What Is Cheyne-Stokes Breathing?

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Cheyne-Stokes respirations are an irregular pattern of breathing consisting of a period of long, labored breathing followed by a period of shallow, rapid breathing and moments of no breathing at all (apnea).

Often referred to as "agonal breathing," Cheyne-Stokes respirations may be a sign of a serious lung, brain, or circulatory problem like a pulmonary edema, stroke, or heart failure. It also commonly occurs as a person approaches the end of life.

Diagnosing Cheyne-Stokes respiration can be difficult because it often occurs while you are asleep. The presence of Cheyne-Stokes respirations, particularly in someone who is awake, is generally indicative of a poor prognosis (outcome).

This article explains what Cheyne-Stokes respirations look like, why they happen, and what can be done to diagnose and treat this distressing respiratory symptom.

Doctor talking to patient in hospital - stock photo
Ariel Skelley / Getty Images

Cheyne-Stokes Breathing Pattern

During Cheyne-Stokes respirations, the breathing may seem erratic, but it occurs in a relatively consistent, three-part cycle:

  1. Bradypnea: Very deep, slow breathing
  2. Tachypnea: Fast, shallow breathing
  3. Apnea: Temporary stoppage of breathing

Each cycle on average lasts 30 seconds to two minutes. For some people, apnea is replaced with periods of extremely shallow breathing, called hypopnea.

The irregular breathing episodes most often occur while a person is sleeping (particularly during REM sleep when a person is dreaming). The episodes tend to be worse when a person sleeps on their back.

Cheyne-Stokes respirations can occur while a person is awake and is generally a sign that their health is deteriorating. This irregular breathing pattern is common in the last days and hours of life when a person is dying.

Other Symptoms

People who experience Cheyne-Stokes respirations at night have at least five apneas or hypopneas per night, typically accompanied by symptoms like:

  • Loud snoring
  • Labored breathing
  • Sudden coughing fits
  • Sudden limb movements or "jerks" during sleep
  • Excessive daytime fatigue and sleepiness
  • Shortness of breath when lying down (orthopnea)

Causes of Cheyne-Stokes Breathing

The mechanisms influencing Cheyne-Stokes respirations are not fully understood but are thought to be related to problems with the respiratory, circulatory, and central nervous systems.

Cheyne-Stokes respirations are a kind of compensatory breathing, meaning a reflex that alters breathing so that the body can quickly restore oxygen levels. This compensatory reflex, directed by the brain, also helps decrease blood acid levels caused by oxygen deprivation.

Circulation problems don't "cause" Cheyne-Stokes respirations but can contribute by further reducing blood oxygen levels. If circulatory problems are chronic and severe, Cheyne-Stokes respirations compensate for the ongoing lack of blood oxygen.

Cheyne-Stokes respiration commonly occurs alongside central sleep apnea. This is the type of sleep apnea where the brain temporarily stops sending signals to the muscles controlling respiration.

Associated Conditions

There are many conditions for which Cheyne-Stokes respirations are common:

  • Congestive heart failure: This is a chronic and progressive condition in which the heart doesn't pump enough blood to service the body's needs.
  • Elevated intracranial pressure: This is increased pressure within the skull caused by brain tumors, head injuries, hemorrhagic stroke, meningitis, encephalitis, and other causes.
  • Cardiogenic pulmonary edema: This is the accumulation of fluid in the lungs caused by the backflow of blood into the heart, usually due to heart failure.
  • Carbon monoxide poisoning: Inhalation of the toxic gas can lead to asphyxia, the condition of which is often preceded by erratic breathing.
  • Hyponatremia: Severely low sodium levels can cause changes in body fluid levels, leading to brain swelling (cerebral edema) and the disruption of normal breathing.
  • Sudden increases in altitude: An example includes arriving at a high-altitude location (usually over 8,000 feet) where oxygen levels are low.
  • Medication overdose: An example includes drugs like morphine that can severely depress the central nervous system, causing shallow breathing, hypopnea, and bradypnea. 

How Common Is It?

Cheyne-Stokes respirations are a relatively uncommon symptom outside of end-of-life situations. With that said, anywhere from 25% to 50% with advanced heart failure will experience Cheyne-Stokes breathing as blood flow from the heart continues to decline.

Cheyne-Stokes Breathing and Dying

Cheyne-Stokes breathing is commonly seen when people are in the dying process. It can occur in the days or hours before a person dies.

Breathing patterns before death may also become louder as the person is no longer able to swallow. This leads to gurgling sounds commonly referred to as the "death rattle.” In the final moments, the person may also have physical reactions, like muscle twitches or deep sighing, caused by chemical imbalances in the body.

Cheyne-Stokes breathing may be agonizing to watch, but it is not uncomfortable for the dying person. It is simply the body's way of compensating for physiological changes as the lungs, heart, kidney, liver, and brain start to fail in succession.

How Long Does It Last Before Death?

When a person is in the process of dying, Cheyne-Stokes respirations generally mean that death will occur within minutes or hours. This is not always the case, however, and the irregular breathing may persist for one or several days.

The same applies to the "death rattle," which generally suggests death within 24 to 48 hours.

Diagnosis

Diagnosing Cheyne-Stokes respirations is relatively straightforward as it involves a characteristic pattern of breathing. With that said, most episodes occur at night and may require a type of sleep study called polysomnography to confirm the diagnosis.

Polysomnography involves an overnight stay in a sleep clinic during which you will be recorded on camera while you sleep. Your heart rate, respiration rate, brain waves, blood oxygen levels, and eye movements will also be monitored.

Cheyne-Stokes breathing in people with heart failure is a poor prognostic sign. It is associated with reduced survival times, particularly in those who experience it while sitting or standing.

Treatment of Cheyne-Stokes Breathing

The treatment of Cheyne-Stokes respirations is based on the underlying cause. With certain causes, such as high altitude, medication overdose, and carbon dioxide poisoning, the condition can be resolved. In others, the condition may be ongoing and will need to be managed.

As heart failure is one of the most common causes of Cheyne-Stokes breathing, the treatment may involve heart failure medications like:

People with severe heart failure may also need to undergo procedures and surgeries like:

Other treatment options for Cheyne-Stokes breathing include:

Summary

Cheyne-Stokes respirations are irregular breathing patterns characterized by cycles of slow breathing, rapid breathing, and no breathing. It is a form of compensatory breathing where the brain will trigger changes in breathing to compensate for low blood oxygen levels.

Cheyne-Stokes respirations most often occur at night and are common in people with advanced heart failure. Other conditions affecting the lungs, brain, or circulatory system can also cause Cheyne-Stokes respiration.

Cheyne-Stokes respirations are also a part of the dying process and typically indicate death within minutes, hours, or days.

6 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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By Lynne Eldridge, MD
 Lynne Eldrige, MD, is a lung cancer physician, patient advocate, and award-winning author of "Avoiding Cancer One Day at a Time."