An overview of the 2025 AASM guideline for adult central sleep apnea and CPAP

Central sleep apnea is not the same as obstructive sleep apnea

Central sleep apnea, or CSA, involves an absence or reduction of breathing effort together with reduced or stopped airflow. The underlying breathing instability can occur in several settings, including heart failure, opioid use, and obstructive sleep apnea. Central events can coexist with an obstructive diagnosis, but they represent a different breathing mechanism that clinicians evaluate in the context of the individual’s health and sleep-study findings.[2]

The guideline covers primary CSA, CSA associated with heart failure, medication or substance use, another medical condition, high altitude, and treatment-emergent CSA.[1]

How strong are the recommendations?

All nine recommendations are conditional. Under the guideline’s framework, a conditional recommendation identifies an option that clinicians should offer to most patients when clinically appropriate, using clinical judgment and considering individual values and preferences. It does not mean that every patient with CSA receives the same treatment.[1][2]

The recommendations concerning PAP therapies and oxygen are supported by low- or very-low-certainty evidence. The AASM developed them through a systematic review and the GRADE process, which considers evidence certainty, benefits and harms, patient preferences, and resource use.[1][2]

The guideline’s good-practice statement emphasizes treating or optimizing conditions contributing to central events and improving symptoms, function, and quality of life rather than focusing only on eliminating respiratory events. When central events persist after treatment begins, the guideline calls for clinician-led reassessment of underlying risk factors and consideration of other treatment options.[1][2]

What the guideline says about CPAP

The AASM conditionally suggests CPAP rather than no CPAP for adults with primary CSA, heart-failure-related CSA, medication- or substance-related CSA, treatment-emergent CSA, and CSA caused by another medical condition or disorder. The certainty of evidence is low.[1]

This recommendation does not establish that CPAP will resolve central events or that every person with CSA requires the same PAP mode. CPAP is one option within individualized clinical care. A qualified clinician determines whether it is appropriate and evaluates ongoing central events without relying on self-directed pressure, setting, or mode changes.[1]

Bilevel PAP and the backup rate

The guideline conditionally suggests bilevel PAP with a backup rate for primary CSA, medication- or substance-related CSA, treatment-emergent CSA, and CSA due to another medical condition. Heart-failure-related CSA is not included among the etiologies listed for this recommendation. The evidence certainty is very low.[1]

The guideline also includes a conditional suggestion against bilevel PAP without a backup rate for primary CSA, heart-failure-related CSA, medication- or substance-related CSA, treatment-emergent CSA, and CSA caused by another medical condition. This recommendation rests on very-low-certainty evidence.[1]

In the context of CSA, “bilevel” or BiPAP does not fully identify the prescribed mode. The guideline distinguishes between bilevel PAP with and without a backup rate, and the AASM’s discussion notes that backup rates matter when considering its recommendations.[1][3] A qualified clinician is responsible for determining the appropriate mode and settings and for reviewing any questions about an existing prescription.

Adaptive servo-ventilation and heart failure

The guideline conditionally suggests adaptive servo-ventilation, or ASV, rather than no ASV for primary CSA, heart-failure-related CSA, medication- or substance-related CSA, treatment-emergent CSA, and CSA caused by another medical condition. The evidence certainty is low.[1]

The AASM recommends shared decision-making before ASV begins, with treatment decisions based on expected symptomatic or quality-of-life improvement. For people with heart failure and reduced ejection fraction, the guideline states that ASV treatment should be limited to experienced centers and include close monitoring and follow-up.[1]

This caution has an important history. A 2016 AASM update reported an increased cardiac-mortality risk in a specific population: patients with a left ventricular ejection fraction of 45% or less and moderate or severe CSA-predominant sleep-disordered breathing. That update recommended against ASV for this defined population. The newer guideline incorporates more recent evidence while continuing to emphasize specialist experience, shared decision-making, and close follow-up for heart failure with reduced ejection fraction.[2][4]

The current conditional recommendation does not establish that ASV is appropriate or risk-free for every person with heart failure. Clinician review includes the type of heart failure, cardiac measurements, symptoms, treatment goals, and monitoring arrangements.[1][2][4]

Oxygen, acetazolamide, and phrenic-nerve stimulation

• Low-flow oxygen: The AASM conditionally suggests low-flow oxygen rather than no low-flow oxygen for CSA due to heart failure, based on low-certainty evidence. It also conditionally suggests low-flow oxygen for CSA associated with high altitude, based on very-low-certainty evidence. A qualified clinician determines whether oxygen is appropriate.[1]
• Acetazolamide: Oral acetazolamide is one of the six treatment options supported for specified CSA etiologies in the guideline. Like all nine recommendations, its use is conditional and requires clinician-led assessment and prescribing.[2]
• Transvenous phrenic-nerve stimulation: The guideline conditionally supports this option for primary CSA and CSA due to heart failure. It uses an implanted device that automatically monitors and stabilizes breathing. The AASM notes that the treatment requires an invasive procedure, is not universally accessible, and can be costly. These factors are part of clinician-led treatment selection.[2]

Topics addressed during clinical follow-up

Because the recommendations depend on the cause of CSA and the individual’s other conditions, a clinical assessment may address the following topics:[1][2]

• The identified type or likely cause of CSA.[1]
• Whether central events are persistent or associated with heart failure, medication or substance use, altitude, or another medical condition, and whether the guideline category of treatment-emergent CSA applies.[1][2]
• Whether a prescribed bilevel PAP mode includes a backup rate and the clinical basis for that selection.[1][3]
• When ASV is under consideration and heart failure is present, the person’s cardiac function and the planned monitoring and follow-up.[1][2][4]
• Symptoms, functional outcomes, and quality-of-life goals in addition to respiratory event counts.[1][2]
• The timing and scope of reassessment for treatment response and persistent central events.[1]

How the guideline relates to current CPAP therapy

The guideline is intended to guide clinicians and does not automatically replace an individual treatment plan. For a person already using CPAP, bilevel PAP, or ASV, decisions involving pressure, mode, oxygen, medication, equipment, or continuation of therapy belong with a qualified clinician. The recommendations provide a framework for clinician-patient discussions about the cause of central events, the prescribed therapy, treatment goals, and follow-up.[1][2]

This article provides general educational information and is not medical advice. Do not start, stop, or change CPAP therapy or settings without guidance from a qualified clinician.

Sources

1. [1] Treatment of central sleep apnea in adults: an American Academy of Sleep Medicine clinical practice guideline — PubMed / National Library of Medicine
2. [2] New guideline provides treatment recommendations for central sleep apnea — American Academy of Sleep Medicine
3. [3] Talking Sleep: Central Sleep Apnea Treatment—New AASM Guidelines — American Academy of Sleep Medicine
4. [4] Updated Adaptive Servo-Ventilation Recommendations for the 2012 AASM Guideline — PubMed / National Library of Medicine