Expiratory Apneas With or Without Catathrenia Presenting As Central Apneas

Here’s an interesting poster that I presented at last week’s SLEEP meeting in Boston: Expiratory Apneas With or Without Catathrenia Presenting As Central Apneas. To explain the terminology, catathrenia is a rare condition where one groans or moans while sleeping. Central sleep apneas occur then your brain doesn’t send signals to your lungs to breathe. It’s more commonly seen in patients with heart failure or neurologic conditions. Apneas are commonly thought to occur during inhalation, with collapse of your throat tissues while you inhale.

However, in some patients, the obstruction happens during mid nasal exhalation. The history is very unique: The person begins a normal nasal exhale, but during mid-exhalation, you hear a sudden occlusion or closure, with breath holding for a few seconds to well over 15 seconds. This breath holding is terminated by an arousal or complete oral exhale and then a few deep breaths, with the cycle happening all over again. In some patients, there will be moaning or groaning during the breath holding portion.

I was able to find a patient that could replicate this finding while awake on his back (see poster). What you see is that during mid-nasal exhalation, the redundant uvula flaps back up into the nasopharnx, blocking nasal exhalation completely. During this event, you can either hold your breath, like straining lightly during a bowel movement, or vocalize continuously, leading to moans. Coincidentally, my wife also had this exact phenomenon during the last trimester of her last pregnancy.

If you look at the sleep study tracings during these episodes, it may seem like a central apnea, since there’s no nasal air flow and there are no chest or abdominal movements. But if you look closer, sounds are being made, and there’s air coming out of the mouth (due to moaning). These events classically occur during REM sleep, in the early morning hours, when muscles are most relaxed. In the American Academy of Sleep Medicine’s International Classification of Sleep Disorders -2, catathrenia is classified as a parasomnia. However, it’s clear from this observation and a handful of other studies that suggest that catathrenia should be classified as a variation of obstructive sleep apnea. Guillminault published a paper a while back showing that all his catathrenia patients were cured with either CPAP or uvulopalatopharyngoplasty.

I’ve had a number of these patients (mostly young and thin) who were diagnosed with central sleep apnea. You can imagine the anxiety that’s created when they find out that they have central sleep apnea, with no plausible explanation.

Do you either moan in the night, or stop breathing suddenly during exhalation while sleeping?

Please note: I reserve the right to delete comments that are offensive or off-topic.

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111 thoughts on “Expiratory Apneas With or Without Catathrenia Presenting As Central Apneas

  1. Christie,

    I don’t think a swim clip will help, since you’ll keep exhaling out through your mouth, which can cause arousals from deep sleep. Many people with this condition can’t tolerate CPAP or dental appliances that pull the lower jaw forward. So far, the only options I’ve seen that works most of the time is palatal surgery, whether or not you have OSA. I’m currently working on more research studies looking at this interesting topic.

  2. Yes – I do both and have found it rectified by simply placing medical tape over my mouth when sleeping.

  3. I don’t know if this blog is still being managed, but if it is – thank you!! I have finally found something I can take to my sleep doc. The description is exactly how I would have described. Ive tried CPAP and BPAP with both not providing relief and both aggravated ongoing autoimmune issue relating to inflammation. So my remedy had been to sleep upright in a recliner as it’s the only way I can keep expiration airway open. Are there any new treatments available?

  4. Mr. Stewart,

    Unfortunately, sleep doctors are not aware of this condition. Even ENTs are generally unaware. We’re in the process of publishing our results in a mainstream sleep journal. In the meantime, stay tuned for a podcast I will be posting shortly on this subject.

  5. About a year ago readers on this blog were speculating about treatments for the expiration problem. One thing I have found that helps is a hard swallow. Of course you can’t do this if you’re asleep, but it works for me if I’m lying in bed awake. Who knows, maybe a more permanent treatment can be discovered around the swallow mechanism.

    Just wanted to pass it along …

  6. this is my problem too. I can’t expel air when I sleep, cpap causes air to get stuck and ingested. I use oral appliance which has moved my jaw and teeth. Ive notice also when I swim and try to hold my breath under water i find it difficult to expel air . so I think I have a large tongune or something. I wonder if having surgery to remove obstruction would be a choking hazard when eating?

  7. Dr. Park – I am wondering if you have uploaded a podcast in response to this blog post, like you stated on May 2018? If so, can you please share the title of the podcast as I am very interested in learning more about this. I am getting desperate for a good night’s sleep. So far I have purchased an adjustable bed (didn’t work) and a new recliner (works, but causes other issues concerning pain from neuropathy issues). Thank you!

  8. Mr. Stewart,

    I’m waiting for news from a journal editor about whether a manuscript on this topic has been accepted. After this, I intend on doing a Podcast about it. Unfortunately, the only option that I’ve found to help is palate surgery.

  9. Dr. Park
    Thank you for replying. I hope there will be other options, besides pallet surgery, in the future. I look forward to hearing the podcast.

  10. I have been looking for this article for years and i hope this material gets out to the general medical community. I am tired of doctors explaining apnea to me and then looking at me like i am crazy when i tell them the problem is on the exhale. I was diagnosed with severe sleep apnea about 20 years ago and told that if i didn’t use a CPAP i would be dead in two years. I remember the technician explaining how high the pressure had to be set. I used the CPAP for a few month; it helped me catch up on my sleep and then started causing all sorts of problems; I stopped using it. I am doing well with a anti inflammatory diet, sleep on my side with face looking slightly downward, and sometimes in a chair, my head has to be straight up or angled slightly forward. I can duplicate the problem while awake, laying on my back or even sitting in a chair. Over the years i have run into a number of people. All have stopped using CPAP. All say the problem is on the exhale. All say they had high CPAP pressure settings.

  11. yes !!! exactly what is happening to me. i caught the other night and tried to duplicate it and i did. now i just turn on my side and try to stay off of my back. i do have a deviated septum if that helps.