What is Cheyne Stokes Respirations?
Cheyne-Stokes respiration is a type of breathing disorder characterized by alternating cycles of periods of no breathing (apnea) and rapid breathing (hyperventilation). This condition was first noted in the early 19th century by John Cheyne and William Stokes, but has recently gained increased attention. Its association with heart failure and stroke, which are among the leading causes of death and illness in developed countries, has led to this heightened interest.
Unlike another condition known as obstructive sleep apnea, which can cause heart failure, Cheyne-Stokes respiration is thought to occur as a result of heart failure. If a patient with heart failure exhibits Cheyne-Stokes respiration, this can indicate a worse prognosis and an increased risk of sudden heart-related death.
Even with growing knowledge and recognition of this condition, Cheyne-Stokes respiration is still poorly understood. Unfortunately, this means that very few treatment options are available for patients.
What Causes Cheyne Stokes Respirations?
Cheyne-Stokes respiration is a specific kind of breathing pattern where breaths increase and decrease in a waxing and waning manner, with periods of no breathing or shallow breathing in between. This pattern must meet specific criteria to be categorized as Cheyne-Stokes breathing according to the recommendations by the American Academy of Sleep Medicine (AASM):
1. There must be at least three consecutive central apneas (pauses in breathing) and/or central hypopneas (shallow breathing) separated by a rise and fall in breathing volume, which lasts at least 40 seconds (usually between 45 to 90 seconds).
2. Within an hour, there must be five or more central apneas and/or central hypopneas matched with the rise and fall breathing pattern recorded over a minimum of two hours of monitoring.
Cheyne-Stokes respiration is different from other central sleep apneas, like idiopathic central sleep apnea, which does not have a rise and fall pattern of ventilation. In Cheyne-Stokes respiration, the breathing cycles last more than 40 seconds, compared to less than 40 seconds in central sleep apnea. Also, the amount of time spent overbreathing is longer than not breathing at all in Cheyne-Stokes respiration. In central apneas, the not breathing period is longer than the overbreathing duration.
Cheyne-Stokes respiration has been notably observed in patients with heart failures and strokes. Factors in heart failure patients such as being male, older, leading a sedentary lifestyle, diagnosis of a heart condition called atrial fibrillation, high ventricular filling pressure, and more advanced heart remodeling are known to increase the likelihood of Cheyne-Stokes respiration. Also, up to 20% of stroke patients may show signs of Cheyne-Stokes respiration.
Risk Factors and Frequency for Cheyne Stokes Respirations
Cheyne-Stokes respiration, a specific type of breathing pattern, is thought to be pretty rare in the general population. However, it’s hard to be sure of the exact number of people affected because different methods are used to identify it. This breathing pattern is more common in people with heart failure, affecting around 25% to 50% of them. This equates to about two to three million people out of the total of nearly 5.7 million patients with heart failure. Cheyne-Stokes respiration is found more often in patients with a type of heart failure known as systolic heart failure compared to diastolic heart failure. It’s also more commonly seen in older patients.
- Cheyne-Stokes respiration is considered to be rare in the general population.
- Among people with heart failure, this condition is quite common, affecting 25% to 50% of them.
- This means out of almost 5.7 million heart failure patients, two to three million are likely to have Cheyne-Stokes respiration.
- It occurs more frequently in people with a type of heart failure called systolic heart failure as compared to diastolic heart failure.
- Cheyne-Stokes respiration is also more common in older individuals.
Signs and Symptoms of Cheyne Stokes Respirations
Cheyne-Stokes respiration is a type of breathing pattern that shares similar characteristics with congestive heart failure. These symptoms can include breathlessness, a persistent cough, and tiredness. People who have both Cheyne-Stokes respiration and heart failure may be even more tired and lethargic than usual. This is thought to be due to sleep problems caused by their bodies’ stress response kicking in. Periodic leg movements, where the legs move or jerk uncontrollably, may also be more common in patients with both heart failure and Cheyne-Stokes respiration compared to those who only have heart failure.
Testing for Cheyne Stokes Respirations
Cheyne-Stokes respiration is a pattern of breathing characterized by alternating periods of rapid breathing and no breathing. It mostly occurs during certain sleep stages (N1 and N2), but can also occur when a person is awake. You can observe this pattern through changes in breathing rhythms and changes in oxygen saturation levels swinging between 90% and 100%. It’s not standard practice to monitor minute ventilation during sleep studies, but you can document hyperventilation by observing rising and falling chest movements and the amount of air that is inhaled and exhaled with each breath (tidal volume). If a person is on a ventilator, these changes can be shown in a graph.
The cycle of no breathing (apnea) and rapid breathing (hyperpnea) typically lasts between 45 to 75 minutes, which is longer than the cycle seen in other causes of central sleep apnea. The Cheyne-Stokes respiration pattern tends to be worse when the person is lying on their back (supine position) or shifts from their back to their side. This type of breathing can also be linked with high blood pressure in patients struggling with type 2 diabetes.
Using a type 3 portable monitor for a sleep apnea study at home could be useful in identifying Cheyne-Stokes respiration and periods of stopped breathing (apneic events) in adults living with chronic heart failure.
Treatment Options for Cheyne Stokes Respirations
The main aim of treating Cheyne-Stokes respiration, a type of abnormal breathing pattern, is by managing the root cause – usually congestive heart failure or stroke. The American Academy of Sleep Medicine suggests that positive airway pressure should be contemplated for all patients with central sleep apnea. The two key non-surgical treatments for Cheyne-Stokes respiration are continuous positive airway pressure (CPAP) and adaptive servo-ventilation (ASV).
CPAP provides continuous positive pressure, helping to keep the upper airway open during apnea, thus stabilising respiratory drives and improving oxygen levels and ejection fraction, the measure of how well your heart is pumping out blood. The positive pressure can also improve heart function by reducing the amount of blood flow to the right atrium and increasing the pressure inside the chest. A clinical study found that CPAP therapy in patients with Cheyne-Stokes respiration improved oxygen levels during sleep, heart function and distance walked in six minutes. However, it did not improve survival rates.
Adaptive servo-ventilation is a newer non-surgical treatment which patients find effective and tolerable. It works by counteracting over-breathing during periods of hyperpnea and preventing under-breathing during periods of apnea. ASV provides constant positive pressure, adapting to the patient’s needs and if necessary, adjusting pressure support with backup ventilation. During over-breathing phases, the pressure support is reduced to prevent large breaths. ASV may be more effective than conventional treatments like CPAP or bilevel positive airway pressure therapy, and it has been shown to improve physical symptoms, heart functions, exercise capacity and brain natriuretic peptide levels, a marker of heart failure. A recent large clinical trial, however, found that adding ASV to standard medical therapy did not improve outcomes and increased the risk of death from cardiovascular conditions among patients with systolic heart failure and Cheyne-Stokes respiration.
While there have been some cases where the drug Theophylline has shown favorable responses in fatal Cheyne-Stokes respiration, it should be used with extreme caution and is not considered a permanent solution.
What else can Cheyne Stokes Respirations be?
Cheyne Stokes breathing is a specific pattern of breathing. But, there are other abnormal breathing patterns that it needs to be distinguished from, such as:
- Biot’s breathing
- Kussmaul breathing
- Apneustic breathing
- Apnea (complete breathing stoppage)
These breathing patterns are different from Cheyne Stokes and should be ruled out when making a diagnosis.
What to expect with Cheyne Stokes Respirations
The recognition of this pattern requires urgent attention as it can suggest a grim outcome. Cheyne-Stokes respiration, when a person is upright, could signal an alarming sign of problems with heart and blood vessel regulation.
Possible Complications When Diagnosed with Cheyne Stokes Respirations
If left untreated for an extended period, this type of breathing can result in disruptions to the level of carbon dioxide in the body and, in severe cases, it could cause death.
Preventing Cheyne Stokes Respirations
Family members of patients who are at risk of developing irregular breathing patterns should be trained to spot any abnormalities. In addition, they should also be educated on how to properly position the patients, operate Continuous Positive Airway Pressure (CPAP) machines, and aid the patients in doing breathing exercises.