DSM-5

Diagnostic Criteria

A. Evidence by polysomnography of five or more central apneas per hour of sleep.

B. The disorder is not better explained by another current sleep disorder.

Specify whether:

  • Idiopathic central sleep apnea: Characterized by repeated episodes of apneas and hypopneas during sleep caused by variability in respiratory effort but without evidence of airway obstruction.
  • Cheyne-Stokes breathing: A pattern of periodic crescendo-decrescendo variation in tidal volume that results in central apneas and hypopneas at a frequency of at least five events per hour, accompanied by frequent arousal.
  • Central sleep apnea comorbid with opioid use: The pathogenesis of this subtype is attributed to the effects of opioids on the respiratory rhythm generators in the medulla as well as the differential effects on hypoxic versus hypercapnic respiratory drive.

Note: When an opioid use disorder is present, first record the opioid use diosrder: mild opioid use disorder or moderate or severe opioid use disorder; then record central sleep apnea comorbid with opioid use. When an opioid use disorder is not present (e.g., after a one-time heavy use of the substance), record only central sleep apnea comorbid with opioid use.

Specify current severity:

Severity of central sleep apnea is graded according to the frequency of the breathing disturbances as well as the extent of associated oxygen desaturation and sleep fragmentation that occur as a consequence of repetitive respiratory disturbances.

Subtypes

Idiopathic central sleep apnea and Cheyne-Stokes breathing are characterized by increased gain of the ventilatory control system, also referred to as high loop gain, which leads to instability inventilation and PaCO2 levels. This instability is termed periodic breathing and can be recognized by hyperventilation alternating with hypoventilation. Individuals with these disorders typically have pCO2 levels while awake that are slightly hypocapneic or normocapneic. Central sleep apnea may also manifest during initiation of treatment of obstructive sleep apnea hypopnea or may occur in association with obstructive sleep apnea hypopnea syndrome (termed complex sleep apnea). The occurrence of central sleep apnea in association with obstructive sleep apnea is also considered to be due to high loop gain. In contrast, the pathogenesis of central sleep apnea comorbid with opioid use has been attributed to the effects of opioids on the respiratory rhythm generators in the medulla as well as to its differential effects on hypoxic versus hypercapneic respiratory drive. These individuals may have elevated pCO2 levels while awake. Individuals receiving chronic methadone maintenance therapy have been noted to have increased somnolence and depression, although the role of breathing disorders associated with opioid medication in causing these problems has not been studied.

Specifiers

An increase in the central apnea index (i.e., number of central apneas per hour of sleep) reflects an increase in severity of central sleep apnea. Sleep continuity and quality may be markedly impaired with reductions in restorative stages of non-rapid eye movement (REM) sleep (i.e., decreased slow-wave sleep [stage N3]). In individuals with severe Cheyne-Stokes breathing, the pattern can also be observed during resting wakefulness, a finding that is thought to be a poor prognostic marker for mortality.

Differential Diagnosis

Idiopathic central sleep apnea must be distinguished from other breathing-related sleep disorders, other sleep disorders, and medical conditions and mental disorders that cause sleep fragmentation, sleepiness, and fatigue. This is achieved using polysomnography.

Other breathing-related sleep disorders and sleep disorders

Central sleep apnea can be distinguished from obstructive sleep apnea hypopnea by the presence of at least five central apneas per hour of sleep. These conditions may co-occur, but central sleep apnea is considered to predominate when the ratio of central to obstructive respiratory events exceeds 50%.

Cheyne-Stokes breathing can be distinguished from other mental disorders, including other sleep disorders, and other medical conditions that cause sleep fragmentation, sleepiness, and fatigue based on the presence of a predisposing condition (e.g., heart failure or stroke) and signs and polysomnographic evidence of the characteristic breathing pattern. Polysomnographic respiratory findings can help distinguish Cheyne-Stokes breathing from insomnia due to other medical conditions. High-altitude periodic breathing has a pattern that resembles Cheyne-Stokes breathing but has a shorter cycle time, occurs only at high altitude, and is not associated with heart failure.

Central sleep apnea comorbid with opioid use can be differentiated from other types of breathing-related sleep disorders based on the use of long-acting opioid medications in conjunction with polysomnographic evidence of central apneas and periodic or ataxic breathing. It can be distinguished from insomnia due to drug or substance use based on polysomnographic evidence of central sleep apnea.

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