Causes of Cheyne-Stokes Breathing
Cheyne-Stokes breathing is primarily caused by heart failure with reduced ejection fraction, but also occurs with stroke, renal failure, atrial fibrillation, pulmonary hypertension, and narcotic use.
Primary Cardiac Cause
Heart failure with reduced ejection fraction is the dominant cause of Cheyne-Stokes breathing, particularly in males over 60 years with atrial fibrillation and recurrent pulmonary edema 1. The severity of cardiac dysfunction directly correlates with the breathing pattern—longer cycle lengths (73.9-85.7 seconds) occur with left ventricular ejection fractions below 20%, while less severe dysfunction produces shorter cycles (49.1-58.9 seconds with LVEF >40%) 1.
- Approximately 40-50% of patients with moderate to severe heart failure (LVEF <40%) develop Cheyne-Stokes respiration 2, 3
- The pattern reflects increased circulation time, elevated central chemoreceptor sensitivity, and reduced CO2/O2 body stores 2, 4
- A central apnea-hypopnea index >30/hour predicts poor survival in heart failure patients 1, 5
Neurological Causes
Stroke is the second major cause, producing central periodic breathing through brainstem dysfunction and impaired respiratory control 1, 4.
- Central periodic breathing (Cheyne-Stokes respirations) frequently complicates stroke and causes oxygen desaturation 1
- Patients with decreased consciousness or brainstem involvement face highest risk due to loss of protective airway reflexes 1
- The breathing pattern was originally described in stroke patients before its cardiac associations were recognized 4
Distinguishing Features by Cycle Length
Cycle length differentiates the underlying cause—this is critical for diagnosis 1:
- Long cycle length (45-75 seconds): Classic heart failure with reduced ejection fraction 1
- Short cycle length (<45 seconds): Atrial fibrillation with heart failure, narcotics, pulmonary hypertension, renal failure, high altitude, or stroke 1
- Very short cycle length (~26 seconds): Primary central sleep apnea without cardiac disease 1
Additional Causes
Other important causes include 1, 5:
- Renal failure: Produces shorter cycle patterns through metabolic derangements
- Narcotic medications: Depress respiratory drive and cause upper airway relaxation 1, 6
- Pulmonary hypertension: Creates ventilatory instability
- Atrial fibrillation: Even with preserved ejection fraction
- Treatment-emergent: Approximately 1% of patients starting CPAP for obstructive sleep apnea develop central apnea, resolving in 1-3 months 1
Pathophysiological Mechanism
The underlying mechanism involves high loop gain—an exaggerated ventilatory response to small blood gas changes 6, 4:
- Increased central chemoreceptor sensitivity to PCO2/PO2 fluctuations drives oscillatory breathing 2, 4
- Prolonged circulation time in heart failure delays feedback, perpetuating the cycle 2, 7
- Hyperventilation-induced hypocapnia triggers the apneic threshold, initiating central apneas 2
- Sleep state changes, particularly light sleep, potentiate instability since breathing becomes purely chemically controlled 1, 6
Clinical Pitfall
Do not assume all periodic breathing is Cheyne-Stokes respiration. Formal diagnosis requires ≥3 consecutive central apneas/hypopneas with crescendo-decrescendo pattern, cycle length ≥40 seconds, and central AHI ≥5/hour over minimum 2 hours monitoring 1, 5. Shorter cycles or absence of the classic crescendo-decrescendo pattern suggests alternative diagnoses like primary central sleep apnea or other causes 1.