From the Research
The patient with stroke and Cheyne-Stokes breathing should not be automatically placed on a ventilator, but rather their overall respiratory status should be assessed to determine the need for ventilatory support. When evaluating the need for mechanical ventilation, it's crucial to consider the patient's oxygen saturation, arterial blood gases, and work of breathing. If the patient is maintaining adequate oxygenation (SpO2 >92%) and has acceptable CO2 levels without significant respiratory distress, ventilatory support may not be necessary 1. Instead, consider supplemental oxygen through the tracheostomy using a tracheostomy collar or T-piece. For Cheyne-Stokes breathing specifically, addressing the underlying neurological injury and optimizing cerebral perfusion is more important than mechanical ventilation. However, if the patient shows signs of respiratory failure (hypoxemia, hypercapnia, increased work of breathing), then ventilatory support is appropriate.
Some key points to consider in the management of these patients include:
- The timing of tracheostomy, with some studies suggesting that early tracheostomy may reduce the incidence of ventilator-associated pneumonia and shorten hospital stay 2.
- The importance of assessing airway safety and secretion handling in determining the need for tracheostomy or extubation 3.
- The need for individualized decision-making, taking into account the patient's specific clinical circumstances and respiratory status.
It's also important to note that Cheyne-Stokes breathing reflects central nervous system dysfunction affecting respiratory control centers, and while concerning, the pattern itself doesn't necessarily require mechanical ventilation unless accompanied by respiratory compromise. The most recent and highest quality study on this topic is from 2021, which found that early tracheostomy was significantly associated with fewer days in the hospital and reduced cases of ventilator-associated pneumonia 1.
In terms of specific management, the following steps can be taken:
- Assess the patient's overall respiratory status, including oxygen saturation, arterial blood gases, and work of breathing.
- Consider supplemental oxygen through the tracheostomy using a tracheostomy collar or T-piece if the patient is maintaining adequate oxygenation.
- Address the underlying neurological injury and optimize cerebral perfusion.
- Provide ventilatory support if the patient shows signs of respiratory failure.