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?

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150 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.

  12. The last half of my spouses exhale is super quick and feels forced, does anyone have a clue what this could be? Is it similar to what is being discussed here?

  13. I have this which causes a snoring like noise on exhale, it is like I’m subconsciously holding my breath, but pushing the air out despite my throat being closed and my tongue blocking the exhalation, my mouth is closed. I also frequently develop swelling of nasal passages when I lie down so hard to get air since I do not open my mouth to breathe. The exhale problem happens sleeping on my back I think when I feel anxious, for example anxious about making noise in my sleep! I also have a tendency to hold my breath while awake when concentrating. I am going to try a mouth guard and see if it reminds me to keep my throat and tongue relaxed during sleep.

  14. My 24yo son is definitely having trouble exhaling when sleeping. I hear small noises as his breath is held, then he exhales orally with a gush of air. He had surgery several years ago to repair a deviated septum and some turbinate reduction. He had a sleep study done many years ago with no reported apnea. I think this issue is more recent. He is definitely tired often, and has a good amount of stress and anxiety being on the autism spectrum. We are currently in LA if anyone would like to have him participate in a study.

  15. For years I’ve told my sleep doctors that I hold my breath during the exhale then release it in small bursts spread over a long period, until I suddenly exhale forcefully and inhale as if out of breath. This is my wife’s description – she describes the sound as “peeping” like a chick. Sometimes when I am half awake I can witness this happening – I inhale fine but when I try to exhale it’s like a flap closes at the back of my tongue and I have to conciously move my tongue in order to exhale.

    None of my sleep doctors (I’ve seen many in the past 20+ years) diagnosed this correctly. They all said I was mistaken and my apneas occurred during inhalation. Sleep studies confirmed that I do have OSA but I also believe, based on symptoms, that I have catathrenia.

    In my 30’s and early 40’s (I’m now 53), a mandibular advancement oral appliance seemed to address both my apnea and catathrenia. Sleep studies confirmed this as did my wife who claimed I rarely held my breath or “peeped” any more. As I got older the device stopped being effective so I started CPAP. However this has proven to be an imperfect solution. I have severe daytime sleepiness, and although my overall AHI on CPAP tends to average around 5, I often have peak per-hour AHI of 20 or more. I believe this happens during REM sleep which accounts for such a small part of my total sleep time that my 8-hour AHI is still fairly low.

    I saw an ENT who performed sinus surgery and a hyoid suspension along with drug induced sleep endoscopy. My symptoms didn’t improve, but the DISE found “clear anterior-posterior obstruction at the level of the tongue base without circumferential collapse”.

    My question to you: I’m seeing an oral surgeon and am scheduled for double jaw surgery to advance my upper and lower jaws as well as a genioglossal advancement (I do not have an under or overbite). While I believe that this surgery has a high chance of greatly reducing my apneas, is it reasonable to expect that it will also improve my catethrenia? My guess is that both my apnea and catethrenia stem from a narrow airway and anything that increases its size will improve matters dramatically.

    Thanks for your thoughts!

  16. not so much a comment as a question …
    My wife has aphasia and dementia and I cannot go to bed with her in the evening because she stops her exhale just after it starts and seems to swallow before bursting the remaining exhale. This seems to happen every other exhale, and I’ve been assuming post-nasal drip as the cause. She also is missing a number of teeth and moves her mouth around during this process. It drives me crazy.
    What’s different, though, is that once she falls asleep her breathing is quite normal.

  17. My 7 year old seems to have trouble exhaling often during sleep and moans or groans a bit, as you described. He doesn’t have to be on his back, though. He has the same problem even when sleeping on his side. He also mostly breathes through his mouth. Do you think this could still be related to the uvula, or might be something else?

  18. I am pretty sure I have Catathrenia. My husband has recorded this awful groaning sound on exhale at times when I sleep. I have, on rare occurrences, woken myself up. I sometimes can tell I’ve been doing it when I wake with s sore throat. This is something that has developed over the past few years. Is this something I need to worry about for me physically? It’s terribly disturbing to him and I feel terrible when I disrupt his sleep. I’m very healthy, I’ve been a regular (daily) runner for almost 30 years plus do strength training. I’m thin and fit, eat healthy and sleep very well. I sleep mostly on my left side. Other than being extremely annoying to my poor husband, I wasnt previously concerned about it affecting my health until reading some recent articles. I have had some occurrences of vertigo…. I recently read that can be caused by catathrenia. Is that true?

  19. Heidi,

    Catatrenia means that you have poor sleep, which by definition can predispose to symptoms of dizziness. Seeing a sleep doctor is a good place to start.

  20. Dr Park, I’ve commented before and am hoping you can provide some additional info. You’ve stated palate surgery is one option to correct expiration apnea. Do you know the percentage of success for this type of surgery? Also, where should a person look to find a qualified surgeon? I ask because my situation is getting worse and I would like to get this corrected, if possible. Thank you

  21. Hello, Dr. Park,

    I think this describes my issue perfectly. This happens to me while prone on my back, even while awake. Any time I try to exhale forcefully (even with slight force), my throat closes up. If I am standing, I cannot replicate it. Head position, while lying down, does not seem to matter (left, right, or straight ahead).

    Now I have something to take to my doctor. Thank you!

  22. My husband seems to have a form of this. He doesn’t stop breathing very often. He has a normal inhalation and then during his exhalation he sounds like he is fighting to push it out. Most if the time he is successful however occasionally his breathing pauses and resumes. Over the years, he has also groaned or moaned during exhalation. Do you think this is the same as what you have described? Should I force him to see a sleep doctor or ENT? (He hates going to the doctor. Lol)

  23. This is exactly what i have but my noise isn’t moaning or groaning, mine is an unmuffled chain saw sound trying to push air out as the throat relaxes more when i exhale blocking the glottic airway. Being slightly overweight continues to this as the second chin affects the form of the neck. Ive tried neck supports to open the airway without resolve. Cpap appears to better the only solution at this time but even then, when my throat relaxes, the tongue blocks the holes in the hard palate of the mouth and forced the exhale through my nose.

  24. Hi I think I have this exact issue. I was diagnosed with extremely mild sleep apnea. The sleep study was done after my spouse told me she could not sleep at night due to my groaning at night. I have never felt tired during the days or feeling like I don’t get sleep. I was given a Cpap which I tried for months which resulted in me now getting little to no sleep and feeling tired during the day. I then switched to a ResMed mandibular repositioning oral device which enabled me to sleep but still the groaning continued to occur according to my wife. So at this point I don’t know what is a solution but I would rather not be sent to the guest room nightly so my wife can get sleep at night. Oh yes I am in mid 40’s and am in great physical shape so it’s not a weight issue. Suggestions

  25. Kelly,

    Unfortunately, the only option I have seen to work sometimes is one of the modified UPPP procedures. Even if it doesn’t work, it may allow CPAP to work better. The Inspire tongue nerve stimulation may be an option, but you must fit their entry criteria.

    Best regards,


  26. Hi – I found this post by searching ‘catathrenia vagus’ because I had a thought that maybe catathrenia was the body’s way of stimulating the vagus nerve – similarly to how cats purr (which is part of their healing mechanism, again i believe through vagal stimulation). I see ‘anonymous’ posted below on this albeit from the opposite perspective, the link to vagal tone is there which is fascinating, so am interested to see where that went.

  27. I have these exact symptoms; however, they are not regular and there may be weeks or even months between noticed occurrences. Sometimes while in a waking moment, or very lite sleep, I can feel the tissue in the upper back of my mouth close off my nasal passage and feel my exhale push against is as it closes. Sometimes this even occurs if I am laying on my side. I has been occurring more frequently of late. I have also noticed that when I have cold symptoms the blockage can occur when I’m fully awake and setting upright. So, I decided to see what an internet search had to offer and thus I happened upon this article.

    I’ve never been to a doctor for this condition as it’s been very sporadic and hasn’t caused much trouble up to the past few months. What kind of medical doctor could or should I see that would know or understand this condition and maybe help control or fix it?

  28. Mr. Bent,

    Unfortunately, most sleep doctors or ENTs will not be aware of this condition. Regardless, you should consider seeing a sleep doctor to see if you have obstructive sleep apnea. If you do have it, then it needs to be treated. Worse case scenario, you may need to see an ENT if you can’t tolerate CPAP. If you do have expiratory palatal obstruction, the only thing I’ve seen work most of the time is surgery. But only an ENT can do this. Good luck.

  29. I have problems with exhaling while lying down if the force is too great. Something on the back of my throat (like a flap?) closes the airway. I believe this is the source of my apnea at night. Lying on the side or on my belly helps. Is there anything I can do to solve this without surgery or devices? Why does this happen? Could it be because of teeth removed when I had braces and having a smaller mouth than I should?

  30. Tim,

    Yes, excessive dental extractions increase your risk of “small-mouth syndrome.” The upper jaw slowly retracts backwards, leading to excess soft palate redundancy, and the process that happens described in my article. In general, I recommend getting diagnosed and treated for any underlying obstructive sleep apnea. In case you don’t meet the criteria for sleep apnea, I have not seen any non-surgical options that help with this condition. An oral appliance that pulls your lower jaw (and tongue) forward may help sometimes, but in some cases, it can make things worse. One minor office procedure that can be performed in the office is called injection snoreplasty. It stiffens the soft palate. Again, it works only some times. Hope this helps.

  31. I seem to have catathrenia as well. My bed partner informed me of the sounds I make when in my deepest sleep and that they are enough to vibrate the bed. I have had 3 neck/throat surgeries, 2 partial parathyroidectomies and a cervical fusion from C3 to C7. I am wondering if these surgeries may have caused scar tissue to form and that is what is obstructing my breathing from happening correctly when I exhale in my most relaxed state. Also, would this be better followed up by an ENT, a pulmonologist, or a GI specialist? This seems to be a recent occurrence for me, as no other sleeping partners, grandchildren and the like, have ever said anything to me about it.

  32. I exhale PUFFS of air. Sometimes it wakes me up. I have noticed this at times while I have laid down for a nap, as I believe it wakes me up. My husband said that I do it in my sleep a lot.

  33. I am thrilled to find this information as I know my issue is during exhalation. I dread a sleep study since I don’t believe it will help for exhalation difficulties. I have described this to my provider as feeling a flap somewhere btw my nasal cavity & throat when I lay down flat. I do make noises that wake me but not really snoring most of the time. I got a CT of my sinuses but only a deviated septum and curved turbinate (sp?) was noted. Please send me information to take to my provider to get successful treatment finally. Thank you again for your informative find!

  34. At first I thought this was describing what my husband’s been doing for years, then realized his isn’t quite like this at all. He did test positive for very mild apnea and got a CPAP machine awhile ago. It was causing more problems than helping though, and since it was only to help with his breathing issue (below) and it wasn’t working, he took it back. I’ve never seen any sign of apnea at all, anyway (including no snoring, daytime fatigue, or breathing irregularities while asleep) and he’s a very tall, thin and healthy specimen, to boot. What he struggles with isn’t really about not enough breath and it occurs at times when he’s simply relaxing on the couch, awake. It primarily takes place though, in bed and *before he falls asleep.

    He’ll start becoming more relaxed and suddenly his exhales will be forceful and his diaphragm and stomach will spasm as he puffs air out. It drives him crazy because its neither smooth or rhythmic like regular breathing. It’s like your bicep muscle as you start a hard, fast punch. There’s a strong contraction and he can’t control it or stop doing it. Once he falls asleep, it disappears. The doctors and Dr Google have yet to tell us what it may be, and he’s seen multiple GPS and sleep specialists. No mention of anything similar, anywhere.

    Poor guy. If this sounds like something you know, I’d like to hear about it. At least, so we can pursue this with one of the specialists. Thanks!

  35. So glad to have found this because at least I know I’m not alone! Add me to the list of people with this condition. I literally CANNOT sleep on my back at all because of this. As soon as my throat muscles relax, the dreaded “flap” closes upon exhalation, just as others have said. You’d think that the body would then simply exhale out the mouth instead, but it does not. Inhalation is not a problem at all for me, so I don’t think I have traditional OSA. Because I cannot sleep on my back, I just flip from side to side all night, like a turkey roasting on a spit. Even on my side it sometimes happens, especially when the weather is dry. Which brings up another observation – I frequently notice thick postnasal drip, such that I have to snort it in and swallow it or hock it out (sorry, it’s disgusting, I know). I think this thick mucus contributes to the problem, because when the mucus dries out it becomes like glue. It is this glue that causes the “flap” at the sinus/throat interface to get stuck. I wake up frequently at night and do a quick sinus rinse with saline. This lubricates the flap and helps me sleep for a couple hours before it dries out again and the problem comes back. I sure hope someone finds a cure for this as I haven’t had a truly good night sleep in over a decade.

  36. At last someone is onto this. 2 years ago, following complaints to my doctor about waking with a dry throat I was sent to a specialist. Without any examination from the specialist I was sent for a sleep test. It showed I had sleep apnea. The return visit to trial various masks was awful, with me finding myself experiencing the sensation of drowning. I didn’t pursue the masks. Since then my cholesterol has risen, I now have fatty liver and my sugar is up, all of which are not hereditary. I eat healthy and exercise. The symptoms have become worse and I am now aware that the blockage is not when I inhale, but when I exhale, which explains my sense of drowning when wearing the mask. For the first hour I am awake I still experience problems at times of exhaling, but have no problems inhaling.

  37. Yes, this sounds like what I am experiencing. I suddenly wake up because I can’t exhale through my nose and I feel like a lump in my throat is blocking it (sometimes it happens when I am lying down but awake as well). Not sure if this is what the cause is, but this article seems to make sense.

  38. Hi Dr. Park

    I was wondering if myofunctional therapy or oropharyngeal exercises could work to treat the Expiatory Apnea?


  39. I mentioned in a comment above, but would like to emphasize, that for me, sinus rinses help. They do not fix the structural problem, but at least lubricate the flap to help prevent it from sticking closed. I recently started doing a good rinse BEFORE bed, a opposed to in the middle of the night, and this works even better. (I still do a quick rinse if needed during the night too, but adding the before-bed rinse has definitely helped) I have also found that a sinus rinse mixture that contains Xylitol, such as Xlear brand, works better than standard saline packets. The xylitol must act as an additional lubricant.

  40. @UncomfortableSleeper … I agree! I moved my Saline rinse from the morning to the evening and it has definitely helped. Hasn’t solved the issue but certainly made the intra-night interventions less frequent. I will look into the Xlear brand.

    Swallowing hard several times (without getting up to get water) will help but swallowing water works much better, but then you have to get up more often.

    I see that “Snore Stop” uses Bella Donna to reduce irritated tonsils, etc. I thought Bella Donna has a different history though!

    A few things I’ve noticed that make the condition worse:

    1) Inadequate hydration during the day into the evening
    2) Excessively salty evening meals
    3) A little too much wine (sulfites maybe) :-)

  41. You’re right, Joe, hydration has a lot to do with it. Another thing that helps is using a humidifier in the room. Glad you mentioned salt… I hadn’t noticed that connection but I’ll be on the lookout for it now.

  42. This perfectly describes what I have been feeling for the last couple of months. I cannot replicate it during the day but at night I can feel my soft palate relax to the point of blockage as I exhale. It causes an incredible pressure within my head and subsequent headaches. Sleeping has become extremely difficult. I am a fitness enthusiast, 30 years old and did not evert think I’d have a sleep apnea issue.

  43. This happens to me both when sleeping and when relaxed and trying to fall asleep. Sometimes the noise will wake me up. When I’m just about to fall asleep – I sometimes find myself holding my breath followed by a large quick “whoosh” of an exhale, and it startles me and wakes me up. I can also reproduce the sound when lying on my back – but for me it’s like a reverse snore, but is a flatter – less “fluttery” snore – originating in the same area that a snore would originate. It usually lasts a lot longer than a single typical snore. I guess because my airway is somewhat blocked as I exhale out my nose – it takes longer to exhale and stretches the “outward snore” to be longer than a typical inhaling snore would sound. I never thought of it as a groaning sound – but now that I think of it – I’m not sure what else you would use to describe it as it doesn’t sound like a snore either. I was diagnosed with obstructive sleep apnea but couldn’t handle the positive air flow because I always felt like I couldn’t exhale enough air against the positive pressure and I would wake up panicked feeling like my lungs were overfilled and struggling to exhale. I have noticed sleeping with my upper body elevated seems to help. I’ll share this with my GP but not sure he’ll know what to do with this ¯\_(ツ)_/¯.

  44. Is there any updates on this? I am positive that I suffer from this as well. I have never been a good sleeper. I side sleep until my shoulder gets sore, then roll to my back… and usually wake myself up with a powerful exhalation through my mouth then flip to my other side…. rinse wash and repeat. My wife years ago watched me sleep and commented that I “stopped breathing” several times for so long that she was worried.
    Recently, I purchased a VR device and was doing one of the relaxation videos laying on my back. I think I was just on the verge of nodding off when.. BAM! I couldn’t exhale. I kept on watching and it kept happening (this was yesterday). Last night lying in bed on the verge of sleep I laid on my back and kept trying to find a position for my head, but every time I was about to go under I kept getting a blockage on exhale… finally I gave up and did my normal side to side crappy sleep routine.

    In any event, has there been anything more about this????? It would be nice to get a good nights sleep for once in my life without having to self medication with 4 strong cocktails before bed

  45. I have some puffing out from the front of my lips, but I’m most perplexed by what I can only describe as snoring out of my nose on exhale. It’s very easy to replicate when awake by pressing my tongue fully to the roof of my mouth then attempting to breathe out of my nose and relaxing my tongue just barely enough to let the air pass. It is as if my tongue is suddenly too big for my mouth and it’s keeping the air from escaping through my nose with my mouth closed. I’m also a serial snorer. Is it time I visit with a doctor?