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Central Sleep Apnea (CSA)

Restless sleep

Sleep apnea describes a form of sleep disorder characterized by disordered breathing. There are two primary types of sleep apnea: central sleep apnea and obtrusive sleep apnea.

Central sleep apnea (CSA) is characterized by pauses in breathing during sleep due to a signal disruption from the central nervous system. Typically, the episodes last for 10-30 seconds (or longer) and can be intermittent in nature or happen in cycles throughout the night. Central sleep apnea is associated with lower oxygen saturation levels, a condition called hypoxia or hypoxemia, which can lead to serious health complications.

Central Sleep Apnea Causes

Oxygen and Carbon Dioxide Imbalance

One of the most common central sleep apnea causes is an imbalance in the body's levels of oxygen and carbon dioxide, both of which should stay fairly constant when the body is at rest. 

There are chemoreceptors in the body, which are governed by oxygen and carbon dioxide levels in the bloodstream. These chemoreceptors send signals to the brain to tell it when to open the throat and other breathing airways, as well as to move the muscles associated with respiratory efforts. Regular respiration allows the body to remove excess, harmful carbon dioxide from the lungs and bloodstream. 

However, in central sleep apnea, the chemoreceptors that lie within the brain dysfunction during sleep, failing to give the brain a signal to inhale. This causes several cycles of breath to be missed, leaving the body with an increase in carbon dioxide levels. 

Issues with Respiratory Regulation

Another central sleep apnea cause is an issue with respiratory regulation. The brain and heart normally work together to keep a balanced level of oxygen and carbon dioxide in the bloodstream.  However, the heart and brain may differ in what each organ considers “normal” inhalation and exhalation cycles.   

Central sleep apnea causes the neurological centers in the brain that are responsible for breathing cycles to fail to react fast enough to keep the respiratory rate even and unlabored. This causes the respiratory rate to fluctuate between central sleep apnea and hypopnea episodes throughout the night.

During the breathing pauses, the individual makes no efforts to start breathing again, the chest does not move, and the muscles do not relax or contract. Individuals will wake up and not be able to immediately start breathing again, leading to a feeling of panic and cognitive dysfunction. These symptoms are associated with excess carbon dioxide levels in the blood.

Cheyne-Stokes Respirations

Cheyne-Stokes respirations are characterized by periodic breathing with regular episodes of alternating between central sleep apnea and rapid breathing, causing extreme fluctuations in oxygen and carbon dioxide levels in the bloodstream. 

This is a condition found in patients with congestive heart failure and is not restricted to sleep, but can happen during waking hours as well. It is also common in patients with kidney failure and stroke. It is believed that treatment of the failing organ leads to a resolution of Cheyne-Stokes respirations.

Central Sleep Apnea Diagnosis Study

Central Sleep Apnea Diagnosis

A central sleep apnea diagnosis can be completed by licensed physicians. The first step in a central sleep apnea diagnosis requires an examination,  which generally includes the individual staying overnight in a sleep laboratory to receive a sleep study, or polysomnography, administered by a technician. 

Periods of breathing cessation are measured in frequency during the sleep study, which will allow the technician to help determine what type of sleep apnea is present.In central sleep apnea, the interruption in breathing is associated with physically being unable to restart the cycle. A polysomnogram will show the relation between the cessation of airflow through the nose and mouth, as well as the absence of muscle movement in the rib cage and abdominal area.

Since central sleep apnea is frequently associated with heart, lung, or kidney diseases, there are other tests that are done with polysomnography, including:

  • Lung function tests
  • MRI of head, spine, or neck
  • Echocardiogram

Central Sleep Apnea Treatments

After diagnosis, a licensed physician will provide a few different options for central sleep apnea treatment. 

CPAP

Continuous positive airway pressure (CPAP) treatment is usually reserved for those with   obstructive sleep apnea, rather than those with central sleep apnea.  The patient wears a face mask that is connected to a machine, which provides pressured airflow into the breathing passages. The device compresses the room air at a constant level so that the airway does not collapse, which is typical in OSA cases. While it is usually at a higher level, it stays low enough so that the individual can easily exhale on their own.

BiPAP

BiLevel Positive airway pressure (BiPAP) is much more common in central sleep apnea treatment . It differs from CPAP (continuous positive airway pressure) in that it is not at a constant high pressure, but is set at two separate pressure settings: IPAP (for inhalation) and EPAP (for exhalation). This allows the user to have a more normal respiratory rhythm. The lungs are inflated at a regular interval, which is a measurement that includes both the duration of a single breath and the normal breathing rate. The BiPAP levels are programmed by the diagnosing provider.

ASV

Adaptive Servo Ventilation (ASV) is a newer technology that is being used for central sleep apnea treatment. . ASV is similar to CPAP, but uses a different algorithm.

Sleeping Position

This is more of a lifestyle change, rather than a treatment, but recent studies have shown that changing your sleep position at night may have an impact on the severity of one type of central sleep apnea : Cheyne-Stokes.

Positional changes are known to affect the severity of obstructive sleep apnea. However, recent research has looked at how these changes may affect central sleep apnea patients as well. There was an increased severity of Cheyne-Stoke respirations when patients slept in the supine position (lying on their back).  Otherwise, patients with central sleep apnea and no known cardiac conditions were not seen to have any symptom changes related to position during sleep.

Implantable Electronic Devices

There are relatively new treatments that use programmed electrical impulse to stimulate the diaphragm for  central sleep apnea treatment. They physically resemble cardiac pacemakers. However, they are attached to the phrenic nerve.

Sources:

  1. Blaivas, A. J., DO, & Zieve, D., MD. (n.d.). Central sleep apnea: MedlinePlus Medical Encyclopedia. Retrieved July 19, 2016, from https://medlineplus.gov/ency/article/003997.htm
  2. Zaharna M; Rama A; Chan R; Kushida C. A case of positional central sleep apnea. J Clin Sleep Med 2013;9(3):265-268.

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6 comments on “Central Sleep Apnea (CSA)”

  1. I was in an auto accident I n 1983. I have complex apnea. Central and osa. I have trouble swallowing also . I suffer with head aches at the base of my skull. I believe that I may have a brain stem injury. I also have RA and spinal stenosis at my C6Candy C7 . I have cracking sound behind my sinus . Doctors just shrug when I bring this up also can't hold my phone with my left hand for more than one minute because of the pain that goes from my neck shoulder down my arm . I would love to find a doctor who would listen to me and get a real diagnosis. Maybe I would be a canidit for this device. My name is Robert.

  2. I have been diagnosed with both types of sleep apneas and would like more information on this implanted device. Can it be installed by a family phisition and what is the cost. Is it covered by the Saskatchewan Health insurance program.

  3. ...edited...

    While there may be other companies with "highly experimental devices,” the Avery Diaphragm Pacemaker is NOT one of them.

    Indeed, the Avery Diaphragm Pacemaker System was first commercially sold in 1971 (46 years ago).
    Since the inception of the regulatory requirement in 1986, The Avery System has full FDA PMA approval.

    In addition, there are numerous long-term studies on the Avery System. In fact, peer-reviewed scientific articles on the benefits of The Avery Diaphragm Pacemaker include, but are not limited to, long-term pacing, financial benefits and improved patient outcomes. Furthermore, testimonials from those using the Avery System (some pacing 24/7 for over 35 years), prefer the Avery pacer to mechanical ventilation (MV) because it:
    *reduces the risk of complications caused by MV such
    as Ventilator-associated Pneumonia, (VAP)
    *allows for normal breathing and speech patterns
    *eases eating and drinking
    *is small and does not require the bulky batteries and awkward tubing of MV, greatly enhancing their mobility
    *operates silently which improves their ability to actively participate in social activities.

    Lastly, implantation of the Avery Diaphragm Pacemaker can be performed either cervical or thoracic using minimally invasive techniques such as video assisted (VATS) or thoracoscopic approaches.
    The Avery Pacing System does not require approval from a hospital investigational review board (IRB).
    Surgeons do not require any specialized training; nor do they require the assistance of a company-employed physician.

    ...edited....

    Avery Biomedical Devices, Inc.

  4. Since having a discectomy and bone fusion (C4/C5) twenty years ago I have had the symptoms of what I now believe to be “ Central Sleep Apnea “ . This alarming condition has worsened as I have grown older and I believe that in my case there will be no simple solution. I am a very fit athletic male who at 63 can still run 5km in 19.5 mins. I do worry that this condition will shorten my life expectancy. Having emigrated to a country which does not give me access to free medicine, I feel that there is not much I can do to address this problem. I found the coverage of this topic on this site to be most helpful.

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