Expiratory Apneas With or Without Catathrenia Presenting As Central Apneas

June 12, 2012

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. Please read the post on this condition that I wrote a few days ago. 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?

Written by Steven Park · Filed Under Blog 
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10 Responses to “Expiratory Apneas With or Without Catathrenia Presenting As Central Apneas”

  1. jess on June 19th, 2012 8:58 pm

    I have catathrenia (confirmed in multiple sleep studies). I have accompanying central apneas that last 5-10 seconds. I exhibit the typical expiratory groaning. Both the groaning and the central apneas occur exclusively during REM sleep.

  2. Tom on June 22nd, 2012 1:29 pm

    I wanted to thank you for researching this condition. I don’t know why but most of my moaning events appear as obstructives but I have the classic moaning and 20 second breath holding episodes. My episodes also exclusively occur during REM sleep.

    I seem to be one of the few sufferers that experiences excessive sleepiness in spite of using CPAP.

  3. Anonymous on September 23rd, 2012 9:45 am

    Dear Dr Park,

    I have been searching the web for “catathrenia” posts for quite some time but I came across your blog only today. First, I would like to thank you for posting a blog on this rare condition.

    I am a catathrenia sufferer myself and have been read all the available literature, esp. the papers published in pubmed.

    With all due respect, I have to contradict the notion that catathrenia may be a form of obstructive sleep apnea.

    Vetrugno et al pusblished a paper where they contridicted that notion promulgated by Guillminault et al. Vetrugno et al demonstrated that Guilleminault’s patient’s had only brief episodes of breath holding, far shorter than the ones seen in their patients. If you take a close look at the polysomnographic graphs provided by Vetrugno et al, you will see completely different patterns in the two cohorts. There was no central output signal to the diaphragm in Vetrugno’s patients for up to 30 seconds.

    The post by Tom dated 22/6/12 seems to be one by a true catathrenia sufferer. He does not profit from CPAP at all. Why does he not if catathrenia was just an obstruction?

    In 2011, Seifert und Ott published a finding showing that there is a complete glottis closure during a catathrenia episode. The underlying mechanismes during the sound production resembled normal speech – taking place during the post-inspiratory phase.

    And naturally, if the glottis is closed and breathing is stopped, CPAP makes no sense. It cannot stop the post-inspiratory apnea.

    Orem et al promulgated the theory that post-inspiratory neurons may be responsible for catathrenia.

    I strongly believe that the condition is caused by a stimutaltion of the vagus nerve. First, the input to all of the motor nerves of the glottis is made by the recurrent laryngeal nerve, a branch of the vagus nerve.

    Rybak et al published a breathing model in 1999, stating that a stimulation of the vagus nerve leads to post-inspiratory apnea.

    I found a paper on animal experiments carried out in Germany in the 1960s where they stimulated the vagus nerve chemically by blocking acetlylcholinesterase. The authors of these experiments produced exactly the same results as can be observed in catathrenia patients: Closure of the glottis, sound production and inhibition of the phrenic nerve. They called it “expiratory apnoe”.

    I have written a five-pager on my theory, drawaing on the literature which it is based on. This paper is currently in German, but if you were interested, I would translate it into English.

    I would be more than happy to hear your view on it.

  4. Steven Park on September 23rd, 2012 10:36 pm

    Dear Anonymous,

    Thanks for your insightful comments. Your theory sounds entirely plausible, since most people with catathrenia also have upper airway resistance syndrome, where vagal tone is also very elevated. Expiratory palatal obstruction can lead to glottic closure, with resultant vocalization.

    I’m not saying that all cases of catathrenia are expiratory apneas with vocalization, but for some people with a good history and an endoscopic exam, you should be able to confirm that it’s an obstructive expiratory palatal event, and thereby potentially treatable with standard options (CPAP or surgery). However, not everyone respond to CPAP or surgery.

    I’m told that the American Academy of Sleep Medicine may be considering recategorizing catathrenia in the obstructive apnea variation category, and removing it from the parasomnia category.

  5. Oscar on December 21st, 2012 10:19 pm

    What is the treatment for catathrenia obstructive apnea?

    I’ve got it big time.

  6. Steven Park on December 22nd, 2012 7:43 am

    Oscar,

    Treatment for catathrenia is the same as for regular obstructive sleep apnea: CPAP, dental appliances, or surgery.

  7. Zeleni on January 13th, 2013 10:49 am

    I’ve been treated for obstructive and central sleep apnea with a CPAP for over a year. I still have excessive sleepiness and fairly high AHI (averaging 9 on my machine – above 10 during all periods of titration study). I also sleep moan – even while on CPAP. Just had another sleep study last night to see if BiPAP or ASV would be a better fit. Do you think CPAP is effective for expiratory apneas? Would BiPAP or ASV be a better fit?

  8. Nelson on January 30th, 2013 3:21 pm

    Dr Park, thank you for this post. It describes what I’m experiencing exactly. I’m not sure if I moan although I’ve been told I make strange noises while sleeping. Can you tell me what kind of surgery is most successful for this condition? I presently have a CPAP machine but the obstruction persists if I lie on my back. Also I don’t understand the physics of how the CPAP is supposed to help. The air pressure from the lungs on exhalation must be greater than the supplied pressure from the machine so how is the soft palate lifted out of the way? What I experience is that it is forced into the obstructing position by the flow and pressure of the exhale and is only relieved when I open my mouth.

    Thanks for any insight you may be able to offer.

  9. LIZ on March 18th, 2013 4:41 am

    Hello, I have a daughter with the same problem. When I was pregnant I would moan and wake myself up, and when my daughter was born she began to moan through the night and my moaning stopped. The doctors told me it would go away, and now my daughter is 15 and she still moans and stops breathing while she moans. That worries me and she feels uncomfortable because she won’t stay or let her friends stay over. Thanks

  10. Tom on March 29th, 2013 10:55 am

    Zeleni,

    I’ve been on CPAP, Bi-PAP and now ASV for 5 months give or take.

    My AHI is still averaging around 12.9.

    Did your last sleep study reveal anything?

    Do you have the ability to view your flow values from your CPAP machine?

    I have some shown here:

    http://www.cpaptalk.com/viewtopic.php?f=1&t=84194&st=0&sk=t&sd=a&start=15

    Sorry if the link isn’t allowed – please edit

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