Understanding Cheyne-Stokes Respiration and Its Link to Sleep Apnea

If you’re a long-time CPAP user, you’ve probably heard of devices that can detect Cheyne-Stokes respiration. You might have also seen this health condition mentioned in your sleep data or by other sleep apnea patients.

Cheyne-Stokes respiration is often associated with central sleep apnea and other serious health issues, like stroke and heart failure. While it sounds frightening, modern medicine has made it possible to treat the underlying conditions of this atypical breathing pattern. 

Whether you’re new to CPAP therapy or not, it’s important to understand the conditions associated with your apneas. So here, we’ll explore the Cheyne-Stokes respiration causes, how this breathing pattern works, and the treatment options your doctor might prescribe. 

Cheyne-Stokes respiration sometimes happens while awake, but it’s more common during sleep. It involves a cycle of abnormal breathing patterns and apneas, as a result of the respiratory system’s imprecise feedback to changing CO₂ levels. 

Try to breathe naturally and notice how even the intervals are between each inhalation and exhalation. Every minute, you’ll take 12 to 16 breaths¹ during normal respiration. 

In Cheyne-Stokes respiration, the brain’s delay in signals to the respiratory system makes it unable to maintain that steady pace of normal breathing. There’s a period of hyperventilating (fast or heavy breathing), followed by hypoventilation (shallow or slow breathing), and a period of stopped breathing or apnea.

So why does this specific pattern occur? Here’s how Cheyne-Stokes respiration works:

1. When an apnea happens, it increases the CO₂ stored in your body.
2. To compensate for this, your body’s response is to breathe it out fast or deeply, which causes a decrease in CO₂ levels.
3. This signals your body to hypoventilate to raise your CO₂ levels.
4. It then triggers an apnea, causing you to hold in your breath, in an attempt to stop exhalation and further increase the CO₂ reserve.
5. The cycle continues. 

When you see this breathing event in graph form, you can see sharp yet gradual rises and falls of the line tracing, then a flat line or the apnea. This can be described as a “waxing and waning pattern” or a “crescendo-diminuendo pattern.”

Usually, the first sign of Cheyne-Stoke respiration is when you breathe in a crescendo-diminuendo pattern while you sleep. This looks like you’re breathing fast and slowly, then stop breathing temporarily.

Cheyne-Stokes respiration can also occur after a serious medical condition such as heart failure. When that happens, Cheyne-Stoke breathing can be accompanied by the symptoms of this illness, the symptoms mentioned above, as well as the following²:

• Labored breathing when lying down or doing other activities
• Increased lethargy
• Coughing
• Periodic leg movements during sleep

As mentioned, Cheyne-Stokes respiration happens because of your respiratory system’s faulty response to varying CO₂ levels. So why does it react incorrectly?

It can be abnormal levels of CO₂ and O₂ in your body, a condition affecting the brain signals to the lungs, or an illness affecting your breathing, such as:

• Heart failure – 30 to 50%³ of patients with congestive heart failure experience Cheyne-Stokes respiration. While these patients experience a delay in circulation, it does not cause Cheyne-Stokes breathing. Rather, the circulation delay is directly related to the duration and unique waxing and waning pattern of these abnormal breathing cycles.⁴
• Stroke – This happens from a burst blood vessel in the brain or a blocked blood supply to the brain. Stroke commonly causes abnormal breathing patterns, including Cheyne-Stokes respiration and central sleep apnea.⁵ 

Apart from these common Cheyne-Stokes respiration causes, here are other factors that can bring about this breathing pattern: 

• High altitude –  Because you’re taking in lower amounts of oxygen at high altitudes, you’re prone to hyperventilating during sleep.⁶
• Acute cardiogenic pulmonary edema – Often a result of heart failure, this type of pulmonary edema occurs when there are increased pressures in the heart, pushing fluid into the air sacs in the lungs. ⁷
• Certain conditions linked to brain lesions (in the posterior fossa and lower pontine regions) and increased intracranial pressure,⁸ such as:

• Brain tumors
• Traumatic brain injuries
• Encephalitis⁹

Also called the “death rattle,” Cheyne-Stokes breathing while awake is often seen in patients nearing the end of their lives.

Because Cheyne-Stokes respiration usually happens during sleep, it can be hard to spot right away. If anyone in your home notices you breathing abnormally at night, or if you’ve observed the waxing and waning pattern in your CPAP machine’s sleep data, you should schedule a visit with your provider right away. They’ll likely advise you to undergo a sleep study.

While there are home sleep testing devices to evaluate moderate forms of sleep apnea, an in-lab test is more reliable for detecting Cheyne-Stokes respiration. This kind of sleep test can provide you with a comprehensive and accurate analysis of your central sleep apnea and breathing patterns.

An overnight in-lab sleep study, or polysomnography, involves various sensors to record and measure the following in your sleep:

• Brain waves
• Blood oxygen level
• Heart rate
• Breathing
• Eye, leg, and torso movements
• Air movement through your nose and mouth

Polysomnography is usually done at a sleep center or sleep clinic. To help patients feel more comfortable, most sleep clinics today look more like hotel rooms. If you’re scheduled for a sleep study and feeling anxious about the upcoming test, learning more about how to prepare for your sleep study can help calm those nerves.

We’ve already discussed that when Cheyne-Stokes breathing occurs during sleep, it is classified as a form of central sleep apnea. Like other central sleep apneas, it causes brief moments of stopped breathing and affects the carbon dioxide levels in your body. It also happens more frequently when you sleep on your back.¹⁰ 

But how does Cheyne-Stokes respiration differ?

In other types of central sleep apneas (e.g. idiopathic and treatment-emergent), there is no crescendo-diminuendo pattern like that observed in Cheyne-Stokes respiration. They also involve longer apneas and shorter periods of hyperventilation than Cheyne-Stokes respiration, in which the abnormal breathing pattern lasts more than 40 seconds.²  

After going through a sleep study and being diagnosed with Cheyne-Stokes respiration, what’s next? Well, the kind of Cheyne-Stokes breathing treatment your doctor will prescribe depends on what’s causing it in the first place. 

Heart Failure Treatment

Congestive heart failure causes most cases of Cheyne-Stokes respiration. If you were diagnosed with this, your doctor may recommend the following treatment options:

• Vasodilators, beta-blockers, and other medications
• Implantable cardioverter-defibrillator
• Pacemaker
• Ventricular assist device
• Heart valve surgery
• Heart transplant (as a last resort)

Oxygen Therapy

It has long been proven that supplemental oxygen therapy during sleep helps reduce the frequency of Cheyne-Stokes respiration.⁴ It can even improve your heart function, sleep apnea symptoms, and quality of life.¹¹

Oxygen therapy involves the use of oxygen delivery systems, such as:

• Compressed gas cylinders: These tanks store pressurized oxygen as a gas. They have to be replaced regularly.
• Liquid oxygen: Liquid oxygen containers are smaller and more portable than gas cylinders. They store pure oxygen as a cold liquid and convert it to gas as you inhale. 
• Oxygen concentrators: As long as they’re plugged in or have batteries in place, concentrators can give you an infinite supply of oxygen. They draw in the surrounding air, filter out the nitrogen, and give you pure oxygen. You can even use FAA-approved travel O2 concentrators for in-flight use.

CPAP

Continuous positive airway pressure (CPAP) therapy is the first step in treating sleep apnea. During this therapy, you’ll use a CPAP device, tubing, and mask as you sleep. A CPAP machine delivers a constant flow of air pressure to keep your airway open and help you breathe normally.

If you’re diagnosed with Cheyne-Stokes breathing, CPAP therapy might benefit you. Though it’s not effective in lowering cardiovascular mortality, it can benefit heart failure patients by improving oxygen levels during sleep, heart function, and cardiovascular endurance.¹² 

ASV

Like CPAP machines, an adaptive servo-ventilation (ASV) device produces pressurized air through a mask and tubing. But the difference is that it monitors your breathing pattern and automatically adjusts the pressure accordingly to stabilize your breathing.

The American Academy of Sleep Medicine recommends ASV machines for treating idiopathic Cheyne-Stokes breathing. These devices can also help alleviate symptoms such as mood problems and daytime sleepiness.¹³

Medications

Other treatment options include respiratory stimulants (like theophylline) and depressants (like benzodiazepines). While there are a few case studies showing the benefits of theophylline for treating life-threatening Cheyne-Stokes respiration,^{15 16}  it should be used with extreme caution and is not recommended as a long-term solution. And while benzodiazepines reduced nighttime awakenings, they were found ineffective in alleviating central sleep apnea.⁴ 

Cheyne-Stokes respiration can be downright scary, especially since it happens after heart failure, stroke, and other severe illnesses or when someone’s about to draw their last breath. But remember: healthy people can experience this breathing pattern too, particularly in high altitudes.

Because it usually occurs during sleep, it’s considered a type of central sleep apnea. That means its symptoms are similar to other kinds of sleep apnea, and it can only be detected by someone in your home or through the sleep data generated by your CPAP machine. For an accurate diagnosis, you’ll need to undergo an in-lab sleep study. 

If you’re diagnosed with central sleep apnea with Cheyne-Stokes breathing, your doctor might advise you to use a CPAP machine, oxygen concentrator or tank, or ASV device. If you have symptoms of heart failure, your cardiologist will assess your LVEF to determine whether ASV therapy is right for you.

Check out our collection of oxygen concentrators and CPAP and ASV devices. If you need prescription assistance or still have questions about Cheyne-Stokes respiration and central sleep apnea, feel free to contact our team of board-certified respiratory therapists and sleep specialists.

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13. Banno, K., Okamura, K., & Kryger, M. H. (2006). Adaptive servo-ventilation in patients with idiopathic Cheyne-Stokes breathing. Journal of Clinical Sleep Medicine, 02(02), 181–186. https://doi.org/10.5664/jcsm.26514

14. Patel, A., Perez, I., & Rabiei-Samani, S. (2021). What Is Adaptive Servo-Ventilation (ASV)? American Journal of Respiratory and Critical Care Medicine, 204(2), P3–P4. https://doi.org/10.1164/rccm.2042P3

15. Wolf, J., Świerblewska, E., Jasiel-Wojculewicz, H., Gockowski, K., Wyrzykowski, B., Somers, V. K., & Narkiewicz, K. (2014). Theophylline therapy for Cheyne-Stokes respiration during sleep in a 41-year-old man with refractory arterial hypertension. Chest, 146(1), e8–e10. https://doi.org/10.1378/chest.13-2897

16. Pesek, C. A., Cooley, R., Narkiewicz, K., Dyken, M., Weintraub, N. L., & Somers, V. K. (1999). Theophylline therapy for near-fatal Cheyne-Stokes respiration. A case report. Annals of internal medicine, 130(5), 427–430. https://doi.org/10.7326/0003-4819-130-5-199903020-00014