What is the appropriate management for a patient with a breathing pattern of very large volumes followed by very small volumes?

Cheyne-Stokes Respiration: Recognition and Management

Immediate Recognition and Assessment

The breathing pattern described—alternating large volumes followed by small volumes—is characteristic of Cheyne-Stokes respiration (CSR), a periodic breathing disorder that requires immediate evaluation for underlying cardiovascular or neurological pathology, particularly congestive heart failure.

• CSR is characterized by cyclical periods of hyperpnea (very heavy breathing with large tidal volumes) followed by hypopnea or apnea (very small or absent breathing), creating a crescendo-decrescendo pattern 1, 2
• This pattern represents a low-frequency oscillation in the cardiorespiratory system that can be quite stable and persist for prolonged periods 2
• The oscillations involve not just ventilation but also arousal state, blood oxygen levels, carbon dioxide levels, and blood pressure 2

Underlying Pathophysiology and Causes

CSR onset results from increased ventilation-perfusion ratio, increased feedback control gain, prolonged transport delay, increased left heart volume, lung congestion, or reduced cardiovascular efficiency—all pointing toward serious cardiovascular disease.

• Congestive heart failure is the most common cause, where reduced cardiac output creates prolonged circulatory delay between the lungs and chemoreceptors 1, 2
• Other serious causes include encephalitis and other neurological conditions affecting respiratory control centers 1
• The pattern can also occur during acclimatization to high altitude 1

Management Strategy

For Non-Intubated Patients

Treat the underlying cardiovascular or neurological pathology aggressively, as reducing or abolishing the oscillation results in clinical improvement.

• Focus on optimizing heart failure management if present, as this is the most common reversible cause 2
• Treatment that reduces the oscillation improves outcomes because it minimizes the pathological fluctuations in oxygen, carbon dioxide, and blood pressure 2
• Monitor for signs of respiratory failure requiring intubation: refractory hypoxemia (PaO2 < 60 despite high-flow oxygen), respiratory rate > 35 breaths/min, or vital capacity < 15 ml/kg 3

For Intubated Patients Requiring Mechanical Ventilation

If mechanical ventilation becomes necessary, use lung-protective strategies with tidal volumes of 6-8 ml/kg predicted body weight, maintain plateau pressure ≤30 cmH2O, and accept permissive hypercapnia to avoid ventilator-induced lung injury.

• Set tidal volume at 6-8 ml/kg predicted body weight (men = 50 + 2.3 × [height in inches - 60]; women = 45.5 + 2.3 × [height in inches - 60]) 4, 3
• Maintain plateau pressure strictly below 30 cmH2O to prevent barotrauma and ventilator-induced lung injury 5, 4
• Target arterial oxygen saturation of approximately 90% (PaO2 ~60 mmHg) 3
• Apply PEEP (typically starting at 5 cmH2O) to prevent alveolar collapse and improve oxygenation 3, 4

Ventilator Settings and Monitoring

Use volume-cycled assist-control mode initially, with each breath delivered over 1 second and tidal volumes of 500-600 ml to achieve visible chest rise.

• Deliver each rescue breath over 1 second with tidal volume of approximately 500-600 ml (6-7 ml/kg) to produce visible chest rise 3
• When advanced airway is in place, provide 1 breath every 6-8 seconds (8-10 breaths/minute) without synchronizing with compressions if in cardiac arrest 3
• For non-arrest situations, use assist-control mode as initial ventilation strategy 3
• Monitor plateau pressure continuously by performing inspiratory hold maneuvers of 0.5-1.0 seconds 5

Permissive Hypercapnia

Accept mild hypoventilation (permissive hypercapnia) to maintain safe plateau pressures, as hypercapnia is typically well tolerated and reduces mortality risk.

• Allow PaCO2 to rise while maintaining plateau pressure < 30 cmH2O, as this prevents alveolar overdistension 3, 4
• Permissive hypercapnia is safe and effective at reducing mortality without adverse consequences 3
• This approach is now standard practice following the ARDS Network trial demonstrating reduced mortality with lung-protective ventilation 3

Critical Pitfalls to Avoid

Never use excessive ventilation (too many breaths or too large volumes), as this increases intrathoracic pressure, decreases venous return, and diminishes cardiac output and survival.

• Excessive ventilation causes gastric inflation, regurgitation, aspiration, and most importantly, hemodynamic compromise 3
• Avoid hyperventilation attempts to normalize blood gases at the expense of lung protection 4
• Do not use high respiratory rates without adequate expiratory time, as this causes dangerous auto-PEEP accumulation 4
• Never delay intubation in patients with apnea, coma, persistent hypercapnia, exhaustion, or severe mental status depression 3, 4

Special Considerations for Heart Failure Patients

In patients with congestive heart failure (the most common cause of CSR), optimize cardiac function while maintaining strict lung-protective ventilation parameters.

• Consider albumin plus furosemide in hypo-oncotic patients with established lung injury, as this may improve physiology and reduce ventilation duration 3
• Monitor for development of ventilator-associated pneumonia, which has significant independent contribution to mortality 3
• Use orotracheal rather than nasotracheal intubation to reduce sinusitis risk 3