Sleep and Breathing

, Volume 11, Issue 4, pp 259–266 | Cite as

Moving beyond empiric continuous positive airway pressure (CPAP) trials for central sleep apnea: a multi-modality titration study

  • Tomasz J. Kuzniar
  • Jason M. Golbin
  • Timothy I. MorgenthalerEmail author
Original Article


There is no universally accepted method to determine effective therapy for central sleep apnea (CSA). Continuous positive airway pressure (CPAP) applied acutely most often does not eliminate apneas and hypopneas. We hypothesized that the application of two or more therapeutic modalities after the diagnostic phase of polysomnography, a multi-modality titration study (MMTS), would identify a successful CSA treatment more often than a standard split-night study (SNS) and obviate the need for additional polysomnograms to determine a successful therapy. We retrospectively analyzed polysomnograms of patients diagnosed with CSA at our Sleep Disorders Center. We defined a therapy trial that resulted in an apnea–hypopnea index < 10 with at least one treatment modality as a therapeutic success. One hundred fifteen patients with CSA were studied. Sixty-six patients (57.4%) underwent a SNS, and 49 patients (42.6%) underwent a MMTS. SNS yielded only 8/66 (12.1%) successes on the first night, whereas a MMTS yielded 19/49 (38.8%) successes (p = 0.001, two-tailed Fishers exact). Patients who underwent a SNS eventually had similar rate of success as patients studied with MMTS (60.6 vs 63.3%, NS), but required more testing. Adaptive servo-ventilation was the most successful modality tested, yielding 36/46 (78.3%) successes. Trials of additional modalities following a failed trial of CPAP often produce a successful option that may guide therapy in patients with CSA. This approach may lead to establishing the diagnosis and treatment plans faster, while reducing unnecessary testing.


Central sleep apnea Positive-pressure respiration Ventilatory support Oxygen inhalation therapy Polysomnography Split-night study 



This work was performed with support from Mayo Clinic Foundation.


  1. 1.
    Cooper VL, Pearson SB, Bowker CM, Elliott MW, Hainsworth R (2005) Interaction of chemoreceptor and baroreceptor reflexes by hypoxia and hypercapnia—a mechanism for promoting hypertension in obstructive sleep apnoea. J Physiol 568:677–687PubMedCrossRefGoogle Scholar
  2. 2.
    Doran T, Fullwood C, Gravelle H et al (2006) Pay-for-performance programs in family practices in the United Kingdom. N Engl J Med 355:375–384PubMedCrossRefGoogle Scholar
  3. 3.
    Dart RA, Gregoire JR, Gutterman DD, Woolf SH (2003) The association of hypertension and secondary cardiovascular disease with sleep-disordered breathing. Chest 123:244–260PubMedCrossRefGoogle Scholar
  4. 4.
    Iber C, O’Brien C, Schluter J, Davies S, Leatherman J, Mahowald M (1991) Single night studies in obstructive sleep apnea. Sleep 14:383–385PubMedGoogle Scholar
  5. 5.
    Strollo PJ Jr, Sanders MH, Costantino JP, Walsh SK, Stiller RA, Atwood CW Jr (1996) Split-night studies for the diagnosis and treatment of sleep-disordered breathing. Sleep 19:S255–S259PubMedGoogle Scholar
  6. 6.
    Elshaug AG, Moss JR, Southcott AM (2005) Implementation of a split-night protocol to improve efficiency in assessment and treatment of obstructive sleep apnoea. Intern Med J 35:251–254PubMedCrossRefGoogle Scholar
  7. 7.
    Kushida CA, Littner MR, Morgenthaler T et al (2005) Practice parameters for the indications for polysomnography and related procedures: an update for 2005. Sleep 28:499–521PubMedGoogle Scholar
  8. 8.
    Sanders MH, Constantino J, Strollo PJ, Studnicki KA, Atwood CW (2000) The impact of split-night polysomnography for diagnosis and positive pressure therapy titration on treatment acceptance and adherence in sleep apnea–hypopnea. Sleep 23:17–24Google Scholar
  9. 9.
    Bradley TD, Floras JS (2003) Sleep apnea and heart failure: part II: central sleep apnea. Circulation 107:1822–1826PubMedCrossRefGoogle Scholar
  10. 10.
    Javaheri S, Parker TJ, Liming JD et al (1998) Sleep apnea in 81 ambulatory male patients with stable heart failure. Types and their prevalences, consequences, and presentations. Circulation 97:2154–2159PubMedGoogle Scholar
  11. 11.
    Sin DD, Fitzgerald F, Parker JD, Newton G, Floras JS, Bradley TD (1999) Risk factors for central and obstructive sleep apnea in 450 men and women with congestive heart failure. Am J Respir Crit Care Med 160:1101–1106PubMedGoogle Scholar
  12. 12.
    Bradley TD, Logan AG, Kimoff RJ et al (2005) Continuous positive airway pressure for central sleep apnea and heart failure. N Engl J Med 353:2025–2033PubMedCrossRefGoogle Scholar
  13. 13.
    Takasaki Y, Orr D, Popkin J, Rutherford R, Liu P, Bradley TD (1989) Effect of nasal continuous positive airway pressure on sleep apnea in congestive heart failure. Am Rev Respir Dis 140:1578–1584PubMedGoogle Scholar
  14. 14.
    Naughton MT, Liu PP, Bernard DC, Goldstein RS, Bradley TD (1995) Treatment of congestive heart failure and Cheyne–Stokes respiration during sleep by continuous positive airway pressure. Am J Respir Crit Care Med 151:92–97PubMedGoogle Scholar
  15. 15.
    Teschler H, Dohring J, Wang YM, Berthon-Jones M (2001) Adaptive pressure support servo-ventilation: a novel treatment for Cheyne–Stokes respiration in heart failure. Am J Respir Crit Care Med 164:614–619PubMedGoogle Scholar
  16. 16.
    Buckle P, Millar T, Kryger M (1992) The effect of short-term nasal CPAP on Cheyne–Stokes respiration in congestive heart failure. Chest 102:31–35PubMedGoogle Scholar
  17. 17.
    Guilleminault C, Clerk A, Labanowski M, Simmons J, Stoohs R (1993) Cardiac failure and benzodiazepines. Sleep 16:524–528PubMedGoogle Scholar
  18. 18.
    Davies RJ, Harrington KJ, Ormerod OJ, Stradling JR (1993) Nasal continuous positive airway pressure in chronic heart failure with sleep-disordered breathing. Am Rev Respir Dis 147:630–634PubMedGoogle Scholar
  19. 19.
    Walsh JT, Andrews R, Starling R, Cowley AJ, Johnston ID, Kinnear WJ (1995) Effects of captopril and oxygen on sleep apnoea in patients with mild to moderate congestive cardiac failure. Br Heart J 73:237–241PubMedCrossRefGoogle Scholar
  20. 20.
    Franklin KA, Eriksson P, Sahlin C, Lundgren R (1997) Reversal of central sleep apnea with oxygen. Chest 111:163–169PubMedGoogle Scholar
  21. 21.
    Andreas S, Clemens C, Sandholzer H, Figulla HR, Kreuzer H (1996) Improvement of exercise capacity with treatment of Cheyne–Stokes respiration in patients with congestive heart failure. J Am Coll Cardiol 27:1486–1490PubMedCrossRefGoogle Scholar
  22. 22.
    Hanly PJ, Millar TW, Steljes DG, Baert R, Frais MA, Kryger MH (1989) The effect of oxygen on respiration and sleep in patients with congestive heart failure. Ann Intern Med 111:777–782PubMedGoogle Scholar
  23. 23.
    Javaheri S, Ahmed M, Parker TJ, Brown CR (1999) Effects of nasal O2 on sleep-related disordered breathing in ambulatory patients with stable heart failure. Sleep 22:1101–1106PubMedGoogle Scholar
  24. 24.
    Krachman SL, D’Alonzo GE, Berger TJ, Eisen HJ (1999) Comparison of oxygen therapy with nasal continuous positive airway pressure on Cheyne–Stokes respiration during sleep in congestive heart failure. Chest 116:1550–1557PubMedCrossRefGoogle Scholar
  25. 25.
    Staniforth AD, Kinnear WJ, Starling R, Hetmanski DJ, Cowley AJ (1998) Effect of oxygen on sleep quality, cognitive function and sympathetic activity in patients with chronic heart failure and Cheyne–Stokes respiration. Eur Heart J 19:922–928PubMedCrossRefGoogle Scholar
  26. 26.
    Willson GN, Wilcox I, Piper AJ et al (2001) Noninvasive pressure preset ventilation for the treatment of Cheyne–Stokes respiration during sleep. Eur Respir J 17:1250–1257PubMedCrossRefGoogle Scholar
  27. 27.
    Kasai T, Narui K, Dohi T et al (2005) Efficacy of nasal bi-level positive airway pressure in congestive heart failure patients with Cheyne–Stokes respiration and central sleep apnea. Circ J 69:913–921PubMedCrossRefGoogle Scholar
  28. 28.
    Kohnlein T, Welte T, Tan LB, Elliott MW (2002) Assisted ventilation for heart failure patients with Cheyne–Stokes respiration. Eur Respir J 20:934–941PubMedCrossRefGoogle Scholar
  29. 29.
    Pepperell JC, Maskell NA, Jones DR et al (2003) A randomized controlled trial of adaptive ventilation for Cheyne–Stokes breathing in heart failure. Am J Respir Crit Care Med 168:1109–1114PubMedCrossRefGoogle Scholar
  30. 30.
    Guilleminault C, Stoohs R, Labanowski M, Simmons J, Clerk A (1993) Cardiac failure, snoring, ventricular arrhythmias and nasal bilevel positive pressure ventilation. Sleep 16:S139–S140PubMedGoogle Scholar
  31. 31.
    Buckle P, Pouliot Z, Millar T, Kerr P, Kryger MH (1992) Polysomnography in acutely ill intensive care unit patients. Chest 102:288–291PubMedGoogle Scholar
  32. 32.
    Philippe C, Stoica-Herman M, Drouot X et al (2006) Compliance with and efficacy of adaptive servo-ventilation (ASV) versus continuous positive airway pressure (CPAP) in the treatment of Cheyne–Stokes respiration in heart failure over a six month period. Heart 92:337–342PubMedCrossRefGoogle Scholar
  33. 33.
    Arzt M, Schulz M, Wensel R et al (2005) Nocturnal continuous positive airway pressure improves ventilatory efficiency during exercise in patients with chronic heart failure. Chest 127:794–802PubMedCrossRefGoogle Scholar
  34. 34.
    Givertz MM, Braunwald E (2004) Neurohormones in heart failure: predicting outcomes, optimizing care. Eur Heart J 25:281–282PubMedCrossRefGoogle Scholar
  35. 35.
    Sin DD, Logan AG, Fitzgerald FS, Liu PP, Bradley TD (2000) Effects of continuous positive airway pressure on cardiovascular outcomes in heart failure patients with and without Cheyne–Stokes respiration. Circulation 102:61–66PubMedGoogle Scholar
  36. 36.
    Naughton MT, Benard DC, Liu PP, Rutherford R, Rankin F, Bradley TD (1995) Effects of nasal CPAP on sympathetic activity in patients with heart failure and central sleep apnea. Am J Respir Crit Care Med 152:473–479PubMedGoogle Scholar
  37. 37.
    Nieto FJ, Young TB, Lind BK et al (2000) Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study. Jama 283:1829–1836PubMedCrossRefGoogle Scholar
  38. 38.
    Peppard PE, Young T, Palta M, Skatrud J (2000) Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med 342:1378–1384PubMedCrossRefGoogle Scholar
  39. 39.
    Shahar E, Whitney CW, Redline S et al (2001) Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med 163:19–25PubMedGoogle Scholar
  40. 40.
    Peker Y, Hedner J, Kraiczi H, Loth S (2000) Respiratory disturbance index: an independent predictor of mortality in coronary artery disease. Am J Respir Crit Care Med 162:81–86PubMedGoogle Scholar
  41. 41.
    Becker HF, Jerrentrup A, Ploch T et al (2003) Effect of nasal continuous positive airway pressure treatment on blood pressure in patients with obstructive sleep apnea. Circulation 107:68–73PubMedCrossRefGoogle Scholar
  42. 42.
    Peker Y, Hedner J, Norum J, Kraiczi H, Carlson J (2002) Increased incidence of cardiovascular disease in middle-aged men with obstructive sleep apnea: a 7-year follow-up. Am J Respir Crit Care Med 166:159–165PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • Tomasz J. Kuzniar
    • 1
    • 3
  • Jason M. Golbin
    • 2
  • Timothy I. Morgenthaler
    • 1
    Email author
  1. 1.Sleep Disorders Center, Division of Pulmonary and Critical Care MedicineMayo ClinicRochesterUSA
  2. 2.Division of Pulmonary and Critical Care MedicineMayo ClinicRochesterUSA
  3. 3.Division of Pulmonary and Critical CareEvanston Northwestern HealthcareEvanstonUSA

Personalised recommendations