Cheyne-Stokes respirations are caused by a delay or disruption in the body’s normal feedback loop for controlling breathing, most commonly due to heart failure or neurological damage. The pattern is distinctive: breathing gradually gets deeper and faster, then slower and shallower, then stops entirely for several seconds before the cycle repeats. Up to 50% of adults with congestive heart failure develop this breathing pattern, making it the single most common cause.
How the Breathing Feedback Loop Breaks Down
Your body constantly monitors carbon dioxide (CO2) levels in the blood. When CO2 rises, specialized sensors called chemoreceptors signal the brain to breathe faster. When CO2 drops, the brain dials breathing back. In healthy people, this system makes smooth, real-time corrections. In Cheyne-Stokes respiration, the system overreacts and overcorrects, creating a repeating wave of too much breathing followed by too little or none at all.
The technical way to describe this is “high loop gain,” meaning the body’s response to a change in CO2 is disproportionately large. Think of it like a thermostat that blasts heat when the temperature drops one degree, then shuts off completely when it overshoots. Three factors contribute to high loop gain: how aggressively the brain responds to CO2 changes (controller gain), how efficiently the lungs clear CO2 (plant gain), and how long it takes blood to travel from the lungs to the brain’s sensors (mixing gain). When any of these are abnormal, breathing becomes unstable.
Each full cycle of waxing and waning breath typically lasts 45 to 90 seconds, which is notably longer than other forms of central sleep apnea, where cycles run 30 to 45 seconds.
Heart Failure: The Most Common Cause
Congestive heart failure is the leading cause of Cheyne-Stokes respirations. About 40 to 50% of patients with a weakened heart (specifically those whose heart pumps less than 40% of its blood with each beat) develop this pattern. The connection comes down to how a failing heart slows blood circulation.
When the heart pumps weakly, blood takes longer to travel from the lungs to the chemoreceptors near the carotid arteries in the neck. Research published in the Journal of the American Heart Association found that heart failure patients with Cheyne-Stokes breathing had an average lung-to-finger circulation time of about 33 to 34 seconds, compared to roughly 26 to 27 seconds in heart failure patients without the pattern. That delay of just a few seconds is enough to destabilize the entire feedback loop. By the time the brain registers that CO2 has dropped (because the lungs already blew it off), it’s too late to make a gentle correction. The brain overshoots in the other direction, suppressing breathing until CO2 climbs again, and the cycle repeats.
Circulation time doesn’t just trigger the pattern; it shapes it. The longer the delay, the longer each breathing cycle lasts. Lung-to-chemoreceptor circulation time was the single strongest predictor of Cheyne-Stokes cycle length in that same study.
Neurological Causes
Damage to the brain itself can also trigger Cheyne-Stokes respirations, even when the heart is functioning normally. Stroke is the most recognized neurological cause, particularly strokes affecting the deeper brain structures that regulate automatic functions like breathing. Traumatic brain injuries, brain tumors, and other conditions that increase pressure inside the skull can produce the same effect.
In these cases, the problem isn’t delayed blood flow but a damaged controller. The brain’s respiratory centers become either overly sensitive to CO2 fluctuations or lose the ability to modulate breathing smoothly, creating the same pattern of overcorrection that heart failure produces through a different route. Cheyne-Stokes breathing after a stroke is sometimes transient, resolving as swelling decreases, but it can also persist depending on the location and severity of the damage.
High Altitude
Even healthy people can develop a version of this breathing pattern at elevations above 6,000 feet. The thin air contains less oxygen, which forces the body into a ventilatory dilemma. Oxygen sensors in the carotid bodies detect low blood oxygen and drive breathing harder. But that deeper breathing blows off too much CO2, making the blood more alkaline. The CO2 sensors then suppress breathing, sometimes to the point of brief pauses. Only when oxygen drops low enough again does the cycle restart.
This is sometimes called high-altitude periodic breathing rather than true Cheyne-Stokes respiration, but the underlying mechanism is the same: two competing signals (low oxygen saying “breathe more” and low CO2 saying “breathe less”) alternating dominance. It typically occurs during sleep and resolves as the body acclimatizes over days.
Other Contributing Conditions
Beyond heart failure, stroke, and altitude, several other conditions can set off Cheyne-Stokes respirations:
- Kidney failure: Changes in blood chemistry, particularly the buildup of metabolic waste products, can alter CO2 sensitivity and destabilize breathing control.
- Opioid and sedative use: These drugs suppress the brainstem’s respiratory drive, which can unmask or worsen periodic breathing patterns, especially during sleep.
- Carbon monoxide poisoning: By displacing oxygen from red blood cells, carbon monoxide creates a state similar to the oxygen deprivation seen at altitude.
- End-of-life changes: Cheyne-Stokes breathing is common in the final hours or days of life as brain function declines. Caregivers often notice this pattern first, with breathing that seems to stop for alarming stretches before resuming in a wave.
How It Differs From Obstructive Sleep Apnea
Cheyne-Stokes respiration is a form of central sleep apnea, meaning the brain temporarily stops sending signals to breathe. This is fundamentally different from obstructive sleep apnea, where the brain is sending the right signals but the airway physically collapses. In obstructive apnea, you can see the chest and abdomen straining to pull air through a blocked throat. In Cheyne-Stokes breathing, there is no effort at all during the pauses. The chest simply stops moving.
The other distinguishing feature is the gradual, wave-like pattern. Obstructive apnea produces abrupt stops and gasping restarts. Cheyne-Stokes breathing ramps up and down smoothly, like a tide coming in and going out. A sleep study can clearly differentiate the two, though some patients with heart failure have both patterns occurring in the same night.
What It Means for Heart Failure Patients
For people with heart failure, discovering Cheyne-Stokes respirations during a sleep study raises an important question: does the breathing pattern itself make the heart condition worse, or is it simply a marker of more advanced disease? The answer is still debated. One study following 57 heart failure patients over an average of 38 months found no statistically significant difference in mortality between those with and without Cheyne-Stokes breathing, though the numbers were small.
What is clear is that treatment must be chosen carefully. A type of breathing machine called adaptive servo-ventilation (ASV), which detects the waxing-and-waning pattern and adjusts air pressure breath by breath, was once widely used. However, a major trial found that ASV increased the risk of cardiovascular death in heart failure patients whose hearts pumped less than 45% of their blood per beat. For patients with severely reduced heart function (below 30%), ASV is now considered unsafe and should not be used. Patients with preserved heart function above 45% may still benefit from ASV. For those in the middle range, treatment typically involves standard positive airway pressure devices or supplemental oxygen, with decisions made on a case-by-case basis.
What the Pattern Looks Like
If you’re observing someone with Cheyne-Stokes breathing, the pattern is recognizable once you know what to watch for. Breathing starts shallow and quiet, gradually grows deeper and louder over 15 to 30 seconds, then fades back to silence over a similar period. The pause that follows can last 10 to 30 seconds or more. The entire cycle then repeats, often for hours. Sleepers with this pattern frequently experience restless sleep, repeated awakenings (sometimes with a sensation of breathlessness), and excessive daytime fatigue. Bed partners often notice the pattern before the person experiencing it does.