Central sleep apnea (CSA) is treated through a combination of addressing underlying medical conditions, using specialized breathing devices during sleep, and in some cases, medication or implantable nerve stimulators. Unlike obstructive sleep apnea, where the airway physically collapses, CSA happens because the brain intermittently fails to send the signal to breathe. That distinction matters because it changes which treatments work and which don’t.
The American Academy of Sleep Medicine currently recommends six treatment options for CSA: continuous positive airway pressure (CPAP), bilevel positive airway pressure with a backup breathing rate, adaptive servo-ventilation, low-flow oxygen, oral acetazolamide, and transvenous phrenic nerve stimulation. All of these recommendations are designated as “conditional,” meaning the best choice depends on what’s causing your CSA, how severe it is, and your overall health.
Treating the Underlying Cause First
The first step in managing CSA is identifying and optimizing whatever medical condition is driving it. For many people, CSA isn’t a standalone problem. It’s a downstream effect of heart failure, kidney disease, opioid use, or even living at high altitude. When the root cause improves, the breathing pauses during sleep often improve too.
For heart failure, this means optimizing cardiac medications and, in some cases, pursuing advanced heart failure therapies. For kidney failure, the focus shifts to managing fluid balance through diuretics or dialysis. If opioid medications are the trigger, the goal is safely reducing or stopping the medication. These aren’t quick fixes, but they target the actual source of the problem rather than just managing symptoms overnight.
Positive Airway Pressure Devices
If treating the underlying condition doesn’t resolve CSA, the next line of treatment is a breathing device worn during sleep. Three types of positive airway pressure (PAP) therapy are used for CSA, and they differ significantly in how well they work.
CPAP
Standard CPAP delivers a constant stream of air pressure to keep the airway open. It’s the go-to treatment for obstructive sleep apnea, and it can help some CSA patients too, particularly those with heart failure-related CSA. However, its track record with central events is mixed. In one study of patients who didn’t respond well to CPAP, the device reduced obstructive pauses but central apneas persisted, leaving the overall apnea-hypopnea index (AHI, the number of breathing disruptions per hour) at a median of 31 events per hour. That’s still in the moderate-to-severe range.
Bilevel PAP With a Backup Rate
Bilevel PAP (often called BiPAP) delivers two different pressure levels: higher when you inhale, lower when you exhale. For CSA, the key feature is the backup rate, a setting that automatically triggers a breath if you stop breathing on your own. Without the backup rate, bilevel therapy can actually make CSA worse. One study found that bilevel PAP in spontaneous mode (no backup rate) pushed the median AHI up to 75 events per hour. With the backup rate activated, it dropped to 15, a meaningful improvement.
Adaptive Servo-Ventilation
Adaptive servo-ventilation (ASV) is the most sophisticated PAP device for CSA. It continuously monitors your breathing pattern and adjusts pressure breath by breath, stepping in more aggressively when it detects a pause and backing off when your breathing normalizes. In clinical testing, ASV reduced the AHI to a mean of 5 events per hour, well within the normal range. About 64 patients in one trial achieved an AHI below 10, which is the typical treatment success threshold.
There is one critical safety caveat. ASV is potentially harmful for people with symptomatic chronic heart failure and a reduced left ventricular ejection fraction of 45% or below. A clinical trial raised serious concerns about increased risk in this group, and the American Academy of Sleep Medicine advises against prescribing ASV for these patients. If you have heart failure and CSA, your doctor should check your ejection fraction before considering ASV. For heart failure patients who do use ASV, treatment should be managed at an experienced center with close follow-up.
Treatment-Emergent Central Sleep Apnea
About 8% of people who start CPAP therapy for obstructive sleep apnea develop central apneas that weren’t there before. This is called treatment-emergent central sleep apnea (TECSA), and it can be alarming when it shows up on a follow-up sleep study. The good news is that it resolves on its own in most cases with continued CPAP use. It’s considered a dynamic, often transient process. A smaller number of patients see it persist, and in rare cases it appears for the first time after months of therapy. For the majority, the recommendation is to continue PAP therapy and monitor. For select patients whose TECSA doesn’t resolve, switching to a different PAP mode like ASV may be appropriate.
Medications
Acetazolamide is the primary medication used for CSA. It works by slightly acidifying the blood, which stimulates the brain’s drive to breathe. Originally recognized for preventing altitude sickness, it has demonstrated real benefits for CSA at sea level as well. A systematic review found that acetazolamide reduced the AHI by an average of about 23 events per hour in CSA patients. Beyond reducing breathing pauses, it improved oxygen levels during sleep, increased total sleep time by roughly 26 minutes per night, and improved sleep efficiency (the percentage of time in bed actually spent asleep) by nearly 5 percentage points.
These are meaningful improvements, particularly for people who can’t tolerate PAP devices. That said, acetazolamide comes with side effects like tingling in the hands and feet, increased urination, and taste changes, which can limit its long-term use for some people.
Phrenic Nerve Stimulation
For patients who don’t respond to PAP therapy or medications, an implantable device that stimulates the phrenic nerve is an option. The phrenic nerve runs from the neck down to the diaphragm, and it’s the main nerve responsible for telling your diaphragm to contract and draw air into your lungs. In CSA, the brain stops sending that signal during sleep. A phrenic nerve stimulator detects when breathing has paused and delivers a small electrical impulse to the nerve, causing the diaphragm to contract and mimicking a natural breath.
The FDA approved this device in 2017 for moderate to severe CSA in adults, and recent AASM guidelines include it as a conditional recommendation for primary CSA and CSA related to heart failure. Because it requires a surgical implant procedure, isn’t widely available at all sleep centers, and carries significant costs, guidelines suggest trying other treatments first. It’s typically reserved for patients who have failed or cannot use other therapies.
High-Altitude CSA
Altitude-induced CSA is its own category. Above roughly 9,000 feet (2,700 meters), periodic breathing during sleep becomes nearly universal. The lower oxygen levels at altitude destabilize the brain’s breathing control, causing a repeating cycle of rapid deep breaths followed by pauses.
Acetazolamide is the most effective treatment for this type of CSA. It raises overnight oxygen saturation and smooths out the cycling breathing pattern. Sleep aids with short half-lives, like zolpidem (5 mg) or zaleplon (5 mg), are considered generally safe for improving sleep quality at altitude, but you should allow at least 8 hours before any activity requiring alertness. Alcohol and opioids should be avoided entirely at altitude because they suppress the breathing drive. Descending to a lower elevation resolves altitude-related CSA entirely.
How Treatment Decisions Are Made
CSA is diagnosed when a sleep study shows more than 5 central breathing pauses per hour, each lasting at least 10 seconds, with more than half of all events being central rather than obstructive. For opioid-related CSA without periodic breathing, the threshold is also an AHI above 5, but it rises to above 10 when periodic breathing is present.
Treatment typically follows a stepwise approach. Optimizing underlying conditions comes first. If CSA persists, CPAP is often tried next. When CPAP falls short, the decision between bilevel PAP with a backup rate, ASV, acetazolamide, or supplemental oxygen depends on the specific type of CSA, whether heart failure is involved (and if so, how severely the heart’s pumping function is reduced), and what the patient can tolerate. Phrenic nerve stimulation sits at the end of the pathway for patients who haven’t found relief elsewhere. Your sleep specialist will likely try several approaches before landing on the combination that works best for your particular situation.