure rather than increasing it 4
Reassess if therapy fails: Persistence of central respiratory events after initiating therapy should prompt re-evaluation of underlying risk factors and consideration of alternative treatments, including BiPAP with backup rate, adaptive servo-ventilation, or acetazolamide 1
Common Pitfalls to Avoid
Do not start with BiPAP without a backup rate, as this lacks efficacy for central apneas and is specifically recommended against 1
Do not assume higher pressure is always better: In treatment-emergent central apnea, reducing inspiratory pressure can actually resolve central events (central apnea index reduced from 17.3 to 1.5 events/hour with pressure reduction) 4
Do not focus solely on eliminating apneas: Prioritize patient-reported outcomes and symptom improvement over polysomnographic metrics alone 1
Alternative and Adjunctive Therapies
If CPAP and BiPAP with backup rate are insufficient:
Adaptive servo-ventilation (ASV) is suggested for CSA, though requires shared decision-making and careful patient selection, particularly avoiding use in heart failure with reduced ejection fraction without close monitoring 1
Acetazolamide is suggested as a pharmacologic option for primary CSA and other CSA etiologies, with conditional recommendation and low certainty of evidence 1
Supplemental oxygen may be considered specifically for CSA due to heart failure or high altitude 1