Central sleep apnea: Treatment
- M Safwan Badr, MD
M Safwan Badr, MD
- Section Editor — Sleep Related Breathing Disorders
- Professor and Chief, Pulmonary Critical Care and Sleep Medicine
- Wayne State University School of Medicine
Central sleep apnea (CSA) is a disorder characterized by repetitive cessation or decrease of both airflow and ventilatory effort during sleep. It can be primary (ie, idiopathic CSA) or secondary. Examples of secondary CSA include CSA associated with Cheyne-Stokes breathing, a medical condition, a drug or substance, or high altitude periodic breathing .
CSA associated with Cheyne-Stokes breathing is particularly common among patients who have heart failure or have had a stroke. It is characterized by central apneas that occur during the decrescendo portion of the cyclic crescendo-decrescendo respiratory pattern. (See "Classification of sleep disorders", section on 'Sleep-related breathing disorders' and "Sleep-disordered breathing in heart failure".)
CSA can alternatively be categorized as hyperventilation- or hypoventilation-related. Hyperventilation-related CSA encompasses most of the types of CSA mentioned above. Hypoventilation-related CSA occurs in disorders in which there is alveolar hypoventilation that is so severe that central apneas occur when the patient falls asleep because the wakefulness stimulus to breathe disappears. Central apneas tend to be a minor component of such disorders. Examples of contexts in which hypoventilation-related CSA may occur include neuromuscular disease, such as muscular dystrophy or myasthenia gravis, and severe abnormalities in pulmonary mechanics (eg, kyphoscoliosis). (See "Central sleep apnea: Pathogenesis", section on 'Central apnea due to hyperventilation' and "Central sleep apnea: Pathogenesis", section on 'Central apnea due to hypoventilation'.)
CSA associated with a drug or substance tends to have features of both hyperventilation and hypoventilation. The evaluation and management of sleep-disordered breathing in this context is reviewed separately. (See "Sleep-disordered breathing in patients chronically using opioids".)
In this topic review, we present an approach to treating CSA and then we describe the evidence supporting each intervention. The definition, risk factors, clinical presentation, diagnosis, and pathogenesis of CSA are discussed separately. (See "Central sleep apnea: Risk factors, clinical presentation, and diagnosis" and "Central sleep apnea: Pathogenesis".)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- American Academy of Sleep Medicine. International Classification of Sleep Disorders, 3rd ed, American Academy of Sleep Medicine, Darien, IL 2014.
- Aurora RN, Chowdhuri S, Ramar K, et al. The treatment of central sleep apnea syndromes in adults: practice parameters with an evidence-based literature review and meta-analyses. Sleep 2012; 35:17.
- Naughton MT, Benard DC, Rutherford R, Bradley TD. Effect of continuous positive airway pressure on central sleep apnea and nocturnal PCO2 in heart failure. Am J Respir Crit Care Med 1994; 150:1598.
- Bradley TD, Logan AG, Kimoff RJ, et al. Continuous positive airway pressure for central sleep apnea and heart failure. N Engl J Med 2005; 353:2025.
- Naughton MT, Liu PP, Bernard DC, et al. Treatment of congestive heart failure and Cheyne-Stokes respiration during sleep by continuous positive airway pressure. Am J Respir Crit Care Med 1995; 151:92.
- Naughton MT, Benard DC, Liu PP, et al. Effects of nasal CPAP on sympathetic activity in patients with heart failure and central sleep apnea. Am J Respir Crit Care Med 1995; 152:473.
- Granton JT, Naughton MT, Benard DC, et al. CPAP improves inspiratory muscle strength in patients with heart failure and central sleep apnea. Am J Respir Crit Care Med 1996; 153:277.
- Arzt M, Floras JS, Logan AG, et al. Suppression of central sleep apnea by continuous positive airway pressure and transplant-free survival in heart failure: a post hoc analysis of the Canadian Continuous Positive Airway Pressure for Patients with Central Sleep Apnea and Heart Failure Trial (CANPAP). Circulation 2007; 115:3173.
- Badr MS, Toiber F, Skatrud JB, Dempsey J. Pharyngeal narrowing/occlusion during central sleep apnea. J Appl Physiol (1985) 1995; 78:1806.
- Olson LG, Strohl KP. Airway secretions influence upper airway patency in the rabbit. Am Rev Respir Dis 1988; 137:1379.
- Harms CA, Zeng YJ, Smith CA, et al. Negative pressure-induced deformation of the upper airway causes central apnea in awake and sleeping dogs. J Appl Physiol (1985) 1996; 80:1528.
- Bordier P, Lataste A, Hofmann P, et al. Nocturnal oxygen therapy in patients with chronic heart failure and sleep apnea: a systematic review. Sleep Med 2016; 17:149.
- Javaheri S, Ahmed M, Parker TJ, Brown CR. Effects of nasal O2 on sleep-related disordered breathing in ambulatory patients with stable heart failure. Sleep 1999; 22:1101.
- Centers for Medicare and Medicaid Services. Home Oxygen Therapy. Department of Health and Human Services, 2015.
- Aurora RN, Bista SR, Casey KR, et al. Updated Adaptive Servo-Ventilation Recommendations for the 2012 AASM Guideline: "The Treatment of Central Sleep Apnea Syndromes in Adults: Practice Parameters with an Evidence-Based Literature Review and Meta-Analyses". J Clin Sleep Med 2016; 12:757.
- Cowie MR, Woehrle H, Wegscheider K, et al. Adaptive Servo-Ventilation for Central Sleep Apnea in Systolic Heart Failure. N Engl J Med 2015; 373:1095.
- Magalang UJ, Pack AI. Heart Failure and Sleep-Disordered Breathing--The Plot Thickens. N Engl J Med 2015; 373:1166.
- Naughton MT. Cheyne-Stokes respiration: friend or foe? Thorax 2012; 67:357.
- O'Connor CM, Whellan DJ, Fiuzat M, et al. Cardiovascular Outcomes With Minute Ventilation-Targeted Adaptive Servo-Ventilation Therapy in Heart Failure: The CAT-HF Trial. J Am Coll Cardiol 2017; 69:1577.
- Pepperell JC, Maskell NA, Jones DR, et al. A randomized controlled trial of adaptive ventilation for Cheyne-Stokes breathing in heart failure. Am J Respir Crit Care Med 2003; 168:1109.
- Oldenburg O, Schmidt A, Lamp B, et al. Adaptive servoventilation improves cardiac function in patients with chronic heart failure and Cheyne-Stokes respiration. Eur J Heart Fail 2008; 10:581.
- Szollosi I, O'Driscoll DM, Dayer MJ, et al. Adaptive servo-ventilation and deadspace: effects on central sleep apnoea. J Sleep Res 2006; 15:199.
- Fietze I, Blau A, Glos M, et al. Bi-level positive pressure ventilation and adaptive servo ventilation in patients with heart failure and Cheyne-Stokes respiration. Sleep Med 2008; 9:652.
- Morgenthaler TI, Gay PC, Gordon N, Brown LK. Adaptive servoventilation versus noninvasive positive pressure ventilation for central, mixed, and complex sleep apnea syndromes. Sleep 2007; 30:468.
- Arzt M, Wensel R, Montalvan S, et al. Effects of dynamic bilevel positive airway pressure support on central sleep apnea in men with heart failure. Chest 2008; 134:61.
- Zhang XL, Yin KS, Li XL, et al. Efficacy of adaptive servoventilation in patients with congestive heart failure and Cheyne-Stokes respiration. Chin Med J (Engl) 2006; 119:622.
- Kasai T, Usui Y, Yoshioka T, et al. Effect of flow-triggered adaptive servo-ventilation compared with continuous positive airway pressure in patients with chronic heart failure with coexisting obstructive sleep apnea and Cheyne-Stokes respiration. Circ Heart Fail 2010; 3:140.
- Philippe C, Stoïca-Herman M, Drouot X, et al. Compliance with and effectiveness of adaptive servoventilation versus continuous positive airway pressure in the treatment of Cheyne-Stokes respiration in heart failure over a six month period. Heart 2006; 92:337.
- Oldenburg O, Bitter T, Lehmann R, et al. Adaptive servoventilation improves cardiac function and respiratory stability. Clin Res Cardiol 2011; 100:107.
- Sharma BK, Bakker JP, McSharry DG, et al. Adaptive servoventilation for treatment of sleep-disordered breathing in heart failure: a systematic review and meta-analysis. Chest 2012; 142:1211.
- Bitter T, Gutleben KJ, Nölker G, et al. Treatment of Cheyne-Stokes respiration reduces arrhythmic events in chronic heart failure. J Cardiovasc Electrophysiol 2013; 24:1132.
- Randerath WJ, Nothofer G, Priegnitz C, et al. Long-term auto-servoventilation or constant positive pressure in heart failure and coexisting central with obstructive sleep apnea. Chest 2012; 142:440.
- Dohi T, Kasai T, Narui K, et al. Bi-level positive airway pressure ventilation for treating heart failure with central sleep apnea that is unresponsive to continuous positive airway pressure. Circ J 2008; 72:1100.
- Kasai T, Narui K, Dohi T, et al. Efficacy of nasal bi-level positive airway pressure in congestive heart failure patients with cheyne-stokes respiration and central sleep apnea. Circ J 2005; 69:913.
- Willson GN, Wilcox I, Piper AJ, et al. Noninvasive pressure preset ventilation for the treatment of Cheyne-Stokes respiration during sleep. Eur Respir J 2001; 17:1250.
- Johnson KG, Johnson DC. Bilevel positive airway pressure worsens central apneas during sleep. Chest 2005; 128:2141.
- Meza S, Mendez M, Ostrowski M, Younes M. Susceptibility to periodic breathing with assisted ventilation during sleep in normal subjects. J Appl Physiol (1985) 1998; 85:1929.
- DeBacker WA, Verbraecken J, Willemen M, et al. Central apnea index decreases after prolonged treatment with acetazolamide. Am J Respir Crit Care Med 1995; 151:87.
- Javaheri S. Acetazolamide improves central sleep apnea in heart failure: a double-blind, prospective study. Am J Respir Crit Care Med 2006; 173:234.
- White DP, Zwillich CW, Pickett CK, et al. Central sleep apnea. Improvement with acetazolamide therapy. Arch Intern Med 1982; 142:1816.
- Javaheri S, Parker TJ, Wexler L, et al. Effect of theophylline on sleep-disordered breathing in heart failure. N Engl J Med 1996; 335:562.
- Hu K, Li Q, Yang J, et al. The effect of theophylline on sleep-disordered breathing in patients with stable chronic congestive heart failure. Chin Med J (Engl) 2003; 116:1711.
- Arzt M. Neurostimulation in patients with heart failure and central sleep apnoea. Lancet 2016; 388:938.
- Costanzo MR, Ponikowski P, Javaheri S, et al. Transvenous neurostimulation for central sleep apnoea: a randomised controlled trial. Lancet 2016; 388:974.
- Jagielski D, Ponikowski P, Augostini R, et al. Transvenous stimulation of the phrenic nerve for the treatment of central sleep apnoea: 12 months' experience with the remedē(®) System. Eur J Heart Fail 2016; 18:1386.
- Fox H, Bitter T, Horstkotte D, et al. Long-Term Experience with First-Generation Implantable Neurostimulation Device in Central Sleep Apnea Treatment. Pacing Clin Electrophysiol 2017; 40:498.
- GOALS OF THERAPY
- ADDRESSING THE UNDERLYING CAUSE
- PATIENTS WITH HYPERVENTILATION-RELATED CSA
- Continuous positive airway pressure
- - Efficacy
- - Mechanism of effect
- - Titration
- - Supplemental oxygen during sleep
- CPAP failure or intolerance
- - Patients with ejection fraction ≤45 percent
- - Patients with ejection fraction >45 percent
- Adaptive servo-ventilation (ASV)
- Bilevel positive airway pressure (BPAP)
- - Pharmacologic therapy
- - Phrenic nerve stimulation
- PATIENTS WITH HYPOVENTILATION-RELATED CSA
- SUMMARY AND RECOMMENDATIONS