When CPAP Does Not Resolve Treatment-Emergent Central Sleep Apnoea
Treatment-emergent central sleep apnoea (TECSA) — also called complex sleep apnoea — occurs when central apnoeic events emerge or persist during therapy for upper airway obstruction. When initial management with CPAP has not achieved sufficient improvement in central event frequency, a structured next-line approach is indicated.
Clinical Scenario
Central sleep apnoea arising in the context of therapy for upper airway obstruction — most commonly CPAP, but also non-PAP OSA treatment modalities. The persistence of these central events despite active treatment defines the complex sleep apnoea or TECSA phenotype.
Prior Treatment & Failure Condition
Continued CPAP therapy — with attention to avoiding excessive titration, minimising mask leak, and optimising co-existing sleep disorders contributing to arousals — did not achieve the treatment goal of improvement in the frequency of central events. The protocol below addresses the step taken after this failure.
Next-Line Approach (partial overview)
The protocol centres on switching to an alternative positive airway pressure modality. Depending on the full clinical picture, additional strategies targeting expiratory dynamics and evaluation for an alternative underlying cause of CSA may also feature in the management plan.
Goal: Reduction in apnoea-hypopnoea index
References
DOI: 10.1183/20734735.0235-2023
- The emergence or persistence of CSA during therapy for upper airway obstruction (often associated with CPAP, but can also occur with non-PAP OSA treatment modalities) is termed complex sleep apnoea or treatment-emergent CSA (TECSA).
- In ∼30% of patients with persistent CSA at 90 days, CPAP can be switched to ASV or bilevel PAP spontaneous/timed modes to reduce AHI and improve adherence (ASV appears superior to bilevel PAP due to sustained response).
- Enhanced expiratory rebreathing space may also be a solution as it prevents all the exhaled air from being vented through the CPAP mask.
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