Central Sleep Apnea

Key Takeaways

• Central sleep apnea is a less common form of sleep apnea in which breathing pauses occur because the brain fails to send proper signals to the muscles that control breathing during sleep.
• CSA can lead to poor sleep quality, excessive daytime sleepiness, difficulty concentrating, and morning headaches if left untreated.
• There are different types of CSA, including primary CSA and forms associated with other conditions (e.g., Cheyne-Stokes breathing).
• Diagnosis typically involves a sleep study, and treatment options may include CPAP or BiPAP, supplemental oxygen, medications, or nerve stimulation.

What Is Central Sleep Apnea?

Central sleep apnea is a sleep-related breathing disorder where breathing temporarily stops as the sleeper makes no effort to breathe. These episodes of abnormal breathing are caused by the brain’s failure to send signals to the parts of the body that control breathing.

Occasional pauses in breathing are normal during sleep. In fact, as many as 40% of people briefly stop breathing as they wake up from sleep or after a deep sigh. As long as there are five or fewer breathing disruptions each hour, these episodes do not indicate a sleep disorder.

Types of Central Sleep Apnea

In adults, CSA is divided into categories based on a person’s clinical picture and the results of a sleep study. CSA is either primary, meaning it occurs on its own, or secondary to another medical condition.

• Primary Central Sleep Apnea: Primary CSA is a rare disorder in which breathing disruptions aren’t related to an underlying health condition. Researchers are unsure of how common primary CSA is in adults.
• Cheyne-Stokes Breathing: Cheyne-Stokes breathing is a pattern of breathing that involves cycles of fast and deep breaths that alternate with shallow or stopped breathing. It's typically associated with an underlying health condition, such as heart failure, kidney failure, or stroke.
• Treatment-Emergent Central Sleep Apnea: Treatment-emergent CSA arises after a person with obstructive sleep apnea (OSA) begins treatment with positive airway pressure (PAP). This form of CSA develops in 5% to 15% of people after starting PAP therapy and often resolves on its own within a few months.

Obstructive Sleep Apnea vs. Central Sleep Apnea

The two types of sleep apnea are central sleep apnea and obstructive sleep apnea. Both involve episodes of abnormal breathing during sleep. However, the cause of abnormal breathing differs between these two sleep disorders.

CSA occurs due to the absence of brain signals that tell the body to breathe, while OSA occurs when the upper airway collapses during sleep. While a person with CSA doesn’t try to breathe during these episodes, a person with OSA attempts to inhale against a narrowed or closed airway.

Another key difference between CSA and OSA is how frequently these conditions occur. Approximately 10% to 30% of adults in the United States have OSA, making it much more common than CSA. Researchers estimate that less than 1% of adults have CSA. In some cases, a person may show characteristics of both CSA and OSA, and the majority event type determines the labeling of the condition.

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Central Sleep Apnea Symptoms

For many people, CSA may develop without any noticeable symptoms. When symptoms are present, abnormal breathing during sleep may be witnessed by a caregiver, bed partner, or by a health provider during hospitalization. Other symptoms of CSA may include:

• Disrupted or restless sleep
• Insomnia
• Poor quality sleep
• Morning headaches
• Excessive daytime sleepiness
• Difficulty concentrating
• Shortness of breath at night
• Nighttime chest pain

Central Sleep Apnea Causes

Central sleep apnea occurs when the brain doesn't send consistent signals to the muscles that control breathing during sleep. Certain medical conditions, such as heart failure, kidney failure, stroke, brainstem disease, or neurological disorders, can interfere with the brain’s ability to control breathing.

A variety of medications and other substances can slow or stop breathing and lead to CSA. Medications and other substances linked to CSA include:

• Methadone
• Morphine
• Oxycodone
• Fentanyl patches
• Suboxone

CSA can also result from being in a high-altitude environment. While breathing disruptions can occur at any elevation, about 25% of people develop symptoms after ascending to around 8,200 feet above sea level. At around 13,100 feet above sea level or higher, virtually everyone experiences aspects of CSA when they sleep.

In some cases, no clear cause is identified, and the condition is classified as primary (idiopathic) central sleep apnea.

Risk Factors for Central Sleep Apnea

While doctors can’t always determine why a person has CSA, there are a number of factors that increase a person’s chances of developing this condition.

• Age: Most people with CSA are over 65 years old. The increased risk of CSA in older adults may be due to the aging process and the higher frequency of certain health conditions in older people.
• Sex: Men and people assigned male at birth experience significantly higher rates of CSA. Researchers suggest that this increased risk may be related to the effect of hormones on breathing.
• Heart failure and stroke: Both heart failure and stroke increase a person’s risk of developing CSA. Heart failure is one of the main risk factors for CSA with Cheyne-Stokes breathing and the development of CSA after a stroke is common.
• Other medical conditions: Additional medical conditions associated with CSA include brain infection, certain spinal conditions, and renal failure.
• Medications or drug use: The use of opioids and other drugs that suppress breathing increase a person’s risk of developing CSA.

Complications of Central Sleep Apnea

If left untreated, CSA can lead to a number of unwanted effects. CSA can cause a person to wake up during the night, leading to complaints of poor quality sleep, insomnia, and chest pain.

During the day, people with CSA may experience sleepiness, difficulty concentrating, and morning headaches. People with CSA are also at greater risk for workplace mistakes and car accidents.

Diagnosing Central Sleep Apnea

CSA is diagnosed based on a person’s health history and symptoms, as well as the results of a diagnostic sleep study. Also called polysomnography, a sleep study involves monitoring certain body functions while a person sleeps including brain waves and breathing patterns.

When diagnosing CSA, a sleep study takes place overnight in a specialized sleep laboratory. Home sleep apnea testing is not appropriate to diagnose the condition.

Central Sleep Apnea Treatment

Treatment for CSA depends on the severity of the symptoms and health complications caused by CSA.

In people with mild symptoms and only minor complications from sleep-related breathing issues, treatment may focus on addressing underlying health conditions that are causing breathing issues. If these treatments don’t resolve CSA, additional treatment may be recommended.

For people with more severe symptoms or complications of CSA, doctors treat the underlying condition at the same time as starting one or more treatments to normalize breathing.

• Continuous positive airway pressure (CPAP): CPAP is the first treatment for most forms of CSA. A CPAP machine keeps the airway open during sleep by delivering pressurized air at a consistent level via a hose connected to a face mask worn during sleep.
• Supplemental oxygen: Supplemental oxygen during sleep may be recommended for people with CSA who experience low levels of oxygen in the blood. Supplemental oxygen can be used on its own or along with CPAP.
• Bilevel positive airway pressure (BiPAP): BiPAP, or BPAP, is recommended as a treatment only if CPAP and/or supplemental oxygen do not resolve CSA. BiPAP delivers air at a higher pressure during inhalation and a lower pressure during exhalation. It's necessary to use modes of bilevel ST (with a timed breath) or adaptive or adaptive servo-ventilation (ASV) to resolve central sleep apnea. ASV may not be appropriate for someone with heart failure who has a left ventricular ejection fraction (LVEF) <45% on an echocardiogram, as it may worsen mortality.
• Medication: If CPAP, BiPAP, or supplemental oxygen aren't successful, medication may be recommended to stimulate breathing. However, medications can have harmful side effects and should be closely monitored by a health care professional.
• Nerve stimulation: Another alternative to CPAP is phrenic nerve stimulation. This treatment involves surgically implanting a device in the chest that stimulates breathing by causing the diaphragm to contract.

When to Talk to a Doctor

You should talk to a healthcare provider if you experience symptoms that may suggest central sleep apnea, especially if they occur frequently or disrupt your sleep. Common signs include repeated nighttime awakenings, shortness of breath during sleep, excessive daytime sleepiness, difficulty concentrating, and morning headaches.

It’s also important to seek medical advice if you have underlying conditions linked to central sleep apnea, such as heart failure, kidney failure, a history of stroke, neurological disease, or if you take medications that affect breathing, including opioids. A healthcare provider can review your symptoms, medical history, and risk factors and determine whether a sleep study or further evaluation is needed to guide appropriate treatment.

Frequently Asked Questions

Can central sleep apnea be cured?