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In blog 4 of this series we discuss the implications for Sleep Medicine Clinicians regarding the evidence that CSA is more prevalent in the real-life setting, as reported in the recent publication by Pepin et al 1.
Pepin et al's 2024 research found that the prevalence of CSA was 20% (1 in 5) in a large real world population of people with Sleep apnoea 1. This is new evidence that warrants Sleep medicine clinicians attention and response.
We already possess the technology to precisely diagnose and treat different types of sleep apnea events, yet we aren't consistently using this technology. This can result in a significant undercounting of CSA, a condition often underdiagnosed as OSA or a mixed apnea type.
This underdiagnosis may have significant consequences, as treatment effectiveness may vary in these individuals.
The emergence trajectory of CSA during CPAP therapy has been observed in a large cohort of patients (133,006) who were remotely monitored to observe the proportion of patients who developed CSA (3.5%). CSA was transient, persist or treatment emergent in 55.1%, 25.2% and 19.7 % respectively over 90 days of monitoring, representing several different clinical phenotypes of CSA.
This finding does warrant more "real life" research in diverse populations as identifying treatment emergent CSA by telemonitoring could facilitate earlier intervention to reduce the risk of therapy discontinuation and improve health outcomes 2. It would also be interesting to see the results of future studies that compare CPAP devices that report on central hypopnoeas as well as central apnoeic events as it is well established that not all CPAP algorithms report central hyponoeas.
What are the Implications to consider for Clinical Practice:
1. Enhanced Post Diagnostic Screening for CSA for those on therapy:
The increased prevalence of CSA suggests more robust screening protocols may be warranted. The technology to conduct on treatment polygraphy already exists as do more novel sleep home sleep testing devices. Clinicians should consider co-existent OSA/CSA in patients presenting with persistent sleep-related symptoms, especially those with neurological conditions, heart failure, or other comorbidities that predispose them to CSA:
This highlights the importance of the remote monitoring capability in CPAP devices that will accurately report on residual central apnoea and hypopnoea events.
How important is it to have an integrated polygraphy system which allows clinicians to conduct an on therapy multi-channel home sleep study with results integrated and visible within a single software system.
2. Consideration of Multi-Morbidity:
CSA often coexists with other medical conditions such as congestive heart failure, stroke, and certain neurodegenerative disorders. It is recommended that Clinicians should assess and manage these comorbidities with a multidisciplinary approach to improve patient care and outcomes.
3. Personalised Treatment Approaches:
Treatment for CSA can differ significantly from OSA and Clinicians should remain up-to-date on the latest treatment modalities for CSA.
Ongoing research into pharmacotherapy and other treatment options for CSA may change standard practices and offer new alternatives for patients.
4. Education and Awareness:
In the light of the reported increased prevalence of CSA, educational programmes should include the latest research on CSA and its implications.
Raising awareness can facilitate early intervention and improve patient outcomes.
5. Monitoring and Follow-Up:
Patients who have been found to have treatment emergent or treatment persistent CSA require regular follow-up to monitor treatment effectiveness and adherence.
This includes reassessing symptoms, conducting follow-up sleep studies, and adjusting prescribed treatment as necessary.
6. Research and Quality Improvement:
Ongoing research is needed to better understand CSA's pathophysiology, risk factors, and long-term health outcomes as indicated by a recent expert panel of key opinion leaders in the journal of clinical sleep medicine 3. Clinical practices should incorporate findings from new research to enhance patient care.
Quality improvement initiatives can help track outcomes in CSA management, ensuring that clinical practices evolve based on evidence-based guidelines.
The recently increased prevalence of CSA by Pepin et al presents challenges and opportunities for clinical practice 1. By enhancing screening techniques, tailoring treatments, and emphasising education and research, healthcare providers can improve diagnosis, management, and patient outcomes related to this sleep disorder.
Some CPAP devices offer sophisticated features, enhanced event detection, accurate leakage compensation, refined event classification, automatic pressure adjustments, and remote monitoring that support much more precise management. These devices can identify subtle breathing irregularities and automatically adjust therapy, optimising treatment. The question isn't always about technological capability; it's about consistent clinical implementation.
In our 5th a final blog we will answer these questions that will support Sleep medicine clinicians in implementing best practice and treating not only OSA but CSA effectively.
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