Treatment of Central Sleep Apnea in US Veterans

Abstract

Background: There are no standard therapies for the management of central sleep apnea (CSA). Either positive pressure therapy (PAP) or supplemental oxygen (O 2 ) may stabilize respiration in CSA by reducing ventilatory chemoresponsiveness. Additionally, increasing opioid use and the presence of comorbid conditions in US veterans necessitates investigations into alternative titration protocols to treat CSA. The goal was to report on the effectiveness of titration with PAP, used alone or in conjunction with O 2 , for the management of CSA associated with varying comorbidities and opioid use. Methods: This was a retrospective chart review over 3 years, performed at a VA sleep disorders center. The effects of CPAP, CPAP+O 2 , and BPAP+O 2 , used in a step-wise titration protocol, on consecutive patients diagnosed with CSA were studied. Results: CSA was diagnosed in 162 patients. The protocol was effective in eliminating CSA (CAI ≤ 5/h) in 84% of patients. CPAP was effective in 48%, while CPAP+O 2 combination was effective in an additional 25%, and BPAP+O 2 in 11%. The remaining 16% were non-responders. Forty-seven patients (29%) were on prescribed opioid therapy for chronic pain, in whom CPAP, CPAP+O 2 , or BPAP+O 2 eliminated CSA in 54%, 28%, and 10% cases,, respectively. CPAP, CPAP+O 2 , and BPAP+O 2 each produced signifi cant declines in the AHI, CAI, and arousal index, and an increase in the SpO 2 .Conclusion: The data demonstrate that using a titration protocol with CPAP and then PAP with O 2 effectively eliminates CSA in individuals with underlying comorbid conditions and prescription opioid use. Comparative studies with other therapeutic modalities are required. S C I E N T I F I C I N V E S T I G A T I O N ST he treatment of central sleep apnea (CSA) continues to lack a universally recognized standard of care.1 Variable etiologies of CSA and the presence of concomitant disorders infl uence the choice of therapy. Thus, therapeutic options have varied markedly from positive airway pressure (PAP) devices, including continuous positive airway pressure (CPAP), 2-6 bilevel positive airway pressure therapy (BPAP), 7-9 and adaptive servoventilation, [10][11][12][13]20 to supplemental O 2 , 14-17 carbon dioxide, 21,22 and/or pharmacologic agents. [23][24][25]29,30 The outcomes of therapy have also varied considerably, with limited evidence to establish the effectiveness of any therapy for CSA. [26][27][28][29]31,32 The majority of published literature has focused on the treatment of CSA secondary to congestive heart failure (CHF), [2][3][4][5][6][7][8][9][10][11][15][16][17][18][19][20][21][22][26][27][28][29] with very little data on patients with "primary" CSA 23,24 or CSA secondary to causes other than CHF. 33 In addition, there is very little data on the treatment of CSA related to opioid use and CSA that is concomitant with OSA. 13,35 The latter entities are of increasing importance in the US veteran population due to the increased use of prescription opioid drugs for chronic pain control and the risk for opioi...

Correlates and consequences of central sleep apnea in a national sample of US veterans

“…We also observed that majority (64.1%) of the CSA group patients had comorbid OSA. This corroborates our findings from a previous smaller study from our sleep lab [28]. The presence of concomitant OSA in patients with CSA highlights the pathophysiological link between central and obstructive apnea.…”

“…Likewise, pharyngeal narrowing or occlusion during episodes of central apnea may be a precursor for OSA [31]. The aforementioned observations may provide a physiological explanation for the benefit of nasal CPAP in treating central apnea in over half of the patients with CSA [28]. However, additional analyses showed largely similar associations with OSA included in the comparison group (Supplementary Material) as well as in the CSA group with CSA and concomitant OSA diagnoses.…”

“…Future studies should also evaluate whether or not there is effect modification on outcomes and mortality based on adequate PAP adherence or other therapies (e.g. supplemental oxygen) for CSA [28]. We anticipate…”

Clinical Use of Loop Gain Measures to Determine Continuous Positive Airway Pressure Efficacy in Patients with Complex Sleep Apnea. A Pilot Study

“…Recognizing patients at higher risk of treatment failure with CPAP may be helpful in the future to identify those more likely to need alternative therapies, such as possibly adaptive servo devices or pharmacological agents to stabilize breathing (32,33). n ORIGINAL RESEARCH…”

Adaptive Servo-Ventilation and Central Apnea Associated with Systolic Heart Failure

“…CPAP may mitigate post-apneic ventilatory overshoot by increasing lung volumes and decreasing loop gain. 11 The majority of patients with central apnea have concomitant obstructive apnea, 12 and many others demonstrate upper airway narrowing or occlusion during central apneic events. 13 Therefore, a trial of CPAP therapy remains the treatment of choice.…”