The International Classification of
Sleep Disorders, Second Edition (ICSD-2) distinguishes 5 subtypes of
central sleep apnea syndromes (CSAS) in adults. Review of the literature suggests that there are two basic mechanisms that trigger central respiratory events: (1) post-
hyperventilation central apnea, which may be triggered by a variety of clinical conditions, and (2)
central apnea secondary to
hypoventilation, which has been described with
opioid use. The preponderance of evidence on the treatment of CSAS supports the use of
continuous positive airway pressure (CPAP). Much of the evidence comes from investigations on CSAS related to
congestive heart failure (CHF), but other subtypes of CSAS appear to respond to CPAP as well. Limited evidence is available to support
alternative therapies in CSAS subtypes. The recommendations for treatment of CSAS are summarized as follows: CPAP
therapy targeted to normalize the
apnea-hypopnea index (AHI) is indicated for the initial treatment of CSAS related to CHF. (STANDARD)Nocturnal
oxygen therapy is indicated for the treatment of CSAS related to CHF. (STANDARD)Adaptive Servo-Ventilation (ASV) targeted to normalize the
apnea-hypopnea index (AHI) is indicated for the treatment of CSAS related to CHF. (STANDARD)BPAP
therapy in a spontaneous timed (ST) mode targeted to normalize the
apnea-hypopnea index (AHI) may be considered for the treatment of CSAS related to CHF only if there is no response to adequate trials of CPAP, ASV, and
oxygen therapies. (OPTION)The following
therapies have limited supporting evidence but may be considered for the treatment of CSAS related to CHF after optimization of standard medical
therapy, if PAP
therapy is not tolerated, and if accompanied by close clinical follow-up:
acetazolamide and
theophylline. (OPTION)Positive airway pressure
therapy may be considered for the treatment of primary CSAS. (OPTION)
Acetazolamide has limited supporting evidence but may be considered for the treatment of primary CSAS. (OPTION)The use of
zolpidem and
triazolam may be considered for the treatment of primary CSAS only if the patient does not have underlying risk factors for
respiratory depression. (OPTION)The following possible treatment options for CSAS related to
end-stage renal disease may be considered: CPAP, supplemental
oxygen,
bicarbonate buffer use during dialysis, and nocturnal dialysis. (OPTION) .