A look at the new guideline for treating central sleep apnea in adults - American Academy of Sleep Medicine – Association for Sleep Clinicians and Researchers

By M. Safwan Badr, MD, MBA

Central sleep apnea (CSA) is a form of sleep-disordered breathing in which decreased or absent flow is coupled with an absence or reduction in effort. CSA is not a single disorder but represents central breathing instability in various clinical conditions, including heart failure, obstructive sleep apnea, and opioid analgesic use. CSA occurs either as a primary condition or in association with several co-morbid conditions, including CSA due to heart failure, CSA due to medication or substance use, treatment-emergent CSA, and CSA due to a medical condition or disorder.The American Academy of Sleep Medicine convened a task force of experts to develop a clinical practice guideline for CSA in adults, updating the previously published practice parameters. Using a systematic review and the GRADE framework, the group assessed the available evidence using standard methodology across all patient groups and therapies. The task force further weighed the benefits and harms, patient values, and resource considerations of each intervention. The clinical practice guideline also reflects advances in research and clinical experience, including recent studies on adaptive servo ventilation and transvenous phrenic nerve stimulation as a novel therapy for CSA.The guideline notes the heterogeneity of CSA and the need for patient-centered, individualized treatment strategies. An overarching good practice statement emphasizes that the optimal approach to CSA treatment should incorporate clinical features, co-morbid conditions, and polysomnographic findings in an individualized manner, aiming to improve quality of life and functional outcomes while underscoring the role of clinical judgment and shared decision-making. Likewise, the guideline notes significant knowledge gaps and the need for future research to refine therapies and guide optimal patient selection. Overall, clinicians must prioritize optimizing therapy for the conditions contributing to central apneas and improving patient-reported outcomes rather than solely focusing on eliminating disordered breathing events. Once therapy for CSA has been initiated, persistence of central respiratory events should prompt re-evaluation of the underlying risk factors and consideration of alternative treatment options.

The guideline includes nine “conditional” treatment recommendations (i.e., “We suggest …”). A “conditional” recommendation is one that clinicians should offer to most patients if clinically appropriate. Some recommendations include remarks that provide additional context to guide clinicians with implementation. Because most studies compared therapies only to no treatment, the guideline does not directly compare treatments with each other, and it does not provide a stepwise algorithm. However, it recognizes that positive-pressure therapies such as CPAP are commonly used as first-line therapy.

From this framework, the guideline provides conditional recommendations for several therapies. CPAP is suggested for most CSA etiologies, while BPAP with a backup rate may also be considered; however, the guideline suggests against using BPAP without a backup rate, as it may worsen central apnea. Adaptive servo ventilation is also conditionally recommended for a wide range of CSA syndromes, including CSA associated with heart failure. However, the task force emphasized that treatment decisions should involve shared decision-making, and use of adaptive servo ventilation in patients with heart failure and reduced ejection fraction should be restricted to experienced centers with close monitoring and follow-up. Other treatment strategies include low-flow oxygen and acetazolamide in specific contexts such as heart failure or high altitude. Transvenous phrenic nerve stimulation is a novel, FDA-approved option. However, it is deemed as a second-line therapy due to its invasiveness, cost and limited availability.

Overall, these recommendations reflect the heterogeneity and complexity of CSA. They emphasize individualized, patient-centered care, prioritizing improvements in quality of life and functional outcomes rather than simply eliminating disordered breathing events. While positive-pressure therapies remain the most commonly used treatments, the availability of newer approaches such as adaptive servo ventilation and transvenous phrenic nerve stimulation expands the therapeutic landscape. The guideline highlights both the progress made and the continuing knowledge gaps, underscoring the need for further research to refine treatment strategies and clarify optimal patient selection for each modality.

Dr. Safwan Badr is the chair of the Wayne State University School of Medicine Department of Internal Medicine in Detroit, Michigan. He is also a professor of internal medicine and physiology, a staff physician at the John D. Dingell VA Medical Center, and the chief clinical officer of the Wayne State University Physician Group. Additionally, Dr. Badr is the editor-in-chief of the Journal of Clinical Sleep Medicine.

References

Aurora RN, Chowdhuri S, Ramar K, et al. The treatment of central sleep apnea syndromes in adults: practice parameters with an evidence-based literature review and meta-analyses. Sleep. Jan 1 2012;35(1):17–40. doi:10.5665/sleep.1580
Aurora RN, Bista SR, Casey KR, et al. Updated Adaptive Servo-Ventilation Recommendations for the 2012 AASM Guideline: “The Treatment of Central Sleep Apnea Syndromes in Adults: Practice Parameters with an Evidence-Based Literature Review and Meta-Analyses”. J Clin Sleep Med. May 15 2016;12(5):757–61. doi:10.5664/jcsm.5812
Guyatt G, Oxman AD, Akl EA, et al. GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. Apr 2011;64(4):383–94. doi:10.1016/j.jclinepi.2010.04.026

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