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Sleep Apnea, Central

Definition :
Central sleep apnea is a disorder in which your breathing repeatedly stops and starts during sleep due to lack of respiratory effort. Unlike obstructive sleep apnea, in which you try to breath normally but can't because of upper airway obstruction, central sleep apnea occurs when your brain doesn't send proper signals to the muscles that control your breathing. Central sleep apnea is much less common than other types, accounting for less than 10 percent of diagnosed sleep apneas.

Central sleep apnea may occur as a result of other conditions, such as heart failure and conditions that affect your nervous system (neurological conditions) such as stroke or Shy-Drager syndrome. Sleeping at a high altitude also may cause central sleep apnea. Signs and symptoms of central sleep apnea include difficulty staying asleep, abrupt awakenings accompanied by shortness of breath and daytime sleepiness.

Treatments for central sleep apnea may involve using a device to keep your airway open or using supplemental oxygen.

Causes:
Central sleep apnea occurs when your brain fails to transmit signals to your breathing muscles. Central sleep apnea can be caused by a number of conditions that affect the ability of your brainstem — which links your brain to your spinal cord and controls many functions such as heart rate and breathing — to control your breathing. The cause varies with the type of central sleep apnea you have. Types include :
  • Idiopathic central sleep apnea. The cause of this uncommon type of central sleep apnea isn't known. It results in repeated pauses in breathing effort and airflow.
  • Cheyne-Stokes respiration. This type of central sleep apnea is most commonly associated with congestive heart failure or stroke, and it is characterized by a rhythmic, gradual increase and then decrease in breathing effort and airflow. During the weakest breathing effort, a total lack of airflow (central apneas) can occur.
  • Medical condition induced. In addition to congestive heart failure and stroke, several medical conditions may give rise to central apneas. Any damage to the part of the brain that controls breathing (the brainstem) or the nerves that supply breathing signals — such as from a tumor, trauma, infection (for example, polio) or degenerative brain disorder — may impair the normal breathing process. In addition, many disorders that affect muscles, such as amyotrophic lateral sclerosis, myotonic dystrophy or myasthenia gravis may lead to central apneas or poor breathing during sleep.
  • High-altitude periodic breathing. Periodic breathing occurs in most people if they're exposed to a high-enough altitude, such as greater than 15,000 feet. The change in barometric pressure at this altitude can cause loss of breath as well as rapid breathing (hyperventilation). The breathing pattern can be similar to Cheyne-Stokes respiration, but the time it takes to cycle through the pattern is shorter.
  • Drug or substance induced. Taking certain medications such as opioids — for example, morphine, oxycodone or codeine — may cause your breathing to become irregular, to increase and decrease in a regular pattern, or to stop completely.
Risk Factor :
Certain factors put you at increased risk of central sleep apnea :
  • Sex. Males are more likely to develop all types of central sleep apnea than are females.
  • Heart disorders. People with atrial fibrillation or congestive heart failure are more at risk of central sleep apnea. Between 25 percent and 40 percent of men with congestive heart failure have central sleep apnea.
  • Stroke or brain tumor. These conditions can impair the brain's ability to regulate breathing.
  • Neuromuscular disorders. Conditions such as amyotrophic lateral sclerosis (Lou Gehrig's disease), spinal cord injuries and Parkinson's disease can affect central nervous system breathing functions.
  • High altitude. Sleeping at an altitude higher than you're accustomed to may increase your risk of sleep apnea. Altitudes above 15,000 feet may cause the condition in some people. Sleeping above 25,000 feet causes sleep apnea in all people. This is no longer a problem when returning to a lower altitude.
  • Taking opioids. Anyone taking long-acting opioids, such as morphine and codeine, for more than two months is at risk of central sleep apnea.

When to seek medical advice :
Consult a medical professional if you experience, or if your partner observes, any signs or symptoms of central sleep apnea, particularly the following :

  • Shortness of breath that awakens you from sleep
  • Intermittent pauses in your breathing during sleep
  • Difficulty staying asleep
  • Excessive daytime drowsiness, which may cause you to fall asleep while you're working, watching television or driving

Ask your doctor about any sleep problem that leaves you chronically fatigued, sleepy and irritable. Excessive daytime drowsiness (hypersomnia) may be due to other disorders, such as narcolepsy.

Symptoms :
The most common signs and symptoms of central sleep apnea include :

  • Observed episodes of stopped breathing or abnormal breathing patterns during sleep
  • Abrupt awakenings accompanied by shortness of breath
  • Difficulty staying asleep (insomnia)
  • Excessive daytime sleepiness (hypersomnia)
  • Momentary shortness of breath at night
  • Difficulty concentrating

If your central sleep apnea is caused by a neurological condition, you may experience other signs and symptoms such as :

  • Lightheadedness on standing up from a sitting or lying position
  • Difficulty swallowing
  • Weakness, or numbness throughout your body

You may also snore if you have central sleep apnea, although this may not be as prominent as it is in those who have obstructive sleep apnea.

Diagnosis:
Your doctor may make an evaluation based on your signs and symptoms or may refer you to a sleep disorder center. There, a sleep specialist can help you decide on your need for further evaluation. Such an evaluation often involves overnight monitoring of your breathing and other body functions during sleep. Tests to detect central sleep apnea may include :

  • Nighttime monitoring (nocturnal polysomnography). During this test, equipment monitors your heart, lung and brain activity, breathing patterns, arm and leg movements, and blood-oxygen levels while you sleep. This can help your doctor rule out other conditions — such as periodic limb movements or narcolepsy — that can cause excessive daytime sleepiness but require different treatment.
  • Blood oxygen monitoring (oximetry). This screening method involves using a small device that monitors and records your blood-oxygen level while you're asleep. A small sleeve fits painlessly over one of your fingers to collect the information overnight at home. If you have sleep apnea, the results of this test will often show drops in your oxygen level during apneas and subsequent rises with awakenings. If the results are abnormal, your doctor may have you undergo polysomnography to confirm the diagnosis. Oximetry doesn't detect all cases of sleep apnea, so your doctor may still recommend a polysomnogram even if the oximetry results are normal.
  • Portable breathing (cardiorespiratory) testing. Under unusual circumstances, your doctor may provide you with tests to be used at home to detect sleep apnea. These tests usually involve oximetry, measurement of airflow and breathing patterns.

An evaluation by a heart specialist (cardiologist) or a doctor who specializes in the nervous system (neurologist) may be necessary to look for causes of central sleep apnea.

Complications :
Central sleep apnea is a serious medical condition. Complications include :

  • Cardiovascular problems. Sudden drops in blood-oxygen levels that occur during sleep apnea increase blood pressure and strain the cardiovascular system. These changes raise the risk of heart failure and stroke. If there's underlying heart disease, these repeated multiple episodes of low blood oxygen (hypoxia or hypoxemia) worsen prognosis and increase the risk of abnormal heart rhythms.
  • Daytime fatigue. In addition, the repeated awakenings associated with sleep apnea make normal, restorative sleep impossible. People with sleep apnea often experience severe daytime drowsiness, fatigue and irritability. You may have difficulty concentrating and find yourself falling asleep at work, while watching TV or even when driving.

Treatment:
Treatments for central sleep apnea may include :

  • Treatment for associated medical problems. Possible causes of central sleep apnea include heart or neuromuscular disorders, and treating those conditions may help your sleep apnea. For example, appropriate therapy for heart failure may eliminate central sleep apnea.
  • Reduction of opioid medications. If opioid medications are causing your sleep apnea, your doctor may gradually reduce your dose of those medications.
  • Supplemental oxygen. Using supplemental oxygen while you sleep may help if you have central sleep apnea. Various forms of oxygen are available as well as different devices to deliver oxygen to your lungs. This treatment isn't recommended for those with heart failure.
  • Medications. Certain medications have been used to stimulate breathing in people with central sleep apnea. For example, some doctors prescribe acetazolamide to prevent central sleep apnea in high altitude.
  • Continuous positive airway pressure (CPAP). This method, also used to treat obstructive sleep apnea, involves wearing a mask over your nose while you sleep. The mask is attached to a small pump that supplies pressurized air which holds open your upper airway. CPAP may eliminate snoring and prevent central sleep apnea. As with obstructive sleep apnea, it's important that you use the device only as directed. If your mask is uncomfortable or the pressure feels too strong, talk with your doctor so that adjustments can be made.
  • Bilevel positive airway pressure (bilevel PAP). Unlike CPAP, which supplies steady, constant pressure to your upper airway as you breathe in and out, bilevel PAP builds to a higher pressure when you inhale and decreases to a lower pressure when you exhale. The goal of this treatment is to boost the weak breathing pattern of central sleep apnea. Some bilevel PAP devices can be set to automatically deliver a breath if the device detects you haven't taken a breath after a certain number of seconds.
  • Adaptive servo-ventilation ASV). This newer airflow device is designed to treat central sleep apnea and complex sleep apnea. The device monitors your normal breathing pattern and stores the information in a built-in computer. After you fall asleep, the machine uses pressure to regulate your breathing pattern and prevent pauses in your breathing.
 
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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