When viewing this topic in a different language, you may notice some differences in the way the content is structured, but it still reflects the latest evidence-based guidance.

Central sleep apnea

Last reviewed: 4 Sep 2023
Last updated: 21 Feb 2023



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
More key diagnostic factors

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
Other diagnostic factors

Risk factors

  • congestive heart failure
  • stroke
  • renal failure
  • male sex
  • atrial fibrillation
  • age ≥60 years
  • opioid use
  • brainstem lesions
  • neuromuscular weakness
  • acromegaly
  • hypothyroidism
More risk factors

Diagnostic investigations

1st investigations to order

  • overnight polysomnography
More 1st investigations to order

Investigations to consider

  • serum thyroid stimulating hormone
  • serum creatinine
  • ECG
  • serum insulin-like growth factor 1 (acromegaly testing)
  • echocardiogram
More investigations to consider

Treatment algorithm


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

treatment-emergent CSA



Bernardo J. Selim, MD

Associate Professor of Medicine

Director of Respiratory Care Unit

Division of Pulmonary, Critical Care, and Sleep Medicine

Mayo Clinic




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

New Haven



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.

Peer reviewers

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.

  • Differentials

    • Obstructive sleep apnea
    • Sleep-related hypoventilation/hypoxemic syndromes
    • Depression
    More Differentials
  • Guidelines

    • Sleep-disordered breathing and cardiac arrhythmias in adults: mechanistic insights and clinical implications: a scientific statement from the American Heart Association
    • The AASM manual for the scoring of sleep and associated events
    More Guidelines
  • Patient leaflets

    Sleep apnea in adults (obstructive)

    More Patient leaflets
  • padlock-lockedLog in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer