A 65-year-old male with a history of heart failure and central sleep apnea with Cheyne-Stokes (CSA-CSB) breathing presents to your clinic for evaluation. He had been started on continuous positive airway pressure (CPAP) therapy but did not tolerate it. His recent echocardiogram shows an ejection fraction (EF) of 40%. His medical therapy has already been optimized.
What is the MOST appropriate management of this patient?A. Initiate adaptive servo-ventilation (ASV)
Correct Answer: C
The optimal treatment of CSA-CSB in patients with an EF ≤45% who do not tolerate CPAP is uncertain. Although ASV use was recommended by the 2012 American Academy of Sleep Medicine (AASM) guidelines (1), a distinction was made in the 2016 update (2) between its use in patients with EF ≤45% (in whom it is contraindicated, option A is therefore wrong) and in patients with EF >45% (in whom it may be considered). Currently, the guidelines suggest initiation of supplemental nocturnal oxygen (option C). In the presence of an established diagnosis of CSA-CSB, another inlaboratory PSG is not indicated (option B). Finally, use of BPAP-ST is only indicated by the guidelines if there is no response to an adequate trial of CPAP and oxygen therapies (therefore option D is incorrect).