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.
A polysomnogram is required for diagnosis.
Central sleep apnea (CSA) syndromes are characterized by repetitive absent or diminished respiratory efforts that occur intermittently or in a cyclical pattern predominantly during sleep. They are classified according to their underlying etiology as primary or secondary. CSA is most commonly encountered in clinical practice as a result of an underlying condition, notably congestive heart failure with reduced or preserved ejection fraction, conferring a poor prognosis. Among forms of medication and substance misuse, opioid intake is another frequent clinical scenario that may lead to CSA. Primary CSA is an idiopathic rare disorder.
History and exam
Key diagnostic factors
- insomnia, especially sleep-maintenance insomnia
- poor concentration and attention span
- observed periodic breathing or cessation of breathing or snoring during sleep (by partner)
- transient dyspnea that awakens from sleep or prevents sleep onset
- headaches upon waking
- complaints of poorly restorative sleep and/or daytime sleepiness
- periodic breathing during wakefulness
Other diagnostic factors
- abnormal heart rhythm or the presence of third or fourth heart sounds
- focal abnormality on neurologic exam
- neuromuscular weakness
- history of endocrine disorders
- congestive heart failure
- renal failure
- male sex
- atrial fibrillation
- age ≥60 years
- opioid use
- brainstem lesions
- neuromuscular weakness
1st investigations to order
- overnight polysomnography
Investigations to consider
- serum thyroid stimulating hormone
- serum creatinine
- serum insulin-like growth factor 1 (acromegaly testing)
without Cheyne-Stokes breathing: due to medical disorder
without Cheyne-Stokes breathing: primary (idiopathic)
with Cheyne-Stokes breathing
due to high-altitude periodic breathing
due to medication or substance misuse
Bernardo J. Selim, MD
Associate Professor of Medicine
Director of Respiratory Care Unit
Division of Pulmonary, Critical Care, and Sleep Medicine
BJS declares that he has no competing interests.
Lauren A. Tobias, MD
Assistant Professor of Medicine
Yale University School of Medicine
Department of Internal Medicine
Section of Pulmonary, Critical Care and Sleep Medicine
LAT declares that she has no competing interests.
Dr Bernardo J. Selim and Dr Lauren A. Tobias would like to gratefully acknowledge Dr J. Shirine Allam, Dr Timothy I. Morgenthaler, and Dr Christine H. Won, previous contributors to this topic.
JSA and TIM declare that they have no competing interests. CHW declares that she has been a speaker for Respironics CME.
Teofilo Lee-Chiong, MD
National Jewish Medical and Research Center
TLC has been reimbursed by the American College of Chest Physicians (ACCP), American Academy of Sleep Medicine, American Thoracic Society, and Cephalon, the manufacturer of modafinil, for attending several conferences. He has been paid by the ACCP for running educational programs and by Elsevier for serving as consultant of the Sleep Medicine Clinics. He has also received research funding from the National Institutes of Health, Respironics, Restore, and Schwarz Pharma, and has been a member of the speakers' bureau for GlaxoSmithKline.
John A. Fleetham, MD, FRCP
University of British Columbia
JAF declares that he has no competing interests.
- Obstructive sleep apnea
- Sleep-related hypoventilation/hypoxemic syndromes
- The AASM manual for the scoring of sleep and associated events
- German S3 guideline nonrestorative sleep/sleep disorders, chapter: sleep-related breathing disorders in adults
Sleep apnea in adults (obstructive)More Patient leaflets
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