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More than 18 million Americans suffer from sleep apnea and many cases go undiagnosed, according to the National Sleep Foundation. The two most prominent types of sleep apnea are obstructive and central. While central sleep apnea, or CSA, is the less common form, if left untreated, it can lead to severe heart and vascular health complications.
Previous treatments for CSA have been largely ineffective, as they haven't tackled the source of the problem. However, experts of the University of Chicago Medicine recently introduced a breakthrough procedure to stimulate the nerves and muscles that keep people with CSA breathing throughout the night. UChicago Medicine is the first hospital in Chicago to offer this latest, implantable treatment option.
We spoke with pulmonologist Babak Mokhlesi, MD, an expert in sleep disorders, and cardiologist Hemal Nayak, MD, an expert in heart rhythm disorders and arrhythmias, about CSA and the treatment options available.
There are more than 80 types of sleep disorders, but the most common is sleep apnea. Sleep apnea is a serious, potentially life-threatening condition that is far more common than generally understood. Obstructive sleep apnea, or OSA, is usually caused when the soft tissue around the airway collapses during sleep. In contrast, CSA is characterized by decrease of breathing effort during sleep, which can decrease oxygen levels.
Unlike OSA, with CSA the upper airway remains mostly open during the apnea. The symptoms of CSA can be similar to those of OSA, though, which include chronic fatigue, daytime sleepiness, morning headaches and restless sleep. However, some patients with heart failure and severe CSA do not complain of snoring or excessive daytime sleepiness. If the cause of CSA is a neurological disease, you may also experience difficulty swallowing, voice changes, and an overall sense of weakness and numbness.
Patients with heart failure, atrial fibrillation, kidney failure, and those who have a chronic use of opioid medications or have had a stroke are at an increased risk for developing CSA. Men are also more likely to develop CSA than women, and patients over age 65 are at an increased risk. Untreated CSA causes sudden drops in blood oxygen levels that occur during the apnea and can lead to significant fluctuations in the blood pressure during sleep. All of this puts a significant strain on the cardiovascular system.
The best way to diagnose any form of sleep apnea is to undergo a sleep study, after which your sleep medicine expert can provide a diagnosis and treatment options. To diagnose CSA, a sleep study that takes place overnight in an outpatient sleep laboratory, also known as a polysomnogram, is recommended.
A polysomnogram is a test that records your brain waves, heart rate and breathing, as well as eye and leg movements, while you sleep. Sensors are placed on your head, face, chest and legs and send tiny electrical signals to a computer. The breathing monitors detect reduction or complete pauses of air flow and changes in oxygen levels so that the diagnosis and the severity of sleep apnea can be established.
Treatment options for CSA can be complex, especially for those who also suffer from heart conditions. It is important that your sleep expert coordinate with your cardiologist for treatment options. In most CSA cases, continuous positive airway pressure, or CPAP, is ineffective. You may be given adaptive-servo-ventilation, or ASV, which is a more complex positive airway pressure device designed to normalize breathing pattern. However, ASV can increase the risk of death in patients with heart failure and reduced ejection fraction.
Additionally, we now offer another breakthrough option -- a U.S. Food and Drug Administration-approved phrenic nerve stimulation treatment called the Remedē System. The implantable device, which was approved in 2017, stimulates a nerve in the chest that is responsible for sending signals to the diaphragm to stimulate breathing.
UChicago Medicine was the first hospital in Chicago to offer this latest, implantable treatment option for patients with CSA. The system is the newest addition to UChicago Medicine's Sleep Disorders Center, which offers a number of noninvasive and minimally invasive sleep disorder treatments.
The Remedē System is usually implanted under the skin in the right upper chest, similar to a pacemaker, during an outpatient procedure with sedation. The generator sits over the pectoral muscle and is connected to two leads, or wires. The leads work in tandem to deliver the therapy and to sense breathing. The stimulating lead activates a nerve in the chest, called the phrenic nerve, to send signals to the large muscle in the chest and abdomen called the diaphragm, mimicking how the brain signals breathing.
The therapy is not turned on immediately. We wait for six weeks after implantation to allow the leads to settle in. After six weeks, the device is programmed to deliver therapy at night during sleep and is tailored to each patient’s specific sleeping habits and needs.
The device will be detectable over the right upper chest, under the skin, just like a pacemaker. Once healed, it will not cause any discomfort. In the beginning, you may feel a slight sensation when the device is actively stimulating the diaphragm. Once you get adjusted to it, most patients no longer become aware of it.
As with any medical procedure, there are risks. But the overall risk is quite small. The risk of minor or major complications is about 1 to 2 percent and includes infection, lead dislodgement, bleeding, excessive pain, lung or heart puncture.
Babak Mokhlesi, MD, MSc, is a pulmonologist and an expert in sleep disorders. He treats patients with a wide variety of disorders, ranging from respiratory disorders of sleep — such as sleep apnea and obesity hypoventilation syndrome — to non-respiratory sleep disorders.Learn more about Dr. Mokhlesi
An expert in cardiac electrophysiology, Hemal M. Nayak, MD, provides care for patients with heart rhythm problems (arrhythmias). He specializes in catheter ablation -- a minimally invasive procedure in which high frequency radio waves are used to eliminate abnormal heart rhythms.Learn more about Dr. Nayak