Central Sleep Apnea (CSA)
A disorder where breathing repeatedly stops during sleep because the brain doesn't send proper signals to the breathing muscles.
What is Central Sleep Apnea (CSA)?
Central Sleep Apnea (CSA) is a less common form of sleep apnea that occurs when your brain doesn't send proper signals to the muscles that control breathing. Unlike obstructive sleep apnea, where there is a physical blockage of the airway, in central sleep apnea the airway is not blocked but the brain fails to signal the muscles to breathe. This results in no breathing effort for brief periods during sleep. CSA can occur on its own or be associated with other conditions, particularly heart failure, stroke, or opioid use.
Prevalence
CSA is less common than obstructive sleep apnea, affecting less than 1% of the general population. However, it is much more prevalent in certain groups: up to 30-50% of patients with heart failure have CSA, and it frequently occurs in patients using long-term opioid medications.
Causes
CSA occurs when the brain fails to transmit signals to breathing muscles. Common causes include heart failure (Cheyne-Stokes respiration), stroke or brain injury affecting the brainstem, high altitude exposure, opioid medication use, and idiopathic (unknown) causes. Medical conditions that affect the brainstem, such as Parkinson's disease or multiple system atrophy, can also cause CSA.
Types
Primary Central Sleep Apnea
Occurs without any identifiable cause (idiopathic). The brain intermittently fails to signal breathing during sleep.
Cheyne-Stokes Respiration
A pattern of gradually increasing then decreasing breathing effort, followed by a central apnea. Common in heart failure and stroke patients.
Treatment-Emergent Central Sleep Apnea
Central apneas that develop or persist when obstructive events are treated with CPAP. Previously called complex sleep apnea.
High-Altitude Periodic Breathing
Central apneas occurring at high altitudes due to changes in oxygen and carbon dioxide levels affecting breathing control.
Opioid-Induced Central Sleep Apnea
CSA caused by chronic use of opioid medications, which depress the respiratory centers in the brain.
Symptoms
Observed episodes of stopped breathing
Unlike OSA, these pauses may not be accompanied by snoring or gasping. A bed partner may notice periods where breathing simply stops.
Shortness of breath awakening you from sleep
You may wake up suddenly feeling short of breath or with a sensation that you need to catch your breath.
Chronic fatigue and daytime sleepiness
Repeated awakenings throughout the night prevent restful sleep, leading to excessive tiredness during the day.
Morning headaches
Low oxygen levels during sleep can cause headaches upon waking.
Difficulty concentrating
Sleep fragmentation impairs cognitive function, affecting memory, attention, and decision-making.
Mood changes
Poor sleep quality can lead to irritability, depression, or anxiety.
Insomnia
Difficulty staying asleep due to repeated arousals from apnea events.
Diagnosis
Self-Assessment Questions
If you answer yes to any of these questions, consider consulting a sleep specialist:
- 1Has anyone observed that you stop breathing during sleep without snoring or choking?
- 2Do you have heart failure, have had a stroke, or take opioid medications?
- 3Do you frequently wake up feeling short of breath?
- 4Do you experience excessive daytime sleepiness despite adequate time in bed?
- 5Have you developed sleep apnea symptoms while using CPAP therapy?
Diagnosis requires an overnight sleep study (polysomnography) to distinguish CSA from obstructive sleep apnea. The study measures brain activity, eye movements, muscle activity, heart rate, breathing effort, airflow, and blood oxygen levels.
Polysomnography
The definitive test for CSA. It shows apnea events occurring without any breathing effort, distinguishing CSA from OSA where effort is present but airflow is blocked.
Blood Tests
May be performed to check for underlying conditions such as heart failure, kidney function, or thyroid disorders that can contribute to CSA.
Cardiac Evaluation
Echocardiogram and other heart tests may be done to assess for heart failure, a common cause of Cheyne-Stokes respiration pattern CSA.
Brain Imaging
MRI or CT scans may be ordered if a brain lesion or stroke is suspected as the cause of CSA.
Treatment
Treatment focuses on addressing the underlying cause when possible and normalizing breathing during sleep. Options vary based on the specific type and cause of CSA.
Treatment of Underlying Conditions
Optimizing treatment for heart failure, reducing opioid dosages when possible, or addressing other underlying causes can significantly improve or resolve CSA.
Adaptive Servo-Ventilation (ASV)
A specialized device that monitors breathing and delivers variable pressure to normalize breathing patterns. Highly effective for many forms of CSA but contraindicated in patients with symptomatic heart failure with reduced ejection fraction.
CPAP Therapy
Continuous positive airway pressure can be effective for some patients with CSA, particularly those with treatment-emergent CSA.
BiPAP with Backup Rate
Bilevel positive airway pressure with a backup respiratory rate ensures minimum breaths per minute, useful when the brain fails to initiate breathing.
Supplemental Oxygen
Nocturnal oxygen therapy can help maintain blood oxygen levels and may reduce the frequency of central apneas in some patients.
Phrenic Nerve Stimulation
An implanted device (Remede System) that stimulates the phrenic nerve to contract the diaphragm, causing the patient to breathe. Approved for moderate to severe CSA.
Lifestyle Adjustments
- •Avoid alcohol and sedative medications that can worsen central apneas
- •Maintain a healthy weight
- •Sleep with head elevated to reduce fluid redistribution to the chest
- •Follow heart-healthy lifestyle if cardiac disease is present
- •Avoid sleeping at high altitudes if altitude-induced CSA is an issue
- •Work with your doctor to minimize opioid medications when safely possible
Find a Specialist
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