title: Recognition and management of complex sleep-disordered breathing.
abstract: OBJECTIVE
  The recent rapid evolution of our understanding of the mechanisms involved in control of respiration during sleep has yielded new insights to guide our care of difficult-to-treat sleep apnea patients with complex sleep-disordered breathing. This review will describe these recent advances in the literature and suggest a model for their incorporation into clinical practice.
  
  
  RESULTS
  Control of respiration during sleep shows amplified instability relative to that seen during wake in these difficult patients. Baseline (eupneic) carbon dioxide levels as well as the responsiveness of the ventilatory system to changes in carbon dioxide are all-important in this relative instability. Furthermore, the instability seen during sleep varies widely across sleep states. A further refinement of our definition of stable and unstable sleep has been developed that directly informs our understanding of the control of respiration across a night of sleep.
  
  
  CONCLUSIONS
  Complex sleep-disordered breathing is a distinct form of sleep apnea. It has recognizable characteristics that are present without, and often worsened during, positive airway pressure treatment. Both sleep state stability and the behavior of the respiratory control system contribute to this complexity. It is only with a clear understanding of the factors contributing to complex sleep-disordered breathing that implementation of truly effective clinical therapy can be achieved for this disorder, which to date is poorly controlled.
authors.affiliation: Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02115, USA.
authors.forename: Geoffrey S
authors.initials: GS
authors.lastname: Gilmartin
authors.forename: Robert W
authors.initials: RW
authors.lastname: Daly
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Thomas
mesh_terms: D000086:Acetazolamide / Q000627:therapeutic use; D000403:Airway Resistance; D002245:Carbon Dioxide / Q000378:metabolism*; D006801:Humans; D016857:Hypocapnia / Q000517:prevention & control; D010102:Oxygen Inhalation Therapy; D017286:Polysomnography; D011175:Positive-Pressure Respiration; D012119:Respiration; D012890:Sleep / Q000502:physiology*; D012891:Sleep Apnea Syndromes / Q000145:classification / Q000503:physiopathology* / Q000628:therapy; D013806:Theophylline / Q000627:therapeutic use
chemical_list: D002245:Carbon Dioxide; D013806:Theophylline; D000086:Acetazolamide