Live Recordings (Sleep Medicine Trends 2026)-11 Treatment of Central Sleep Apnea

Video Transcription

Video Summary

The speaker shifts to central sleep apnea (CSA), emphasizing that pathophysiology should guide treatment and reviewing new American Academy of Sleep Medicine (AASM) guidelines. CSA is framed as ventilatory instability: hyperventilation lowers CO₂ below an individual “apnea threshold,” triggering central apneas; “apnea begets apnea” through cycles of hypocapnia, arousals, hypoxia, and even upper-airway narrowing. Loop gain (propensity for instability) depends on “plant gain” (how easily CO₂ changes with ventilation, influenced by lung size) and “controller gain” (chemoreflex sensitivity, often high in heart failure and low with opioids). The speaker argues the CSA–OSA separation is false: central events often coincide with airway closure and many patients have comorbid OSA (“COSA”).<br /><br />Treatment is discussed as largely repurposed from OSA therapies. CPAP improves CSA in ~50% of patients. The guideline recommendations are mostly conditional with low/very-low certainty. BPAP without a backup rate is discouraged (can worsen CSA); BPAP with backup rate is supported. ASV is highly efficacious and, with newer evidence, no longer shows a mortality signal in heart failure, improving symptoms and quality of life; shared decision-making and experienced centers are advised. Oxygen (heart failure, high altitude), acetazolamide, and phrenic nerve stimulation are additional options. Practical approach: treat underlying conditions first, start with CPAP, escalate/combine therapies as needed, and individualize decisions—sometimes observing mild residual CSA if patients are asymptomatic. Pediatric CSA is cautioned as different from adult CSA.

Keywords

central sleep apnea (CSA)

AASM guidelines

ventilatory instability

loop gain (plant gain, controller gain)

hypocapnia and apnea threshold

CPAP and BPAP with backup rate

adaptive servo-ventilation (ASV) in heart failure

oxygen therapy, acetazolamide, phrenic nerve stimulation