What Are Cheyne-Stokes Respirations?

Key Takeaways

• Cheyne-Stokes respirations are characterized by cycles of increasingly heavy and then shallower breathing.
• Most cases of Cheyne-Stokes respirations are linked to heart failure or other medical conditions, like stroke and kidney disease.
• Treatment for Cheyne-Stokes respirations involves addressing the underlying cause, as well as using methods to stabilize breathing during sleep.

What Is Cheyne-Stokes Breathing?

Cheyne-Stokes breathing is an abnormal pattern of breathing that fluctuates between shallow and heavy breaths. Although it can happen at any time of the day or night, it’s most commonly seen during sleep. 

Doctors describe CSB as having a cyclic crescendo-decrescendo pattern, gradually getting bigger and then smaller. A person’s breathing slows down as the body stops making an effort to breathe, then subsequently speeds up and increases in depth. Once the rate and depth of breathing reach a peak, they begin to fall again as the cycle repeats.

People with Cheyne-Stokes respirations may experience recurrent apneas, during which they temporarily stop breathing completely. Or, they may experience hypopneas, which are periods of very shallow breathing. With hypopneas, bed partners will observe the person stops snoring, and their chest movements may contrast with their breathing patterns. 

When Cheyne-Stokes breathing happens during sleep and involves brief pauses in breathing during each decrescendo, it may be diagnosed as a type of central sleep apnea. CSA is a type of sleep apnea in which breathing is disrupted during sleep due to communication issues between the brain and the muscles responsible for breathing.

What Are the Symptoms of Cheyne-Stokes Breathing?

The main symptom of Cheyne-Stokes breathing is the cyclical pattern of shallow and heavy breathing. There may be a range of other symptoms, depending on the pattern’s underlying cause.

To be formally diagnosed with CSB, a person must have at least one of the following:

• Sleepiness
• Trouble falling asleep or restless or unrefreshing sleep
• Waking up short of breath
• Snoring
• Visible pauses in breathing
• Atrial fibrillation/flutter, a neurological disorder, or congestive heart failure

People with Cheyne-Stokes respirations are most likely to experience disrupted sleep at the point where they are expending the most effort to breath, between two lapses in breathing. This may manifest as passing into a lighter sleep stage or waking up short of breath. This is the reverse of what happens in other types of central sleep apnea, in which people wake up at the end of a lapse in breathing. 

Some people with Cheyne-Stokes respirations may experience chest pain, shortness of breath, or cough during the periods of increased breathing. Sleep-related breathing disorders can also trigger arrhythmias.

Symptoms of Cheyne-Stokes breathing can be very similar to symptoms of heart failure, and it can be difficult to identify whether symptoms such as daytime sleepiness are due to Cheyne-Stokes breathing. Doctors may ask a person’s bed partner if they’ve noticed periods of heavy breathing, shallow breathing, or stopped breathing during sleep.

Central sleep apnea with Cheyne-Stokes breathing doesn’t cause physical symptoms, but people may have physical symptoms due to the underlying disorder, such as weakness on one side of the body following a stroke. People with central sleep apnea may also experience morning headaches, although these are not an official diagnostic symptom.

What Does Cheyne-Stokes Breathing Sound Like?

Cheyne-Stokes breathing sounds like periods of heavy breathing alternating with periods of shallow or stopped breathing. Whereas a person still noticeably makes a physical effort to breathe during apneas in obstructive sleep apnea (OSA), someone with central sleep apnea stops making the effort to breathe during these periods.

How Long Can Cheyne-Stokes Last?

Compared with other types of central sleep apnea in which cycles last less than 40 seconds, the Cheyne-Stokes breathing cycle lasts longer, typically at least 45 seconds and up to a minute and a half. People with systolic heart failure tend to have a longer cycle than those with diastolic heart failure. Breathing issues occur more often in the lighter sleep stages.

Cheyne-Stokes breathing may last indefinitely, or it may improve with treatment of the underlying condition. Cheyne-Stokes breathing usually appears in conjunction with congestive heart failure, and sometimes stroke or kidney failure. Experiencing CSB while awake may be linked to a worse outcome. 

What Causes Cheyne-Stokes Respirations?

Researchers are still working to understand why Cheyne-Stokes breathing happens. The current theory is that Cheyne-Stokes occurs when there’s a delay in how long it takes for the brain to detect and respond to changes in the level of carbon dioxide in the blood — something that’s common in heart failure.

On detecting lower levels of carbon dioxide, the brain tries to raise carbon dioxide levels by issuing the order to stop breathing. Carbon dioxide levels start to rise, but because the heart isn’t working as it should, it takes a while for the brain to receive feedback on new levels of carbon dioxide in the blood. 

By the time the brain finally receives the new blood, levels of carbon dioxide are too high. This causes the brain to increase breathing to get rid of carbon dioxide, which plunges the levels down too low again and restarts the cycle.

Cheyne-Stokes breathing may be more likely to occur when the heart is slow to pump blood, when tissues aren’t able to effectively store carbon dioxide and oxygen, or when breathing drive is too strong because the controls aren’t doing their job. This is why Cheyne-Stokes respirations are most common in heart failure and certain other medical conditions.

• Heart failure: Cheyne-Stokes breathing is mostly commonly linked to heart failure, a health condition where the heart struggles to deliver blood to the rest of the body. Up to 50% of those with heart failure experience Cheyne-Stokes breathing. Having CSB is associated with a worse long-term outlook for heart health. 
• Stroke: A stroke occurs when blood flow is cut off to part of the brain. Around half of people develop CSA with Cheyne-Stokes breathing in the days following a stroke, although this may eventually resolve or morph into OSA. 

Cheyne-Stokes breathing is also linked to sedation, changes in altitude, and other medical conditions like kidney failure, acid-base disorders, and disorders that affect the nervous system.

CSB is less noticeable in deep sleep and REM sleep. This is because people usually have higher carbon dioxide levels during deep sleep, while REM sleep dampens the body’s response mechanisms to low oxygen and carbon dioxide. 

What Are Risk Factors for Cheyne-Stokes Respirations?

By far the most cases of Cheyne-Stokes respirations occur in people with heart failure. Among people with heart failure, Cheyne-Stokes breathing may be more likely to happen in people who meet the following criteria: 

• Male sex
• Age over 60
• Atrial fibrillation
• Abnormally low levels of carbon dioxide in the blood during the daytime or reduced ejection fraction 

There’s no known genetic or familial component to Cheyne-Stokes breathing. While CSB is common in premature infants, it’s otherwise rare for it to occur in children, even those with congestive heart failure.

Cheyne-Stokes breathing may be more severe when back sleeping. Central sleep apnea with CSB sometimes appears after a person starts using CPAP therapy for obstructive sleep apnea.

How Are Cheyne-Stokes Respirations Diagnosed?

If doctors suspect that a person has central sleep apnea, Cheyne-Stokes breathing may be detected during a sleep study. A sleep study is an overnight medical exam that monitors various processes in a person’s body as they sleep. Though widely available, a home sleep test is not a reliable way to diagnose Cheyne-Stokes breathing.

A sleep study usually takes place at a specialized sleep center and is monitored by a trained specialist. The sleep center offers a comfortable place to sleep while allowing a technician to record key data, including:

• Heart rate
• Breathing rate and effort
• Airflow
• Oxygen levels in the blood
• Eye and body movements
• Brain and muscle activity

When diagnosing CSA-CSB, doctors look for at least five apneas (stopped breathing) or hypopneas (shallow breathing) per hour. They also look for a pattern of predominantly central, rather than obstructive, apneas and hypopneas.

Doctors will rule out whether other sleep disorders or substances could be causing the symptoms before diagnosing Cheyne-Stokes breathing. It’s possible to receive a diagnosis of both central sleep apnea with Cheyne-Stokes breathing and OSA, which involves physical blockages in the airway.

People with heart disease have a high chance of developing Cheyne-Stokes breathing. Talk to your doctor if you notice you have nocturnal angina, arrhythmias, or odd breathing patterns, or if your heart failure symptoms aren’t responding to treatment.

How Is Cheyne-Stokes Breathing Treated?

Doctors treat central sleep apnea with Cheyne-Stokes breathing by treating the heart failure or other underlying cause, as well as taking steps to normalize nighttime breathing. 

Heart failure may be addressed with medication, a heart transplant, a pacemaker or other implanted device. These interventions usually help with sleep apnea, but most people also need to use treatments that are specifically designed to help with breathing during sleep.

Treatments focused on restoring a normal breathing pattern include:

• CPAP therapy: CPAP therapy stabilizes breathing during sleep by delivering a steady stream of pressurized air through a mask and into the nose and/or mouth. Alternatives to CPAP include adaptive servo-ventilation (ASV) and bilevel positive airway pressure (BiPAP), which adjust pressure levels throughout the night. ASV and BiPAP aren’t recommended for people with certain types of heart failure.
• Supplemental oxygen during sleep: Supplemental oxygen helps raise blood oxygen to a healthier level and may improve Cheyne-Stokes symptoms by reducing the brain’s response to low carbon dioxide levels.
• Medication: Medications such as acetazolamide or theophylline may help regulate breathing. Medications come with side effects, so they’re not a first-line option.
• Surgery to implant a device that regulates breathing: CSB is sometimes treated with an implanted stimulator in the upper chest. The device stimulates the phrenic nerve, triggering contractions of the diaphragm that mimic breathing. This is a second-line option, since it’s expensive and requires an operation to implant the device.

More research is needed to know whether alternative treatment options are as safe and effective as CPAP therapy.

Frequently Asked Questions 

Is Cheyne-Stokes breathing dangerous?

Like other types of sleep apnea, Cheyne-Stokes breathing is dangerous in that it may contribute to long-term health issues. In particular, sleep apnea puts pressure on the heart and may exacerbate heart disease. Because it causes people to wake frequently during the night, Cheyne-Stokes breathing also generally causes people to spend less time in deep sleep, which is one of the more important sleep stages for overall health.

How long does Cheyne-Stokes last before death?

Cheyne-Stokes respirations don’t always mean that death is imminent, and the timing can vary widely depending on the underlying cause. While this breathing pattern is sometimes seen in the final days or hours of life, it can also occur in people with conditions such as heart failure or neurological disorders who may live with it for months or longer. 

Because of this variability, Cheyne-Stokes respirations should be evaluated in the context of a person’s overall health, and a healthcare provider can help determine what it may indicate in each individual case.

How does heart failure cause Cheyne-Stokes breathing?

Heart failure affects the heart’s capacity to pump blood around the body. Since blood takes longer to reach breathing receptors in the brain, the brain is slow to receive accurate readings of carbon dioxide and oxygen levels. This delay results in erratic cycles of breathing as the brain tries to compensate.

What is the difference between Kussmaul and Cheyne-Stokes?

Kussmaul and Cheyne-Stokes breathing are both linked to carbon dioxide levels in the blood, but while Cheyne-Stokes alternates between heavy and shallow breathing, Kussmaul involves continuous deep, rapid breathing. Kussmaul breathing is usually a sign of a medical emergency that requires immediate treatment, such as diabetic ketoacidosis.