Sleep-related breathing disorders
Central Sleep Apnea
Your brain briefly stops sending the signal to breathe during sleep. It is often linked to heart failure, stroke, opioid use or high altitude.
Overview
In central sleep apnea (CSA) the airway stays open, but the brain temporarily fails to tell the breathing muscles to work. Breathing pauses or becomes very shallow, oxygen levels fall and you wake briefly to restart it. Unlike obstructive apnea, there is little or no effort to breathe during the pause.
CSA is much less common than obstructive sleep apnea and usually has an underlying cause. A pattern called Cheyne-Stokes breathing, a cycle of breaths that grow deeper and then fade away, is common in people with heart failure or after a stroke. Opioid medicines, very high altitude and certain neurological conditions can also cause it, and sometimes no cause is found (primary CSA).
Because the treatment depends on the cause, CSA should be managed by a sleep specialist working with your other doctors, especially your cardiologist if you have heart disease.
Common symptoms
- Pauses in breathing observed by someone else
- Waking up suddenly short of breath
- Difficulty staying asleep (insomnia)
- Excessive daytime sleepiness
- Unrefreshing sleep
- Trouble concentrating
- Morning headaches
- Snoring (less prominent than in obstructive apnea)
Causes and risk factors
- Heart failure
- Stroke or other brainstem conditions
- Opioid medicines, including long-acting prescription opioids
- Sleeping at high altitude
- Atrial fibrillation
- Kidney failure
- Older age and male sex
- Starting positive airway pressure for obstructive apnea (treatment-emergent CSA)
How it is diagnosed
CSA is diagnosed with an overnight in-lab polysomnogram, which can tell central events (no breathing effort) apart from obstructive events (effort against a blocked airway). Home sleep apnea tests are generally not recommended when CSA is suspected because many do not measure breathing effort reliably.
In adults, a diagnosis typically requires five or more central apneas or hypopneas per hour of sleep, with central events making up more than half of all breathing events, plus symptoms such as sleepiness, insomnia or waking short of breath. Your clinician will also look for causes, for example with heart tests, a review of medicines or brain imaging.
Treatment options
Treating the underlying cause
Optimising heart failure treatment, adjusting opioid medicines or descending from altitude can reduce or resolve central apneas.
CPAP
Continuous positive airway pressure helps some types of CSA and is often tried first.
Adaptive servo-ventilation (ASV)
A specialised device that adjusts pressure breath by breath. It is suggested for several types of CSA, but needs careful evaluation in people with heart failure with reduced ejection fraction, after a large trial (SERVE-HF) found higher cardiovascular death in that group.
Bilevel pressure with a backup rate
Delivers breaths if your own breathing pauses, used in selected cases.
Supplemental oxygen
Low-flow oxygen at night is an option for CSA related to heart failure.
Transvenous phrenic nerve stimulation
An implanted device stimulates the diaphragm nerve. Guidelines suggest it for some people with primary CSA or CSA due to heart failure, usually after other options are considered.
Medication
Drugs such as acetazolamide are sometimes used in specific situations under specialist supervision.
What you can do yourself
- Take heart failure and other prescribed medicines exactly as directed
- Tell every prescriber if you use opioids, and never adjust them on your own
- Avoid alcohol and sedatives near bedtime
- Use your prescribed device every night
- Plan ahead with your doctor before trips to high altitude
When to see a doctor
- You wake up gasping or short of breath
- You have heart failure or have had a stroke and feel unusually sleepy or sleep poorly
- You take opioids and someone notices pauses in your breathing
- New breathing pauses appear after you started CPAP for obstructive apnea
Frequently asked questions
How is central sleep apnea different from obstructive sleep apnea?
In obstructive apnea your body keeps trying to breathe against a blocked airway. In central apnea the brain briefly stops sending the signal to breathe, so there is no effort at all. A full in-lab sleep study that measures chest and belly movement can tell the two apart.
Can opioids cause central sleep apnea?
Yes. Long-term opioid use is a well-recognised cause of central sleep apnea and can also cause irregular, slow breathing during sleep. Do not stop or reduce opioids on your own; talk to your prescriber and a sleep specialist about options.
Is ASV safe if I have heart failure?
It depends on the type of heart failure. A large trial found more cardiovascular deaths with ASV in people with heart failure with reduced ejection fraction, so specialists assess heart function carefully before choosing it. Your sleep doctor and cardiologist should make this decision together.
Does altitude sickness cause breathing pauses at night?
Many people develop periodic breathing with central pauses when sleeping at high altitude, because low oxygen changes how the brain controls breathing. It usually improves after acclimatising or returning to lower altitude. Ask a clinician before a high-altitude trip if you already have a sleep or heart condition.
Sources
This page is general information, not a diagnosis or medical advice. Read our medical disclaimer.