Therapy for Sleep Hypoventilation and Central Apnea Syndromes
• Primary Central Sleep Apnea (CSA): We would recommend a trial of Positive Airway Pressure (PAP), acetazolamide, or zolpidem based on thorough consideration of risks and benefits and incorporation of patient preferences.
• Central Sleep Apnea Due to Cheyne-Stokes Breathing Pattern in Congestive Heart Failure (CSR-CHF): We would recommend PAP devices such as continuous positive airway pressure (CPAP) or adaptive servo-ventilation (ASV) to normalize sleep-disordered breathing after optimizing treatment of heart failure. Oxygen may also be an effective therapy. Acetazolamide and theophylline may be considered if PAP or oxygen is not effective.
• Central Sleep Apnea due to High-Altitude Periodic Breathing: We would recommend descent from altitude or supplemental oxygen. Acetazolamide may be used when descent or oxygen are not feasible, or in preparation for ascent to high altitude. Slow ascent may be preventative.
• Central Sleep Apnea due to Drug or Substance: If discontinuation or reduction of opiate dose is not feasible or effective, we would recommend a trial of CPAP, and if not successful, treatment with ASV. If ASV is ineffective or if nocturnal hypercapnia develops, bilevel positive airway pressure-spontaneous timed mode (BPAP-ST) is recommended.
• Obesity hypoventilation syndrome: We would recommend an initial CPAP trial. If hypoxia or hypercapnia persists on CPAP, BPAP, BPAP-ST or average volume assured pressure support (AVAPS™) is recommended. Tracheostomy with nocturnal ventilation should be considered when the above measures are not effective. Weight loss may be curative.
• Neuromuscular or chest wall disease: We would recommend early implementation of BPAP-ST based on thorough consideration of risks and benefits and patient preferences. AVAPS™ may also be considered. We recommend close follow up due to disease progression.
KeywordsSleep hypoventilation Central apnea syndromes Alveolar hypoventilation syndromes Sleep-related hypoventilation syndromes Cheyne-Stokes breathing pattern High-altitude periodic breathing Drugs Narcotics Therapy
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance•• Of major importance
- 1.Wester IL. American Academy of Sleep Medicine. International classification of sleep-disorders, second edition: diagnostic and coding manual. American Academy of Sleep Medicine. 2005.Google Scholar
- 3.••Aurora RN, Chowdhuri S, Ramar K, Bista SR, Casey KR, Lamm CI, et al. The treatment of central sleep apnea syndromes in adults: practice parameters with an evidence-based literature review and meta-analyses. Sleep. 2012;35:17–40. This article defines the most current practice parameters in the management of central sleep apnea syndrome in adults based on evidence-based literature review. It critically reviews pharmacological, positive pressure ventilation and surgical interventions when indicated.PubMedGoogle Scholar
- 6.•Yoshihisa A, Shimizu T, Owada T, Nakamura Y, Iwaya S, Yamauchi H, et al. Adaptive servo ventilation improves cardiac dysfunction and prognosis in chronic heart failure patients with Cheyne-Stokes respiration. Int Heart J. 2011;52: 218–23. This study shows improvement of CSR in patients with chronic heart failure on adaptive servo ventilation, as well as improvement of functional status of heart failure, cardiac function and event free survival rate.PubMedCrossRefGoogle Scholar
- 8.•Koyama T, Watanabe H, Kobukai Y, Makabe S, Munehisa Y, Iino K, et al. Beneficial effects of adaptive servo ventilation in patients with chronic heart failure. Circulation. 2010;74:2118–24. This article not only confirmed the improvement of nocturnal respiratory events (AHI) and cardiac function (LVEF) in patients with chronic heart failure on adaptive servo ventilation, but it also showed an anti-inflammatory effect in this population.CrossRefGoogle Scholar
- 13.Toyama T, Seki R, Kasama S, Isobe N, Sakurai S, Adachi H, et al. Effectiveness of nocturnal home oxygen therapy to improve exercise capacity, cardiac function and cardiac sympathetic nerve activity in patients with chronic heart failure and central sleep apnea. Circ J. 2009;73:299–304.PubMedCrossRefGoogle Scholar
- 18.•Radunovic A, Annane D, Jewitt K, Mustfa N. Mechanical ventilation for amyotrophic lateral sclerosis/motor neuron disease. Cochrane Database Syst Rev. 2009;4:CD004427. Evidence from a single randomised trial of non-invasive ventilation shows improvement in survival and quality of life in patients with ALS.Google Scholar
- 19.•Fitzgerald DA, Follett J, Van Asperen PP. The effect of supplemental oxygen on hypercapnia in subjects with obesity-associated hypoventilation: a randomized, crossover, clinical study. Chest. 2011;139:1018–24. This article contributes to current guidelines recommending the judicious use of oxygen in patients with obesity hypoventilation syndrome.PubMedCrossRefGoogle Scholar