Central sleep apnea: Risk factors, clinical presentation, and diagnosis
- 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. The condition can be primary (ie, idiopathic CSA) or secondary. Secondary CSA can arise, for example, in association 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, especially 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; a notable exception is CSA associated with a drug or substance. 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 central nervous system diseases, central nervous system suppressing drugs or substances, neuromuscular diseases, 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'.)
The clinical presentation and diagnosis of hyperventilation-related CSA are reviewed here. Hypoventilation-related CSA is not discussed here because central apneas tend to be a minor component of the underlying condition and, therefore, the presentation and diagnosis are dictated by the underlying condition. The pathogenesis and treatment of CSA are discussed separately. (See "Central sleep apnea: Pathogenesis" and "Central sleep apnea: Treatment".)
CSA is common, although less prevalent in the general population than obstructive sleep apnea (OSA). In a population-based study that included 5804 community-dwelling adults aged 40 years and older, the overall prevalence of CSA on polysomnography was 0.9 percent . Approximately half of the CSA cases were associated with Cheyne-Stokes breathing (0.4 percent overall). The median age of patients with CSA was 69 years. CSA was more common among patients with heart failure (4.8 percent) and in men compared with women (1.8 versus 0.2 percent).
The prevalence of symptomatic CSA (ie, CSA syndrome) appears to be higher among individuals who are elderly, male, or have certain comorbid conditions.
- American Academy of Sleep Medicine. International Classification of Sleep Disorders, 3rd ed, American Academy of Sleep Medicine, Darien, IL 2014.
- Donovan LM, Kapur VK. Prevalence and Characteristics of Central Compared to Obstructive Sleep Apnea: Analyses from the Sleep Heart Health Study Cohort. Sleep 2016; 39:1353.
- Bixler EO, Vgontzas AN, Ten Have T, et al. Effects of age on sleep apnea in men: I. Prevalence and severity. Am J Respir Crit Care Med 1998; 157:144.
- Bradley TD, Floras JS. Sleep apnea and heart failure: Part II: central sleep apnea. Circulation 2003; 107:1822.
- Leung RS, Huber MA, Rogge T, et al. Association between atrial fibrillation and central sleep apnea. Sleep 2005; 28:1543.
- Bassetti C, Aldrich MS. Sleep apnea in acute cerebrovascular diseases: final report on 128 patients. Sleep 1999; 22:217.
- Johnson KG, Johnson DC. Frequency of sleep apnea in stroke and TIA patients: a meta-analysis. J Clin Sleep Med 2010; 6:131.
- Pack AI, Silage DA, Millman RP, et al. Spectral analysis of ventilation in elderly subjects awake and asleep. J Appl Physiol (1985) 1988; 64:1257.
- Bixler EO, Vgontzas AN, Lin HM, et al. Prevalence of sleep-disordered breathing in women: effects of gender. Am J Respir Crit Care Med 2001; 163:608.
- Skatrud JB, Dempsey JA. Interaction of sleep state and chemical stimuli in sustaining rhythmic ventilation. J Appl Physiol Respir Environ Exerc Physiol 1983; 55:813.
- Zhou XS, Rowley JA, Demirovic F, et al. Effect of testosterone on the apneic threshold in women during NREM sleep. J Appl Physiol (1985) 2003; 94:101.
- Mateika JH, Omran Q, Rowley JA, et al. Treatment with leuprolide acetate decreases the threshold of the ventilatory response to carbon dioxide in healthy males. J Physiol 2004; 561:637.
- Javaheri S, Parker TJ, Liming JD, et al. Sleep apnea in 81 ambulatory male patients with stable heart failure. Types and their prevalences, consequences, and presentations. Circulation 1998; 97:2154.
- Javaheri S, Parker TJ, Wexler L, et al. Occult sleep-disordered breathing in stable congestive heart failure. Ann Intern Med 1995; 122:487.
- Javaheri S. Central sleep apnea-hypopnea syndrome in heart failure: prevalence, impact, and treatment. Sleep 1996; 19:S229.
- Sin DD, Fitzgerald F, Parker JD, et al. Risk factors for central and obstructive sleep apnea in 450 men and women with congestive heart failure. Am J Respir Crit Care Med 1999; 160:1101.
- Bassetti C, Aldrich MS, Chervin RD, Quint D. Sleep apnea in patients with transient ischemic attack and stroke: a prospective study of 59 patients. Neurology 1996; 47:1167.
- Grunstein RR, Ho KY, Berthon-Jones M, et al. Central sleep apnea is associated with increased ventilatory response to carbon dioxide and hypersecretion of growth hormone in patients with acromegaly. Am J Respir Crit Care Med 1994; 150:496.
- Grunstein RR, Ho KY, Sullivan CE. Sleep apnea in acromegaly. Ann Intern Med 1991; 115:527.
- Hanly PJ, Pierratos A. Improvement of sleep apnea in patients with chronic renal failure who undergo nocturnal hemodialysis. N Engl J Med 2001; 344:102.
- Mehra R, Stone KL, Varosy PD, et al. Nocturnal Arrhythmias across a spectrum of obstructive and central sleep-disordered breathing in older men: outcomes of sleep disorders in older men (MrOS sleep) study. Arch Intern Med 2009; 169:1147.
- Sankari A, Bascom A, Oomman S, Badr MS. Sleep disordered breathing in chronic spinal cord injury. J Clin Sleep Med 2014; 10:65.
- Ramezani RJ, Stacpoole PW. Sleep disorders associated with primary mitochondrial diseases. J Clin Sleep Med 2014; 10:1233.
- Berry RB, Budhiraja R, Gottlieb DJ, et al. Rules for scoring respiratory events in sleep: update of the 2007 AASM Manual for the Scoring of Sleep and Associated Events. Deliberations of the Sleep Apnea Definitions Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med 2012; 8:597.
- Black JE, Brooks SN, Nishino S. Conditions of primary excessive daytime sleepiness. Neurol Clin 2005; 23:1025.