Table of Contents

Definition of Sleep related Hypoventilation

Sleep-related hypoventilation refers to a condition characterized by inadequate breathing during sleep, leading to a decrease in the amount of air taken into the lungs. In hypoventilation, there is a reduction in the rate or depth of breathing, causing an insufficient intake of oxygen and inadequate removal of carbon dioxide from the body.

  • During sleep, the body’s respiratory drive may decrease, leading to shallow or slower breathing patterns. In some cases, this reduction in breathing efficiency can result in the retention of carbon dioxide in the bloodstream, leading to higher than normal levels of carbon dioxide (hypercapnia) in the body during sleep.
  • Sleep-related hypoventilation is often associated with certain medical conditions such as obesity hypoventilation syndrome (OHS), neuromuscular disorders, respiratory muscle weakness, chronic obstructive pulmonary disease (COPD), or other respiratory conditions. It can also occur due to anatomical abnormalities in the airways or due to the use of certain medications that affect breathing.
  • This condition can result in symptoms such as excessive daytime sleepiness, fatigue, morning headaches, cognitive impairment, and in severe cases, it can lead to complications like pulmonary hypertension or heart problems due to chronically elevated levels of carbon dioxide in the blood.

Treatment for sleep-related hypoventilation may involve addressing the underlying cause, using continuous positive airway pressure (CPAP) therapy, supplemental oxygen, or, in some cases, assistive ventilation to support breathing during sleep. It’s essential for individuals experiencing symptoms of sleep-related hypoventilation to consult a healthcare professional for proper evaluation and management.

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History of Sleep related Hypoventilation

The understanding and recognition of sleep-related hypoventilation have evolved over time alongside advancements in sleep medicine and respiratory physiology research.

  • Hypoventilation during sleep was initially observed and described in the context of certain medical conditions that affect breathing, such as neuromuscular disorders and obesity hypoventilation syndrome (OHS). These conditions often exhibited symptoms of respiratory impairment during sleep, including increased levels of carbon dioxide and decreased oxygen saturation in the blood.
  • The term “obesity hypoventilation syndrome” was coined to describe a specific condition characterized by obesity, daytime hypoventilation, and episodes of disordered breathing during sleep. It became recognized as a distinct clinical entity primarily affecting obese individuals.
  • The development and widespread use of polysomnography (a comprehensive sleep study) in the latter half of the 20th century greatly contributed to the understanding and diagnosis of various sleep disorders, including sleep-related hypoventilation. Polysomnography allowed healthcare professionals to monitor multiple physiological parameters during sleep, enabling the identification and characterization of breathing abnormalities and their relationship with sleep stages.
  • With the evolution of sleep medicine as a specialized field, researchers and clinicians gained deeper insights into the mechanisms and consequences of hypoventilation during sleep. This included the identification of conditions beyond obesity hypoventilation syndrome that could lead to sleep-related hypoventilation, such as certain neuromuscular diseases, respiratory muscle weakness, chronic obstructive pulmonary disease (COPD), and others.
  • As awareness increased and diagnostic tools improved, guidelines for the diagnosis and management of sleep-related hypoventilation were established. Continuous positive airway pressure (CPAP) therapy, which helps keep the airways open during sleep, emerged as a key treatment for some individuals with this condition. Additionally, other interventions such as bilevel positive airway pressure (BiPAP), supplemental oxygen, and assistive ventilation have been utilized based on the underlying causes and severity of hypoventilation.

Continued research and advancements in sleep medicine have furthered our understanding of sleep-related hypoventilation, leading to improved diagnostic criteria, treatment strategies, and a better understanding of its impact on overall health and well-being.

DSM-5 Criteria of Sleep related Hypoventilation

In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), sleep-related hypoventilation is not classified as a specific disorder. However, the DSM-5 does provide diagnostic criteria for other sleep-related breathing disorders, such as sleep-related hypoventilation being a feature or a consequence of certain conditions.

For instance, sleep-related hypoventilation might be a prominent feature of conditions like obesity hypoventilation syndrome (OHS). In such cases, the DSM-5 would not provide specific criteria for sleep-related hypoventilation but might address the criteria for the underlying condition causing the hypoventilation.

DSM-5 criteria typically focus on specific sleep disorders and their associated features rather than directly addressing sleep-related hypoventilation as an independent diagnostic category. Instead, it often relates to the assessment and diagnosis of disorders that can lead to sleep-related hypoventilation, such as:

Obstructive Sleep Apnea (OSA):

DSM-5 might detail criteria for OSA, which can sometimes be associated with hypoventilation during sleep due to airway obstructions leading to breathing disturbances.

Other specified sleep-related breathing disorders:

This category in DSM-5 includes conditions where sleep-related breathing abnormalities cause significant distress or impairment but do not fit the specific criteria for established sleep disorders. This category might encompass scenarios where hypoventilation occurs as a result of different medical or physiological conditions.

Therefore, while DSM-5 doesn’t provide explicit criteria for sleep-related hypoventilation as a separate diagnosis, it acknowledges hypoventilation as a component or consequence of certain sleep-related breathing disorders or medical conditions, directing clinicians to assess and address the underlying issues causing hypoventilation during sleep.

Etiology of Sleep related Hypoventilation

Sleep-related hypoventilation can result from various underlying conditions or factors that impair normal respiratory function during sleep. Some of the primary causes or etiological factors include:

Obesity Hypoventilation Syndrome (OHS):

This condition is characterized by obesity, daytime hypoventilation, and disordered breathing during sleep. Excess weight can lead to mechanical restriction of lung expansion and compromise respiratory function, causing hypoventilation during sleep

Neuromuscular Disorders:

Conditions affecting the nerves or muscles involved in breathing, such as muscular dystrophy, myasthenia gravis, amyotrophic lateral sclerosis (ALS), or spinal cord injuries, can lead to weakened respiratory muscles, resulting in hypoventilation during sleep

Central Nervous System Disorders:

Certain neurological conditions, including brainstem disorders, congenital central hypoventilation syndrome, or conditions affecting the control of breathing, can disrupt the brain’s respiratory regulation, leading to hypoventilation during sleep.

Chronic Obstructive Pulmonary Disease (COPD):

Individuals with COPD, including chronic bronchitis and emphysema, may experience decreased lung function, airway obstruction, and reduced gas exchange capacity, contributing to hypoventilation during sleep.

Medications and Substance Use:

Some medications or substances can depress the respiratory drive, leading to decreased breathing efforts during sleep and subsequent hypoventilation. This includes opioid medications, sedatives, and alcohol.

Anatomic Abnormalities:

Structural abnormalities in the airways or chest wall, such as severe kyphoscoliosis or conditions affecting the upper airway anatomy, can restrict airflow and contribute to hypoventilation during sleep.

Hypoventilation in the Setting of Sleep Apnea:

In some cases, individuals with obstructive sleep apnea may also experience episodes of hypoventilation due to periods of reduced airflow or complete cessation of breathing during sleep, leading to changes in blood gases.

Endocrine Disorders:

Certain endocrine conditions like hypothyroidism can affect the body’s metabolism and respiratory drive, contributing to sleep-related hypoventilation.

Management of sleep-related hypoventilation typically involves treating the underlying cause. This can include weight loss strategies for OHS, optimizing treatment for neuromuscular conditions, addressing airway obstructions, adjusting medications, and using positive airway pressure devices like CPAP or BiPAP to support breathing during sleep. Additionally, supplemental oxygen therapy might be used in some cases to improve oxygen levels during sleep.

Theories related to Sleep related Hypoventilation

Sleep-related hypoventilation involves complex interactions between multiple physiological systems, and various theories attempt to explain the mechanisms underlying this condition. Some of the key theories related to sleep-related hypoventilation include:

Altered Respiratory Control:

Changes in the brain’s respiratory control mechanisms during sleep can contribute to hypoventilation. This alteration may involve diminished responsiveness of the respiratory centers in the brainstem that regulate breathing patterns, leading to reduced respiratory drive during sleep.

Ventilatory Control Instability:

Fluctuations or instability in the control of breathing during sleep can lead to irregularities in ventilation, resulting in periods of inadequate airflow and hypoventilation. This instability might be influenced by factors affecting chemoreceptor sensitivity to carbon dioxide and oxygen levels.

Upper Airway Obstruction and Resistance:

Conditions such as obstructive sleep apnea can coexist with sleep-related hypoventilation. Repeated episodes of upper airway obstruction and subsequent arousal can disrupt normal breathing patterns, causing fluctuations in ventilation and contributing to hypoventilation.

Respiratory Muscle Weakness:

Weakness in the muscles responsible for breathing, whether due to neuromuscular disorders or other conditions, can impair the ability to generate adequate respiratory effort during sleep, leading to hypoventilation.

Ventilatory Control Response to Carbon Dioxide:

Changes in the body’s response to carbon dioxide levels during sleep might lead to inadequate adjustments in breathing, resulting in hypoventilation. Conditions affecting chemoreceptor sensitivity or responsiveness to carbon dioxide levels can contribute to this phenomenon.

Mechanical Factors and Obesity:

Excessive weight, especially in obesity hypoventilation syndrome (OHS), can mechanically impede lung expansion and chest wall movement, limiting the ability to breathe effectively during sleep and contributing to hypoventilation.

Neurological Dysfunction:

Disorders affecting the central nervous system, such as congenital central hypoventilation syndrome or certain brainstem abnormalities, can disrupt the neural control of breathing, leading to hypoventilation during sleep.

These theories often overlap, and sleep-related hypoventilation may result from a combination of factors rather than a single isolated cause. Understanding the interplay between these mechanisms is crucial in diagnosing and managing individuals with sleep-related hypoventilation, as treatments may vary depending on the underlying mechanisms involved. Treatment approaches often focus on addressing the specific cause or contributing factors to improve respiratory function during sleep.

Risk factors of Sleep related Hypoventilation

Sleep-related hypoventilation can be influenced by various risk factors, which increase the likelihood of experiencing impaired breathing during sleep. These risk factors can be related to underlying medical conditions, lifestyle factors, physiological aspects, or demographic characteristics. Some of the significant risk factors associated with sleep-related hypoventilation include:


Obesity is a major risk factor for developing obesity hypoventilation syndrome (OHS). Excess weight can lead to mechanical restriction of lung expansion, impairing respiratory function and contributing to hypoventilation during sleep.

Neuromuscular Disorders:

Conditions that affect the nerves, muscles, or neuromuscular junctions involved in breathing (such as muscular dystrophy, ALS, myasthenia gravis) can weaken the respiratory muscles, increasing the risk of hypoventilation during sleep.

Chronic Respiratory Conditions:

Individuals with chronic lung diseases like chronic obstructive pulmonary disease (COPD), bronchiectasis, or interstitial lung diseases have compromised lung function, which can predispose them to sleep-related hypoventilation.


Advanced age can be a risk factor due to age-related changes in respiratory function and muscle strength, potentially increasing susceptibility to hypoventilation during sleep.


There might be a higher prevalence of sleep-related breathing disorders, including hypoventilation, in males compared to females, although this can vary among different populations.

Anatomical Abnormalities:

Structural abnormalities in the airways or chest wall, such as severe kyphoscoliosis, can restrict airflow and contribute to hypoventilation during sleep.

Use of Sedatives or Opioids:

Certain medications or substances, especially sedatives, tranquilizers, opioids, or alcohol, can depress the central nervous system and decrease respiratory drive, potentially leading to hypoventilation during sleep.


Endocrine disorders like hypothyroidism can affect metabolism and respiratory drive, increasing the risk of hypoventilation during sleep.


Smoking and exposure to tobacco smoke can exacerbate respiratory conditions and impair lung function, potentially increasing the risk of sleep-related breathing disorders, including hypoventilation.

Family History:

Some conditions associated with hypoventilation, such as congenital central hypoventilation syndrome (CCHS), can have a genetic component, indicating a higher risk for affected individuals within families.

Understanding these risk factors can help clinicians identify individuals who may be more susceptible to sleep-related hypoventilation and facilitate early diagnosis and intervention to mitigate its effects on health and well-being.

Treatment for Sleep related Hypoventilation

The treatment for sleep-related hypoventilation depends on the underlying cause and severity of the condition. Managing sleep-related hypoventilation typically involves addressing the root cause, improving ventilation, and ensuring adequate oxygenation during sleep. Treatment approaches may include:

Positive Airway Pressure (PAP) Therapy:

Continuous Positive Airway Pressure (CPAP) or Bilevel Positive Airway Pressure (BiPAP) machines are commonly used to support breathing during sleep. These devices deliver pressurized air through a mask, helping to keep the airway open and facilitating adequate ventilation.

Supplemental Oxygen Therapy:

In cases where low blood oxygen levels (hypoxemia) occur during sleep-related hypoventilation, supplemental oxygen can be provided to improve oxygenation. This may be used in combination with PAP therapy or other interventions.

Weight Management:

For individuals with obesity hypoventilation syndrome (OHS), weight loss through lifestyle changes, diet modifications, and exercise can significantly improve respiratory function and alleviate symptoms.

Medication Adjustments:

If sleep-related hypoventilation is associated with certain medications that depress the respiratory drive (such as opioids or sedatives), adjusting or discontinuing these medications under medical supervision may be necessary.

Treatment of Underlying Medical Conditions:

Addressing underlying medical conditions contributing to hypoventilation, such as neuromuscular disorders, chronic lung diseases, or endocrine disorders, is crucial. This may involve disease-specific treatments, physiotherapy, or other interventions aimed at managing the primary condition.

Non-invasive Ventilation (NIV):

In more severe cases or when PAP therapy alone isn’t sufficient, non-invasive ventilation devices like BiPAP or adaptive servo-ventilation (ASV) might be recommended to assist with breathing during sleep.

Respiratory Muscle Training:

Some individuals may benefit from respiratory muscle training exercises to strengthen respiratory muscles, enhancing their ability to breathe effectively during sleep.

Lifestyle Modifications:

Avoiding alcohol and sedatives, maintaining a regular sleep schedule, sleeping in certain positions, and optimizing sleep hygiene practices can sometimes help improve breathing patterns during sleep.

Regular Monitoring and Follow-up:

Periodic evaluation and monitoring of symptoms, sleep patterns, and response to treatment are essential. Adjustments to the treatment plan may be made based on the individual’s progress and needs.

It’s crucial for individuals with suspected sleep-related hypoventilation to undergo a thorough evaluation by a healthcare professional, often a pulmonologist or sleep specialist. Tailored treatment plans considering the specific underlying causes and individual characteristics are essential to effectively manage sleep-related hypoventilation and improve overall quality of life.

Therapies for Sleep related Hypoventilation

Several therapies and interventions can be employed to manage sleep-related hypoventilation, aiming to improve breathing patterns and oxygenation during sleep. These therapies can vary based on the underlying cause and severity of hypoventilation. Some of the main therapeutic approaches include:

Positive Airway Pressure (PAP) Therapy:

Continuous Positive Airway Pressure (CPAP) and Bilevel Positive Airway Pressure (BiPAP) are commonly used therapies. CPAP delivers a constant pressure to keep the airway open, while BiPAP delivers different pressures during inhalation and exhalation, providing more support for individuals with varying respiratory needs.

Adaptive Servo-Ventilation (ASV):

ASV devices adjust airflow in response to the patient’s breathing patterns, delivering varying pressures to support ventilation, especially for those with central sleep apnea or complex sleep apnea.

Non-Invasive Ventilation (NIV):

In more severe cases, non-invasive ventilation devices like BiPAP or ASV might be used to provide stronger respiratory support, assisting with breathing during sleep.

Supplemental Oxygen Therapy:

For individuals with low blood oxygen levels during sleep, supplemental oxygen can be administered via nasal cannula or face mask to improve oxygenation.

Respiratory Muscle Training:

Breathing exercises and respiratory muscle training, including inspiratory muscle training (IMT), may help strengthen respiratory muscles, potentially improving ventilation.

Weight Management Programs:

For individuals with obesity hypoventilation syndrome (OHS), weight loss programs involving dietary changes, exercise, and lifestyle modifications can be effective in reducing hypoventilation by improving respiratory function.

Medication Adjustments:

If hypoventilation is associated with medications that depress the respiratory drive (such as opioids or sedatives), adjustments or changes in medication under medical supervision may be necessary.

Positional Therapy:

Sleeping in specific positions may sometimes help alleviate sleep-related breathing problems. For example, avoiding sleeping in the supine position might reduce the severity of obstructive sleep apnea and related hypoventilation.

Continuous Monitoring and Follow-up: Regular monitoring of symptoms, sleep patterns, and treatment effectiveness is essential. Follow-up visits with healthcare providers help assess progress and make necessary adjustments to the treatment plan.

Individuals experiencing symptoms of sleep-related hypoventilation should consult a healthcare professional for a comprehensive evaluation and personalized treatment plan tailored to their specific condition and needs. Effective management often involves a combination of therapies to optimize respiratory function during sleep and improve overall quality of life.

Preventions of Sleep related Hypoventilation

Preventing sleep-related hypoventilation involves addressing risk factors, adopting healthy lifestyle habits, and managing underlying conditions that contribute to impaired breathing during sleep. While some causes of sleep-related hypoventilation might not be entirely preventable, certain strategies can help reduce the risk and potentially alleviate symptoms. Here are preventive measures:

Maintain a Healthy Weight:

Obesity is a significant risk factor for obesity hypoventilation syndrome (OHS). Maintaining a healthy weight through regular exercise and a balanced diet can reduce the risk of developing OHS.

Manage Underlying Health Conditions:

Proper management of chronic respiratory conditions, neuromuscular disorders, endocrine disorders like hypothyroidism, and other medical conditions that can affect breathing may help prevent or minimize sleep-related hypoventilation.

Avoid Smoking and Limit Alcohol Intake:

Smoking can worsen respiratory conditions, while excessive alcohol consumption can depress the central nervous system and compromise breathing. Avoiding smoking and limiting alcohol intake can be beneficial.

Medication Management:

Be cautious with medications that can suppress respiratory drive, especially opioids, sedatives, or tranquilizers. Use them as prescribed and under medical supervision.

Regular Sleep Schedule and Sleep Hygiene:

Maintaining a regular sleep schedule and practicing good sleep hygiene habits, such as creating a conducive sleep environment, can promote better sleep quality and potentially reduce sleep-related breathing disturbances.

Positional Changes During Sleep:

Some individuals experience worsened breathing in specific sleeping positions. Sleeping on the side instead of the back might alleviate some obstructive sleep apnea-related symptoms and improve ventilation.

Stay Active and Exercise:

Regular physical activity can improve overall health, including respiratory function. Engaging in regular exercise can help in weight management and improve lung function, potentially reducing the risk of hypoventilation.

Respiratory Muscle Training:

For individuals at risk due to neuromuscular conditions or respiratory muscle weakness, specific exercises designed to strengthen respiratory muscles might be beneficial in preventing worsening hypoventilation.

Regular Health Check-ups:

Periodic check-ups with healthcare providers allow for the early detection and management of any developing health issues that might contribute to sleep-related hypoventilation.

While these preventive measures can reduce the risk or severity of sleep-related hypoventilation, it’s essential for individuals experiencing symptoms or at risk for hypoventilation to seek medical evaluation and guidance from healthcare professionals. Identifying and addressing potential issues early on can significantly improve outcomes and prevent complications associated with sleep-related breathing disorders.

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