By Alyx Arnett
Central sleep apnea (CSA) has long been one of the most complex and frustrating disorders for sleep clinicians. Its diverse etiologies, limited high-quality evidence, and historically narrow treatment options often left providers balancing uncertainty against risk.
The American Academy of Sleep Medicine (AASM) has now released a major clinical practice guideline update, revising prior guidance from 2012 and 2016. The new recommendations reflect both emerging evidence and a philosophical shift in how CSA should be treated—not just as a polysomnographic abnormality, but as a condition that meaningfully impacts patients’ lives.
Key updates include:
- Adaptive servo-ventilation (ASV) reemerging with defined guardrails
- Transvenous phrenic nerve stimulation added as a guideline-supported option
- A strong emphasis on individualized, patient-centered care, with success metrics extending beyond the apnea-hypopnea index (AHI)
“At the end of the day, we’re not just improving polysomnographic findings,” says M. Safwan Badr, MD, chair of the AASM guideline task force. “We have to make a difference in the lives of our patients.”
ASV Returns—With Caution and Context
The most closely watched change in the guideline is the reinstatement of ASV for treating CSA across multiple etiologies, including heart failure. This marks a reversal from the 2016 guideline, which advised against ASV following safety concerns raised by the 2015 SERVE-HF trial.
That trial reported increased mortality among patients with heart failure and reduced ejection fraction (HFrEF) treated with ASV—findings that significantly curtailed ASV use, even beyond the studied population.
“When we put all the evidence together, there is no mortality signal,” says Badr. “Some will disagree, but the task force followed the GRADE process to its conclusion.”
More recent data, including the 2024 ADVENT-HF trial, found that ASV safely eliminated sleep-disordered breathing in patients with HFrEF without increasing mortality. However, a subsequent meta-analysis concluded that available randomized controlled trials remain too limited to draw firm conclusions about cardiovascular mortality.
Guardrails for ASV Use
In response, the AASM added two key considerations:
- Shared decision-making is required, with transparent discussion of knowns and unknowns
- ASV should be initiated only in experienced centers, with close monitoring
“This may not be the right setting to initiate such a complex therapy” in all environments, Badr cautions.
For many clinicians, the update helps recalibrate practice patterns that became overly restrictive after SERVE-HF. “Labs greatly minimized—maybe over-minimized—their ASV use,” says James Blevins, product manager for sleep diagnostics at Cadwell.
Sleep physician Nancy Collop, MD, professor emeritus at Emory University, adds, “I would still personally try ASV on most patients—unless they have a low ejection fraction—and I’d let the patient decide after discussing the evidence.”
A New Option: Transvenous Phrenic Nerve Stimulation
For the first time, the AASM guideline formally recommends transvenous phrenic nerve stimulation for CSA. The implantable neurostimulator stabilizes breathing during sleep by stimulating the phrenic nerve and is positioned as a second-line option after more conservative therapies.
In the U.S., the only FDA-approved device for this indication is remedē® (ZOLL Respicardia).
“For PAP-intolerant patients, it’s something you can offer,” says Collop. “It’s not for everyone, but for symptomatic patients or those with significant comorbidities, it’s a reasonably good option.”
With its inclusion in the guideline, phrenic nerve stimulation is likely to reach more patients who previously may not have been informed of this therapy.
What’s Out—and What’s Discouraged
The guideline makes one explicit “against” recommendation:
Do not use bilevel PAP (BPAP) without a backup rate for CSA.
“Without a backup rate, BPAP will induce central apnea in essentially everyone,” says Badr. “This is how we induce central apnea in our research laboratory.”
BPAP with a backup rate remains recommended, supported by evidence showing improvements in sleepiness, disease severity, and cardiovascular outcomes.
The guideline also removes two pharmacologic therapies:
- Zolpidem, due to lack of evidence supporting arousal suppression for CSA
- Theophylline, reflecting limited efficacy and safety concerns
Moving Beyond AHI: Patient-Centered Outcomes Take Priority
One of the most meaningful shifts in the new guideline is its emphasis on patient-reported outcomes, not just numerical targets like AHI.
“If patients don’t see themselves in that AHI under five, there’s a sense of failure,” says Lacey Adams, RPSGT, CCSH, sleep coach at EnsoData. “Quality of life and how the patient feels have to matter.”
Rather than treating to a single threshold, clinicians are encouraged to ask:
- Is the patient less sleepy?
- Is fatigue improved?
- Are desaturations reduced?
- Is cardiovascular risk better controlled?
“Numbers alone don’t tell the full story,” Adams says.
This shift also aligns with growing interest in hypoxic burden, which captures the depth and duration of oxygen desaturation—metrics increasingly linked to cardiovascular outcomes.
Practical Pathways: From CPAP to Advanced Therapies
The guideline stops short of offering a rigid algorithm, but it does outline a logical progression.
CPAP remains a reasonable first-line therapy. “About 50% of patients may respond,” says Badr.
If central events persist or PAP is not tolerated, recommended options include:
- BPAP with backup rate
- ASV
- Low-flow oxygen
- Acetazolamide
- Transvenous phrenic nerve stimulation
“Successful outcomes depend not on one therapy, but on having many options,” says Teofilo Lee-Chiong, MD, medical liaison lead at Philips.
Etiology Matters in Central Sleep Apnea
CSA is not a single disease, and the guideline reinforces the importance of phenotyping:
- Heart failure–related CSA
- Opioid-induced CSA
- Treatment-emergent CSA
- Idiopathic CSA
“Why the patient has CSA often determines what treatment works best,” says Collop.
The guideline breaks recommendations down by etiology, though experts note that many trials still lump phenotypes together—highlighting a need for more targeted research.
Rising Complexity Demands Advanced Skills
Sleep labs are increasingly managing complex sleep-disordered breathing, driven by home sleep testing, medication effects, long COVID, and comorbid disease.
As advanced modalities become more common, detailed documentation of device settings and titration changes is critical. “Every adjustment matters,” says Blevins.
To support this shift, the Board of Registered Polysomnographic Technologists (BRPT) is developing an Advanced Titration Certificate, aimed at standardizing competencies for managing advanced therapies.
“This guideline validates a higher level of clinical skill,” says Jill West, RPSGT, CCSH, a member of the BRPT board.
What Comes Next
Experts agree the field needs:
- More randomized controlled trials
- Head-to-head and combination-therapy studies
- CSA-specific patient-reported outcome measures
- Better phenotyping to match treatments to subgroups
Still, the updated guideline sends a clear message: central sleep apnea is worth treating—when patients are symptomatic and therapies improve how they live and feel.
“We’re not just improving respiratory event counts,” says Badr. “We’re making a favorable difference in patients’ lives.”
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