Mode selection for positive airway pressure titration in adult patients with central sleep apnea syndromes
- Tomasz J Kuzniar, MD, PhD, FCCP, FAASM
Tomasz J Kuzniar, MD, PhD, FCCP, FAASM
- Assistant Professor of Medicine
- NorthShore University HealthSystem, University of Chicago
- Neil Freedman, MD
Neil Freedman, MD
- Head, Division of Pulmonary, Critical Care, Allergy and Immunology
- North Shore University Health System
Positive airway pressure (PAP) is used to treat sleep-disordered breathing in patients with central sleep apnea (CSA) and hypoventilation syndromes. Determining the optimal pressure settings is of paramount importance to eliminate apneas and to help assure patient adherence to therapy.
Selecting a titration method to determine the optimal pressure in patients with CSA is discussed in this topic. An overview of the treatment of CSA, selection of a titration method for patients with obstructive sleep apnea, and PAP therapy for hypoventilation syndromes are discussed separately. (See "Central sleep apnea: Treatment" and "Types of noninvasive nocturnal ventilatory support in neuromuscular and chest wall disease" and "Continuous noninvasive ventilatory support for patients with respiratory muscle dysfunction" and "Noninvasive positive airway pressure therapy of the obesity hypoventilation syndrome".)
DIAGNOSIS AND CAUSES OF CENTRAL SLEEP APNEA (CSA)
Central sleep apnea (CSA) syndromes are characterized by the absence of both airflow and ventilatory effort during sleep. CSA is usually best diagnosed during an attended in-laboratory polysomnographic (PSG)-based sleep test but can occasionally be diagnosed on a home sleep apnea test (HSAT). (See "Central sleep apnea: Risk factors, clinical presentation, and diagnosis", section on 'Diagnostic evaluation'.)
CSA can be primary (ie, idiopathic CSA) or secondary to other conditions (Cheyne-Stokes breathing, medical conditions such as stroke or heart failure, suppressant drug or substance use, high altitude periodic breathing, or treatment-emergent central sleep apnea). Alternatively, CSA can be classified as hyperventilation-related (eg, Cheyne-Stokes breathing, primary CSA) or hypoventilation-related (eg, central nervous system diseases, drugs or substances) (table 1). There is also a subset of conditions primarily associated with alveolar hypoventilation (neuromuscular diseases, severe thoracic cage disorders such as kyphoscoliosis) in which central sleep apneas or hypopneas may be present. In many of these conditions, central apnea is not the only or even dominant type of sleep-disordered breathing that is present. It is therefore prudent that the clinician be aware of the proportional spectrum of sleep-disordered breathing type in a given patient such that an appropriate modality targeted at the major type of sleep-disordered breathing is chosen. (See "Polysomnography in the evaluation of sleep-disordered breathing in adults".)
Hypoventilation syndromes without apneic events may be central (eg, spinal cord injury) or peripheral (eg, myasthenia gravis), and when severe enough may be treated with noninvasive positive airway pressure (PAP), the details of which are discussed separately. (See 'Patients with central hypoventilation syndromes' below and "Respiratory muscle weakness due to neuromuscular disease: Clinical manifestations and evaluation".)
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- DIAGNOSIS AND CAUSES OF CENTRAL SLEEP APNEA (CSA)
- PRINCIPLES AND GOALS OF POSITIVE AIRWAY PRESSURE (PAP)
- General principles
- Goals of PAP titration in CSA
- Caveats of PAP titration in CSA
- PATIENTS WITH CSA AND HEART FAILURE
- Continuous positive airway pressure (CPAP)
- - Attended in-laboratory PAP titration
- - Unattended in-home "acclimation" CPAP trial
- - Other titration methods
- Multimodality titration
- PATIENTS WITH CSA AND HEART FAILURE WHO FAIL CPAP
- Patients with ejection fraction >45 percent
- - Adaptive servo-ventilation (ASV)
- Titration modules
- - Bilevel positive airway pressure (BPAP)
- Patients with ejection fraction ≤45 percent
- PATIENTS WITH CSA AND OPIOID USE
- Attended in-laboratory CPAP titration
- Attended in-laboratory ASV titration
- Attended in-laboratory BPAP titration
- PATIENTS WITH TREATMENT-EMERGENT CSA
- PATIENTS WITH RARE ETIOLOGIES OF CSA
- PATIENTS WITH CENTRAL HYPOVENTILATION SYNDROMES
- SUMMARY AND RECOMMENDATIONS