Central sleep apnea - Symptoms, Causes, Images, and Treatment Options

Diseases

Highlights & Basics

Key Highlights

Central sleep apnea (CSA) is characterized by repetitive apneas or hypopneas with absent or diminished respiratory effort during sleep, occurring 5 or more times per hour.
Important to search for underlying disorders such as congestive heart failure (CHF), renal failure, stroke, brainstem lesions, acromegaly, hypothyroidism, or opioid use.
Presence portends a poorer prognosis for CHF patients.
Management of the underlying disorder may suffice to resolve the condition.
Presenting symptoms may be the same as with other sleep-related breathing disorders. The disorder may be asymptomatic, observed by a partner, or detected on testing.

Quick Reference

History & Exam
- Key Factors
- Other Factors
More information...
Diagnostics Tests
More information...
Treatment Options
More information...

Definition

Epidemiology

Etiology

Pathophysiology

Images

Cheyne-Stokes breathing: polysomnography demonstrating the characteristic waxing and waning of ventilation separated by central apneas (seen best in the nasal pressure transducer signal [Nasal P] and the abdominal [Abd], chest [Chest], and Sum respiratory impedance traces), resulting in almost sinusoidal desaturations in oxyhemoglobin saturation. Cycle duration between events is 75 seconds; ECG demonstrates atrial fibrillation, both characteristic of a patient with advanced heart failure

Citations

Key Articles

American Academy of Sleep Medicine. The AASM international classification of sleep disorders - third edition, text revision (ICSD-3-TR). Jun 2023 [internet publication].[Full Text]
Randerath W, Verbraecken J, Andreas S, et al. Definition, discrimination, diagnosis and treatment of central breathing disturbances during sleep. Eur Respir J. 2017 Jan;49(1):1600959.[Abstract][Full Text]
Mayer G, Arzt M, Braumann B, et al. German S3 guideline nonrestorative sleep/sleep disorders, chapter "sleep-related breathing disorders in adults," short version: German Sleep Society (Deutsche Gesellschaft für Schlafforschung und Schlafmedizin, DGSM). Somnologie (Berl). 2017;21(4):290-301.[Abstract][Full Text]
Aurora RN, Bista SR, Casey KR, et al. Updated adaptive servo-ventilation recommendations for the 2012 AASM guideline: the treatment of central sleep apnea syndromes in adults: practice parameters with an evidence-based literature review and meta-analyses. J Clin Sleep Med. 2016 May 15;12(5):757-61. [Abstract][Full Text]
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 Jan 1;35(1):17-40.[Abstract][Full Text]

Referenced Articles

1. American Academy of Sleep Medicine. The AASM international classification of sleep disorders - third edition, text revision (ICSD-3-TR). Jun 2023 [internet publication].[Full Text]
2. Eckert DJ, Jordan AS, Merchia P, et al. Central sleep apnea: pathophysiology and treatment. Chest. 2007 Feb;131(2):595-607.[Abstract][Full Text]
3. Latshang TD, Bloch KE, Lynm C, et al. JAMA patient page: Traveling to high altitude when you have sleep apnea. JAMA. 2012 Dec 12;308(22):2418.[Abstract][Full Text]
4. Brack T. Cheyne-Stokes respiration in patients with heart failure: ominous sign or innocent bystander? Swiss Med Wkly. 2007 Mar 10;137(9-10):133-8.[Abstract]
5. Brack T, Thuer I, Clarenbach CF, et al. Daytime Cheyne-Stokes respiration in ambulatory patients with severe congestive heart failure is associated with increased mortality. Chest. 2007 Nov;132(5):1463-71.[Abstract]
6. Lanfranchi PA, Braghiroli A, Bosimini E, et al. Prognostic value of nocturnal Cheyne-Stokes respiration in chronic heart failure. Circulation. 1999 Mar 23;99(11):1435-40.[Abstract][Full Text]
7. Yeghiazarians Y, Jneid H, Tietjens JR, et al. Obstructive sleep apnea and cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2021 Jul 20;144(3):e56-e67.[Abstract][Full Text]
8. Oldenburg O, Lamp B, Faber L, et al. Sleep-disordered breathing in patients with symptomatic heart failure: a contemporary study of prevalence in and characteristics of 700 patients. Eur J Heart Fail. 2007 Mar;9(3):251-7.[Abstract]
9. 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 Oct;160(4):1101-6.[Abstract][Full Text]
10. Javaheri S. Sleep disorders in systolic heart failure: a prospective study of 100 male patients. The final report. Int J Cardiol. 2006 Jan 4;106(1):21-8.[Abstract]
11. Schütz SG, Lisabeth LD, Hsu CW, et al. Central sleep apnea is uncommon after stroke. Sleep Med. 2021 Jan;77:304-6.[Abstract][Full Text]
12. Seiler A, Camilo M, Korostovtseva L, et al. Prevalence of sleep-disordered breathing after stroke and TIA: a meta-analysis. Neurology. 2019 Feb 12;92(7):e648-54.[Abstract]
13. Nopmaneejumruslers C, Kaneko Y, Hajek V, et al. Cheyne-Stokes respiration in stroke: relationship to hypocapnia and occult cardiac dysfunction. Am J Respir Crit Care Med. 2005 May 1;171(9):1048-52.[Abstract][Full Text]
14. Wang D, Teichtahl H, Drummer OH, et al. Central sleep apnea in stable methadone maintenance treatment patients. Chest. 2005 Sep;128(3):1348-56.[Abstract]
15. Kouri I, Kolla BP, Morgenthaler TI, et al. Frequency and outcomes of primary central sleep apnea in a population-based study. Sleep Med. 2020 Apr;68:177-83.[Abstract][Full Text]
16. Torlasco C, Bilo G, Giuliano A, et al. Effects of acute exposure to moderate altitude on blood pressure and sleep breathing patterns. Int J Cardiol. 2020 Feb 15;301:173-9.[Abstract]
17. Lombardi C, Meriggi P, Agostoni P, et al; HIGHCARE Investigators. High-altitude hypoxia and periodic breathing during sleep: gender-related differences. J Sleep Res. 2013 Jun;22(3):322-30.[Abstract][Full Text]
18. Randerath W, Verbraecken J, Andreas S, et al. Definition, discrimination, diagnosis and treatment of central breathing disturbances during sleep. Eur Respir J. 2017 Jan;49(1):1600959.[Abstract][Full Text]
19. Dempsey JA. Crossing the apnoeic threshold: causes and consequences. Exp Physiol. 2005 Jan;90(1):13-24.[Abstract][Full Text]
20. Javaheri S. Central sleep apnea in congestive heart failure: prevalence, mechanisms, impact, and therapeutic options. Semin Respir Crit Care Med. 2005 Feb;26(1):44-55.[Abstract]
21. Tamura A, Kawano Y, Naono S, et al. Relationship between beta-blocker treatment and the severity of central sleep apnea in chronic heart failure. Chest. 2007 Jan;131(1):130-5.[Abstract]
22. Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA Guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines. Circulation. 2022 May 3;145(18):e895-e1032.[Abstract][Full Text]
23. Hermann DM, Siccoli M, Kirov P, et al. Central periodic breathing during sleep in acute ischemic stroke. Stroke. 2007 Mar;38(3):1082-4.[Abstract][Full Text]
24. Huang HC, Walters G, Talaulikar G, et al. Sleep apnea prevalence in chronic kidney disease - association with total body water and symptoms. BMC Nephrol. 2017 Apr 4;18(1):125.[Abstract][Full Text]
25. Pisano A, Zoccali C, Bolignano D, et al. Sleep apnoea syndrome prevalence in chronic kidney disease and end-stage kidney disease patients: a systematic review and meta-analysis. Clin Kidney J. 2024 Jan;17(1):sfad179.[Abstract][Full Text]
26. Nigam G, Pathak C, Riaz M. A systematic review of central sleep apnea in adult patients with chronic kidney disease. Sleep Breath. 2016 Sep;20(3):957-64.[Abstract]
27. 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 Mar;163(3 Pt 1):608-13.[Abstract][Full Text]
28. Mehra R, Chung MK, Olshansky B, et al. Sleep-disordered breathing and cardiac arrhythmias in adults: mechanistic insights and clinical implications: a scientific statement from the American Heart Association. Circulation. 2022 Aug 30;146(9):e119-36.[Abstract][Full Text]
29. Tung P, Levitzky YS, Wang R, et al. Obstructive and central sleep apnea and the risk of incident atrial fibrillation in a community cohort of men and women. J Am Heart Assoc. 2017 Jul 1;6(7):1161.[Abstract][Full Text]
30. May AM, Blackwell T, Stone PH, et al. Central sleep-disordered breathing predicts incident atrial fibrillation in older men. Am J Respir Crit Care Med. 2016 Apr 1;193(7):783-91.[Abstract][Full Text]
31. Hoch CC, Reynolds CF 3rd, Monk TH, et al. Comparison of sleep-disordered breathing among healthy elderly in the seventh, eighth, and ninth decades of life. Sleep. 1990 Dec;13(6):502-11.[Abstract]
32. Grunstein RR, Ho KY, Sullivan CE. Sleep apnea in acromegaly. Ann Intern Med. 1991 Oct 1;115(7):527-32.[Abstract]
33. Lombardi C, Faini A, Meriggi P, et al. Acetazolamide effect on high altitude periodic breathing during sleep. The Highcare Alps project. European Heart Journal. 2013 Aug 1;34(1):1590.[Full Text]
34. Correa D, Farney RJ, Chung F, et al. Chronic opioid use and central sleep apnea: a review of the prevalence, mechanisms, and perioperative considerations. Anesth Analg. 2015 Jun;120(6):1273-85.[Abstract][Full Text]
35. Sériès F, Kimoff RJ, Morrison D, et al. Prospective evaluation of nocturnal oximetry for detection of sleep-related breathing disturbances in patients with chronic heart failure. Chest. 2005 May;127(5):1507-14.[Abstract]
36. Mayer G, Arzt M, Braumann B, et al. German S3 guideline nonrestorative sleep/sleep disorders, chapter "sleep-related breathing disorders in adults," short version: German Sleep Society (Deutsche Gesellschaft für Schlafforschung und Schlafmedizin, DGSM). Somnologie (Berl). 2017;21(4):290-301.[Abstract][Full Text]
37. Morgenthaler TI, Kagramanov V, Hanak V, et al. Complex sleep apnea syndrome: is it a unique clinical syndrome? Sleep. 2006 Sep;29(9):1203-9.[Abstract]
38. American Academy of Sleep Medicine. The AASM manual for the scoring of sleep and associated events. Feb 2023 [internet publication].[Full Text]
39. Aurora RN, Bista SR, Casey KR, et al. Updated adaptive servo-ventilation recommendations for the 2012 AASM guideline: the treatment of central sleep apnea syndromes in adults: practice parameters with an evidence-based literature review and meta-analyses. J Clin Sleep Med. 2016 May 15;12(5):757-61. [Abstract][Full Text]
40. National Institute for Health and Care Excellence. Obstructive sleep apnoea/hypopnoea syndrome and obesity hypoventilation syndrome in over 16s. Aug 2021 [internet publication].[Full Text]
41. Hanly PJ, Zuberi-Khokhar NS. Increased mortality associated with Cheyne-Stokes respiration in patients with congestive heart failure. Am J Respir Crit Care Med. 1996 Jan;153(1):272-6.[Abstract]
42. Bradley TD, Logan AG, Kimoff RJ, et al. Continuous positive airway pressure for central sleep apnea and heart failure. N Engl J Med. 2005 Nov 10;353(19):2025-33.[Abstract][Full Text]
43. Arzt M, Floras JS, Logan AG, et al. Suppression of central sleep apnea by continuous positive airway pressure and transplant-free survival in heart failure. Circulation. 2007 Jun 26;115(25):3173-80.[Abstract][Full Text]
44. Fleetham J, Ayas N, Bradley D, et al; Canadian Thoracic Society Sleep Disordered Breathing Committee. Canadian Thoracic Society 2011 guideline update: diagnosis and treatment of sleep disordered breathing. Can Respir J. 2011 Jan-Feb;18(1):25-47.[Abstract][Full Text]
45. 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 Jan 1;35(1):17-40.[Abstract][Full Text]
46. 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.[Abstract]
47. Hoffstein V, Slutsky AS. Central sleep apnea reversed by continuous positive airway pressure. Am Rev Respir Dis. 1987 May;135(5):1210-2.[Abstract]
48. Issa FG, Sullivan CE. Reversal of central sleep apnea using nasal CPAP. Chest. 1986 Aug;90(2):165-71.[Abstract][Full Text]
49. Banno K, Okamura K, Kryger MH. Adaptive servo-ventilation in patients with idiopathic Cheyne-Stokes breathing. J Clin Sleep Med. 2006 Apr 15;2(2):181-6.[Abstract]
50. DeBacker WA, Verbraecken J, Willemen M, et al. Central apnea index decreases after prolonged treatment with acetazolamide. Am J Respir Crit Care Med. 1995 Jan;151(1):87-91.[Abstract]
51. White DP, Zwillich CW, Pickett CK, et al. Central sleep apnea. Improvement with acetazolamide therapy. Arch Intern Med. 1982 Oct;142(10):1816-9.[Abstract]
52. Quadri S, Drake C, Hudgel DW. Improvement of idiopathic central sleep apnea with zolpidem. J Clin Sleep Med. 2009 Apr 15;5(2):122-9.[Abstract][Full Text]
53. Bonnet MH, Dexter JR, Arand DL. The effect of triazolam on arousal and respiration in central sleep apnea patients. Sleep. 1990 Feb;13(1):31-41.[Abstract]
54. Somers VK, White DP, Amin R, et al. AHA/ACCF scientific statement: Sleep apnea and cardiovascular disease. Circulation. 2008 Sep 2;118(10):1080-111.[Abstract][Full Text]
55. Eulenburg C, Wegscheider K, Woehrle H, et al. Mechanisms underlying increased mortality risk in patients with heart failure and reduced ejection fraction randomly assigned to adaptive servoventilation in the SERVE-HF study: results of a secondary multistate modelling analysis. Lancet Respir Med. 2016 Nov;4(11):873-81.[Abstract]
56. O'Connor CM, Whellan DJ, Fiuzat M, et al. Cardiovascular outcomes with minute ventilation-targeted adaptive servo-ventilation therapy in heart failure: The CAT-HF Trial. J Am Coll Cardiol. 2017 Mar 28;69(12):1577-87.[Abstract][Full Text]
57. Yamamoto S, Yamaga T, Nishie K, et al. Positive airway pressure therapy for the treatment of central sleep apnoea associated with heart failure. Cochrane Database Syst Rev. 2019 Dec 4;(12):CD012803.[Abstract][Full Text]
58. Teschler H, Döhring J, Wang YM, et al. Adaptive pressure support servo-ventilation: a novel treatment for Cheyne-Stokes respiration in heart failure. Am J Respir Crit Care Med. 2001 Aug 15;164(4):614-9.[Abstract][Full Text]
59. Lamba J, Simpson CS, Redfearn DP, et al. Cardiac resynchronization therapy for the treatment of sleep apnoea: a meta-analysis. Europace. 2011 Aug;13(8):1174-9.[Abstract][Full Text]
60. Javaheri S. Acetazolamide improves central sleep apnea in heart failure: a double-blind, prospective study. Am J Respir Crit Care Med. 2006 Jan 15;173(2):234-7.[Abstract][Full Text]
61. Javaheri S, Parker TJ, Wexler L, et al. Effect of theophylline on sleep-disordered breathing in heart failure. N Engl J Med. 1996 Aug 22;335(8):562-7.[Abstract][Full Text]
62. Hu K, Li Q, Yang J, et al. The effect of theophylline on sleep-disordered breathing in patients with stable chronic congestive heart failure. Chin Med J (Engl). 2003 Nov;116(11):1711-6.[Abstract]
63. Liu HM, Chiang IJ, Kuo KN, et al. The effect of acetazolamide on sleep apnea at high altitude: a systematic review and meta-analysis. Ther Adv Respir Dis. 2017 Jan;11(1):20-9.[Abstract][Full Text]
64. Nussbaumer-Ochsner Y, Latshang TD, Ulrich S, et al. Patients with obstructive sleep apnea syndrome benefit from acetazolamide during an altitude sojourn: a randomized, placebo-controlled, double-blind trial. Chest. 2012 Jan;141(1):131-8.[Abstract]
65. Latshang TD, Nussbaumer-Ochsner Y, Henn RM, et al. Effect of acetazolamide and autoCPAP therapy on breathing disturbances among patients with obstructive sleep apnea syndrome who travel to altitude: a randomized controlled trial. JAMA. 2012 Dec 12;308(22):2390-8.[Abstract][Full Text]
66. Allam JS, Olson EJ, Gay PC, et al. Efficacy of adaptive servoventilation in treatment of complex and central sleep apnea syndromes. Chest. 2007 Dec;132(6):1839-46.[Abstract]
67. Talcott B, Morgenthaler TI, Silber M. Opioid use and sleep disordered breathing: a case control study. Sleep. 2007;30(suppl):A160.
68. Javaheri S, Malik A, Smith J, et al. Adaptive pressure support servoventilation: a novel treatment for sleep apnea associated with use of opioids. J Clin Sleep Med. 2008 Aug 15;4(4):305-10.[Abstract][Full Text]
69. Farney RJ, Walker JM, Boyle KM, et al. Adaptive servoventilation (ASV) in patients with sleep disordered breathing associated with chronic opioid medications for non-malignant pain. J Clin Sleep Med. 2008 Aug 15;4(4):311-9.[Abstract][Full Text]
70. Javaheri S, Harris N, Howard J, et al. Adaptive servoventilation for treatment of opioid-associated central sleep apnea. J Clin Sleep Med. 2014 Jun 15;10(6):637-43.[Abstract][Full Text]
71. Guilleminault C, Cao M, Yue HJ, et al. Obstructive sleep apnea and chronic opioid use. Lung. 2010 Dec;188(6):459-68.[Abstract]
72. Morgenthaler TI, Kuzniar TJ, Wolfe LF, et al. The complex sleep apnea resolution study: a prospective randomized controlled trial of continuous positive airway pressure versus adaptive servoventilation therapy. Sleep. 2014 May 1;37(5):927-34.[Abstract][Full Text]
73. Morgenthaler TI, Gay PC, Gordon N, et al. Adaptive servoventilation versus noninvasive positive pressure ventilation for central, mixed, and complex sleep apnea syndromes. Sleep. 2007 Apr;30(4):468-75.[Abstract]
74. Westhoff M, Arzt M, Litterst P. Influence of adaptive servoventilation on B-type natriuretic petide in patients with Cheyne-Stokes respiration and mild to moderate systolic and diastolic heart failure [in German]. Pneumologie. 2010 Aug;64(8):467-73.[Abstract]
75. US Food and Drug Administration. FDA drug safety communication: FDA approves new label changes and dosing for zolpidem products and a recommendation to avoid driving the day after using Ambien CR. May 2013 [internet publication].[Full Text]
76. Hagenah G, Andreas S, Clemens C, et al. Nocturnal oxygen administration and cardiac arrhythmias during Cheyne-Stokes respiration in patients with heart failure [in German]. Z Kardiol. 1996 Jun;85(6):435-41.[Abstract]
77. Andreas S, Weidel K, Hagenah G, et al. Treatment of Cheyne-Stokes respiration with nasal oxygen and carbon dioxide. Eur Respir J. 1998 Aug;12(2):414-9.[Abstract][Full Text]
78. Luks AM, van Melick H, Batarse RR, et al. Room oxygen enrichment improves sleep and subsequent day-time performance at high altitude. Respir Physiol. 1998 Sep;113(3):247-58.[Abstract]
79. McElroy MK, Gerard A, Powell FL, et al. Nocturnal O2 enrichment of room air at high altitude increases daytime O2 saturation without changing control of ventilation. High Alt Med Biol. 2000 Fall;1(3):197-206.[Abstract]
80. Nickol AH, Leverment J, Richards P, et al. Temazepam at high altitude reduces periodic breathing without impairing next-day performance: a randomized cross-over double-blind study. J Sleep Res. 2006 Dec;15(4):445-54.[Abstract][Full Text]
81. Thomas RJ, Daly RW, Weiss JW. Low-concentration carbon dioxide is an effective adjunct to positive airway pressure in the treatment of refractory mixed central and obstructive sleep-disordered breathing. Sleep. 2005 Jan;28(1):69-77.[Abstract]
82. Xie A, Rankin F, Rutherford R, et al. Effects of inhaled CO2 and added dead space on idiopathic central sleep apnea. J Appl Physiol. 1997 Mar;82(3):918-26.[Abstract][Full Text]
83. Baranchuk A, Healey JS, Simpson CS, et al. Atrial overdrive pacing in sleep apnoea: a meta-analysis. Europace. 2009 Aug;11(8):1037-40.[Abstract]
84. Abe H, Takahashi M, Yaegashi H, et al. Valve repair improves central sleep apnea in heart failure patients with valvular heart diseases. Circ J. 2009 Nov;73(11):2148-53.[Abstract][Full Text]
85. Fox H, Oldenburg O, Javaheri S, et al. Long-term efficacy and safety of phrenic nerve stimulation for the treatment of central sleep apnea. Sleep. 2019 Oct 21;42(11):zsz158.[Abstract][Full Text]
86. Costanzo MR, Ponikowski P, Javaheri S, et al. Transvenous neurostimulation for central sleep apnoea: a randomised controlled trial. Lancet. 2016 Sep 3;388(10048):974-82.[Abstract]
87. Jagielski D, Ponikowski P, Augostini R, et al. Transvenous stimulation of the phrenic nerve for the treatment of central sleep apnoea: 12 months' experience with the remedē(®) System. Eur J Heart Fail. 2016 Nov;18(11):1386-93.[Abstract]
88. Di Fusco SA, Pignalberi C, Santini L, et al. Arrhythmias and sleep apnea: physiopathologic link and clinical implications. J Interv Card Electrophysiol. 2020 Apr;57(3):387-97.[Abstract]