New AASM Guideline Updates Central Sleep Apnea Treatment Options
A task force from the American Academy of Sleep Medicine (AASM) has released updated clinical practice guidelines for the treatment of central sleep apnea (CSA). Available as an accepted paper in the Journal of Clinical Sleep Medicine, the guideline revises the AASM’s prior parameters published in 2012 and 2016, reflecting advances in CSA research and new therapeutic technologies. The emphasis remains on individualized, patient-centered care aimed at improving quality of life and functional outcomes alongside reducing disordered breathing events.
Key Features of the Guideline
All nine clinical recommendations in the new guideline are designated as “conditional.” This designation indicates a lower certainty level and requires clinicians to apply careful judgment that incorporates patient values, preferences, and resource considerations when choosing the best treatment path. The recommendations support six treatment options for specific CSA etiologies, including:
- Continuous positive airway pressure (CPAP)
- Bilevel positive airway pressure with a backup rate (BPAP)
- Adaptive servo ventilation (ASV)
- Low-flow oxygen
- Oral acetazolamide
- Transvenous phrenic nerve stimulation
The guideline stresses the need to consider the underlying condition contributing to breathing instability, such as heart failure, obstructive sleep apnea, or opioid use, when selecting and optimizing CSA therapy. This approach aligns with the overall goal of improving patient-centered outcomes beyond merely suppressing apnea events.
Adaptive Servo Ventilation: Cautious Use in Heart Failure
Adaptive servo ventilation received a conditional recommendation for CSA with multiple etiologies. However, the guideline notes concerns raised by a clinical trial involving CSA patients with systolic heart failure (heart failure with reduced ejection fraction, HFrEF). As a result, the use of ASV in HFrEF patients should be confined to experienced centers with careful monitoring and follow-up to ensure patient safety and effectiveness of therapy.
Transvenous Phrenic Nerve Stimulation: An Emerging Option
The guideline adds a conditional recommendation for transvenous phrenic nerve stimulation as a treatment for primary CSA and CSA due to heart failure. This therapy uses an implantable device that senses breathing and provides automatic stimulation to stabilize respiration. FDA approval for moderate to severe adult CSA was granted in 2017, recognizing its potential. Nevertheless, given the invasive nature, accessibility challenges, and high cost, the guideline advises that other treatments may be explored first before considering this option.
How Clinicians Should Apply the Guideline
The methods used to develop the guideline followed the GRADE approach, evaluating the certainty of evidence, potential benefits and harms, patient values, and resource use. A systematic literature review informed the recommendations, which were reviewed publicly before final approval by the AASM board. The guideline was endorsed by a wide range of sleep and respiratory care organizations, underscoring its relevance to multidisciplinary CSA care.
Clinical Implications and Next Steps
Central sleep apnea is a complex disorder that often coexists with other medical conditions such as heart failure and COPD, or complications from opioid use. The updated recommendations reflect a move away from a one-size-fits-all approach toward a nuanced, individualized strategy. Clinicians should engage in shared decision-making with patients, balancing potential benefits with risks, costs, and accessibility of therapies. Ongoing monitoring and follow-up are essential, particularly for conditional recommendations that require tailoring to each patient’s clinical status and life circumstances.
About the Guideline Development
The AASM task force was composed of sleep medicine physicians with expertise in CSA. The panel conducted a rigorous systematic review and applied the GRADE framework to assess evidence strength. Public commentary helped shape final recommendations, and the board granted endorsement to reflect broad professional support for these updates. The co-authors and GRADE methodologist contributed to the manuscript, with some disclosure of conflicts of interest as appropriate.
View more AASM clinical practice guidelines and learn about the guideline development process on the association’s website.
