Central Sleep Apnea Guidelines: AASM Recommendations & Clinical Practice
- New clinical practice guidelines from the American Academy of Sleep Medicine (AASM) offer updated recommendations for the treatment of central sleep apnea (CSA) in adults.
- Central sleep apnea is a condition where the brain doesn’t send proper signals to the muscles that control breathing, causing pauses in breathing during sleep.
- The AASM utilized the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to assess the certainty of evidence and assign strengths to each recommendation.
New clinical practice guidelines from the American Academy of Sleep Medicine (AASM) offer updated recommendations for the treatment of central sleep apnea (CSA) in adults. Released in late August 2025, these guidelines aim to standardize care and improve outcomes for individuals living with this often complex sleep disorder. The guidelines, developed by a task force of sleep medicine experts, are based on a systematic review of available literature and an assessment of the evidence.
Understanding Central Sleep Apnea
Central sleep apnea is a condition where the brain doesn’t send proper signals to the muscles that control breathing, causing pauses in breathing during sleep. This differs from obstructive sleep apnea, where the airway becomes physically blocked. CSA can stem from various causes, including underlying medical conditions, medication use, or can occur without a clear identifiable cause (primary CSA).
Guideline Development and Strength of Recommendations
The AASM utilized the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to assess the certainty of evidence and assign strengths to each recommendation. Recommendations are categorized as either “Strong” – meaning clinicians should follow them under most circumstances – or “Conditional,” indicating a more nuanced approach may be necessary based on individual patient factors. The process behind guideline development was rigorous, clarifying the distinction between evidence-based recommendations and expert opinion, as discussed in a recent episode of the “Talking Sleep” podcast featuring members of the AASM guideline committee.
Treatment Recommendations by CSA Etiology
The guidelines provide specific recommendations based on the underlying cause of CSA. For several etiologies – primary CSA, CSA due to heart failure, CSA due to medication or substance use, treatment-emergent CSA, and CSA due to a medical condition or disorder – the AASM suggests continuous positive airway pressure (CPAP) over no CPAP. Similarly, bilevel positive airway pressure (BPAP) with a backup rate is suggested over no BPAP with a backup rate for the same etiologies.
However, the guidelines specifically suggest against the use of BPAP without a backup rate in these same scenarios. Experts noted that backup rates are crucial, and heart failure patients are excluded from certain BPAP recommendations. This distinction highlights the importance of tailoring treatment to the specific needs of each patient.
Adaptive Servo-Ventilation (ASV): A Re-evaluation
Adaptive servo-ventilation (ASV) has been a controversial treatment for CSA, particularly following the SERVE-HF trial. Despite previous concerns, the AASM now conditionally recommends ASV over no ASV for the aforementioned CSA etiologies. This shift is due to newer ASV algorithms differing from those used in the SERVE-HF study. The guidelines emphasize the importance of shared decision-making between patients and providers, and treatment at experienced centers.
Other Therapeutic Options and Considerations
Beyond PAP therapies, the guidelines address other potential treatments. Oxygen therapy is considered for heart failure and high-altitude CSA, though insurance coverage can be a challenge. Acetazolamide is also discussed as a potential option across multiple CSA etiologies, with recommendations for prescribing and follow-up protocols. Transvenous phrenic nerve stimulation is noted as an option for select patients, but its invasive nature, limited accessibility, and high cost were acknowledged.
Shifting Towards Chronic Disease Management
The AASM guidelines reflect a growing understanding of CSA as a chronic condition requiring ongoing management. This includes monitoring beyond the apnea-hypopnea index (AHI) – a measure of breathing disturbances – and focusing on patient-reported symptoms and improvements in quality of life. The shift also has implications for billing, with the introduction of billing code G211.
Clinical Judgment Remains Paramount
The AASM emphasizes that these guidelines are intended to guide, but not constrain, clinical judgment. The optimal approach to CSA treatment should incorporate clinical features, comorbid conditions, and polysomnographic findings in an individualized manner. Clinicians must prioritize optimizing therapy for the conditions contributing to central apneas and improving patient-reported outcomes rather than solely focusing on eliminating disordered breathing events. If central respiratory events persist after initiating therapy, re-evaluation of underlying risk factors and consideration of alternative treatment options is recommended.
These updated guidelines, published on , represent a significant step forward in the evidence-based management of central sleep apnea, offering clinicians a framework for providing individualized and effective care. As of , these guidelines are the most current recommendations from the AASM regarding CSA treatment.