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central sleep apnea

Classification: 1) primary central sleep apnea 2) Cheyne-Stokes respirations 3) sleep-onset central apneas 4) central apnea emerging during CPAP titration 5) central apneas related to medical disorders or medication use Etiology: 1) defects in metabolic control or respiratory muscles a) primary & secondary central alveolar hypoventilation syndrome b) respiratory muscle weakness 2) transient instabilities in central respiratory drive a) sleep onset b) hyperventilation-induced hypocapnia 1] hypoxia a] high altitude b] pulmonary disease 2] cardiovascular disease, pulmonary congestion, heart failure, atrial fibrillation (Cheyne-Stokes respirations) [2,4] 3] CNS disease a] stroke b] brainstem lesions c) prolonged circulation time 3) inhibition of central respiratory drive by upper airway reflexes a) gastroesophageal reflux b) aspiration c) upper airway collapse 4) other a) renal failure b) opioid agonist (opiate) use [2] Pathology: - absence of respiratory effort associated with loss of airflow for at least 10 seconds [2] - loss of output from central respiratory centers in the brainstem [2] Laboratory: - arterial blood gas: pCO2 Management: 1) treat comorbidities [2] - treatment of heart failure (Cheyne-Stokes respirations) [2,4] - eliminate opiates [2] 2) treat sleep-related symptoms a) adaptive servoventilation increases mortality in patients with CHF [3] b) supplemental oxygen may be of benefit, esp if due to CHF [3] c) CPAP of benefit [3,8] 2) acetazolamide may be of benefit [3] 3) zolpidem & triazolam may be of benefit if no risk factors for respiratory depression [3] 4) respiratory stimulants such as medroxyprogesterone not recommended in [3] 5) implantable transvenous phrenic nerve stimulator FDA-approved 2017 [6,9] 6) also see sleep apnea

Specific

central hypoventilation syndrome; primary alveolar hypoventilation; Ondine's curse

General

sleep apnea

References

  1. Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 1238
  2. Medical Knowledge Self Assessment Program (MKSAP) 15, 16. 17, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018, 2022.
  3. 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(1):17-40 PMID: 22215916 - Selim BJ, Ramar K. Management of Sleep Apnea Syndromes in Heart Failure. Sleep Med Clin. 2017 Mar;12(1):107-121. Review. PMID: 28159090 - Cowie MR, Woehrle H, Wegscheider K et al Adaptive Servo-Ventilation for Central Sleep Apnea in Systolic Heart Failure. N Engl J Med. 2015 Sep 17;373(12):1095-105. Epub 2015 Sep 1. PMID: 26323938 Free PMC Article
  4. Yumino D, Bradley TD. Central sleep apnea and Cheyne-Stokes respiration. Proc Am Thorac Soc. 2008 Feb 15;5(2):226-36 PMID: 18250216
  5. Lowes R Implant to Treat Central Sleep Apnea Approved by FDA, Medscape - Oct 06, 2017. http://www.medscape.com/viewarticle/886744 - FDA News Release. Oct 6, 2017 FDA approves implantable device to treat moderate to severe central sleep apnea. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm579506.htm
  6. Hernandez AB, Patil SP. Pathophysiology of central sleep apneas. Sleep Breath. 2016 May;20(2):467-82. Review. PMID: 26782104
  7. Randerath W, Verbraecken J, Andreas S et al Definition, discrimination, diagnosis and treatment of central breathing disturbances during sleep. Eur Respir J. 2017 Jan 18;49(1). pii: 1600959. PMID: 27920092 Free Article
  8. Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019
  9. Lou N Phrenic Nerve Stimulation Holds Up for Central Sleep Apnea - Apnea indices, daytime sleepiness improved over 5 years. MedPage Today October 5, 2020 https://www.medpagetoday.com/meetingcoverage/hfsa/88963 - Costanzo MR, et al Transvenous phrenic nerve stimulation in patients with central sleep apnea: 5-year safety and efficacy results Heart Failure Society of America (HFSA) 2020.