What is the diagnosis and treatment for a breathing pattern characterized by cycles of apnea followed by rapid and deep breathing?

From the Guidelines

The diagnosis for a breathing pattern characterized by cycles of apnea followed by rapid and deep breathing is Cheyne-Stokes respiration. This abnormal breathing pattern is typically treated by addressing the underlying cause, which commonly includes heart failure, stroke, brain injury, or kidney failure. According to the most recent and highest quality study available, 1, treatment often involves optimizing management of heart failure with medications such as ACE inhibitors (like lisinopril 10-40 mg daily), beta-blockers (such as carvedilol 3.125-25 mg twice daily), and diuretics (like furosemide 20-80 mg daily).

Key Considerations

• For patients with heart failure and sleep-disordered breathing, continuous positive airway pressure (CPAP) therapy at pressures of 8-12 cmH2O during sleep may be beneficial, as noted in 1.
• Adaptive servo-ventilation might be considered for central sleep apnea, though it requires careful patient selection, as discussed in 1.
• Supplemental oxygen at 2-4 L/min may help maintain oxygen saturation.
• Cheyne-Stokes respiration occurs due to delays in feedback between blood gas levels and respiratory control centers in the brain, causing the respiratory system to overcompensate and creating the characteristic waxing and waning pattern, as explained in 1.

Treatment Approach

• The severity of this breathing pattern often correlates with the severity of the underlying condition, so monitoring and aggressive management of the primary disease is essential for improving outcomes, as emphasized in 1.
• Addressing the underlying cause is crucial, and treatment should be tailored to the individual patient's needs, taking into account the severity of the underlying condition and the presence of any comorbidities.
• A comprehensive treatment plan should include optimization of heart failure management, consideration of CPAP or adaptive servo-ventilation therapy, and supplemental oxygen as needed, as supported by the evidence from 1 and 1.

From the Research

Diagnosis of Breathing Pattern

• The breathing pattern characterized by cycles of apnea followed by rapid and deep breathing is known as Cheyne-Stokes respiration (CSR) 2, 3, 4, 5, 6.
• CSR is a form of central sleep-disordered breathing (SDB) that leads to periods of central apneas/hypopnea, which alternate with periods of hyperpnea 2.
• The diagnosis of CSR is based on the presence of cyclic oscillations of tidal volume and respiratory rate with periods of hyperpnea alternating with hypopnea or apnea 3.

Treatment of Cheyne-Stokes Respiration

• The management of CSR involves optimal control of underlying heart failure, oxygen therapy, and positive airway pressure support 2.
• Noninvasive adaptive servoventilation is currently the most promising treatment for CSR when it persists despite optimal therapy of heart failure 3.
• Other treatment modalities that have been proposed for CSR include continuous positive airway pressure (CPAP), nocturnal home oxygen therapy (HOT), nocturnal supplemental CO2, and phrenic nerve stimulation 6.
• The current treatment recommendations for CSR are for CPAP and HOT as standard therapies, while adaptive servoventilation (ASV) is an option only in patients with EF > 45% 6.

Pathophysiology of Cheyne-Stokes Respiration

• The pathophysiology of CSR has been explained by the loop gain theory, where a controller (the respiratory center) and a plant (the lungs) are operating in a reciprocal relationship (negative feedback) to regulate a key parameter (partial pressure of carbon dioxide (pCO2)) 6.
• Increased chemosensitivity/chemoresponsiveness of the respiratory center and/or augmented ascending non-CO2 stimuli from the C-fibers in the lungs (interstitial pulmonary edema) are involved in the development of CSR 6.
• An alternative hypothesis of CSR being an adaptive response of the failing heart has its merits as well 6.

Clinical Manifestation of Cheyne-Stokes Respiration

• The clinical manifestation of CSR is usually poor, lacking striking symptoms and complaints 6.
• Witnessed apneas and snoring are infrequently reported by the sleep partner, and patients may report poor sleep quality with frequent awakenings, paroxysmal nocturnal dyspnea, and frequent urination at night 6.
• Standard instrumental and laboratory studies, performed in CHF patients, may present clues to the presence of CSR, including concentric remodeling of the left ventricle and dilated left atrium (echocardiography), high BNP and C-reactive protein levels, and increased ventilation-carbon dioxide output (VEVCO2) 6.