How to manage Cheyne-Stokes respiration (CSR) in patients with underlying neurological conditions?

Management of Cheyne-Stokes Respiration in Neurological Conditions

In patients with Cheyne-Stokes respiration (CSR) due to neurological conditions, particularly acute stroke, provide supplemental oxygen to maintain oxygen saturation ≥92-95% and position the patient with head of bed elevated 15-30° if there is risk of airway compromise or elevated intracranial pressure. 1

Immediate Assessment and Monitoring

• Monitor oxygen saturation continuously with pulse oximetry, targeting SpO2 ≥92-95% in stroke patients with CSR 1
• Recognize that CSR occurs frequently after stroke (particularly with bilateral hemispheric involvement, large-artery atherosclerosis, or cardioembolic stroke) and causes oxygen desaturation that can worsen neurological injury 1, 2
• Administer supplemental oxygen when hypoxia is documented by pulse oximetry or blood gas determination, as CSR-related desaturations can be readily reversed with oxygen supplementation 1

Patient Positioning Strategy

• For nonhypoxic patients who can tolerate lying flat, use supine position to optimize cerebral perfusion 1
• Elevate head of bed 15-30° in patients with:
  • Risk of airway obstruction or aspiration 1
  • Decreased level of consciousness 1
  • Brain stem dysfunction 1
  • Suspected elevated intracranial pressure 1
• Monitor airway, oxygenation, and neurological status closely when changing patient position, adjusting as clinical parameters change 1

Airway Management Considerations

• Consider endotracheal intubation if the airway is threatened, particularly in patients with decreased consciousness or brain stem stroke who have impaired oropharyngeal mobility and loss of protective reflexes 1
• Note that approximately 50% of stroke patients requiring intubation die within 30 days, but airway protection prevents aspiration pneumonia—a leading cause of post-stroke death 1
• Elective intubation may be necessary for patients with severely increased intracranial pressure or malignant brain edema 1

Oxygen Therapy Specifics

• Do not routinely administer supplemental oxygen at 3 L/min to all stroke patients, as controlled trials show no benefit in normoxic patients 1
• Provide oxygen only when indicated by:
  • Pulse oximetry showing desaturation 1
  • Blood gas determination confirming hypoxia 1
  • Clinical evidence of respiratory compromise 1
• High-flow normobaric oxygen started within 12 hours may provide transient neurological improvement, though evidence is limited 1
• Avoid hyperbaric oxygen therapy, as data show no benefit and potential harm in acute ischemic stroke 1

Medications to Avoid

• Avoid sedative medications and central nervous system depressants as they worsen hypoventilation and can further depress respiratory drive in patients with CSR 1
• This includes opiates, benzodiazepines, and other agents that depress upper airway tone 1

Treatment of Underlying Cardiac Dysfunction

• If CSR is associated with congestive heart failure (common comorbidity), optimize cardiac function medically as this may improve breathing abnormalities 1, 3, 4
• Note that low left ventricular ejection fraction and left atrial enlargement are associated with CSR in acute stroke 2
• CPAP is not recommended as first-line treatment for CSR in heart failure patients, as randomized trials suggest increased mortality in the first 2 years 1

Common Pitfalls

• Do not delay stroke treatment to address CSR—manage oxygenation and ventilation while proceeding with acute stroke protocols 1
• Recognize that CSR indicates severe neurological disorder and is associated with worse outcomes, particularly with bilateral hemispheric involvement 5, 2
• CSR may not be immediately recognized as clinical features are often dominated by the underlying stroke 3
• Continuous monitoring is essential because patients with CSR may experience profound hypoxemia before physiologic compromise is clinically detected 1

Long-term Ventilatory Support

• For patients with chronic neurological conditions requiring ongoing ventilatory support (e.g., neuromuscular disorders), positive pressure ventilation via tracheostomy is preferred over noninvasive ventilation to ensure optimal oxygenation 1
• Tracheostomy may be indicated for prolonged weaning from mechanical ventilation in acquired, potentially reversible neuromuscular disorders 1
• Do not perform tracheostomy in the acute setting with intracranial hypertension (ICP >15 mmHg) or severe hypoxemia (PaO2/FiO2 <100 mmHg) 1