Cheyne-Stokes Breathing: Causes, Symptoms and Treatment Options
Learn what Cheyne-Stokes breathing is, its causes, symptoms and treatment options. Find out how it differs from sleep apnoea and when to seek medical advice.
Unusual breathing patterns during sleep or serious illness can be concerning. One such pattern is Cheyne-Stokes breathing a distinctive cycle of progressively deeper, then shallower breathing followed by a brief pause (apnoea). It is most often linked to heart failure, stroke, or neurological conditions and should be medically assessed.
What Is Cheyne-Stokes Breathing?
Cheyne-Stokes breathing is a specific, cyclical breathing pattern characterised by alternating periods of hyperventilation (deeper, faster breathing) and apnoea (a complete pause in breathing). Unlike normal breathing, which maintains a relatively steady depth and rhythm, Cheyne-Stokes breathing follows a predictable crescendo-decrescendo pattern that repeats throughout the night or, in severe cases, during wakefulness.
It occurs because the brain’s respiratory control centres receive delayed or dysregulated feedback about blood oxygen and carbon dioxide levels most commonly as a result of impaired cardiac output or neurological disruption. The result is an oscillating drive to breathe rather than a stable one.
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Breathing Deepens
Breaths become progressively deeper and faster as CO₂ rises
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Breathing Shallows
Breaths gradually become shallower as CO₂ drops below threshold
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Breathing Stops
A brief apnoea occurs breathing pauses completely
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Cycle Repeats
The pattern begins again, repeating throughout sleep
The Cheyne-Stokes breathing pattern (bottom) compared with normal breathing (top). The cyclical crescendo-decrescendo waveform followed by an apnoea is the defining characteristic that differentiates it from both normal breathing and simple obstructive sleep apnoea.
What Causes Cheyne-Stokes Breathing?
Cheyne-Stokes breathing is usually a sign of an underlying medical condition rather than a condition on its own. Identifying and treating the underlying cause is central to managing it effectively.
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Heart Failure
Most common cause
Heart failure especially with reduced ejection fraction is the most frequently identified cause of Cheyne-Stokes breathing. Impaired cardiac output slows the circulation of blood to the brain, introducing a delay in the feedback loop that regulates breathing drive. This circulatory delay is the mechanism behind the oscillating pattern.
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Stroke & Neurological Conditions
Central respiratory control disruption
Stroke, brain injury and neurological diseases can damage the brainstem respiratory control centres or alter their sensitivity to CO₂ and O₂ signals. This dysregulation produces an oscillating breathing drive similar to that seen in heart failure, even without cardiac involvement.
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High Altitude & Other Causes
Temporary or secondary
High altitude exposure can produce a temporary form of Cheyne-Stokes breathing in otherwise healthy individuals, resolving on descent. Central sleep apnoea and certain medications are less common causes. In all cases, the pattern reflects impaired respiratory control rather than a primary airway problem.
Symptoms of Cheyne-Stokes Breathing
Many people with Cheyne-Stokes breathing are unaware of the pattern during sleep. A bed partner may notice the breathing changes before the affected person does.
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Recognised Symptoms
Reported by affected individuals and their bed partners
Symptoms Noticed During Sleep
Pauses in breathingLoud breathing changesFrequent wakingInterrupted sleep
The cyclical breathing pattern observable as periods of increasingly loud breathing followed by silence is often the first thing a bed partner notices. The affected person may wake briefly at the end of each apnoeic episode, often with a sense of breathlessness or gasping, though many of these micro-arousals are not consciously recalled in the morning.
Daytime consequences mirror those of other forms of sleep-disordered breathing persistent fatigue, reduced cognitive performance, and morning headaches from overnight CO₂ fluctuation. In people with underlying heart failure, breathlessness may be present both at rest and on exertion, independently of the sleep-related breathing pattern.
Cheyne-Stokes Breathing vs Obstructive Sleep Apnoea
These two conditions can both cause pauses in breathing during sleep and share some daytime symptoms, but they have fundamentally different causes and require different treatment approaches.
Feature
Cheyne-Stokes Breathing
Obstructive Sleep Apnoea
Primary mechanism
Brain temporarily reduces breathing drive
Airway becomes physically blocked
Underlying associations
Often linked to heart failure or neurological conditions
Usually caused by upper airway collapse
Breathing pattern
Cyclical crescendo-decrescendo with apnoea
Snoring followed by obstructive apnoeas
Apnoea type
Central sleep apnoea
Obstructive sleep apnoea
Respiratory effort during apnoea
Absent no effort to breathe
Present effort continues against blocked airway
Primary treatment focus
Treating the underlying cardiac or neurological condition
Opening and maintaining the upper airway
How Is It Diagnosed?
Identifying Cheyne-Stokes breathing and its underlying cause requires clinical assessment. Recognising the pattern alone is not sufficient understanding why it is occurring is essential to determining appropriate treatment.
Medical history and physical examination — including cardiovascular and neurological assessment to identify contributing conditions
Sleep study (polysomnography) — the gold standard for characterising the breathing pattern, distinguishing central from obstructive apnoeas, and quantifying severity
Overnight oxygen monitoring — a simpler screening tool that can detect oxygen desaturation patterns consistent with Cheyne-Stokes breathing
Echocardiogram — indicated where heart failure is suspected, to assess cardiac function and ejection fraction
Brain imaging — where stroke or neurological disease may be contributing, CT or MRI may be clinically indicated
Why identifying the underlying cause matters: Cheyne-Stokes breathing is a symptom of an underlying condition, not a standalone diagnosis. Treatment directed only at the breathing pattern without addressing its cause is unlikely to be effective or safe. A sleep specialist working alongside a cardiologist or neurologist (as appropriate) is the recommended approach.
Treatment Options
Treatment for Cheyne-Stokes breathing is tailored to the underlying cause and the specific type of sleep-disordered breathing identified on sleep study. There is no single universal treatment.
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Treatment Approaches by Category
Management depends on the underlying diagnosis and specialist assessment
Managing the Underlying Condition
✓ First priority in all casesCardiac, neurological or altitude-related
Optimising heart failure treatment including medication titration, cardiac resynchronisation therapy where indicated, and fluid management is the most important intervention for heart failure-related Cheyne-Stokes breathing, and often reduces the breathing pattern independently. Similarly, stroke rehabilitation and neurological care address the source of the disrupted respiratory drive rather than its consequence.
CPAP (Continuous Positive Airway Pressure)
Useful in selected patientsNot appropriate for everyoneRequires specialist prescription
CPAP may benefit some people who have central sleep apnoea associated with Cheyne-Stokes breathing, primarily by splinting the upper airway and reducing the arousal burden. It is not appropriate for everyone with this condition and treatment suitability depends on the underlying diagnosis. A sleep specialist will determine whether CPAP is the most suitable therapy for an individual patient.
BiPAP (Bilevel Positive Airway Pressure)
When clinically appropriatePrescribed by specialist only
BiPAP delivers separate pressures for inhalation and exhalation and may be used in selected patients where CPAP alone is insufficient or inappropriate. As with all positive airway pressure therapies for Cheyne-Stokes breathing, prescription and monitoring by a specialist is essential.
Adaptive Servo-Ventilation (ASV)
Contraindicated in certain heart failure patientsSpecialist assessment mandatoryBreath-by-breath pressure adaptation
ASV devices adapt breath-by-breath to the patient’s breathing pattern, providing additional pressure support during hypopnoea and reducing support during hyperventilation. However, ASV is generally not recommended for patients with symptomatic chronic heart failure and significantly reduced left ventricular ejection fraction, following evidence from clinical trials showing potential harm in this group. Therapy should always be prescribed and monitored by a specialist with full knowledge of the patient’s cardiac status.
Can CPAP Help?
CPAP may benefit some people who have central sleep apnoea associated with Cheyne-Stokes breathing. However, it is important to understand both the potential and the limitations of this approach.
What CPAP Can and Cannot Do in This Context
The role of CPAP is supportive rather than curative in Cheyne-Stokes breathing
CPAP may reduce the arousal burden from central apnoeas, stabilise upper airway patency, and improve sleep quality in appropriately selected patients. It does not address the underlying cardiac or neurological dysfunction driving the pattern. It is not appropriate for everyone with Cheyne-Stokes breathing, and in some patients particularly those with significantly impaired cardiac function more specialised ventilation modes are required. A sleep specialist will determine the most suitable therapy based on the full clinical picture, including cardiac function, severity of the breathing pattern, and other individual factors.
Treatment for Cheyne-Stokes breathing should always be prescribed and managed within a specialist clinical pathway, not self-initiated.
When Should You Seek Medical Advice?
Prompt medical assessment is recommended if you or someone you know experiences any of the following. Do not wait for a routine appointment if symptoms are new, worsening, or accompanied by the warning signs below.
Repeated pauses in breathing observed by a bed partner
Worsening breathlessness, particularly at rest or at night
Chest pain or pressure
Fainting or near-fainting episodes
Symptoms that may indicate stroke (facial drooping, arm weakness, speech difficulties)
Severe daytime sleepiness that is new or rapidly worsening
New abnormal breathing pattern during sleep not previously present
⚠ Seek urgent medical attention for chest pain, stroke symptoms, or sudden severe breathlessness. These symptoms may indicate a cardiac or neurological emergency and require immediate assessment rather than a scheduled GP appointment. Call 999 in the UK if you are concerned about a stroke or a cardiac event.
A three-tier guide to when and how urgently to seek medical help based on the symptoms you or a bed partner are experiencing. When in doubt, contact your GP rather than waiting to see whether symptoms resolve.
Frequently Asked Questions
Is Cheyne-Stokes breathing the same as sleep apnoea?
No. It is a specific breathing pattern that often involves central sleep apnoea but differs from obstructive sleep apnoea. Obstructive sleep apnoea is caused by the upper airway collapsing during sleep. Cheyne-Stokes breathing is caused by the brain’s respiratory control system oscillating typically as a result of heart failure or neurological conditions rather than by any physical obstruction of the airway.
Is Cheyne-Stokes breathing serious?
It can be, as it is frequently associated with significant heart or neurological conditions and warrants medical evaluation. The seriousness depends largely on the underlying condition causing it. In the context of heart failure, its presence is associated with poorer prognosis and underlines the importance of optimising cardiac treatment.
Can CPAP treat Cheyne-Stokes breathing?
CPAP may help some people, but the most appropriate treatment depends on the underlying cause and specialist assessment. It is not a universal treatment for this condition and should not be self-prescribed. In some patients with specific cardiac conditions, certain ventilation therapies are contraindicated.
Can Cheyne-Stokes breathing occur while awake?
Yes. Although commonly observed during sleep, it may also occur in people with advanced heart failure or severe neurological illness while awake. The pattern reflects the underlying disruption to respiratory control, which is not exclusively a sleep-related phenomenon in severe cases.
Does everyone with heart failure develop Cheyne-Stokes breathing?
No. It affects only a proportion of people with heart failure. Its presence is more strongly associated with reduced ejection fraction and more advanced disease, but many people with heart failure have normal or near-normal breathing patterns during sleep.
Disclaimer: This article is intended for general informational purposes only and does not constitute medical advice. Cheyne-Stokes breathing is associated with serious underlying medical conditions. If you or someone you know is experiencing unusual breathing patterns, breathlessness, or other symptoms described in this article, please seek medical assessment promptly. Do not adjust or initiate any positive airway pressure therapy without a specialist prescription.
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