Thursday, April 7, 2011

Treatment of Cheyne-Stokes Respiration

There is an article in Therapeutic Advances in Respiratory Disease that reviews Cheyne-Stokes respiration and its treatment. Viewer warning, this is a technically complicated subject.

There are two main types of sleep apnea. The most common is obstructive (OSA) characterized by repetitive closure of the throat while asleep. The other is central sleep apnea CSA), where the upper airway is open, but the brain does not tell the lungs to breathe often or deep enough. One type of CSA is Cheyne-Stokes respiration (CSR) characterized by brief, repetitive periods of waxing and waning breath depths and brief, repetitive complete pauses in breathing. It is most common in neurological and heart disease.

The exact reasons of why or how patients develop CSR is unknown. Breathing during sleep is controlled by carbon dioxide levels (and oxygen to some degree). In CSR, it is theorized that the brain is over- and under-reacting to changes in CO2 in such a way that the patient breathes too deep sometimes and not at all at other times.

Treatment of CSR is more challenging than OSA. Maximizing medical treatment of the underlyinig heart or brain disease is the first step. Supplemental oxygen used during sleep can help some CSR patients. Certain medications can help because, in theory, they are respiratory stimulants, but objective data do not overwhelmingly support their use.

CPAP has been shown to be effective in some, but not all CSR patients. There was a large trial in Canada that showed that CPAP can improve cardiac function, respiratory disturbances, sympatheticoadrenal activity, and exercise performance, but NOT survival times. However, a re-analysis of the Canadian trial showed a survival benefit in those patients whose breathing disturbances were sufficiently reduced as compared to those without improvement in respiratory disturbances. Therefore, optimal suppression of respiratory disturbances is essential in CSR patients.

Bilevel positive airway pressure (BiPAP) is occasionally used in CSR patients, but there is very limited data on this mode of therapy. Adaptive servo-ventilation (ASV) is a new type of airway pressure that adapts to the patient's waxing and waning breathing patterns. It has been shown to be effective in CSR patients and studies have shown it superior to CPAP and BiPAP.

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