What is Cheyne-Stokes breathing?

What is Cheyne-Stokes Breathing?

Cheyne-Stokes breathing is an abnormal respiratory pattern characterized by episodes of at least 3 consecutive central apneas and/or central hypopneas separated by a crescendo-decrescendo change in breathing amplitude, with cycle lengths typically ranging from 45 to 90 seconds. 1

Formal Diagnostic Criteria

The American Academy of Sleep Medicine defines Cheyne-Stokes breathing when both of the following are met: 1

• At least 3 consecutive central apneas and/or central hypopneas separated by crescendo-decrescendo breathing with a cycle length of at least 40 seconds (typically 45-90 seconds) 1
• 5 or more central apneas and/or central hypopneas per hour associated with this pattern, recorded over a minimum of 2 hours of monitoring 1

The duration of Cheyne-Stokes breathing (absolute time or percentage of total sleep time) should be documented in sleep study reports. 1

The Breathing Pattern Explained

The pattern consists of: 2, 3

• Periods of apnea or hypopnea (no breathing or reduced breathing)
• Followed by gradually increasing tidal volume (crescendo phase)
• Then gradually decreasing tidal volume (decrescendo phase)
• Returning to apnea/hypopnea, completing the cycle

This crescendo-decrescendo pattern represents compensation for changing levels of blood oxygen and carbon dioxide. 2

Cycle Length Characteristics

Cycle length varies with disease severity and helps distinguish Cheyne-Stokes breathing from other forms of periodic breathing: 1

• Heart failure patients: Cycle length typically 45-90 seconds, with longer cycles correlating with worse left ventricular function 1
  • LVEF >50%: ~49 seconds
  • LVEF <20%: ~86 seconds 1
• Primary central sleep apnea (without heart failure): Cycle length ~37 seconds 1
• Narcotic-induced central apnea: Shorter cycle length, typically without true crescendo-decrescendo pattern 1

Primary Clinical Associations

Heart failure is the most common cause of Cheyne-Stokes breathing, occurring in approximately 40-50% of patients with moderate to severe congestive heart failure (left ventricular ejection fraction <40%). 3, 4

Other associated conditions include: 5, 6

• Neurological disorders (particularly stroke) 5, 6
• Atrial fibrillation 5, 6
• Pulmonary hypertension 5, 6
• Renal failure 5, 6

Pathophysiological Mechanisms

The underlying mechanisms involve: 3, 7

• Increased CNS sensitivity to arterial PCO2 and PO2 changes (increased central controller gain) 3
• Decreased total body stores of CO2 and O2, causing instability in arterial blood gas tensions 3
• Prolonged circulatory time in heart failure patients 3
• Hyperventilation-induced hypocapnia as an important determinant 3
• Instability in feedback control of chemical regulation of breathing 7

The pattern occurs primarily during light sleep (stages N1 and N2) when breathing is under chemical control rather than voluntary control. 8, 6

Clinical Presentation

Patients may present with: 3, 9

• Excessive daytime sleepiness 3
• Paroxysmal nocturnal dyspnea 3
• Insomnia 3
• Snoring 3
• Frequent nocturnal arousals with disrupted sleep 3
• Oxygen desaturation 9
• Cardiac arrhythmias 9
• Changes in mental status 9

In many patients, the abnormal breathing pattern may not be recognized, and clinical features are dominated by the underlying disease process. 9

Prognostic Significance

Cheyne-Stokes breathing carries important prognostic implications in heart failure: 1, 5

• Central apnea-hypopnea index >30/hour is associated with poor survival in heart failure patients 1, 5
• Longer duration of Cheyne-Stokes breathing correlates with higher mortality and elevated NT-proBNP (a marker of poor cardiac function) 1, 5
• Mortality is increased compared to heart failure patients without Cheyne-Stokes breathing at similar levels of left ventricular dysfunction 3

The presence of Cheyne-Stokes breathing may reflect unrecognized congestive heart failure and is a risk factor for early mortality or need for heart transplant. 1, 5

Recognition in Clinical Practice

Cheyne-Stokes breathing may be observed as an irregular or periodic breathing pattern on physical examination in patients with acute decompensated heart failure. 1

The American College of Cardiology/American Heart Association lists Cheyne-Stokes respirations among physical findings that may support the diagnosis of heart failure, though it is not included in the required diagnostic criteria. 1

Management Approach

The primary intervention is optimizing guideline-based heart failure therapy, as Cheyne-Stokes breathing often improves with effective treatment of the underlying heart failure. 5, 8

Additional considerations: 8, 3, 9

• Avoid interventions specifically aimed at suppressing the breathing pattern after heart failure therapy has been optimized, as it may be a compensatory mechanism 8
• Nocturnal oxygen therapy may be considered 3, 9
• Nasal continuous positive airway pressure may be considered 3, 9
• Adaptive servo-ventilation is contraindicated in heart failure patients with reduced ejection fraction due to increased mortality risk 8, 6

Critical Pitfall to Avoid

Do not confuse Cheyne-Stokes breathing with other forms of periodic breathing. The key distinguishing features are: 1

• Minimum cycle length of 40 seconds (typically 45-90 seconds in heart failure)
• True crescendo-decrescendo pattern between apneas/hypopneas
• At least 3 consecutive cycles meeting these criteria

Primary central sleep apnea and narcotic-induced central apnea have shorter cycle lengths (~26-37 seconds) and typically lack the true crescendo-decrescendo pattern. 1