New clinical practice guideline provides updated recommendations for treatment of central sleep apnea

A new clinical practice guideline developed by a task force of the American Academy of Sleep Medicine provides updated recommendations for the treatment of central sleep apnea.

Available online as an accepted paper in the Journal of Clinical Sleep Medicine, the guideline updates the AASM's previous practice parameters published in 2012 and 2016. Among other significant updates, it incorporates evidence from recent studies of adaptive servo ventilation and addresses new developments including the introduction of transvenous phrenic nerve stimulation as a novel therapy.

Central sleep apnea is a complex form of sleep-disordered breathing that requires individualized, patient-centered care. It is essential for the treating clinician to prioritize improvements in quality of life and functional outcomes rather than focusing exclusively on the elimination of disordered breathing events."

Dr. M. Safwan Badr, lead author, chair of the AASM task force and chair of the department of internal medicine at Wayne State University School of Medicine in Detroit, Michigan

Central sleep apnea involves disruption of sleep due to an absence or reduction in breathing effort coupled with a reduction or cessation in airflow. This breathing instability can occur with various clinical conditions including heart failure, obstructive sleep apnea, and use of opioids. The pathogenesis of central sleep apnea can vary depending on the underlying clinical condition.

All nine clinical recommendations in the guideline are designated as "conditional," meaning that they reflect a lower degree of certainty and require the clinician to use clinical judgment while considering the patient's values and preferences to determine the best course of action. These recommendations support six treatment options for specific etiologies of central sleep apnea: continuous positive airway pressure, bilevel positive airway pressure with a backup rate, adaptive servo ventilation, low-flow oxygen, oral acetazolamide, and transvenous phrenic nerve stimulation. The guideline states that clinicians must consider the underlying condition contributing to breathing instability when selecting and optimizing therapy for central sleep apnea.

Adaptive servo ventilation received a conditional recommendation for central sleep apnea due to multiple etiologies. However, because of questions raised by one clinical trial involving patients with central sleep apnea and systolic heart failure, the guideline emphasizes that treatment with adaptive servo ventilation in patients with heart failure with reduced ejection fraction should be limited to centers with experience and should include close monitoring and follow-up.

The guideline includes a new conditional recommendation for transvenous phrenic nerve stimulation for primary central sleep apnea and central sleep apnea due to heart failure. This treatment involves the use of an implantable device that turns on automatically and works continuously to monitor and stabilize breathing. In 2017 the Food and Drug Administration approved the device to treat moderate to severe central sleep apnea in adult patients. Because the treatment requires an invasive procedure, is not universally accessible, and is associated with high costs, the guideline advises that it may be more appropriate to consider other treatments first.

To develop the guideline, the AASM commissioned a task force of sleep medicine physicians with expertise in treating central sleep apnea. They crafted clinical practice recommendations based on a systematic review of the literature and an assessment of the evidence according to the GRADE process, taking into consideration the certainty of evidence, beneficial and harmful effects, patient values and preferences, and resource use. The draft guideline was posted for public comment, and the AASM board of directors approved the final recommendations.

This guideline was endorsed by the Alliance of Sleep Apnea Partners, American Association for Respiratory Care, American Association of Sleep Technologists, Australasian Sleep Association, European Respiratory

Society, European Sleep Research Society, Heart Failure Society of America, Society of Anesthesia and Sleep Medicine, and the Society of Behavioral Sleep Medicine. The American Academy of Otolaryngology-Head and Neck Surgery and its foundation affirmed the value of this guideline.

The co-authors of the guideline are Dr. Rami N. Khayat, Dr. J. Shirine Allam, Suzanne Hyer, Dr. Reem A. Mustafa, Dr. Matthew T. Naughton, Dr. Susheel Patil, Dr. Grace Pien, Dr. Winfried Randerath, and Dr. Christine Won. GRADE methodologist Rebecca Morgan provided additional assistance.

View more AASM clinical practice guidelines and learn more about the guideline development process.

Hyer is employed by the AASM. Patil serves on the AASM board of directors. Randerath received support for a speaking engagement from Philips Respironics and therefore did not participate in voting for the adaptive servo ventilation recommendation. The task force members reported no other relevant conflicts of interest.

To request a copy of the clinical practice guideline, "Treatment of central sleep apnea in adults: an American Academy of Sleep Medicine clinical practice guideline," or the systematic review, meta-analysis, and GRADE assessment, or to arrange an interview with Dr. Badr or an AASM spokesperson, please contact the AASM at [email protected]. Accepted papers, which are published online prior to their final inclusion in an issue of the journal, are not embargoed. The guideline was posted as an accepted paper on Aug. 18 and is scheduled to be published in the December issue of the Journal of Clinical Sleep Medicine.