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 when 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 a 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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187 thoughts on “Expiratory Apneas With or Without Catathrenia Presenting As Central Apneas

  1. Hi and thanks for this blog. My symptoms match what everyone else here is reporting to a tee.
    My question is, if I ask my otolaryngologist to operate to help alleviate this problem, is there a specific procedure I should ask for? Are there variants of a standard sleep study that can clarify what exactly is happening in my case to help guide the operation?
    Is this a particularly risky operation? Are there better options by now that I should consider, rather than an operation?
    I am 53 years old and otherwise healthy and fit.

    Thanks in advance!

  2. Mr. Wallgreen,

    In general, most modern versions of the UPPP should suffice, since it will prevent the midline uvula and lower soft palate from flapping up into the nose. However, it’s something to think about as a surgeon. If he or she can do drug induced sleep endoscopy, then it can be visualized. However, it doesn’t always show up and the diagnosis has to be made by history.

    Good luck…

  3. Hi, I make noise on exhale when asleep but it does not match the symptoms of Catathrenia at all. My partner recorded my snoring noises and I only make sound on exhale and the sound can only be described as sounding like a pressure valve being released! I do not hold my breath or wake up, in fact my breathing continues at the same, even, rhythmic pace. Is this something I should be worried about?
    Your thoughts would be much appreciated

  4. I have exactly the condition that you describe and can sense it even when lying on my back awake and relaxed. The problem is accompanied by my lower jaw falling open, so I have usually used a small pillow under my jaw to keep it more or less closed. But I can tell on exhalation that my soft palate is closed, I cannot exhale through my nose and I feel my cheeks flex open from the pressure of the exhale. I can eliminate it by sleeping on my side, but I have nasal congestion then and often cannot sleep well in that position. So I’m in a dilemma what to do.

  5. Mr. Portman,

    Unfortunately, the only solution I’ve seen that potentially resolve this condition is palatal surgery. You may want to see an ENT about it. Good luck!

  6. Wow, this sounds like my problem! I’ve been searching the internet and could not find my issue. Apparently it’s rare enough there is no formal name for this disorder. I am 44 years old, male, 5’8” and 148 pounds. I’ve always been a light sleeper, average only about 30 minutes deep sleep per my Fitbit. I don’t snore. Recently I’ve added this new problem to my sleep: I’ll wake up with the recollection that I can’t exhale. Of course once I’m awake I can breathe normally again but while I’m in that barely awake state I can feel something closing shut between the back of my throat and back of my nose which I assume is my soft palate. While lying there I can voluntarily open it up, and open and close it back and forth. It’s the same movement I might make when trying to swallow some post-nasal drip which I often have a mild case of but it hasn’t bothered me. I’ve started taking loratadine but it doesn’t seem to have reduced this occurrence. To be clear, this ONLY happens when I start to exhale, and never during the daytime. As I begin to drift back to sleep I often feel it want to close again. Then I’ll wake up more fully and breathe fine again, but it’s very frustrating because often I don’t get back to sleep again, and I already had problems sleeping. I’m a nose breather but sometimes when this has been happening I’ll notice that my tongue and inside of my lips/cheeks are dried out because I’m breathing through my mouth, which probably happens when I can’t breathe out through my nose. I’m a side sleeper but I’ve tried every other position and nothing else helps. A couple other interesting facts: I apparently have pretty bad bruxism per my dentist, so now I wear my Invisalign retainer every night. I also had my adenoids removed at age 11 (still have my tonsils) due to constant clearing of my throat. Since the etiology of this is different from the normal OSA I’m not sure how much a CPAP will help.

  7. Eric,

    It does sound classic for expiratory palatal obstruction. Unfortunately, CPAP will not work because you can’t breathe out. Your best bet is to find a sympathetic ENT surgeon to address this for you. Good luck.

  8. Wow, this sounds like my problem! I’ve been searching the internet and could not find my issue. Apparently it’s rare enough there is no formal name for this disorder. I am 44 years old, male, 5’8” and 148 pounds. I’ve always been a light sleeper, average only about 30 minutes deep sleep per my Fitbit. I don’t snore. Recently I’ve added this new problem to my sleep: I’ll wake up with the recollection that I can’t exhale. Of course once I’m awake I can breathe normally again but while I’m in that barely awake state I can feel something closing shut between the back of my throat and back of my nose which I assume is my soft palate. While lying there I can voluntarily open it up, and open and close it back and forth. It’s the same movement I might make when trying to swallow some post-nasal drip which I often have a mild case of but it hasn’t bothered me. I’ve started taking loratadine but it doesn’t seem to have reduced this occurrence. To be clear, this ONLY happens when I start to exhale, and never during the daytime. As I begin to drift back to sleep I often feel it want to close again. Then I’ll wake up more fully and breathe fine again, but it’s very frustrating because often I don’t get back to sleep again, and I already had problems sleeping. I’m a nose breather but sometimes when this has been happening I’ll notice that my tongue and inside of my lips/cheeks are dried out because I’m breathing through my mouth, which probably happens when I can’t breathe out through my nose. I’m a side sleeper but I’ve tried every other position and nothing else helps. A couple other interesting facts: I apparently have pretty bad bruxism per my dentist, so now I wear my Invisalign retainer every night. I also had my adenoids removed at age 11 (still have my tonsils) due to constant clearing of my throat.

  9. Dr Park, can expiratory sleep apnea cause hyperinflation of the lungs?

    I have been following your thread for many years since the time I suspected I have expiratory sleep apnea. My issues started while I was in medical school and I would notice that I was waking myself up at night with large exhalation groaning / snoring sounds. This has now translated (5 years later) into pulmonary issues with chest X-ray showing lung hyperinflation. I’m not a smoker nor have I ever been and have never had signs of asthma. My hypothesis is that I have expiratory sleep apnea which is now creating this new issue. Also as a side note, I feel as though anxiety has related to both issues. Just curious to your thoughts on this. Thanks!

  10. Chris,

    What you’re describing is consistent with catathrenia. It used to categorized under the parasomnia section in the sleep medicine diagnostic category but recently has been moved to the sleep-related breathing disorder. I’m not too sure about its relation to lung hyperinflation, but here’s my thought experiment: If you have constant obstruction during exhalation, you most likely will keep waking up during sleep to a lighter stage so you can exhale fully. But rather than wake up to exhale, you inhale more reflexively, causing a kind of stacking situation, with more and more inhalation and over-inflation of your lungs.

    One suggestion to try before considering palatal surgery is to fully optimize your nasal breathing temporarily with Breathe Right strips and oxymetazoline for 3 days only along with vertically taping your lips (to go under your jaws to keep your mouth closed). When the mouth opens during sleep, the tongue base falls back and the soft palate relaxes more. Most people with expiratory obstruction also have inspiratory obstruction as well.

    This is a fascinating condition that’s been reported after maxillo-mandibular advancement surgery, palatal expansion (in this forum), and I’ve also seen it after someone started using a mandibular advancement device.

  11. Eric, your symptoms sound like mine. I have found help with a nasal rinse, especially one containing xylitol, such as XLear brand. Get a nasal rinse bottle and use 1 packet of XLear with distilled water. I do a quick rinse before bed and sometimes when I get up to pee in the middle of the night. Make sure you let some of the rinse trickle down into the back of your throat. It doesn’t “solve” the problem permanently, but it helps a lot. Regular saline nasal rinse packets work OK, but the ones with xylitol seem to work better, as it helps lubricate the back of the sinuses and soft palate, thus preventing the floppy bits from sticking together.

  12. Dr. Park, I commented several years ago concerning expiratory apnea. I wanted to share some things that have been helpful. I have a dental appliance (mouth guard) that pulls the bottom jaw forward and keeps a separation between the top and bottom teeth – this allows room for the tongue to rest in a forward position. The mouth guard with multiple pillows and sleeping on my side does allow for better sleep. Another thing that has helped is the use of a forced suction nasal washer (Navage). The forced suction is the only thing that cleans out the solution satisfactorily. I’ve tried other products and could never get good clearing. Given all of that, I still sleep in a recliner when able as it allows the best sleep.

  13. Jamie,

    Thanks for following up. Great to hear that you’re doing better. The mandibular advancement device pulls your lower jaw forward which pulls your tongue forward, as well as providing some tension on the redundant soft palate as well. Adding the other maneuvers help, but this only gets you so far. Eventually, you may need to look into modifying your soft palate, upper jaw with devices or expanders, or both. Good luck. Please keep us up to date.

  14. I have developed this problem after a life of mouth breathing caused by a broken nose at age three, plastic surgery on the nose at age 30, then it got broken again when I was knocked down by a van at age 47, and it was rebroken and reset a few months later… But what seems to have really done it is the fact that i got Bell’s Palsy 9 years ago, which seems to have weakened my mouth and tongue permanently.

    Whatever the cause it is now ruining my life, I have become so anxious about my breathing
    that I can never relax, and when I wake at 2.30 am and cannot breathe out through my nose, I panic, and cannot get back to sleep.

    I have not been able to describe my symptoms accurately to my doctor and although I took her a copy of this article to read, she didn’t look at it…

    IS there any treatment for this? And how can I get my gp to take it seriously? (I live in the uk in London, am in my late 70’s and have got Parkinson’s disease)

  15. Heather,

    So sorry to hear about your situation. What I describe in my article is not something that most doctors will read about or acknowledge. My recommendation is that you consult with your doctor to see whether or not you have obstructive sleep apnea, and then perhaps by addressing your sleep-breathing problems, you can start to feel better. Worst case scenario, if you’re still struggling, you can see an ENT surgeon about this particular palatal condition. Good luck.

  16. I posted a comment here a few days ago so why can’t I see it?
    (YOU KINDLY SENT ME A REPLY TO MY EMAIL ADDRESS)

  17. I am so sorry about my last reply, there must have been some delay in the post becoming available, because I can see them now.. but what I need to ask is do you think that a mandibular device might help, because I sleep with my mouth taped up which seems to help in the first part of the night but when I wake needing to urinate at any time from 2am I always start to worry that my tongue has fallen down, and although I try to keep it behind my front upper teeth ,it is sometimes impossible and I can’t get back to sleep, and even if I get up and retape my mouth, it doesn’t work. I am almost certain that I don’t have sleep apnea, because I only wake when i need to urinate. (a sleep study was organised but didn’t work because I was unable to sleep), and I know that I wouldn’t be able to sleep anywhere except in my bed at home….

    thank you very much for your advice so far!

  18. Thank you, I will try to get one…

    In the meantime, I have ordered your book “sleep interrupted” and am hoping to read more about catathrenia, but am wondering if your second book ‘totally CPAP’ would be more informative?

    thank you for all your helpful information,

    Heather

  19. Dr Park,
    Thank you for this article on Catathrenia. I discovered that I was having this issue just last Summer and the episodes have slowly increased (or I’ve become more aware of the frequency). I did an at home sleep study with a WatchPat just 3 wks ago and it came back saying I have mild sleep apnea. I don’t think this device can differentiate the difference between OSA and Catathrenia since it only measures episodes, oxygen, & snoring, which can be the case for both disorders. My symptoms are exactly as your article states, holding breath, wake up, exhale. Sometimes I hear myself groan on the exhale and that wakes me up. I have constant post nasal drip all during the day, constantly having to have tissues with me. It doesn’t matter where I am, drip drip drip. I think I’m allergic to myself (prob the detergent, hmm). This allergy issue is not new, I’ve had it for years, but the breathing issue was only first noticed last Summer. I think surgery sounds a bit drastic for my case, maybe an allergy med might be in store for me, but what would be safe to use in an ongoing basis? I don’t like taking meds unless absolutely necessary. I feel the back of my throat close up, maybe due to being a bit sticky from the phlegm that I notice accumulated. Do you have any safe recommendations that I can try?
    (I might also add that my anxiety is a little higher than normal lately due to going through a recent divorce. Can this bring about more episodes?) Thank you for your response!

  20. RosieB, in general, I usually recommend going ahead and treating for OSA even though it’s mild. Your two options are APAP or a mandibular advancement device. If you have any nasal congestion, then that should be addressed as well to keep your mouth closed. Losing weight is also a priority if you’re overweight. Avoid eating 3-4 hours of bedtime. Sleep 7-8 hours. These are some of my general conservative principles that everyone should start with. I have a lot more on my website and podcast. Worse case, scenario, if you’re still having these symptoms, then see an ENT about it. However, most ENTs may not believe you about this particular problem. Expiratory palatal obstruction can only be formally diagnosed with an examination and drug-induced sleep endoscopy. If you make it that far, and you’re still having problems, it’s time to consider a surgical procedure (in-office or in the operating room). Good luck.

  21. This sounds exactly like the problems I have – I’ve been all over the internet on and off for years looking for information, and this is the first description I’ve seen that matches. I snore only on my back, and on a couple of occasions while falling asleep, I’ve felt something slide back and close my airway while exhaling. I also commonly have issues where when I’m blowing my nose, it will “slam shut.”

    But the most problematic instance is during dental procedures. I can inhale through my nose, but quite often I am physically unable to exhale through my nose. The necessity to exhale through my mouth is often incompatible with procedures involving a dental dam, or having impressions taken, or any number of involved things, and what should be a simple procedure turns into a struggle to breathe. Past experience suggests that there is still a lot of involved dental work in my future, and I’m at my wit’s end about how to manage it. I hate being “that” patient, but it’s not something under my control.

  22. Kris,

    Thanks for sharing. Yes, this is a very annoying and bothersome issue. I wish there was an easy solution, but there doesn’t appear to be at the moment looking through the responses and Dr. Pak’s comments. Some have pointed to a dry mouth exacerbating the problem. I believe this, as the problem gets worse for me with higher salt intake. I find that if I drink some water during the night when suffering from it I get temporary relief (enough to get back to sleep.) Perhaps you could arrange for this in the dentist’s office.

    Your description of blowing your nose is right on. I have noticed this particular problem only lately though I believe I’ve had it for quite some time.

  23. I’m not sure what I have, I seen a sleep specialist who had little interest in my stopping breathing. We did a sleep study and I was borderline narcolepsy.

    My concern is this
    I was be sleeping, I will be dreaming and in my dream my brain will tell me to hold my breath. So I do and I wake up unable to breath until I switch back to breathing. I don’t remember the dream prior to the awake only that I know my brain told me to do it.

    I cant find anything to help me with this phenomenon.

    It worries me because I’m holding my breath and what if I don’t wake myself up or if I’m damaging brain cells.

    Any advice?

    I recently had surgery in my sinuses to help with my allergies and breathing this is has been pre and post surgery and happens few times a year. Started after removal of braces in 2019 to shrink a overbite of top teeth. I did stop using retainer
    I also suffered anxiety during the pandemic
    Any advice appreciated.

  24. Jessie,

    Sorry to hear about your sleep struggles. Your sleep doctor’s response is not surprising. Their interpretation of sleep is mainly through objective numbers seen on a sleep study, which doesn’t tell you where the blockage is coming from anatomically. From your description of your breathing pattern, it could be expiratory palatal obstruction, but it can be various other conditions as well, while not showing any significant obstructive sleep apnea. In general, a drug-induced sleep endoscopy is the best next step.The challenge will be finding an ENT that’s willing to do this for your particular symptoms. Your worsening of symptoms after the removal of braces fits very well with upper airway crowding due to dental shifting. It’s all connected. You can also look into finding an airway-centric dentist. One particular dental organization is the American Academy of Physiologic Medicine and Dentistry. Good luck!

  25. I have this issue. I can also do it on command while fully awake.
    When exhaling through my nose I feel a flap completely close off my breathing. I have to open my mouth to continue breathing.
    It’s very annoying at night while sleeping and I suspect it’s the cause of my snoring.

  26. I’ve noticed that I moan as I’m falling asleep and sometimes I wake up startled by the noise. I also have the expiratory apnea problem when on my back. I moan in any position, though. (That doesn’t sound like how I meant it…)

  27. I’m wondering about genetic predisposition? I do this 40 y/o female. My 9 year old daughter is also doing this in her sleep. Neither of us have been evaluated but we are waiting on appointments. She has a lot of throat irritation that jas always been diagnosed as allergic rhinitis but allergy medications have never worked for this.

  28. Jenny,

    Since children inherit their parents’ anatomy, it’s possible. Be prepared to be met with some skepticism by your doctor. Perhaps show your doctor this short video clip from my blog. With children, you have another variable, which is possible enlarged adenoids, which can possibly contribute. Good luck!

  29. Hello
    Excuse me for my English , I live in France and disparately searching for my problem and I found your blog doctor Park. It started about 12 years ago , while exhaling it was a bit annoying and obstructed, it became worse threw the years. Right now it’s just awful , Evry night I wake up more than 5 times where my exhaling breath is completely blocked and I can’t sleep on my back of course and mouth open and saliva coming out.
    2 days ago it was just terrifying, I woke up with exhale obstruction and even though I worked I didn’t , it was like there was a big amount of pressure while exhaling it just blocked and didn’t open , it took about 10 seconds while I was awake to find back my exhale.

    NB : I can simulate the exhale obstruction while lying on my back without sleeping the air pass by the mouth and push the mouth to open.
    the ORL here in France told me it’s maybe the soft palate issue .
    I have medical dates firs of September with a maxillo-faciale doctor and 3D scanner

    Hope you give your opinion

    Thanks

  30. Fadel,

    It does sound like you have expiratory palatal obstruction. Unfortunately, the only long-term solution I’ve found to help is palatal surgery. Double jaw surgery is another option, but not your first choice.

    Good luck!

  31. Yes. I stop breathing during exhalation while sleeping on my back only. Is there a way to fix this?

  32. Margaret,

    Unfortunately, the only way I’ve seen any success is with palatal surgery (modified UPPP). One potential temporary measure is scarring the soft palate with a chemical that’s used for varicose veins. However, it’s going to be challenging to find an ENT that’s willing to do this.

  33. Don’t know about moaning but believe I’m experiencing these nasal exhale events. I can replicate them when conscious, blowing hard through the nose a ‘valve’ slams shut preventing further exhalation.

    Further evidence is that, if I apply light finger pressure to the nostrils thus creating a back pressure then the ‘valve’ remains open. Evidence, as, recognizing this malady there’s a gadget available somewhere in the world which you shove up your nose to create this back pressure.

    Have lived with increasingly severe sleep apnea for 30 years. From MAP to Cpap to Cpap with cervical collar and now a rucksack full of air. This nasal business seems like a new development.

    With Cpap, by the way, this nasal thing is more severe when Exhale Pressure Relief is off which fits in with the need for increased back pressure idea.

    Also, keeping it simple, it could be that what CPAP machines interpret as Cheynee Stokes events are actually sometimes nasal obstructions.

    Any advice please? Surgery? BongoRX?

  34. Peter,

    From what you’re telling me, it does sound like expiratory palatal obstruction (EPO). Yes, it can sometimes lead to what looks like central apneas, but not really. Cheyne Stokes breathing is also central, but there’s a specific pattern (you can see in Google images). EPO looks different. If you look at the CPAP flow tracings that show central events, you’ll see a normal inhalation, but sudden flat-lining during mid-exhalation.

    Unfortunately, the only option that I’ve seen help with this is palatal surgery. I did see temporary relief with palatal scarring with injection snoreplasty. Another option that may work theoretically is the Alaxo stent.

  35. Don’t know about moaning but believe I’m experiencing these nasal exhale events. I can replicate them when conscious, blowing hard through the nose a ‘valve’ slams shut preventing further exhalation.

    Further evidence is that, if I apply light finger pressure to the nostrils thus creating a back pressure then the ‘valve’ remains open. Evidence, as, recognizing this malady there’s a gadget available somewhere in the world which you shove up your nose to create this back pressure.

    Have lived with increasingly severe sleep apnea for 30 years. From MAP to Cpap to Cpap with cervical collar and now a rucksack full of air. The nasal business seems like a new development.

    With Cpap, by the way, this nasal thing is more severe when Exhale Pressure Relief is on which fits in with the need for increased back pressure idea.

    Also, keeping it simple, it could be that what CPAP machines interpret as Cheynee Stokes events are sometimes actually nasal obstructions.

    Any advice please? Surgery? BongoRX?

  36. Believe I’m experiencing these nasal exhale events. I can replicate them when conscious, blowing hard through the nose a ‘valve’ slams shut preventing further exhalation.

    Further evidence is that, if I apply light finger pressure to the nostrils thus creating a back pressure then this ‘valve’ remains open hence allowing exhalation. Evidence, as, recognizing this malady there’s a gadget available somewhere in the world which you shove up your nose to create this back pressure.

    Have lived with increasingly severe sleep apnea for 30 years. From MAP to Cpap to Cpap with cervical collar and now a rucksack full of air. The nasal business seems like a new development.

    With Cpap, by the way, this nasal thing is more severe when Exhale Pressure Relief is on which fits in with the need for increased back pressure idea.

    Also, keeping it simple, it could be that what CPAP machines interpret as Cheynee Stokes events are sometimes actually nasal obstructions.

    Any advice please? Surgery? BongoRX?