Medical Image of the Week: Cheyne Stokes Breathing on Polysomnography

Figure 1. A 5-minute epoch showing Cheyne-Stokes breathing (arrow).

A 79-year-old man presented to the sleep lab for a split-night polysomnography (PSG) after a positive Berlin Questionnaire.  He was screened and directly referred to our sleep lab through his PCP.  Patient has a chart documented medical history of atrial fibrillation, idiopathic pulmonary fibrosis, obesity, and CHF. He did not have an echocardiogram available therefore the etiology of his CHF was unclear.  He was found to have severe obstructive sleep apnea and was split early in the night.  Prior to positive airway pressure, his apnea-hypopnea index (AHI) was 77 and were predominantly obstructive hypopneas.  Soon after initiation of positive airway pressure, his PSG revealed the breathing pattern seen in Figure 1.  His respirations exhibited a crescendo-decrescendo pattern (arrow) followed by a period of central apnea consistent with Cheyne Stokes breathing (CSB).  In this patient, CSB was likely due to heart failure, although systolic or diastolic remained unclear.  Of note, he was not on medications found to be responsible for CSB, and did not have a history of cerebral vascular accident. 

Cheyne-Stokes breathing (CSB) is a well-documented but poorly understood abnormal breathing pattern that is believed to be a type of central sleep apnea (CSA), meaning apneas without upper airway obstruction. This compensatory mechanism is characterized by a cyclic change from oscillating events of apnea and hyperpnea. The characteristic feature of CSA-CSB is a longer cycle length, typically 45-60 seconds, alternating with a respiratory phase exhibiting a crescendo-decrescendo pattern of flow. This result is thought to be due to a delay in correction centrally when an elevated arterial PCO2 is detected within the blood stream by chemoreceptors.  Co-morbid conditions often include cardiac disease (primarily heart failure independent of NYHA classification), neurologic disorders, prematurity, or sedation. Diagnosis is made by polysomnography.  Treatment often entails treating the underlying cause or associated disorder.  When all other strategies fail, remaining treatment includes the use of nocturnal continuous positive airway pressure (CPAP), supplemental oxygen, or adaptive servoventilation (ASV).  Although, systolic heart failure with LVEF <45% in patients with predominantly central sleep apnea currently precludes the use of ASV.

Tam Le, MD and Sekhon Kawanjit, MD

Banner University Medical Center Tucson

Tucson, AZ USA

References

1. Cherniack NS, Longobardo GS. Cheyne-Stokes breathing. An instability in physiologic control. N Engl J Med. 1973 May 3;288(18):952-7. [CrossRef] [PubMed]
2. Naughton M, Benard D, Tam A, Rutherford R, Bradley TD. Role of hyperventilation in the pathogenesis of central sleep apneas in patients with congestive heart failure. Am Rev Respir Dis. 1993 Aug;148(2):330-8. [CrossRef] [PubMed]
3. American Academy of Sleep Medicine. International classification of sleep disorders, 3rd ed. Darien, IL: American Academy of Sleep Medicine, 2014.

Reference as: Le T, Kawanjit S. Medical image of the week: Cheyne Stokes breathing on polysomnography. Southwest J Pulm Crit Care. 2016 Apr;12(4):163-4. doi: http://dx.doi.org/10.13175/swjpcc022-16 PDF 

Medical Image of the Week: Cheyne-Stokes Respiration

Figure 1. Cheyne-Stokes Breathing pattern seen. The red arrow indicates the cycle time which is defined as the duration of the central apnea (or hypopnea) + the duration of a respiratory phase.

A 62 year-old male with a past medical history congestive heart failure, chronic obstructive pulmonary disease, and obesity with a body mass index of 38.02 kg/m² underwent an overnight polysomnogram for clinical suspicion for obstructive sleep apnea. He was found to have a periodic breathing as seen in the image above.

Cheyne-stokes respiration (CSR) is a type of periodic breathing characterized by crescendo-decrescendo pattern of respiration separated by central sleep apneas (CSA) or hypopneas (1). CSR-CSA may be seen in up to 15-37% of systolic heart failure patients (2,3). A longer cycle length, usually between 45-90 seconds, as well as the waxing and waning breathing pattern differentiate CSR from other forms of cyclic central apnea. CSA leads to chronically increased sympathetic activity and exerts multiple deleterious effects on the failing heart (2). The presence of CSR has been associated with higher mortality and rapid deterioration in cardiac function (4).

Jared Bartell and Safal Shetty, MD

University of Arizona Medical Center

Tucson, AZ

References

1. Berry RB, Budhiraja R, Gottlieb DJ, Gozal D, Iber C, Kapur VK, Marcus CL, Mehra R, Parthasarathy S, Quan SF, Redline S, Strohl KP, Davidson Ward SL, Tangredi MM; American Academy of Sleep Medicine. Rules for scoring respiratory events in sleep: update of the 2007 AASM Manual for the Scoring of Sleep and Associated Events. Deliberations of the Sleep Apnea Definitions Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med. 2012;8(5):597-619. [CrossRef]  [PubMed]
2. Yumino D, Bradley TD. Central sleep apnea and Cheyne-Stokes respiration. Proc Am Thorac Soc. 2008;5(2):226-36. [CrossRef] [PubMed]
3. Garcia-Touchard A, Somers VK, Olson LJ, Caples SM. Central sleep apnea: implications for congestive heart failure. Chest. 2008;133(6):1495-504. [CrossRef] [PubMed]
4. Hanly PJ, Zuberi-Khokhar NS. Increased mortality associated with Cheyne-Stokes respiration in patients with congestive heart failure. Am J Respir Crit Care Med. 1996;153(1):272-6. [CrossRef] [PubMed] 

Reference as: Bartell J, Shetty S. Medical image of the week: Cheyne-Stokes respiration. Southwest J Pulm Crit Care. 2015;10(3):145-6. doi: http://dx.doi.org/10.13175/swjpcc017-15 PDF

Medical Image of the Week: Cheyne-Stokes Respiration on Overnight Polysomnography

Figure 1. 300 second polysomnogram window showing crescendo-decrescendo pattern of Cheyne-Stokes respiration (solid black arrows). Cycle length is approximately 60 seconds in duration (Outlined black arrows).

A 75 year old man with a significant past medical history of atrial fibrillation, hypertension, complete heart block status-post pacemaker implantation, thoracic aortic aneurysm, and ischemic cardiomyopathy, was referred to the sleep laboratory for evaluation for suspected sleep disordered breathing. The patient had subjective complaints of morning headaches, reported apnea, un-refreshing sleep, nocturnal urination, and intermittent snoring. The diagnostic polysomnogram was significant for periodic breathing, Cheyne-Stokes pattern, with a cycle length that ranged from 60-65 seconds (Figure 1). Oxygen saturation nadir was 79% as measured by pulse oximetry. Electrocardiogram showed a persistently paced rhythm.

Cheyne-Stokes respiration is a periodic breathing pattern characterized by crescendo-decrescendo episodes of respiratory effort that are interspersed between periods of apnea. It is typically seen in individuals with systolic heart failure, but can also be seen in those with intracerebral hemorrhage or infarction. The mechanism for Cheyne-Stokes respiration involves increased central controller gain causing increased central nervous system sensitivity to changes in arterial blood gas PCO₂ and PO₂. Increased circulation time results in circulatory delay between gas exchange occurring at the alveolar capillary membrane and the central chemoreceptors in the medulla. The result is instability in respiration (1).

Ryan Nahapetian, MD, MPH and Sairam Parthasarathy, MD

Pulmonary, Allergy, Critical Care, & Sleep Medicine

University of Arizona, Tucson, AZ

Reference

1. Quaranta AJ, D'Alonzo GE, Krachman SL. Cheyne-Stokes respiration during sleep in congestive heart failure. Chest. 1997;111(2):467-73. [CrossRef] [PubMed]

Reference as: Nahapetian R, Parthsarathy S. Medical image of the week: Cheyne-Stokes respiration on overnight polysomnography. Southwest J Pulm Crit Care. 2014;8(6):328-9. doi: http://dx.doi.org/10.13175/swjpcc055-14 PDF