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Central Sleep Apnea Syndromes Differential Diagnoses

  • Author: Kendra Becker, MD, MPH; Chief Editor: Ryland P Byrd, Jr, MD  more...
 
Updated: Mar 16, 2015
 
 

Diagnostic Considerations

This discussion includes the differentiation of central sleep apnea from non–central sleep apnea conditions.

  • Obstructive sleep apnea: This is a sleep disorder in which recurrent complete or partial upper airway obstruction produces snoring, oxygen desaturations, and numerous arousals. The repetitive upper airway collapse occurs during sleep because negative pressure generated during inspiration is not effectively counteracted by splinting by pharyngeal dilators, especially when narrowing occurs as a result of excessive soft tissue or vulnerable craniofacial anatomy. Patients may report loud snoring, witnessed apneas, and excessive daytime sleepiness. Physical examination characteristics often include a crowded oropharynx, increased neck and waist circumferences, and increased body mass index. Further, polysomnography (PSG) demonstrates prominent snoring and obstructive respiratory events (airflow is absent but ventilatory effort persists, as opposed to absent ventilatory effort in central sleep apnea) (see the image below).
    Obstructive sleep apnea (OSA): This polysomnogram Obstructive sleep apnea (OSA): This polysomnogram demonstrates typical hypopneas occurring in OSA prior to continuous positive airway pressure titration. In OSA, airflow is absent or reduced, but ventilatory effort persists.
  • Pseudocentral sleep apnea: Patients with diaphragmatic paralysis and other neuromuscular diseases, who are dependent on accessory muscles of breathing to maintain ventilation, may appear to have central apneas during rapid eye movement (REM) sleep. This is due to the REM atonia of skeletal muscles. Many of these patients actually have obstructive sleep apnea but do not have enough diaphragmatic excursions to be recorded by the piezoelectric belts used during routine PSG. A history of neuromuscular disease and worsening of central apneas during REM sleep should alert to the possibility of pseudocentral apnea.
  • Sleep-related hypoventilation syndrome: Sleep-related hypoventilation with central sleep apneas can be observed in many conditions, such as neuromuscular weakness or chronic obstructive pulmonary disease. These conditions are characterized by a history of a preexisting disorder of hypoventilation, elevated resting PaCO2, and severe oxygen desaturation during sleep, which is more prominent during REM sleep in contrast to primary central sleep apnea and Cheyne-Stokes breathing-central sleep apnea (CSB-CSA), which are mostly observed during NREM sleep.
 
 
Contributor Information and Disclosures
Author

Kendra Becker, MD, MPH Sleep Medicine Department, Kaiser Permanente Fontana Medical Center

Kendra Becker, MD, MPH is a member of the following medical societies: American College of Physicians, American Medical Association, American Academy of Sleep Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Jeanne M Wallace, MD, MPH Professor of Clinical Medicine, University of California at Los Angeles School of Medicine

Jeanne M Wallace, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Daniel R Ouellette, MD, FCCP Associate Professor of Medicine, Wayne State University School of Medicine; Chair of the Clinical Competency Committee, Pulmonary and Critical Care Fellowship Program, Senior Staff and Attending Physician, Division of Pulmonary and Critical Care Medicine, Henry Ford Health System; Chair, Guideline Oversight Committee, American College of Chest Physicians

Daniel R Ouellette, MD, FCCP is a member of the following medical societies: American College of Chest Physicians, Society of Critical Care Medicine, American Thoracic Society

Disclosure: Nothing to disclose.

Chief Editor

Ryland P Byrd, Jr, MD Professor of Medicine, Division of Pulmonary Disease and Critical Care Medicine, James H Quillen College of Medicine, East Tennessee State University

Ryland P Byrd, Jr, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

Sat Sharma, MD, FRCPC Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital

Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, World Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Rahul K Kakkar, MD, FCCP, FAASM, to the development and writing of this article.

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The role of loop gain in determining respiratory instability. A) When loop gain is less than 1, the tendency for an overshoot of the corrective response to an apnea or hypopnea is lessened, and ventilation returns to a steady pattern. B) When loop gain is greater than or equal to 1, the vigorous responses to respiratory disturbances result in continuous oscillation between the events and the corrections, resulting in an unstable periodic breathing pattern. Adapted from White DP Pathogenesis of obstructive and central sleep apnea. Am J Respir Crit Care Med. Dec 1 2005;172(11):1363-70.
This polysomnogram demonstrates central sleep apnea and Biot respiration in a patient receiving long-term morphine for chronic pain. The Biot pattern may be irregular without any type of periodicity, or it can consist of runs of similar-sized breaths alternating with central apneas.
Obstructive sleep apnea (OSA): This polysomnogram demonstrates typical hypopneas occurring in OSA prior to continuous positive airway pressure titration. In OSA, airflow is absent or reduced, but ventilatory effort persists.
Cheyne Stokes: This polysomnogram represents Cheyne Stokes breathing and occurred subsequent to continuous positive airway pressure titration for OSA in the same patient in the previous media file. Cheyne Stokes breathing has a classic crescendo-decrescendo breathing pattern.
 
 
 
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