Cheyne-Stokes breathing

Specialty: Respiratory.

• periodic breathing
• cyclic apnea-hyperapnea

Why it occurs

• Advanced congestive heart failure with reduced ejection fraction (due to delayed blood circulation time from the lungs to the brain chemoreceptors, which destabilizes the respiratory feedback loop)
• Bilateral cerebrovascular accident (CVA) of hemispheric location or involvement of the diencephalon (alteration of the supratentorial respiratory control pathways)
• Moderate to severe head trauma (diffuse cerebral edema that depresses central sensitivity to CO2)
• Severe uremic or metabolic encephalopathy (accumulation of toxins that alter the response threshold of the respiratory center)
• Tumors of the central nervous system with supratentorial mass effect (indirect compression of brainstem structures)

Initial workup

Complete nocturnal polysomnography with monitoring of nasal flow, thoracoabdominal effort and oximetry; Transthoracic color Doppler echocardiogram (to evaluate left ventricular function and filling pressures); Magnetic resonance imaging (MRI) of the brain with posterior fossa and brainstem protocol; Basal arterial blood gas analysis during the apnea and hyperventilation phases.

Standard management

• Adaptive servoventilation — SAV) or continuous positive airway pressure (CPAP) (devices of choice to stabilize periodic breathing during sleep
• Carvedilol — beta-adrenergic antagonist, prescribed at a starting dose of 3,125 mg every 12 hours with progressive increases to improve cardiac function in patients with underlying heart failure
• Furosemide (20-40 mg orally to optimize blood volume and reduce circulatory transit time).