OBJECTIVE:Understanding respiratory control during sleep is fundamental to understanding the approach to the diagnosis and management of central sleep apnea (CSA). LATEST DEVELOPMENTS:CSA is not one disease but rather a syndrome resulting from a heterogeneous group of etiologies. There are complex chemical, metabolic, mechanical, and neural contributions that can cause dysregulation in loop gain, decreased central respiratory drive, or both. The traditional dichotomy between obstructive versus central sleep apnea is overly simplistic. Conventional CSA is the extreme end along a continuum between obstructive and central phenotypes of sleep apnea. In addition to assessing CSA severity from sleep study data, new approaches, including computational analytics and the use of wearable technologies, are increasingly aimed at extrapolating additional information to characterize CSA etiology. Various positive airway pressure modalities are available to treat CSA, but residual disease is common. There is a better understanding of drugs as causes and as treatments of CSA. Phrenic nerve stimulation is a new treatment option. Multimodal therapy is the likely future of CSA therapy. ESSENTIAL POINTS:CSA can be mechanistically divided into hypercapnic and hypocapnic CSA, with the six CSA syndromes in the International Classification of Sleep Disorders (Third Edition, Text Revision) falling under one or both of these categories depending on their etiology. Understanding the obstructive-central continuum of sleep apnea, in which the degree of contribution from each underlying sleep apnea driver, known as endotypes, predicts the relative central disease of a given patient on this continuum, can enhance comprehensive management.
OBJECTIVE:This article reviews the growing field of inpatient sleep medicine, addressing the importance of inpatient sleep quality and the evaluation and treatment of sleep disorders during and shortly after hospitalization. LATEST DEVELOPMENTS:Sleep disruption and sleep disorders in the inpatient setting are associated with worse outcomes. Improving sleep quality and duration in the hospital and treating sleep disorders such as obstructive sleep apnea may improve in-hospital and short-term outcomes, such as mortality, stroke recurrence, and recovery. The 2025 American Academy of Sleep Medicine guidelines conditionally recommend the availability of inpatient sleep medicine services. Screening questionnaires can be used to prioritize objective testing for obstructive sleep apnea or empiric treatment in inpatients, but atypical symptoms in patients with stroke and congestive heart failure make them less sensitive. Objective screening tools such as high-resolution pulse oximetry may help prioritize resources but do not qualify patients for therapy such as CPAP; portable or in-laboratory sleep testing may be needed. ESSENTIAL POINTS:Inpatient sleep medicine may be delivered by a multidisciplinary team based on available resources. Even if diagnosis or treatment cannot occur in the inpatient setting, recognizing sleep disorders during inpatient admissions increases the chances for successful outpatient treatment and can facilitate timely outpatient workup.
OBJECTIVE:The purpose of this article is to provide an overview of how to evaluate, diagnose, and manage patients with hypersomnia disorders. LATEST DEVELOPMENTS:The extended-release formulation of sodium oxybate to treat narcolepsy with a dosage of once a night, rather than twice a night, was approved in 2023 for adults and in 2024 for pediatric patients aged 7 years and older by the US Food and Drug Administration (FDA). The novel pharmacokinetics of this formulation may improve medication adherence and reduce nighttime disruptions and sleep fragmentation for patients and their bed partners. Orexin receptor 2 agonists are also being investigated for the treatment of narcolepsy and idiopathic hypersomnia. CSF orexin testing can be used to diagnose narcolepsy type 1. ESSENTIAL POINTS:Patients with hypersomnia have excessive daytime sleepiness, which can be due to an underlying sleep disorder or can be secondary to another condition. Diagnostic tools are useful but imperfect. It is essential to obtain a detailed sleep history to understand how patient symptoms are affecting daily life.
OBJECTIVE:This article reviews sleep basics, including stages, need, changes with aging, sleep drive, and circadian rhythm, to provide a normative framework and to reveal potential opportunities for insomnia intervention. In addition, it elucidates the symptoms, causes, consequences, diagnosis, and treatment of insomnia, including the role of sleep aids and cognitive behavioral therapy (CBT) for insomnia. LATEST DEVELOPMENTS:The wide-ranging consequences of insomnia are increasingly appreciated, with research highlighting its detrimental effects on health. Newer medication options include three orexin receptor antagonists. Home-based sleep tracking may allow screening to identify contributing factors, including sleep disorders that require treatment, and assessment of the environment for early intervention to optimize sleep. Existing and emerging wearable technology and software as digital therapy will increase access to CBT for insomnia through increasingly individualized programs. ESSENTIAL POINTS:Insomnia is the most common sleep disorder, with significant effects on quality of life and long-term health. Optimizing the sleep drive and circadian rhythm, addressing underlying causes, reducing hyperarousal, and enhancing conditioning are key components of improving the disorder. Over-the-counter and prescription sleep aids may have a limited role because of modest benefits and the potential for side effects. CBT for insomnia remains the preferred treatment, with a growing number of novel modes of access.
