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".)
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- GOALS OF THERAPY
- ADDRESSING THE UNDERLYING CAUSE
- POSITIVE AIRWAY PRESSURE THERAPY
- Patients with hyperventilation-related CSA
- - Continuous positive airway pressure
- Mechanism of effect
- - 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
- Patients with hypoventilation-related CSA
- SUMMARY AND RECOMMENDATIONS