Cheyne Stokes Respirations


Article Author:
Mohan Rudrappa


Article Editor:
Pradeep Bollu


Editors In Chief:
Mohamed Alhajjaj
Fatima Anjum
Pramil Cheriyath


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Pritesh Sheth
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes
Kavin Sugumar


Updated:
6/4/2019 12:46:38 PM

Introduction

Cheyne-Stokes respiration is a type of breathing disorder characterized by cyclical episodes of apnea and hyperventilation. Although described in the early 19th century by John Cheyne and William Stokes, this disorder has received considerable attention in the last decade due to its association with heart failure and stroke, two major cause of mortality and morbidity in developed countries. Unlike obstructive sleep apnea (OSA) which can be the cause of heart failure, Cheyne-Stokes respiration is believed to be a result of heart failure. The presence of Cheyne-Stokes respiration in patients with heart failure also predicts worse outcomes and increases the risk of sudden cardiac death. Despite increasing recognition and growing knowledge, Cheyne-Stokes respiration remains elusive, and patients have very limited treatment options.[1][2][3][4]

Etiology

Cheyne-Stokes respiration is a specific form of periodic breathing (waxing and waning amplitude of flow or tidal volume) characterized by a crescendo-decrescendo pattern of respiration between central apneas or central hypopneas. The American Academy of Sleep Medicine (AASM) recommends to score a respiratory event as Cheyne-Stokes breathing if both of the following criteria are met:

  1. There are episodes of at least three consecutive central apneas and/or central hypopneas separated by a crescendo and decrescendo change in breathing amplitude with a cycle length of at least 40 seconds (typically 45 to 90 seconds).
  2. There are five or more central apneas and/or central hypopneas per hour associated with the crescendo/decrescendo breathing pattern recorded over a minimum of two hours of monitoring.

Cheyne-Stokes respiration should be differentiated from other central sleep apneas like idiopathic central sleep apnea where in there is no waxing and the waning pattern of ventilation. The ventilation length in patients with Cheyne-Stokes respiration is more than 40 seconds compared to less than 40 seconds in central sleep apnea. Also, the relative duration of hyperventilation is more than apnea duration in Cheyne-Stokes respiration. In central apneas, the duration of apnea is more than the duration of hyperventilation.

Cheyne-Stokes respiration is well-studied in patients with heart failure and stroke. In patients with heart failure, male gender, older age, sedentary lifestyle, diagnosis of atrial fibrillation, increased ventricular filling pressure and more advanced cardiac remodeling are known to predispose to Cheyne-Stokes respiration. Up to 20% of patients with stroke can exhibit Cheyne-Stokes respiration. [5][6][7]

Epidemiology

The true prevalence of Cheyne-Stokes respiration in the general population is not known and is considered to be rare. Due to varied definitions and modality of detection used, the incidence in Cheyne-Stokes respiration in patients with heart failure varies from 25% to 50%. This means that out of nearly 5.7 million patients of heart failure, two to three million patients are expected to have Cheyne-Stokes respiration. The incidence is reported to be more in patients with systolic heart failure compared to diastolic heart failure, and Cheyne-Stokes respiration is also more common in elderly patients.

Pathophysiology

Cheyne-Stokes respiration is initiated and maintained due to change in the apnea threshold and the fluctuating PCO2 levels around this threshold in patients with heart failure or stroke who are at risk of unstable central respiratory control. Under normal awake conditions, ventilation is under both cortical and metabolic control. Normal respiration is maintained through the negative feedback mechanism. Peripheral and central chemoreceptors will sense PCO2 levels and trigger either positive with negative reciprocal feedback signals. Normal PCO2 levels are around 45 millimeters of mercury. The highest PCO2 levels to suppress respiration, called apnea threshold, is usually around 4 mm to 6 mm lower than the normal PCO2 levels.  The sleep apnea threshold is equal or marginally lower than the aware threshold levels. The difference between these two levels is called carbon dioxide reserve. Patients with heart failure are normally tachypneic and maintain lower PCO2 levels both awake and during sleep. Also, the carbon dioxide reserve in these patients is reduced to 1.3 mm to 3 mm of mercury lower than the resting levels.

During transition from awake to non-rapid eye movement (NREM) sleep, cortical control of respiration is progressively diminished, and respiration is dependent on metabolic control based on PCO2 levels. During REM sleep, ventilation is predominately under central control by pontomedullary inspiratory neurons. During N1 or N2 NREM stage, any unstable respiratory state like arousal or sudden change in sleep stage will result in hyperventilation and decrease in PCO2 levels. If the PCO2 levels decrease below the already increased apnea threshold levels, central apnea ensues. This slow rise in PCO2 levels will stimulate chemoreceptors and will result in the hyperventilation phase. Due to unstable central control and imprecise feedback support in patients with heart failure and stroke, the PCO2 levels during hyperventilation will fall below the apnea threshold levels,  resulting in apnea again. These cycles of apnea and hypercapnia continue, resulting in Cheyne-Stokes respiration.

History and Physical

The clinical features of Cheyne-Stokes respiration are similar to congestive heart failure, including dyspnea, cough, and fatigue. A patient with Cheyne-Stokes respiration with heart failure shows more lethargy and fatigue due to increased sympathetic activity because of disturbed sleep. Periodic leg movements are more common in patients with heart failure with Cheyne-Stokes respiration than patients without Cheyne-Stokes respiration.

Evaluation

Cheyne-Stokes respiration is characterized by alternating apnea and hyperventilation during sleep, mostly in the N1 and N2 sleep, and also when awake. This can be clinically observed and documented with a cyclic variation of breathing pattern with a change in saturation from 90% to 100%. Minute ventilation is not routinely monitored during sleep studies. The hyperventilation is documented by rising and falling chest excursions and the tidal volume. If the patient is on a ventilator, then the cyclical change in tidal volume and minute ventilation can be graphed together. The apnea/hyperapnea cycle is around 45 minutes to 75 minutes. This cycle is longer than other causes of central sleep apnea cycle which typically have a cycle length of 30 to 45 minutes. Cheyne-Stokes respiration is worse in the supine position or moving from supine to lateral body position.

Treatment / Management

The main cornerstone of management of Cheyne-Stokes respiration is optimizing the treatment for the trigger factor, congestive heart failure (CHF), or stroke. The American Academy of Sleep Medicine recommends that positive airway pressure should be considered for all patients with central sleep apnea. The two main modalities of noninvasive treatment for Cheyne-Stokes respiration are continuous positive airway pressure (CPAP) and adaptive servo-ventilation (ASV).[8][9][10][9]

CPAP delivers continuous positive pressure and has several mechanisms of actions. The positive pressure keeps the upper airway splinted during the central apnea, leading to stabilization of respiratory drives and improvement in oxygenation and ejection fraction. The positive pressure will also reduce the preload by reducing the venous blood flow to the right atrium and afterload by increasing the intrathoracic pressure, thereby improving the ejection fraction. In a clinical trial, CPAP therapy in patients with Cheyne-Stokes respiration showed improvement in nocturnal desaturation, Left ventricular function and six-minute walk distance, but there was no improvement in survival.

Adaptive servo-ventilation is the newer modality of noninvasive treatment which is effective and well tolerated by patients. This mode of noninvasive ventilation can counteract hyperventilation during the hyperpnea phase and prevent hypoventilation during the apnea phase. It delivers constant continuous pressure and can recognize apnea or hypopnea and adjust pressure support with backup ventilation if needed to deliver preset tidal volume. During the hyperventilation phase, the pressure support is reduced, depending on the patient to prevent large tidal volume. Adaptive servo-ventilation is more effective than conventional noninvasive ventilation therapies like continuous positive airway pressure and bilevel positive airway pressure therapy and has been shown to improve the functional class, cardiac functions, exercise capacity and brain natriuretic peptide (BNP) levels. However, in a recent large clinical trial involving patients with systolic heart failure and Cheyne-Stokes respiration breathing, the addition of adaptive servo-ventilation to guideline-based medical therapy did not improve outcome and increased the risk of cardiovascular death.

Pearls and Other Issues

The repeated interruption in breathing imposes an autonomic, chemical, mechanical and inflammatory burden on heart and circulation. The hypoxia during apnea or hypopnea phase will increase sympathetic activity and myocardial damage. Hypoxia is also known to precipitate rupture of plaques, vasoconstriction of vessels and to promote dementia. Hypercapnia can cause arrhythmia and contribute to lethargic and feeling of fragmented sleep.  The presence of Cheyne-Stokes respiration in a patient with heart failure is a strong independent predictor of cardiac death and hospital readmission. In clinical studies, the presence of Cheyne-Stokes respiration in patients with heart failure is linked to arrhythmia and arrhythmia-related death.  Patients with heart failure with Cheyne-Stokes respiration are more likely to have lower ejection fraction, higher brain natriuretic peptide, and increased plasma catecholamines compared to patients without Cheyne-Stokes respiration.

Cheyne-Stokes respiration is a complex breathing disorder seen in patients with heart failure. The presence of Cheyne-Stokes respiration affects overall prognosis of patients with heart failure.  Although the exact pathophysiology of Cheyne-Stokes respiration is still not clear, the latest development in noninvasive therapy offers hope for a potential cure. Further research is needed to understand and treat this disorder precisely.

Enhancing Healthcare Team Outcomes

The management of patients with heart failure is by a multidisciplinary team. One of the complications of heart failure is Cheyne Stokes breathing. Cheyne-Stokes respiration is a type of breathing disorder characterized by cyclical episodes of apnea and hyperventilation. Although described in the early 19th century by John Cheyne and William Stokes, this disorder has received considerable attention in the last decade due to its association with heart failure and stroke, two major cause of mortality and morbidity in developed countries. Unlike obstructive sleep apnea (OSA) which can be the cause of heart failure, Cheyne-Stokes respiration is believed to be a result of heart failure. The presence of Cheyne-Stokes respiration in patients with heart failure also predicts worse outcomes and increases the risk of sudden cardiac death. Despite increasing recognition and growing knowledge, Cheyne-Stokes respiration remains elusive, and patients have very limited treatment options. These patients are best managed by a cardiologist, pulmonologist, heart failure specialist, intensivist and critical care nurses. With no ideal treatment, the prognosis for these patients is guarded.


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Cheyne Stokes Respirations - Questions

Take a quiz of the questions on this article.

Take Quiz
Cheyne-Stokes respirations can be seen in which of the following conditions?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is the most common cause of Cheyne-Stokes respiration?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
With what condition is Cheyne-Stokes respiration associated?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 60-year-old patient with a nonischemic cardiomyopathy with ejection fraction less than 15%, status post automatic implantable cardioverter-defibrillator (AICD) insertion, paroxysmal atrial fibrillation presents to the heart failure clinic with his wife for follow up. He reports that his breathing is getting better and ankle swelling has come down. His vitals are normal: respiratory rate of 16/min, heart rate of 90 bpm, blood pressure of 100/60 mmHg, and a BMI of 17. His wife states that for the past six months his breathing has become abnormal. He completely stops breathing for approximately one minute, then breathes heavily. This pattern occurs both at night and during the day. The patient and his wife deny any prior breathing problem. His wife has not noticed snoring or daytime sleepiness. Cheyne-Stokes respiration is suspected. How are these characterized?

(Move Mouse on Image to Enlarge)
  • Image 5719 Not availableImage 5719 Not available
    Contributed by the Creative Commons
Attributed To: Contributed by the Creative Commons



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is associated with Cheyne Stokes respirations?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 70-year-old patient was diagnosed with ischemic cardiomyopathy last year. During his hospitalization one month back, apneic episodes were detected during telemonitoring. He underwent sleep study last week and presents for the follow up in the sleep clinic. Based on polysomnography findings Cheyne Stokes respiration was diagnosed. Which of the following statements about Cheyne Strokes respiration is false?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Cheyne Stokes Respirations - References

References

Vargas-Ramirez L,Gonzalez-Garcia M,Franco-Reyes C,Bazurto-Zapata MA, Severe sleep apnea, Cheyne-Stokes respiration and desaturation in patients with decompensated heart failure at high altitude. Sleep science (Sao Paulo, Brazil). 2018 May-Jun;     [PubMed]
Granitza P,Kraemer JF,Schoebel C,Penzel T,Kurths J,Wessel N, Is dynamic desaturation better than a static index to quantify the mortality risk in heart failure patients with Cheyne-Stokes respiration? Chaos (Woodbury, N.Y.). 2018 Oct;     [PubMed]
Tinoco A,Mortara DW,Hu X,Sandoval CP,Pelter MM, ECG derived Cheyne-Stokes respiration and periodic breathing are associated with cardiorespiratory arrest in intensive care unit patients. Heart     [PubMed]
Kim Y,Kim S,Ryu DR,Lee SY,Im KB, Factors Associated with Cheyne-Stokes Respiration in Acute Ischemic Stroke. Journal of clinical neurology (Seoul, Korea). 2018 Oct;     [PubMed]
Stellbrink C,Hansky B,Baumann P,Lawin D, [Transvenous neurostimulation in central sleep apnea associated with heart failure]. Herzschrittmachertherapie     [PubMed]
Yamaoka-Tojo M, Is It Possible to Distinguish Patients with Terminal Stage of Heart Failure by Analyzing Their Breathing Patterns? International heart journal. 2018;     [PubMed]
Pinna GD,Robbi E,Terzaghi M,Corbellini D,La Rovere MT,Maestri R, Temporal relationship between arousals and Cheyne-Stokes respiration with central sleep apnea in heart failure patients. Clinical neurophysiology : official journal of the International Federation of Clinical Neurophysiology. 2018 Sep;     [PubMed]
Wolf J,Narkiewicz K, Managing comorbid cardiovascular disease and sleep apnea with pharmacotherapy. Expert opinion on pharmacotherapy. 2018 Jun;     [PubMed]
Drager LF,McEvoy RD,Barbe F,Lorenzi-Filho G,Redline S, Sleep Apnea and Cardiovascular Disease: Lessons From Recent Trials and Need for Team Science. Circulation. 2017 Nov 7;     [PubMed]
Whited L,Graham DD, Abnormal Respirations 2018 Jan;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Pulmonary. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Pulmonary, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Pulmonary, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Pulmonary. When it is time for the Pulmonary board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Pulmonary.