Central sleep apnea<\/a> (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.<\/p>\n\n\n\nThe American Academy of Sleep Medicine (AASM)<\/strong> has now released a major clinical practice guideline update<\/strong>, revising prior guidance from 2012 and 2016. The new recommendations reflect both emerging evidence and a philosophical shift in how CSA should be treated\u2014not just as a polysomnographic abnormality, but as a condition that meaningfully impacts patients\u2019 lives.<\/p>\n\n\n\nKey updates include:<\/p>\n\n\n\n
\n- Adaptive servo-ventilation (ASV)<\/strong> reemerging with defined guardrails<\/li>\n\n\n\n
- Transvenous phrenic nerve stimulation<\/strong> added as a guideline-supported option<\/li>\n\n\n\n
- A strong emphasis on individualized, patient-centered care<\/strong>, with success metrics extending beyond the apnea-hypopnea index (AHI)<\/li>\n<\/ul>\n\n\n\n
\u201cAt the end of the day, we\u2019re not just improving polysomnographic findings,\u201d says M. Safwan Badr, MD<\/strong>, chair of the AASM guideline task force. \u201cWe have to make a difference in the lives of our patients.\u201d<\/p>\n\n\n\n
\n\n\n\nASV Returns\u2014With Caution and Context<\/h2>\n\n\n\n
The most closely watched change in the guideline is the reinstatement of ASV<\/strong> 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<\/strong>.<\/p>\n\n\n\nThat trial reported increased mortality among patients with heart failure and reduced ejection fraction (HFrEF)<\/strong> treated with ASV\u2014findings that significantly curtailed ASV use, even beyond the studied population.<\/p>\n\n\n\n\u201cWhen we put all the evidence together, there is no mortality signal,\u201d says Badr. \u201cSome will disagree, but the task force followed the GRADE process to its conclusion.\u201d<\/p>\n\n\n\n
More recent data, including the 2024 ADVENT-HF trial<\/strong>, 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.<\/p>\n\n\n\nGuardrails for ASV Use<\/h3>\n\n\n\n
In response, the AASM added two key considerations:<\/p>\n\n\n\n
\n- Shared decision-making is required<\/strong>, with transparent discussion of knowns and unknowns<\/li>\n\n\n\n
- ASV should be initiated only in experienced centers<\/strong>, with close monitoring<\/li>\n<\/ol>\n\n\n\n
\u201cThis may not be the right setting to initiate such a complex therapy\u201d in all environments, Badr cautions.<\/p>\n\n\n\n
For many clinicians, the update helps recalibrate practice patterns that became overly restrictive after SERVE-HF. \u201cLabs greatly minimized\u2014maybe over-minimized\u2014their ASV use,\u201d says James Blevins<\/strong>, product manager for sleep diagnostics at Cadwell.<\/p>\n\n\n\nSleep physician Nancy Collop, MD<\/strong>, professor emeritus at Emory University, adds, \u201cI would still personally try ASV on most patients\u2014unless they have a low ejection fraction\u2014and I\u2019d let the patient decide after discussing the evidence.\u201d<\/p>\n\n\n\n
\n\n\n\nA New Option: Transvenous Phrenic Nerve Stimulation<\/h2>\n\n\n\n
For the first time, the AASM guideline formally recommends transvenous phrenic nerve stimulation<\/strong> for CSA. The implantable neurostimulator stabilizes breathing during sleep by stimulating the phrenic nerve and is positioned as a second-line option<\/strong> after more conservative therapies.<\/p>\n\n\n\nIn the U.S., the only FDA-approved device for this indication is remed\u0113\u00ae<\/strong> (ZOLL Respicardia).<\/p>\n\n\n\n\u201cFor PAP-intolerant patients, it\u2019s something you can offer,\u201d says Collop. \u201cIt\u2019s not for everyone, but for symptomatic patients or those with significant comorbidities, it\u2019s a reasonably good option.\u201d<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
\n\n\n\nWhat\u2019s Out\u2014and What\u2019s Discouraged<\/h2>\n\n\n\n
The guideline makes one explicit \u201cagainst\u201d recommendation<\/strong>:
Do not use bilevel PAP (BPAP) without a backup rate<\/strong> for CSA.<\/p>\n\n\n\n\u201cWithout a backup rate, BPAP will induce central apnea in essentially everyone,\u201d says Badr. \u201cThis is how we induce central apnea in our research laboratory.\u201d<\/p>\n\n\n\n
BPAP with<\/strong> a backup rate remains recommended, supported by evidence showing improvements in sleepiness, disease severity, and cardiovascular outcomes.<\/p>\n\n\n\nThe guideline also removes two pharmacologic therapies<\/strong>:<\/p>\n\n\n\n\n- Zolpidem<\/strong>, due to lack of evidence supporting arousal suppression for CSA<\/li>\n\n\n\n
- Theophylline<\/strong>, reflecting limited efficacy and safety concerns<\/li>\n<\/ul>\n\n\n\n
\n\n\n\nMoving Beyond AHI: Patient-Centered Outcomes Take Priority<\/h2>\n\n\n\n
One of the most meaningful shifts in the new guideline is its emphasis on patient-reported outcomes<\/strong>, not just numerical targets like AHI.<\/p>\n\n\n\n\u201cIf patients don\u2019t see themselves in that AHI under five, there\u2019s a sense of failure,\u201d says Lacey Adams, RPSGT, CCSH<\/strong>, sleep coach at EnsoData. \u201cQuality of life and how the patient feels have to matter.\u201d<\/p>\n\n\n\nRather than treating to a single threshold, clinicians are encouraged to ask:<\/p>\n\n\n\n
\n- Is the patient less sleepy?<\/li>\n\n\n\n
- Is fatigue improved?<\/li>\n\n\n\n
- Are desaturations reduced?<\/li>\n\n\n\n
- Is cardiovascular risk better controlled?<\/li>\n<\/ul>\n\n\n\n
\u201cNumbers alone don\u2019t tell the full story,\u201d Adams says.<\/p>\n\n\n\n
This shift also aligns with growing interest in hypoxic burden<\/strong>, which captures the depth and duration of oxygen desaturation\u2014metrics increasingly linked to cardiovascular outcomes.<\/p>\n\n\n\n
\n\n\n\nPractical Pathways: From CPAP to Advanced Therapies<\/h2>\n\n\n\n
The guideline stops short of offering a rigid algorithm, but it does outline a logical progression.<\/p>\n\n\n\n
CPAP<\/strong> remains a reasonable first-line therapy. \u201cAbout 50% of patients may respond,\u201d says Badr.<\/p>\n\n\n\nIf central events persist or PAP is not tolerated, recommended options include:<\/p>\n\n\n\n
\n- BPAP with backup rate<\/li>\n\n\n\n
- ASV<\/li>\n\n\n\n
- Low-flow oxygen<\/li>\n\n\n\n
- Acetazolamide<\/li>\n\n\n\n
- Transvenous phrenic nerve stimulation<\/li>\n<\/ul>\n\n\n\n
\u201cSuccessful outcomes depend not on one therapy, but on having many options,\u201d says Teofilo Lee-Chiong, MD<\/strong>, medical liaison lead at Philips.<\/p>\n\n\n\n
\n\n\n\nEtiology Matters in Central Sleep Apnea<\/h2>\n\n\n\n
CSA is not a single disease, and the guideline reinforces the importance of phenotyping<\/strong>:<\/p>\n\n\n\n\n- Heart failure\u2013related CSA<\/li>\n\n\n\n
- Opioid-induced CSA<\/li>\n\n\n\n
- Treatment-emergent CSA<\/li>\n\n\n\n
- Idiopathic CSA<\/li>\n<\/ul>\n\n\n\n
\u201cWhy the patient has CSA often determines what treatment works best,\u201d says Collop.<\/p>\n\n\n\n
The guideline breaks recommendations down by etiology, though experts note that many trials still lump phenotypes together\u2014highlighting a need for more targeted research.<\/p>\n\n\n\n
\n\n\n\nRising Complexity Demands Advanced Skills<\/h2>\n\n\n\n
Sleep labs are increasingly managing complex sleep-disordered breathing<\/strong>, driven by home sleep testing, medication effects, long COVID, and comorbid disease.<\/p>\n\n\n\nAs advanced modalities become more common, detailed documentation of device settings and titration changes is critical. \u201cEvery adjustment matters,\u201d says Blevins.<\/p>\n\n\n\n
To support this shift, the Board of Registered Polysomnographic Technologists (BRPT)<\/strong> is developing an Advanced Titration Certificate<\/strong>, aimed at standardizing competencies for managing advanced therapies.<\/p>\n\n\n\n\u201cThis guideline validates a higher level of clinical skill,\u201d says Jill West, RPSGT, CCSH<\/strong>, a member of the BRPT board.<\/p>\n\n\n\n
\n\n\n\nWhat Comes Next<\/h2>\n\n\n\n
Experts agree the field needs:<\/p>\n\n\n\n
\n- More randomized controlled trials<\/li>\n\n\n\n
- Head-to-head and combination-therapy studies<\/li>\n\n\n\n
- CSA-specific patient-reported outcome measures<\/li>\n\n\n\n
- Better phenotyping to match treatments to subgroups<\/li>\n<\/ul>\n\n\n\n
Still, the updated guideline sends a clear message: central sleep apnea is worth treating\u2014when patients are symptomatic and therapies improve how they live and feel.<\/strong><\/p>\n\n\n\n\u201cWe\u2019re not just improving respiratory event counts,\u201d says Badr. \u201cWe\u2019re making a favorable difference in patients\u2019 lives.\u201d<\/p>\n\n\n\n
\n","protected":false},"excerpt":{"rendered":"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, […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-204","post","type-post","status-publish","format-standard","hentry","category-uncategorized"],"_links":{"self":[{"href":"https:\/\/canisleep.com\/index.php\/wp-json\/wp\/v2\/posts\/204","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/canisleep.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/canisleep.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/canisleep.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/canisleep.com\/index.php\/wp-json\/wp\/v2\/comments?post=204"}],"version-history":[{"count":1,"href":"https:\/\/canisleep.com\/index.php\/wp-json\/wp\/v2\/posts\/204\/revisions"}],"predecessor-version":[{"id":205,"href":"https:\/\/canisleep.com\/index.php\/wp-json\/wp\/v2\/posts\/204\/revisions\/205"}],"wp:attachment":[{"href":"https:\/\/canisleep.com\/index.php\/wp-json\/wp\/v2\/media?parent=204"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/canisleep.com\/index.php\/wp-json\/wp\/v2\/categories?post=204"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/canisleep.com\/index.php\/wp-json\/wp\/v2\/tags?post=204"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}