Cheyne-Stokes respiration
Encyclopedia
Cheyne-Stokes respiration (icon) is an abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing called an apnea
. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes. It is an oscillation of ventilation between apnea and hyperpnea
with a crescendo-diminuendo pattern, and is associated with changing serum
partial pressure
s of oxygen
and carbon dioxide
.
Cheyne-Stokes respiration and periodic breathing
are the two regions on a spectrum of severity of oscillatory tidal volume. The distinction lies in what we observe happening at the trough of ventilation: if there is apnea, we describe it as Cheyne-Stokes respiration (since apnea is a prominent feature in their original description); if there is only hypopnea (abnormally small but not absent breaths) then we call it periodic breathing. Physiologically and mathematically, the phenomena are less different than they appear, because breaths that are smaller than the anatomical dead space do not actually ventilate the lung and so - from the point of view of gas concentrations in an alveolus - the nadir of hypopnea in periodic breathing may be indistinguishable from apnea.
These phenomena can occur during wakefulness or during sleep, where they are called the Central sleep apnea syndrome (CSAS).
It may be caused by damage to respiratory center
s, or by physiological abnormalities in chronic heart failure, and is also seen in newborns with immature respiratory systems and in visitors new to high altitudes.
allows a steady level of alveolar gas concentrations to be maintained, and therefore stable tissue levels of oxygen and carbon dioxide (CO2). At the steady state, the rate of production of CO2 equals the net rate at which it is exhaled from the body, which (assuming no CO2 in the ambient air) is the product of the alveolar ventilation and the end-tidal CO2 concentration. Because of this interrelationship, the set of possible steady states forms a hyperbola:
Alveolar ventilation = (body CO2 production)/end-tidal CO2 fraction.
In the figure below, this relationship is the curve falling from the top left to the bottom right. Only positions along this curve permit the body's CO2 production to be exactly compensated for by exhalation of CO2. Meanwhile there is another curve, shown in the figure for simplicity as a straight line from bottom left to top right, which is the body's ventilatory response to different levels of CO2. Where the curves cross is the potential steady state (S).
Through respiratory control reflexes, any small transient fall in ventilation (A) leads to a corresponding small rise (A') in alveolar CO2 concentration which is sensed by the respiratory control system so that there is a subsequent small compensatory rise in ventilation (B) above its steady state level (S) that helps restore CO2 back to its steady state
value. In general, transient or persistent disturbances in ventilation, CO2 or oxygen levels can be counteracted by the respiratory control system in this way.
However, in some pathological states, the feedback is more powerful than is necessary to simply return the system towards its steady state
. Instead, ventilation overshoots and can generate an opposite disturbance to the original disturbance. If this secondary disturbance is larger than the original, the next response will be even larger, and so on, until very large oscillations have developed, as shown in the figure below.
The cycle of enlargement of disturbances reaches a limit when successive disturbances are no longer larger, which occurs when physiological responses no longer increase linearly
in relation to the size of the stimulus. The most obvious example of this is when ventilation falls to zero: it cannot be any lower. Thus Cheyne-Stokes respiration can be maintained over periods of many minutes or hours with a repetitive pattern of apneas and hyperpneas.
The end of the linear decrease in ventilation in response to falls in CO2 is not, however, at apnea. It occurs when ventilation is so small that air being breathed in never reaches the alveolar space, because the inspired tidal volume
is no larger than the volume of the large airways such as the trachea
. Consequently, at the nadir of periodic breathing, ventilation of the alveolar space
may be effectively zero; the easily-observable counterpart of this is failure at that time point of the end-tidal gas concentrations
to resemble realistic alveolar concentrations.
Many potential contributory factors have been identified by clinical observation, but unfortunately they are all interlinked and covary extensively. Widely accepted risk factors are hyperventilation, prolonged circulation time, and reduced blood gas buffering capacity.
They are physiologically interlinked in that (for any given patient) circulation time decreases as cardiac output increases. Likewise, for any given total body CO2 production rate, alveolar ventilation is inversely proportional to end-tidal CO2 concentration (since their mutual product must equal total body CO2 production rate). Chemoreflex sensitivity is closely linked to the position of the steady state, because if chemoreflex sensitivity increases (other things being equal) the steady-state ventilation will rise and the steady-state CO2 will fall. Because ventilation and CO2 are easily to observe because they are commonly-measured clinical variables which do not require any particular experiment to be conducted in order to observe them, abnormalities in these variables are more likely to be reported in the literature. However, other variables, such as chemoreflex sensitivity can only be measured by specific experiment, and therefore abnormalities will not in them will not be found in routine clinical data. When measured in patients with Cheyne-Stokes respiration, hypercapnic ventilatory responsiveness may be elevated by 100% or more. When not measured, its consequences - such as a low mean PaCO2 and elevated mean ventilation - may sometimes appear to be the most prominent feature.
Circulatory delay may determine the length of the apnea-hyperpnea cycle although it is rarely sufficiently prolonged itself to be a major driving factor for instability.
of breathing
, in which breathing is absent for a period and then rapid for a period, can be seen in patients with heart failure, stroke
s, traumatic brain injuries
and brain tumor
s. In some instances, it can occur in otherwise healthy people during sleep
at high altitudes. It can occur in all forms of toxic metabolic encephalopathy. It is a symptom of carbon monoxide poisoning
, along with syncope
or coma
. This type of respiration is also often seen after morphine
administration.
Hospice personnel sometimes document the presence of Cheyne-Stokes breathing as a patient nears death, and report that patients able to speak after such episodes do not report any distress associated with the breathing, although it is sometimes disturbing to the family.
s ("cluster breathing"), in which groups of breaths tend to be similar in size.
They differ from Kussmaul respirations
in that the Kussmaul pattern is one of consistent very deep breathing at a normal or increased rate.
Apnea
Apnea, apnoea, or apnœa is a term for suspension of external breathing. During apnea there is no movement of the muscles of respiration and the volume of the lungs initially remains unchanged...
. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes. It is an oscillation of ventilation between apnea and hyperpnea
Hyperpnea
Hyperpnea or hyperpnoea is increased depth of breathing when required to meet metabolic demand of body tissues, such as during or following exercise, or when the body lacks oxygen , for instance in high altitude or as a result of anemia....
with a crescendo-diminuendo pattern, and is associated with changing serum
Blood plasma
Blood plasma is the straw-colored liquid component of blood in which the blood cells in whole blood are normally suspended. It makes up about 55% of the total blood volume. It is the intravascular fluid part of extracellular fluid...
partial pressure
Partial pressure
In a mixture of ideal gases, each gas has a partial pressure which is the pressure which the gas would have if it alone occupied the volume. The total pressure of a gas mixture is the sum of the partial pressures of each individual gas in the mixture....
s of oxygen
Oxygen
Oxygen is the element with atomic number 8 and represented by the symbol O. Its name derives from the Greek roots ὀξύς and -γενής , because at the time of naming, it was mistakenly thought that all acids required oxygen in their composition...
and carbon dioxide
Carbon dioxide
Carbon dioxide is a naturally occurring chemical compound composed of two oxygen atoms covalently bonded to a single carbon atom...
.
Cheyne-Stokes respiration and periodic breathing
Periodic breathing
Periodic breathing is an abnormal pattern of breathing characterized by oscillation of ventilation between hyperpnea and hypopnea with a crescendo-decrescendo pattern in the depth of respirations, to compensate for changing serum partial pressures of oxygen and carbon dioxide.Cheyne-Stokes...
are the two regions on a spectrum of severity of oscillatory tidal volume. The distinction lies in what we observe happening at the trough of ventilation: if there is apnea, we describe it as Cheyne-Stokes respiration (since apnea is a prominent feature in their original description); if there is only hypopnea (abnormally small but not absent breaths) then we call it periodic breathing. Physiologically and mathematically, the phenomena are less different than they appear, because breaths that are smaller than the anatomical dead space do not actually ventilate the lung and so - from the point of view of gas concentrations in an alveolus - the nadir of hypopnea in periodic breathing may be indistinguishable from apnea.
These phenomena can occur during wakefulness or during sleep, where they are called the Central sleep apnea syndrome (CSAS).
It may be caused by damage to respiratory center
Respiratory center
The respiratory center is located in the medulla oblongata, which is the lowermost part of the brain stem. The RC receives controlling signals of neural, chemical and hormonal nature and controls the rate and depth of respiratory movements of the diaphragm and other respiratory muscles...
s, or by physiological abnormalities in chronic heart failure, and is also seen in newborns with immature respiratory systems and in visitors new to high altitudes.
History
The condition was named after John Cheyne and William Stokes, the physicians who first described it in the 19th century.Pathophysiology
In heart failure, the mechanism of the oscillation is unstable feedback in the respiratory control system. In normal respiratory control, negative feedbackNegative feedback
Negative feedback occurs when the output of a system acts to oppose changes to the input of the system, with the result that the changes are attenuated. If the overall feedback of the system is negative, then the system will tend to be stable.- Overview :...
allows a steady level of alveolar gas concentrations to be maintained, and therefore stable tissue levels of oxygen and carbon dioxide (CO2). At the steady state, the rate of production of CO2 equals the net rate at which it is exhaled from the body, which (assuming no CO2 in the ambient air) is the product of the alveolar ventilation and the end-tidal CO2 concentration. Because of this interrelationship, the set of possible steady states forms a hyperbola:
Alveolar ventilation = (body CO2 production)/end-tidal CO2 fraction.
In the figure below, this relationship is the curve falling from the top left to the bottom right. Only positions along this curve permit the body's CO2 production to be exactly compensated for by exhalation of CO2. Meanwhile there is another curve, shown in the figure for simplicity as a straight line from bottom left to top right, which is the body's ventilatory response to different levels of CO2. Where the curves cross is the potential steady state (S).
Through respiratory control reflexes, any small transient fall in ventilation (A) leads to a corresponding small rise (A') in alveolar CO2 concentration which is sensed by the respiratory control system so that there is a subsequent small compensatory rise in ventilation (B) above its steady state level (S) that helps restore CO2 back to its steady state
Steady state (chemistry)
In chemistry, a steady state is a situation in which all state variables are constant in spite of ongoing processes that strive to change them. For an entire system to be at steady state, i.e. for all state variables of a system to be constant, there must be a flow through the system...
value. In general, transient or persistent disturbances in ventilation, CO2 or oxygen levels can be counteracted by the respiratory control system in this way.
However, in some pathological states, the feedback is more powerful than is necessary to simply return the system towards its steady state
Steady state (chemistry)
In chemistry, a steady state is a situation in which all state variables are constant in spite of ongoing processes that strive to change them. For an entire system to be at steady state, i.e. for all state variables of a system to be constant, there must be a flow through the system...
. Instead, ventilation overshoots and can generate an opposite disturbance to the original disturbance. If this secondary disturbance is larger than the original, the next response will be even larger, and so on, until very large oscillations have developed, as shown in the figure below.
The cycle of enlargement of disturbances reaches a limit when successive disturbances are no longer larger, which occurs when physiological responses no longer increase linearly
Linear regression
In statistics, linear regression is an approach to modeling the relationship between a scalar variable y and one or more explanatory variables denoted X. The case of one explanatory variable is called simple regression...
in relation to the size of the stimulus. The most obvious example of this is when ventilation falls to zero: it cannot be any lower. Thus Cheyne-Stokes respiration can be maintained over periods of many minutes or hours with a repetitive pattern of apneas and hyperpneas.
The end of the linear decrease in ventilation in response to falls in CO2 is not, however, at apnea. It occurs when ventilation is so small that air being breathed in never reaches the alveolar space, because the inspired tidal volume
Tidal volume
Tidal volume is the lung volume representing the normal volume of air displaced between normal inspiration and expiration when extra effort is not applied.Typical values are around 500ml or 7ml/kg bodyweight.-Mechanical Ventilation:...
is no larger than the volume of the large airways such as the trachea
Vertebrate trachea
In tetrapod anatomy the trachea, or windpipe, is a tube that connects the pharynx or larynx to the lungs, allowing the passage of air. It is lined with pseudostratified ciliated columnar epithelium cells with goblet cells that produce mucus...
. Consequently, at the nadir of periodic breathing, ventilation of the alveolar space
Ventilation (physiology)
In respiratory physiology, ventilation is the rate at which gas enters or leaves the lung. It is categorized under the following definitions:-Sample values:...
may be effectively zero; the easily-observable counterpart of this is failure at that time point of the end-tidal gas concentrations
Capnography
Capnography is the monitoring of the concentration or partial pressure of carbon dioxide in the respiratory gases. Its main development has been as a monitoring tool for use during anaesthesia and intensive care. It is usually presented as a graph of expiratory plotted against time, or, less...
to resemble realistic alveolar concentrations.
Many potential contributory factors have been identified by clinical observation, but unfortunately they are all interlinked and covary extensively. Widely accepted risk factors are hyperventilation, prolonged circulation time, and reduced blood gas buffering capacity.
They are physiologically interlinked in that (for any given patient) circulation time decreases as cardiac output increases. Likewise, for any given total body CO2 production rate, alveolar ventilation is inversely proportional to end-tidal CO2 concentration (since their mutual product must equal total body CO2 production rate). Chemoreflex sensitivity is closely linked to the position of the steady state, because if chemoreflex sensitivity increases (other things being equal) the steady-state ventilation will rise and the steady-state CO2 will fall. Because ventilation and CO2 are easily to observe because they are commonly-measured clinical variables which do not require any particular experiment to be conducted in order to observe them, abnormalities in these variables are more likely to be reported in the literature. However, other variables, such as chemoreflex sensitivity can only be measured by specific experiment, and therefore abnormalities will not in them will not be found in routine clinical data. When measured in patients with Cheyne-Stokes respiration, hypercapnic ventilatory responsiveness may be elevated by 100% or more. When not measured, its consequences - such as a low mean PaCO2 and elevated mean ventilation - may sometimes appear to be the most prominent feature.
Circulatory delay may determine the length of the apnea-hyperpnea cycle although it is rarely sufficiently prolonged itself to be a major driving factor for instability.
Associated conditions
This abnormal patternPattern
A pattern, from the French patron, is a type of theme of recurring events or objects, sometimes referred to as elements of a set of objects.These elements repeat in a predictable manner...
of breathing
Breathing
Breathing is the process that moves air in and out of the lungs. Aerobic organisms require oxygen to release energy via respiration, in the form of the metabolism of energy-rich molecules such as glucose. Breathing is only one process that delivers oxygen to where it is needed in the body and...
, in which breathing is absent for a period and then rapid for a period, can be seen in patients with heart failure, stroke
Stroke
A stroke, previously known medically as a cerebrovascular accident , is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia caused by blockage , or a hemorrhage...
s, traumatic brain injuries
Traumatic brain injury
Traumatic brain injury , also known as intracranial injury, occurs when an external force traumatically injures the brain. TBI can be classified based on severity, mechanism , or other features...
and brain tumor
Brain tumor
A brain tumor is an intracranial solid neoplasm, a tumor within the brain or the central spinal canal.Brain tumors include all tumors inside the cranium or in the central spinal canal...
s. In some instances, it can occur in otherwise healthy people during sleep
Sleep
Sleep is a naturally recurring state characterized by reduced or absent consciousness, relatively suspended sensory activity, and inactivity of nearly all voluntary muscles. It is distinguished from quiet wakefulness by a decreased ability to react to stimuli, and is more easily reversible than...
at high altitudes. It can occur in all forms of toxic metabolic encephalopathy. It is a symptom of carbon monoxide poisoning
Carbon monoxide poisoning
Carbon monoxide poisoning occurs after enough inhalation of carbon monoxide . Carbon monoxide is a toxic gas, but, being colorless, odorless, tasteless, and initially non-irritating, it is very difficult for people to detect...
, along with syncope
Syncope (medicine)
Syncope , the medical term for fainting, is precisely defined as a transient loss of consciousness and postural tone characterized by rapid onset, short duration, and spontaneous recovery due to global cerebral hypoperfusion that most often results from hypotension.Many forms of syncope are...
or coma
Coma
In medicine, a coma is a state of unconsciousness, lasting more than 6 hours in which a person cannot be awakened, fails to respond normally to painful stimuli, light or sound, lacks a normal sleep-wake cycle and does not initiate voluntary actions. A person in a state of coma is described as...
. This type of respiration is also often seen after morphine
Morphine
Morphine is a potent opiate analgesic medication and is considered to be the prototypical opioid. It was first isolated in 1804 by Friedrich Sertürner, first distributed by same in 1817, and first commercially sold by Merck in 1827, which at the time was a single small chemists' shop. It was more...
administration.
Hospice personnel sometimes document the presence of Cheyne-Stokes breathing as a patient nears death, and report that patients able to speak after such episodes do not report any distress associated with the breathing, although it is sometimes disturbing to the family.
Related patterns
Cheyne-Stokes respirations are not the same as Biot's respirationBiot's respiration
Biot's respiration, sometimes also called ataxic respiration, is an abnormal pattern of breathing characterized by groups of quick, shallow inspirations followed by regular or irregular periods of apnea.It generally indicates a poor prognosis....
s ("cluster breathing"), in which groups of breaths tend to be similar in size.
They differ from Kussmaul respirations
Kussmaul breathing
Kussmaul breathing is a deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis but also renal failure. It is a form of hyperventilation, which is any breathing pattern that reduces carbon dioxide in the blood due to increased rate or...
in that the Kussmaul pattern is one of consistent very deep breathing at a normal or increased rate.