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Central Sleep Apnea

By Kingman P. Strohl, MD, Professor of Medicine;Program Director, Case Fellowship in Sleep Medicine, Case School of Medicine, Case Western Reserve University;UH Cleveland Medical Center

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Central sleep apnea (CSA) is a heterogeneous group of conditions characterized by changes in ventilatory drive without airway obstruction. Most of these conditions cause asymptomatic changes in breathing pattern during sleep. The diagnosis is based on clinical findings and, when necessary, confirmed by polysomnography. Treatment is supportive.

Etiology

Patients with central sleep apnea fall into 2 groups based on their carbon dioxide level and ventilatory drive.

  • Hypercapnia with decreased ventilatory drive

  • Eucapnia or hypocapnia with increased ventilatory drive but with episodes of apnea, periodic breathing, or both

Causes of hypercapnia with decreased ventilatory drive include hypothyroidism and central lesions (eg, brain stem infarctions, encephalitis, Chiari II type malformation).

Cheyne-Stokes breathing, a discrete pattern of the second form of central sleep apnea, is thought to be caused by intrinsic properties of the respiratory control center in the response to hypoxia and acidosis with hyperpnea, causing reoxygenation and alkalosis, leading to hypoventilation by hypopnea and apnea.

High altitude is another cause of recurrent CSA manifesting with hypocapnia.

Chronic use of opioids (eg, patients on methadone maintenance, cancer patients with chronic pain) triggers CSA with an erratic rate and depth of breathing and episodes of apnea; CSA can be hypercapneic or hypocapneic.

Congenital central hypoventilation(a form of Ondine curse) is a rare form of idiopathic CSA in neonates and may be associated with Hirschsprung disease. A mutation in the PHOX2 gene is responsible for 80 to 90% of cases. This mutation produces variable phenotypes, and clinically evident cases are inherited in a dominant pattern.

Symptoms and Signs

Central sleep apnea is usually asymptomatic and is detected by caretakers or bed partners who notice long respiratory pauses, shallow breaths, or restless sleep. Patients with hypercapnic forms may experience daytime somnolence, lethargy, and morning headache.

Diagnosis

  • Clinical evaluation

  • Often polysomnography

Diagnosis of central sleep apnea is suspected on the basis of history and is confirmed by polysomnography. However, testing may not be necessary if CSA causes no symptoms or is clearly related to an identifiable disorder. To diagnose causes of CSA, brain or brain stem imaging may be indicated.

Treatment

  • Supportive care

Primary treatment of central sleep apnea is optimal management of underlying conditions and avoidance of opioids and other sedatives. Secondary treatment of symptomatic patients can be a trial of supplemental oxygen or, in patients with hypercapnic CSA who have symptoms despite other treatments, noninvasive continuous or bilevel positive airway pressure.

For patients who have CSA and Cheyne-Stokes breathing, continuous positive airway pressure may decrease apneic and hypopneic episodes, but effects on clinical outcomes are not clear. Acetazolamide is effective in CSA caused by high altitude.

Electrode pacing of the phrenic nerve and/or diaphragm is an option, such as for children > 2 yr with congenital central hypoventilation syndrome.

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