Overview of the New AASM Guideline
A task force from the American Academy of Sleep Medicine (AASM) has released updated clinical practice recommendations for the treatment of central sleep apnea (CSA). Published online as an accepted paper in the Journal of Clinical Sleep Medicine, the guideline replaces and expands upon the AASM’s earlier parameters from 2012 and 2016. Led by Dr. M. Safwan Badr, chair of the AASM task force and physician-in-chief at Wayne State University, the guideline reflects the latest evidence on CSA management and emphasizes patient-centered care focused on quality of life and functional outcomes.
Key Features and Scope
Central sleep apnea is characterized by pauses or reductions in breathing caused by impaired respiratory effort. CSA can arise in various clinical contexts, including heart failure, obstructive sleep apnea, and opioid use. The pathophysiology and optimal treatment can differ depending on the underlying condition, so the guideline stresses individualized decision-making rather than a one-size-fits-all approach.
All nine recommendations in the guideline are labeled as “conditional.” This designation signals a lower certainty level and invites clinicians to apply clinical judgment, balancing patient preferences, values, and resource considerations when choosing therapies.
The document endorses six treatment options aligned with specific CSA etiologies: continuous positive airway pressure (CPAP), bilevel positive airway pressure with a backup rate (BPAP), adaptive servo ventilation (ASV), low-flow oxygen, oral acetazolamide, and transvenous phrenic nerve stimulation. Clinicians are advised to tailor therapy to the contributing condition driving breathing instability.
Adaptive Servo Ventilation and Cardiac Considerations
ASV remains a conditional recommendation for CSA with multiple etiologies. A notable caveat is the mixed evidence from a trial focused on CSA with systolic heart failure, which prompted the guideline to recommend cautious use of ASV in patients with heart failure with reduced ejection fraction (HFrEF). For these patients, treatment should occur in experienced centers with rigorous monitoring and follow-up to mitigate potential risks.
Transvenous Phrenic Nerve Stimulation
A new conditional recommendation highlights transvenous phrenic nerve stimulation as a therapeutic option for primary CSA and CSA secondary to heart failure. This involves an implanted device that continuously senses breathing and stimulates the phrenic nerve to stabilize respiration. FDA approval for moderate to severe CSA came in 2017, but the guideline notes that the procedure is invasive, not universally available, and costly. As such, it may be considered after other, less invasive treatments have been evaluated.
Clinical Application and Decision-Making
The guideline was developed through a rigorous process using the GRADE framework, which assesses the certainty of evidence, benefits and harms, patient values, and resource use. The task force conducted a systematic literature review and sought public input before finalizing the recommendations. The result is a nuanced set of conditional guidelines that aim to guide clinicians while acknowledging uncertainties and the need for patient-centered care.
Endorsements and Authorship
The guideline received support from multiple professional organizations, including the Alliance of Sleep Apnea Partners, the American Association for Respiratory Care, and the European Respiratory Society, among others. Co-authors include Dr. Rami N. Khayat, Dr. J. Shirine Allam, and several others, with methodological input from GRADE expert Rebecca Morgan. Some task force members disclosed associations that were carefully managed to maintain voting integrity.
Practical Takeaways for Clinicians
- Assess the underlying cause of CSA in each patient and prioritize improvements in quality of life and daily functioning.
- Consider CPAP, BPAP with backup rate, ASV, low-flow oxygen, acetazolamide, and transvenous phrenic nerve stimulation as part of a personalized treatment plan.
- Use ASV cautiously in patients with HFrEF, within experienced centers and with close follow-up.
- Discuss invasive options like phrenic nerve stimulation with patients, weighing benefits, risks, accessibility, and costs against noninvasive therapies.
Conclusion
The updated AASM guideline reflects evolving evidence on central sleep apnea therapies and reinforces a patient-centered approach. By acknowledging the conditional nature of the recommendations and the need for individualized care, the guideline supports clinicians in delivering effective, patient-valued treatment strategies for CSA across diverse clinical scenarios.
