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 demonstrates typical hypopneas occurring in OSA prior to continuous positive airway pressure titration. In OSA, airflow is absent or reduced, but ventilatory effort persists.

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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.

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Media Gallery

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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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; Medical Director, Pulmonary Medicine General Practice Unit (F2), Senior Staff and Attending Physician, Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital

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

Disclosure: Received research grant from: Sanofi Pharmaceutical.

Chief Editor

Zab Mosenifar, MD, FACP, FCCP Geri and Richard Brawerman Chair in Pulmonary and Critical Care Medicine, Professor and Executive Vice Chairman, Department of Medicine, Medical Director, Women's Guild Lung Institute, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD, FACP, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, 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 Faculty of Medicine; Site Director, Respiratory Medicine, St Boniface General Hospital, Canada

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.

Central Sleep Apnea Syndromes Differential Diagnoses

Diagnostic Considerations

Obstructive sleep apnea

Pseudocentral sleep apnea

Sleep-related hypoventilation syndrome

References

Tables

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