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

  1. Mr. Hughes,

    Thanks for sharing your story. The link to the poster is working now. Thanks for pointing it out. As expected, sleep physicians are not aware of this condition. You’re welcome to take a copy of the poster to your physician. I’m working on a manuscript on this condition. Hope to submit for publication soon.

  2. I do this while awake and have been doing so for as long as I can remember. I have no idea if I do it while asleep, but I don’t think so since no one has ever mentioned it. I never notice I’m doing it but people get weirded out and point it out to me. I’ve had it described as the moaning video games characters do when dying. 99% of the time it happens when I’m lying down at home at night. Even after I’m made aware of it, it takes a lot of focus to normalise my breathing. I’m currently feeling a bit freaked out cause googling it didn’t give me much of an answer.

  3. Thank you for this blog. I would love to hear your insight in relation to my daughter. Between ages 4 and 8 she had a handful of fainting episodes immediately followed by what looked like a brief petite mal seizure. After one of the episodes, she had a period of coughing which started and stopped abruptly. This made me wonder if the brainstem was somehow involved. However, no lesions or abnormalities were noted on her CAT scan. After a cardiac and neurological work-up, the presumptive diagnosis is a vaso-vagal reaction. She is now 12, thin/normal weight and otherwise healthy. She has not had any fainting episodes since 3rd grade. For as long as I can remember, she has not been a “morning person”. Now that she is older, she is sharing with us that she does not feel rested in the morning (and is often tired throughout the day). I have observed (for the last 3-4 years) that she makes odd snoring noises – typically around 3:00am. Recently, I have gone into her room to learn more. She frequently awakens immediately and asks why I am in her room. However, when she does not awaken, I have noted that she is on her stomach, without a pillow, making prolonged expiratory moaning sounds. I could not discern any periods of apnea or a cessation of breathing. I am curious about a potential link between her previous episodes and her current sleep patterns. Is there a good resource where I can look to find research related to catathrenia and similar disorders?

  4. This sounds like me exactly. I’m young and thin and have been having this unique problem for as long as I remember. It only happens to me when I’m trying to fall asleep and rarely while I’m sleeping but it will wake me up. It defers me from sleeping and has become so annoying. My boyfriend calls it “dry heaving”, I’ll have a sudden abdominal jerk and quick forced exhale usually with a groan. Happens multiple times a night before I fall asleep. I’ve noticed if I take controlled deep breaths it will cease but that’s harder to do as you’re falling asleep. I am exclusively a stomach sleeper.

    I personally have found an association to if my hands are hot, it will occur more often. Sometimes if I put lotion on my hands and sleep palms up with the circulating air it will stop the breathing problems. But only sometimes. I told my PCP this and I think he thought I was crazy. The forced exhale will also occur sometimes if my hands are in hot water (like a bathtub).

    I’d like to think it’s a unique attribute and not a serious medical issue, but some answers or treatment would be awesome.

  5. Hello

    I’ve just been told i do this. In fact I noticed myself waking and exhaling thu my mouth. It felt rushed and false.

  6. I have had this problem for a while and its very problematic especially while sleeping. While sleeping i sometimes wake up out of my sleep after trying to exhale thru my nose but notice that im exhaling with a rush of air thru my mouth. Im not sure but i think while this is happening, that im not breathing properly while sleeping. is there a remedy to fix this problem?

  7. Dr. Park, please forgive me if I’ve missed this elsewhere, but could you give a short description of the surgery that can correct this condition? Can it be done on an outpatient basis?

  8. Hello, I am a 38yr old male. Im 185 lbs and 6’2. I dont smoke or use tobacco, yet over the past couple of years I have started to have HBP which I am being treated for as well as the onset of snoring. The type of snoring that I am having is different from most types I have read about. My snoring actually wakes me up and its extremely loud. From what I can tell, it seems to be occurring as I exhale through my nose. It is not a groan though. I wake up often at night feeling like I can’t breathe. I have also started having the feeling during the day like I cant get a full breath. I am a second year medical student and have chalked it up to anxiety but as I have further investigated my situation, it seems like I may have some type of sleep apnea that could possibly be causing all of these sequelae. Does this sound like anything anyone has ever heard of before?

  9. Chris,

    Regardless of what’s going on with your throat, your first step is to get tested and treated for possible obstructive sleep apnea by a certified sleep doctor. Only if standard treatments don’t work do these unusual anatomic variations become relevant.

    Good luck…

  10. I am 33 weeks pregnant and this has been happening to me for about 6 weeks now and seems to be worsening. I only sleep on my side and have been trying to elevate my upper body to see if that helps (it doesn’t). In addition, I have also become a serious snorer – my husband has even recorded me to show me how bad it is… Two questions- do you think a c-pap machine might help? Or do you have another suggestion as I can’t have surgery while pregnant. Did anything work for your wife? And second, did the condition reverse for your wife once she gave birth? This is seriously interrupting my sleep and I’m not sure I can handle it much longer. Thank you for any insights that may help.

  11. I have come to the conclusion that I have this blockage on exhale and I can duplicate it while awake lying on my back, and focusing on completly relaxing my jaw/tongue etc. I have used a CPAP for a number of years now and it seems to have not had the miracle cure to my sleepiness as advertised and wondered why. I also use a chin strap, which also hasn’t helped.

  12. Ms. Hammitt,

    In general, if you snore that much, it’s probably a good idea to get tested for sleep apnea and undergo treatment (usually CPAP or dental appliance for pregnant women). Only if you have trouble with CPAP due to this particular palatal issue will it need to be addressed.

    My wife got an anti-snoring shot in the soft palate (called injection snoreplaty). It helped for a few months. There’s no medical literature on this at all, so you’ll have to see a sleep doctor or ENT that’s knowledgeable about this.

  13. I know this is pretty old but it is the best resource I have found on catathrenia and it is good to hear stories from people who suffer from it. My wife originally said I made crazy noises and would snore years ago so I had a take home sleep study and was diagnosed with complex apnea. I honestly think that I just have catathrenia and the study thought they were apnea events. I got a CPAP machine and then an ASV but my AHI numbers are always pretty bad no matter what settings I have tried on either machine. I really think it is because I have catathrenia and not apnea.

  14. I actually have a question, does anyone have a general idea of the settings to use on an ASV machine to properly treat catathrenia? Is it a minimum amount of pressure or high pressure? I can’t seem to find any info regarding this anywhere.

  15. This is what is happening to me when I am almost asleep. When I lay on my back and begin to drift off, there is an occlusion in the back of my throat that prevents me from exhaling through my nose. I can feel what I can only describe as a “flap” blocking my exhalation process. I can hear it as it drops in place. I am 40 years old and work extremely odd hours. I thought that had something to do with it and am sure my uncharacteristic sleep schedule is how it began. I am tired during the day and have a hard time sleeping at night. I have tried to find out what is going on but have been unable to find d any information until coming across this article. I do not want to use cpap but am worried my condition is only going to get worse. I am also able to instigate the process while awake. I am not sure what I should do. Any help in this area would be greatly appreciated.

  16. Yes I do. My sleep doc thinks I’m imagining it. I catch it even sometimes when I’m trying to fall asleep.

  17. This is exactly what happens to me! I too can replicate the expiratory apnea while awake. I can breathe out through my nose (while laying on my back) and something in the back of my throat will “flap shut” and I can no longer exhale nasally. I can inhale, but not exhale. I can do both orally no problem. My ENT and my sleep doctor both seemed as if I was describing a completely alien event. The ENT even scoped out my nasal passages and throat because he was intrigued but did not notice anything unusual. I did start CPAP therapy and that seems to have helped with snoring and apnea, but the expiratory apnea still occurs as a series of clicks, or pops, instead of a complete obstruction due to the positive pressure. Of course, going to the dentist (reclined in chair, mouth full of tools/water and really needing to breathe through my nose) is still an adventure. Thank you for posting this!!

  18. Dear Dr. Park,

    At night, only whilst lying flat on my back (not on either side) there is an abrupt shutting off of my ability to exhale through my nasal passage. I am unaware of any accompanying sound. This clears immediately if I turn over to my left or right, suggesting a possibly gravitational implication.

    There is no associated discomfort.

    My first thought was that something (possibly a post natal drip following a chronic cough a couple of weeks ago when I first became aware of this) was triggering the epiglottis to react in the normal way but then the epiglottis seemed to me to be not physically high enough to match the sensation (nasopharnx proximity) or indeed likely to flop about as I turned.

    Following my reading of your article, I looked at my uvula which seemed longer, thinner and more ‘dangly’ than I had imagined but healthy in every other respect. Perhaps age (71) could have a stretching/elongating effect which might account for the uvula’s ability to reach a position capable of creating the effect you describe when I lie on my back, and then fall aside as I turn over?

    I would be most grateful and of course very interested to read any comment you may feel inclined to make. Thank you for your time.

  19. These are my symptoms exactly except that I am neither young nor thin. In the early morning hours “if” I am sleeping on my back which I don’t ordinarily do. Occasionally, I can replicate the “sudden occlusion or closure” during the day while awake. It is nice to finally know what this is. :)

  20. I have this. When lying on my back (but elevated because I have a hospital bed), I can inhale through my nose, then something audibly “drops”, when I exhale, blocking my nose entirely, forcing the air out of my mouth, which comes out sounding like a “razz”, or a fart, with EVERY EXHALATION. It wakes me up with EVERY breath. I do have obstructive sleep apnea, but this is new. I have a bi-pap, and use 24-hr oxygen. So can this be fixed?

  21. Unfortunately, the only way to save this problem is through soft palate surgery. In some cases, the soft palate can be scarred using an agent for varicose veins. Only an in-office personal exam can confirm this.

  22. I like so many deal with expiratory apnea and I can make it happen by just laying my head back and relaxing it’s as if a door with shutting tried using the CPAP machines and chin straps mouthguard with my dentist and even nasal dilation devices I’m assuming it’s the uvula or palette? And is surgery my only option I know I could go and see the ENT but it sounds like there is no consensus?

  23. I experience my nasal passage “slamming” shut like this but I do not make the moaning sounds. I have been on a CPAP for several years now but still do not feel rested. It is my observation that this “slamming shut” of my nasal airway when I exhail is what is causing my breathing issues. The ENT doctor wants to do a UPPP. Is this surgery something that could correct the issue?? If possible, can you relate your thoughts on this?? I am 62yo female and weigh approx 178. I am able to replacate this issue when the doctor looks with the scope. My sleep doctor and his assistant also observed this issue and it caused problems with the sleep study as I had to keep adjusting my head to breathe my air out through my nose. Does anybody else reading this have the same issue?? How did you correct it??

  24. When lying on my back, I wake up suddenly unable to exhale, I have done this all my life.
    It is worse when I have a cold. If I lay on my side it doesn’t happen. I figured it was mild sleep apnea (mild since lying on my side prevents it).
    Are there exercises which would strengthen the uvula?

  25. Is there surgery to remedy this problem? I never had it until I had posterior C1-3 fusion for a C2 ondontoid fracture. It’s very annoying and worrisome, I have to make myself exhale when it’s bad or when I have to take pain meds ad night. Then I feel like I’m have to think to breathe! Would an ENT physician be the best choice of doctors to seek?

    Thank you!

  26. Hello Dr Park. In answer to the question posted here, yes. I’ve seen you regarding this, and you did determine that I do the exact same thing. For me, it started almost immediately after my UPPP. I believe you found that my UPPP wasn’t really done aggressively enough. You and most other Dr’s say it looks as if I didn’t even have it done were it not for the tonsils not being there.
    I still struggle with this problem and it explains a lot why I don’t feel so refreshed after using CPAP all night. Also, my palate feels a bit sore every morning as if it was being used as a punching bag all night.
    At any rate, you felt that UPPP, again, would be something helpful to me. I chickened out having it done because it is so painful afterwards. However, I would be interested in LAUP. I was wondering if that could be a better option in treating this condition?
    I really feel it was the UPPP that caused it, perhaps it weakened my palate and caused the condition and tweaking it with LAUP can help? Or is happening cause the tonsils are gone, and thus the structure of my thought is different now so the air reacts differently?
    As a side note, I am having a Sleep Induced Endoscopy done to see whats really going on.

  27. Mr. Petitto,

    Sorry to hear. Your best bet is to re-evaluate what your needs are after drug induced sleep endoscopy. There are a number of different less invasive soft palate options available. LAUP is not generally recommended for OSA anymore.

  28. Denise,

    What you describe does agree with what I’m findings. a C1-C3 fusion, especially if performed in front of the c-spine, can in theory narrow the space behind the soft palate. It’s been shown to happen to the epiglottis for fusion at levels 3 to 5.

  29. This happens to me when awake as well. When i sleep there is only one position on my side that i can sleep peacefully. I am a grinder so my jaw is locked when i sleep and if not in right position i cant exhale through my nose and choke. Even when awake it feels like my uvula is too big and it will seal my throat passage when my nasal passage does not allow exhale.

  30. Thank you! I saw an ENT because I felt I had something partially obstructing my nasopharynx randomly while awake and upright. He did a sleep study showing I had apnea and prescribed CPAP. On my first day of PT today( for something else) I found I had complete blocking of exhalation while flat on my back on the table. He had me tucking my chin down to stretch muscles when I discovered how bad that was in this position. He was amazed when I was able to repeatedly demonstrate to him that I could inhale but not exhale. It’s great to know that someone knows what I’m talking about !

  31. I was diagnosed with sleep apnea and now use a C-pap with good results. But if I try to relax while lying supine (as in meditation), my exhale is completely blocked by the soft tissue in my nasopharanx. I suspect this also happened if I slept supine. I got tested b/c friends complained of my snoring (presumably inspiratory) and no reports of moaning. I sleep on my side almost exclusively. Not sure how C-pap would address the expiratory blockage. Sounds like this would lead to repeated valsalva manuevers. I now have a hiatal hernia and wonder if this sleep problem could have contributed to it.

  32. This is what I’ve been trying to describe to others about falling asleep on my back or in a recliner. My “croaking” wakes me up – and it happens just AS I am FALLING asleep. It seems that some conscious control of the muscles that hold my throat open during exhale ceases as soon as I fall asleep. Wouldn’t continuous inflow from CPAP provide even more resistence to keeping my epiglottis in the open position?

  33. MG,

    What you’re describing can occur with expiratory palatal obstruction (nasal exhalation) or epiglottic collapse (inhalation). CPAP can in theory help, but just the physical act of breathing in and out can cause these inspiratory and expiratory “valves” to collapse, no matter how high the pressure.

  34. I believe this is the problem I’ve been experiencing my entire adult life. It started in high school when I was on the swim team and very much in good physical shape. I am now much heavier, and would be classified as obese. It is because of that that I don’t know how to approach a doctor about this without being automatically told I have sleep apnea. I don’t stop breathing while I sleep. I hold my breath. And often let it out in short bursts before finally releasing it entirely. I remember this freaking my wife out when we were first married and freaked out a friend in college who heard me do it, too. It starts even before I fall asleep. As I’m getting tired, or even shortly after I wake up, I find myself holding my breath. I’ve never been able to breathe through my nose very well. I’m sure that plays a big part of this. I don’t wake up out of breath or with headaches. In fact, I rarely get headaches. My chest never really hurts when I wake up. Is there a recommendation on what type of doctor I should see about this and how I should approach them so that I’m properly diagnosed and treated, if possible? Thank you.

  35. My son is 6 and does this every night! It’s actually more toward the morning when his sleep is lighter. He breathes and then when he needs to exhale, I can feel he’s holding his breath for a few seconds and starts to make noise the whole time he’s exhaling. I thought it might be sleep apnea but this sounds exactly right. He’s very high strung and hyped up and it just always seemed like his sleep matched how he was during the day. Well I’m glad it’s just a nuisance.

  36. My fiance just brought it up to my attention. While both awake and alseep, inparticilarly especially if I’m on my back, I’ll be breathing then it’s as if I hold my breathe for 10-20 seconds then exhale. Its not rushed or gasping. I have noticed it a few times while I’m awake, and I’m like why are you holding your breathe. Breathe….. Not sure if it could be central apnea. I’m 33, 5’4 and 115 lbs. I don’t feel rested ever when I get up.

  37. I cease to exhale when excess mucous blocks my airway. I inhale just fine, but when I start to fall asleep, I am continually woken by the mucous blocking when trying to exhale, then I either swallow or cough it up. I have bronchiectasis from a heritable connective tissue disorder. C-pap does not work for me. I don’t think my providers understand. I self monitor my SpO2 at night and some nights I meet criteria for oxygen therapy, with episodes of O2 <88 for over 5 minutes. My doctor wants another (2nd) sleep study for apnea, but I don't think this will help. I would like to try oxygen, but they keep pushing the C-pap. Any suggestions?

  38. Karen,

    Your situation could be from mucous like what you described, but only an in-office exam or possible sleep endoscopy can tell if you have expiratory palatal obstruction.

  39. My son has difficulties breathing his pediatrician gave him mometasone nose drops and erolin medicine.and that helps but he developed a cold that got infected and I kept him for over month with now I brought him to the doctor and he gave him breathe you 5mg chewable tablets and aeroflux 2mg- 7,5 mg /5ml to take 3 times daily and antibiotics azithronmycin Macs 100’s to take but he just started taking them one day now but he still has difficulties breathing in the nights and makes alot of groaning sounds and twit he’s in his sleep and sleep with his mouth open doctor please tell me what I should do or can do.should I give him his mometasone nasal drops same way alongside with the antibiotic and medicine and breathezy tablets please help me.and my son his 8 and he his fat too

  40. I try to explain the “flap” or “one-way valve” feeling (only on exhaling, and on my back, although it also prevents me from fully blowing my nose while upright, too) to my doctor. He tells me to take an antihistimine for post-nasal drip This doesn’t work. I’m not sleeping well and wake up tired and usually with a headache. Sleepy all day. Constantly “clearing phlegm” from my throat all day.

    I have two things to add to what I’ve read.

    1. Because of this, sometimes it’s really difficult to take the first bite of breakfast after waking up. Sometimes it feels like I’m going to choke and can’t exhale until I calm down and try to breathe through my mouth.

    2. I have had two bouts, over tbe past couple of years, of waking up to the feeling that a large chunk of phlegm is blocking my throat, only to find, as I come out of sleep while trying to swallow it down, that it is my uvula that I’m “trying to swallow”. This results in an even more elongated uvula, which keeps touching the back of my throat, triggering my gag reflex all day. Only by staying calm, not talking, and sipping cool water slowly does it recede. I wonder if these bouts contributed to the exhale flap closing thing?

  41. While I have had the nasal exhale problem lying on the couch with head partially elevated, I am now experiencing this during the night while sleeping. I’ve read all the comments and am not sure a dependable solution has been identified. I guess it all depends on the patient and exact conditions.

    Nonetheless, I’m wondering if there might not be a pre-sleep gargling solution. I.e., some combination of liquids (lemon?) that would have a ‘shrinking’ effect on the uvula and the soft tissue in the nasopharanx?

  42. Ganga,

    Pregnancy causes increased swelling as well as added fat to the soft palate, so it can flop back more easily.

  43. I have this. I can replicate while awake. While asleep I end up holding breath and then exhaling like a horse. I am going for a sleep study next month and I’m afraid they won’t pick it up. What is the treatment? I was thinking that if I plugged my nose with a swim clip then I would just breath through mouth and wouldn’t have a problem.