Idiopathic Central Sleep Apnea

Abdul Alraiyes MD
 Objectives
•Central Sleep Apnea:

•Manifestation
•Types and prevalence
•Pathophysiology

•Idiopathic Central Sleep Apnea (ICSA)

•Differential diagnosis of ICSA
•Treatment ICSA and CSA
 HPI
47 year-old male referred for evaluation of obstructive sleep
apnea due to:
• nocturnal symptoms include:
• Restless and light sleeping
• Easily aroused and frequent awakening at night
• Difficulty falling back to sleep
• Snoring
• witnessed apneas
• Nocturia
• And daytime symptoms include:
• Fatigue
• Unpleasant dry mouth
• Morning headaches.
• Epworth sleepiness scale 15/24 “on Adderall”.
 HPI
47 year-old male referred for evaluation of obstructive sleep
apnea due to:

The patient’s usual bedtime is 10:00 and wake time is

7:15 and obtains 8 hours of sleep on average no naps.
Restless interrupted sleep
 PMHx
Co-morbidities:
asthma
depression
GERD
Sinusitis.
Medications:
Protonix
Welburtin XL
Adderall
Advair
Omnaris
Multivitamins
Milatonin
 Physical Exam
•BP: 127/83 HR: 75, RR: 14, O2 saturation of 97% RA

•HEENT: congested bilateral enlarged turbinates, Mallampati class I, tonsils

+1, normal size uvula and normal size tongue,
•Neck: No lymphadenopathy, thyromegaly, 16.5 inches
•Chest: . Clear chest. Good air entry
•CVS: S1 and S2 regular no murmurs
•Abd: soft lax no mass or HSM
•Ext: no edema or erythema
•Neuro: Normal CN, speech, gait, balance, motor and power
PSG
Diagnostic portion
CPAP 8 cwp
CPAP 10 cwp
 Echocardiogram

•The left ventricular chamber size is normal.

•There is normal left ventricular systolic function LVEF 55-60%
•Normal left ventricular diastolic filling is observed.
•The left atrium is mildly dilated
•The right atrium is mildly dilated
 Central Sleep Apnea (CSA)
characterized by:

• Lack of drive to breathe during sleep

• Results in insufficient or absent ventilation and compromised gas exchange
• lack of respiratory effort during cessations of airflow.
CSA is considered to be the primary diagnosis when ≥50% of apneas are
scored as central in origin

Eckert, D.J., et al., Central sleep apnea: Pathophysiology and treatment. Chest, 2007. 131(2): p. 595-607.
 Manifestation of CSA
Central Sleep Apnea

Hypercapnic Hypocapnic

Impaired Cheyne stokes Idiopathic

Impaired central
respiratory motor Central Sleep
drive:
control: breathing Apnea

- Tumors or trauma Neuromuscular disorders

- CCHS - NM junction
- Opioid -based Rx - Motor neuron disease
- OHS - Myopathies
- Chest wall deformity

Eckert, D.J., et al., Central sleep apnea: Pathophysiology and treatment. Chest, 2007. 131(2): p. 595-607.
 ICSA

The international classification of sleep disorders ICSA diagnostic

criteria:

A. at least one of the following

•Excessive daytime sleepiness
•Frequent arousals and awakening during sleep or insomnia complains
•Awakening short of breath

B. Polysomnography shows five or more central apneas per hour of sleep

C. The disorder is not better explained by another current sleep disorder,

medical or neurological disorder, medication use, or substance use

Eckert, D.J., et al., Central sleep apnea: Pathophysiology and treatment. Chest, 2007. 131(2): p. 595-607.
 ICSA DDx
The international classification of sleep disorders ICSA DDx:

A. Obstructive sleep apnea

B. Cheyne Stokes Breathing

C. Sleep related hypoventilation/hypoxemic syndromes

 OSA ICSA

Respiratory efforts

Eckert, D.J., et al., Central sleep apnea: Pathophysiology and treatment. Chest, 2007. 131(2): p. 595-607.
 CSB

Eckert, D.J., et al., Central sleep apnea: Pathophysiology and treatment. Chest, 2007. 131(2): p. 595-607.
 CSB

•Crescendo/decrescendo ventilatory pattern

•Common during light sleep stages
•Cycle time (60-90 s)
•Arousals occur mid-cycle at the peak of ventilatory efforts
Eckert, D.J., et al., Central sleep apnea: Pathophysiology and treatment. Chest, 2007. 131(2): p. 595-607.
 ICSA

Eckert, D.J., et al., Central sleep apnea: Pathophysiology and treatment. Chest, 2007. 131(2): p. 595-607.
 ICSA

•Repetitive cyclic manner pattern

•Common during light sleep stages
•Cycle time (20-40 s)
•Arousals occur at the termination of central apnea

Eckert, D.J., et al., Central sleep apnea: Pathophysiology and treatment. Chest, 2007. 131(2): p. 595-607.
 Chemical Control of Breathing
CO2
Breathing instability:

• highly sensitive chemoresponses

O2 • Long delay in the loop

Hering-Breuer inflation reflex

Eckert, D.J., et al., Central sleep apnea: Pathophysiology and treatment. Chest, 2007. 131(2): p. 595-607.
 Transition from Wake to sleep

Apnea threshold
Sleep eucapnic set point 45 mmHg
Wake eucapnic set point 40 mmHg
Apnea threshold PaCO2

Arousal

Wake Sleep

Eckert, D.J., et al., Central sleep apnea: Pathophysiology and treatment. Chest, 2007. 131(2): p. 595-607.
 Cheyne Stokes Breathing

Apnea threshold
Sleep eucapnic set point 45 mmHg
Wake eucapnic set point 40 mmHg
Apnea threshold PaCO2

Arousal

Wake Sleep

Eckert, D.J., et al., Central sleep apnea: Pathophysiology and treatment. Chest, 2007. 131(2): p. 595-607.
 ICSA

Apnea threshold
Sleep eucapnic set point 45 mmHg
Wake eucapnic set point 40 mmHg
Apnea threshold PaCO2

Arousal

Wake Sleep

Eckert, D.J., et al., Central sleep apnea: Pathophysiology and treatment. Chest, 2007. 131(2): p. 595-607.
CSA and OSA
Badr, M.S., et al., Pharyngeal narrowing/occlusion during central sleep apnea. J Appl Physiol, 1995. 78(5): p. 1806-15.
 Upper airway and CSA
normal subjects (3 of 25 apneas) SAH (31 of 44 apneas)

Subatmospheric intraluminal pressure is not required for pharyngeal occlusion

to occur.
Pharyngeal narrowing or occlusion during central apnea may be due to passive
collapse or active constriction.

Badr, M.S., et al., Pharyngeal narrowing/occlusion during central sleep apnea. J Appl Physiol, 1995. 78(5): p. 1806-15.
 CSA and OSA

Within 50 min of UA local

anesthesia

After 65 min of UA local

anesthesia

Issa, F.G. and C.E. Sullivan, Reversal of central sleep apnea using nasal CPAP. Chest, 1986. 90(2): p. 165-71.
Hoffstein, V. and A.S. Slutsky, Central sleep apnea reversed by continuous positive airway pressure. Am Rev Respir Dis, 1987.
135(5): p. 1210-2.
 CSA and OSA

Issa, F.G. and C.E. Sullivan, Reversal of central sleep apnea using nasal CPAP. Chest, 1986. 90(2): p. 165-71.
Hoffstein, V. and A.S. Slutsky, Central sleep apnea reversed by continuous positive airway pressure. Am Rev Respir Dis, 1987.
135(5): p. 1210-2.
 CPAP Treatment

2 cmH2O 6 cmH2O 10 cmH2O 15 cmH2O

Issa, F.G. and C.E. Sullivan, Reversal of central sleep apnea using nasal CPAP. Chest, 1986. 90(2): p. 165-71.
Hoffstein, V. and A.S. Slutsky, Central sleep apnea reversed by continuous positive airway pressure. Am Rev Respir Dis, 1987.
135(5): p. 1210-2.
CSA Treatment
 CO2 treatment

Improve AHI
Doesn’t improve sleep quality or arousal index
May lead to sympatho-excitation
Apnea threshold PaCO2

Arousal

Wake Sleep

Xie, A., et al., Effects of inhaled CO2 and added dead space on idiopathic central sleep apnea. J Appl Physiol, 1997. 82(3): p.
918-26
 Zolpidem

Quadri, S., C. Drake, and D.W. Hudgel, Improvement of idiopathic central sleep apnea with zolpidem. J Clin Sleep Med, 2009. 5(2): p. 122-9.
 Zolpidem

Quadri, S., C. Drake, and D.W. Hudgel, Improvement of idiopathic central sleep apnea with zolpidem. J Clin Sleep Med, 2009. 5(2): p. 122-9.
 CPAP Treatment

Prevention of inhibitory reflex mechanisms that arise

during airway closure

CPAP-induced increases in lung volume/O2 stores.

Issa, F.G. and C.E. Sullivan, Reversal of central sleep apnea using nasal CPAP. Chest, 1986. 90(2): p. 165-71.
Hoffstein, V. and A.S. Slutsky, Central sleep apnea reversed by continuous positive airway pressure. Am Rev Respir Dis, 1987.
135(5): p. 1210-2.
 CPAP Treatment
• improved nocturnal oxygenation
• Increased the ejection fraction
• lowered Norepinephrine levels,
• increased the distance walked in six minutes,

Bradley, T.D., et al., Continuous positive airway pressure for central sleep apnea and heart failure. N Engl J Med, 2005.
353(19): p. 2025-33.
 CPAP Treatment

No improvement in survival

Bradley, T.D., et al., Continuous positive airway pressure for central sleep apnea and heart failure. N Engl J Med, 2005.
353(19): p. 2025-33.
CPAP Vs Adaptive servoventilation
Treatment

• Both ASV and CPAP decreased the AHI

• Compliance with ASV > CPAP at 6 months.
• the improvement in quality of life was higher with ASV and
• Only ASV induced a significant increase in LVEF

Philippe, C., et al., Compliance with and effectiveness of adaptive servoventilation versus continuous positive airway pressure
in the treatment of Cheyne-Stokes respiration in heart failure over a six month period. Heart, 2006. 92(3): p. 337-42.
 Respiratory Stimulants

Theophylline Progesterone

Philippe, C., et al., Compliance with and effectiveness of adaptive servoventilation versus continuous positive airway pressure
in the treatment of Cheyne-Stokes respiration in heart failure over a six month period. Heart, 2006. 92(3): p. 337-42.
 Respiratory Stimulants

Acetazolamide
Apnea threshold PaCO2

Wake Sleep
Javaheri, S., Acetazolamide improves central sleep apnea in heart failure: a double-blind, prospective study. Am J Respir Crit
Care Med, 2006. 173(2): p. 234-7.
Questions?
Thank You
 References
1. Franklin, K.A., et al., Reversal of central sleep apnea with oxygen. Chest, 1997. 111(1): p. 163-9.
2. Krachman, S.L., et al., Comparison of oxygen therapy with nasal continuous positive airway pressure
on Cheyne-Stokes respiration during sleep in congestive heart failure. Chest, 1999. 116(6): p. 1550-7.
3. Xie, A., et al., Effects of inhaled CO2 and added dead space on idiopathic central sleep apnea. J Appl
Physiol, 1997. 82(3): p. 918-26
4. Hoffstein, V. and A.S. Slutsky, Central sleep apnea reversed by continuous positive airway pressure.
Am Rev Respir Dis, 1987. 135(5): p. 1210-2
5. Bradley, T.D., et al., Continuous positive airway pressure for central sleep apnea and heart failure. N
Engl J Med, 2005. 353(19): p. 2025-33.
6. Philippe, C., et al., Compliance with and effectiveness of adaptive servoventilation versus continuous
positive airway pressure in the treatment of Cheyne-Stokes respiration in heart failure over a six
month period. Heart, 2006. 92(3): p. 337-42.
7. Mansfield, D.R., et al., The effect of successful heart transplant treatment of heart failure on central
sleep apnea. Cest, 203. 124(5): p. 1675-81.
8. Javaheri, S., Acetazolamide improves central sleep apnea in heart failure: a double-blind, prospective
study. Am J Respir Crit Care Med, 2006. 173(2): p. 234-7.
9. Badr, M.S., et al., Pharyngeal narrowing/occlusion during central sleep apnea. J Appl Physiol, 1995.
78(5): p. 1806-15.
10.Eckert, D.J., et al., Central sleep apnea: Pathophysiology and treatment. Chest, 2007. 131(2): p. 595-
607.
11.Quadri, S., C. Drake, and D.W. Hudgel, Improvement of idiopathic central sleep apnea with zolpidem. J
Clin Sleep Med, 2009. 5(2): p. 122-9.