Treatment of Cheyne-Stokes Breathing
The primary treatment for Cheyne-Stokes breathing is optimization of guideline-based heart failure therapy, as the breathing pattern often improves with effective treatment of the underlying cardiac condition. 1, 2
Understanding the Clinical Context
Cheyne-Stokes breathing (CSB) is not simply a breathing disorder to be suppressed—it may represent a compensatory mechanism in heart failure patients. 2 The pattern occurs primarily during light sleep and is characterized by respiratory alkalosis with low carbon dioxide levels. 2 Importantly, CSB appears to improve breathing efficiency and reduce respiratory muscle fatigue, with the periodic rest and hyperventilation phases increasing end-expiratory lung volume and oxygen stores. 2
Primary Treatment Approach: Optimize Heart Failure Management
Focus first on maximizing medical therapy for the underlying heart failure before considering any interventions specifically targeting the breathing pattern. 1, 2 This is critical because:
- CSB often resolves or improves when heart failure is adequately treated 1, 2
- The breathing pattern may be a marker of heart failure severity rather than a primary therapeutic target 2
- Interventions aimed at suppressing CSB can be harmful (see below) 2
What NOT to Do: Critical Safety Considerations
Avoid adaptive servo-ventilation (ASV) in heart failure patients with reduced ejection fraction, as it has been associated with increased mortality. 3, 4 This represents one of the most important clinical pitfalls in managing CSB. 3
Do not use medications that stimulate ventilation to suppress the breathing pattern after heart failure therapy has been optimized. 2 These medications can:
- Reduce periods of central apneic rest but increase unrelenting hyperventilation 2
- Cause electrolyte disturbances, laryngeal spasm during sleep, and cardiac arrhythmias 2
- Be potentially detrimental to the patient 2
Treatment Options When Heart Failure Therapy is Optimized
If CSB persists despite optimal heart failure management, the American Academy of Sleep Medicine recommends the following standard therapies:
First-Line Options:
- Continuous positive airway pressure (CPAP) as a standard therapy 4, 5
- Nocturnal home oxygen therapy (HOT) as a standard therapy 4, 5, 6
Second-Line Options (only after inadequate response):
- Bilevel positive airway pressure (BPAP) only when there is no adequate response to CPAP or oxygen 4
- Acetazolamide or theophylline only after failing the above modalities and with close follow-up 4
Contraindicated:
- ASV is contraindicated in patients with ejection fraction ≤45% due to increased mortality risk 3, 4
- ASV is only an option in patients with ejection fraction >45% 4
Prognostic Implications
Recognize that CSB has important prognostic significance:
- A central apnea-hypopnea index (AHI) >30/hour is associated with poor survival 1
- Longer duration of CSB correlates with higher mortality and elevated NT-proBNP levels 1
- The presence of CSB should prompt thorough evaluation and optimization of heart failure management 2
Clinical Monitoring
Document the duration of CSB (absolute or as percentage of total sleep time) or the number of CSB events in sleep study reports. 1 This allows for tracking of treatment response and provides prognostic information. 1
The Permissive Hypercapnia Concept
After optimal medical therapy for heart failure has been implemented, consider that CSB may be a compensatory mechanism that should not be aggressively suppressed. 2 The periodic breathing pattern may offset adverse effects of heart failure by improving breathing efficiency and overcoming restrictive ventilatory defects, particularly when patients are supine. 2