title: What is central sleep apnea?
abstract: Central sleep apnea (CSA) describes a group of conditions in which cessations in air flow occur without respiratory effort. In contrast, obstructive sleep apnea patients have ongoing respiratory effort during respiratory events. However, considerable overlap exists in the pathogenesis and clinical presentation of obstructive sleep apnea and CSA. A good working knowledge of the mechanisms underlying CSA is important for optimal clinical care. In general, CSA can be classified into those with excessive drive (eg, Cheyne-Stokes breathing) versus those with inadequate drive (eg, sleep hypoventilation syndrome). One critical factor contributing to the cessation of air flow during sleep is the concept of the apnea threshold, such that a P(aCO(2)) value below a certain level will lead to cessations in breathing. P(aCO(2)) can fall below the chemical apnea threshold when drive is excessive (eg, robust chemosensitivity) or when hyperventilation is occurring (eg, following arousal). Another important factor is the loss of the so-called wakefulness drive to breathe, such that some rise in P(aCO(2)) is likely to occur at the onset of sleep. A variety of factors contribute to this rise, including upper-airway collapse and diminished chemosensitivity (particularly during rapid-eye-movement sleep). In patients with low central drive, this further loss of drive at sleep onset can lead to marked hypercapnia in some cases. The treatment of CSA is also reviewed in some detail, including a role for positive airway pressure (eg, bi-level positive airway pressure in hypoventilation patients) and optimization of medical therapy (eg, in Cheyne-Stokes breathing). A paucity of research exists in this area, emphasizing the opportunities for young investigators who are interested in this field.
authors.affiliation: Division of Sleep, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA. amalhotra1@partners.org
authors.forename: Atul
authors.initials: A
authors.lastname: Malhotra
authors.forename: Robert L
authors.initials: RL
authors.lastname: Owens
mesh_terms: D002639:Cheyne-Stokes Respiration / Q000503:physiopathology; D045422:Continuous Positive Airway Pressure; D003937:Diagnosis, Differential; D004569:Electroencephalography; D006801:Humans; D017286:Polysomnography; D020182:Sleep Apnea, Central / Q000175:diagnosis / Q000503:physiopathology* / Q000628:therapy; D020181:Sleep Apnea, Obstructive / Q000503:physiopathology
references.citation: J Appl Physiol (1985). 1988 Oct;65(4):1676-85
references.pmid: 3141362
references.citation: J Intensive Care Med. 2007 Jan-Feb;22(1):44-51
references.pmid: 17259568
references.citation: J Appl Physiol (1985). 2008 Aug;105(2):404-16
references.pmid: 18535135
references.citation: Am J Respir Crit Care Med. 2001 Aug 15;164(4):614-9
references.pmid: 11520725
references.citation: N Engl J Med. 1982 Oct 7;307(15):931-3
references.pmid: 6810179
references.citation: J Physiol. 2004 Aug 1;558(Pt 3):993-1004
references.pmid: 15218069
references.citation: N Engl J Med. 1996 Aug 22;335(8):562-7
references.pmid: 8678934
references.citation: Chest. 2007 Aug;132(2):433-9
references.pmid: 17573498
references.citation: Respir Physiol Neurobiol. 2008 Dec 10;164(1-2):38-48
references.pmid: 18579454
references.citation: N Engl J Med. 2005 Nov 10;353(19):2025-33
references.pmid: 16282177
references.citation: Prog Cardiovasc Dis. 2009 Jan-Feb;51(4):339-49
references.pmid: 19110135
references.citation: Curr Opin Pulm Med. 2008 Nov;14(6):519-24
references.pmid: 18812828
references.citation: J Clin Sleep Med. 2008 Oct 15;4(5):406-8
references.pmid: 18853695
references.citation: J Am Coll Cardiol. 2004 Jul 7;44(1):68-71
references.pmid: 15234409
references.citation: Clin Chest Med. 1998 Mar;19(1):21-32
references.pmid: 9554215
references.citation: Am J Respir Crit Care Med. 2001 Dec 15;164(12):2147-65
references.pmid: 11751180
references.citation: Am J Respir Crit Care Med. 2010 Jan 15;181(2):189-93
references.pmid: 19762565
references.citation: Brain Res. 1997 Dec 5;778(1):127-34
references.pmid: 9462884
references.citation: Chest. 2003 Feb;123(2):322-5
references.pmid: 12576341
references.citation: Chest. 2007 Feb;131(2):595-607
references.pmid: 17296668
references.citation: Sleep. 2007 Apr;30(4):468-75
references.pmid: 17520791
references.citation: Circulation. 2000 Jul 4;102(1):61-6
references.pmid: 10880416
references.citation: Circulation. 1999 Mar 23;99(11):1435-40
references.pmid: 10086966
references.citation: Curr Opin Pulm Med. 2005 Nov;11(6):485-93
references.pmid: 16217173
references.citation: N Engl J Med. 1981 Aug 6;305(6):325-30
references.pmid: 7017417
references.citation: Lancet. 1997 Jun 14;349(9067):1720-4
references.pmid: 9193381
references.citation: J Appl Physiol (1985). 1993 Apr;74(4):1475-83
references.pmid: 8514660
references.citation: J Appl Physiol (1985). 1988 Sep;65(3):1389-99
references.pmid: 3141355
references.citation: Chest. 2007 Jul;132(1):81-7
references.pmid: 17475636
references.citation: J Appl Physiol (1985). 2007 Aug;103(2):578-86
references.pmid: 17495123
references.citation: Am J Respir Crit Care Med. 2001 Apr;163(5):1181-90
references.pmid: 11316657
references.citation: Sleep. 2006 Jan;29(1):16-8
references.pmid: 16453975
references.citation: Am J Respir Crit Care Med. 2004 Feb 1;169(3):361-6
references.pmid: 14597482
references.citation: Eur Respir J. 1997 Jan;10(1):226-37
references.pmid: 9032519
references.citation: Thorax. 2009 Jul;64(7):561-6
references.pmid: 19213769
references.citation: Int Rev Physiol. 1976;9:341-85
references.pmid: 135739
references.citation: Am J Respir Crit Care Med. 2006 Jan 15;173(2):234-7
references.pmid: 16239622
references.citation: Am J Respir Crit Care Med. 2002 May 1;165(9):1203-4
references.pmid: 11991865
references.citation: Chest. 2007 Apr;131(4):964-71
references.pmid: 17426196
references.citation: J Clin Sleep Med. 2008 Aug 15;4(4):305-10
references.pmid: 18763420
references.citation: Chest. 1993 Oct;104(4):1079-84
references.pmid: 8404170
references.citation: Arch Intern Med. 2006 Sep 18;166(16):1716-22
references.pmid: 16983049
references.citation: Proc Am Thorac Soc. 2008 Feb 15;5(2):144-53
references.pmid: 18250206
references.citation: Am J Respir Crit Care Med. 2006 Oct 15;174(8):923-7
references.pmid: 16873766
references.citation: Ann Intern Med. 1995 Apr 1;122(7):487-92
references.pmid: 7872582
references.citation: N Engl J Med. 2000 Jul 27;343(4):269-80
references.pmid: 10911010
references.citation: Med Clin North Am. 1985 Nov;69(6):1205-19
references.pmid: 3934482
references.citation: Lancet. 2002 Jul 20;360(9328):237-45
references.pmid: 12133673
references.citation: Respir Physiol. 2000 Sep;122(2-3):167-82
references.pmid: 10967342
references.citation: Prog Cardiovasc Dis. 2009 Jan-Feb;51(4):313-23
references.pmid: 19110133
references.citation: J Appl Physiol (1985). 1988 Sep;65(3):1244-50
references.pmid: 3053581
references.citation: Arch Intern Med. 1982 Oct;142(10):1816-9
references.pmid: 6812522
references.citation: Am J Med Genet. 1993 Sep 1;47(3):360-7
references.pmid: 8135282
references.citation: Am J Med. 2004 Jan 1;116(1):1-7
references.pmid: 14706658
references.citation: J Clin Sleep Med. 2009 Jun 15;5(3):205-11
references.pmid: 19960639
references.citation: Circulation. 1999 Mar 30;99(12):1574-9
references.pmid: 10096933
references.citation: Lancet. 2001 Mar 17;357(9259):884-5
references.pmid: 11265981
references.citation: Prog Clin Biol Res. 1990;345:23-30; discussion 31
references.pmid: 2198591
references.citation: Exp Physiol. 2005 Jan;90(1):13-24
references.pmid: 15572458
references.citation: Prog Cardiovasc Dis. 2009 Jan-Feb;51(4):279-84
references.pmid: 19110129
references.citation: Respir Care. 2010 Oct;55(10):1333-44; discussion 1344-6
references.pmid: 20875160
references.citation: Clin Chest Med. 1998 Mar;19(1):115-25
references.pmid: 9554222
references.citation: N Engl J Med. 2003 Mar 27;348(13):1233-41
references.pmid: 12660387
references.citation: J Appl Physiol (1985). 1998 Jan;84(1):3-12
references.pmid: 9451611
references.citation: J Clin Sleep Med. 2008 Feb 15;4(1):38-42
references.pmid: 18350960
references.citation: Chest. 2005 Aug;128(2):657-62
references.pmid: 16100151
references.citation: Eur Respir J. 2008 Nov;32(5):1328-36
references.pmid: 18579546
references.citation: Intensive Care Med. 1998 Jul;24(7):651-3
references.pmid: 9722033
references.citation: Circulation. 2007 Jun 26;115(25):3173-80
references.pmid: 17562959