Cheyne-Stokes respiration is a repeating breathing pattern. Breaths gradually become deeper, and sometimes faster, then become progressively shallower. A central apnea or marked reduction in breathing follows, and the cycle begins again.
The pattern is a clinical sign, not a diagnosis or prognosis on its own. It is strongly associated with heart failure, but it can occur in other medical and environmental settings. A person who appears to breathe this way for the first time should be evaluated rather than diagnosed from a video or bedside observation.
What makes the pattern Cheyne-Stokes respiration?
The defining feature is the smooth waxing and waning of ventilation around central events. During a central apnea, airflow and breathing effort both stop. That differs from an obstructive apnea, in which airflow stops even though the chest and abdomen continue trying to breathe.
Sleep-medicine scoring is more specific than the everyday description. A Cheyne-Stokes breathing sequence includes at least three consecutive central apneas or central hypopneas separated by a crescendo-decrescendo change in breathing, with a cycle length of at least 40 seconds. A diagnosis of central sleep apnea with Cheyne-Stokes breathing requires more than one sequence. It also considers how many events occur during sleep, whether central events predominate, symptoms or observations, associated conditions, and alternative explanations 1.
This is why one deep breath, a few pauses after turning over, or irregular breathing while awake is not enough to identify the pattern.
It can occur during sleep or while awake
Cheyne-Stokes respiration can be visible while a person is awake, especially during serious cardiac or neurologic illness. During sleep, it is usually most apparent in non-REM sleep and around lighter sleep, when breathing depends more heavily on chemical feedback from oxygen and carbon dioxide. Formal central sleep apnea diagnoses are based on events measured during sleep 1.
A report that says "Cheyne-Stokes breathing" therefore needs context. It may describe an observed bedside pattern, a finding on a sleep study, or a percentage estimated by a PAP device. Those are not interchangeable.
Why breathing rises and falls
Breathing is controlled by a feedback system. Sensors respond to carbon dioxide, oxygen, and acidity, and the brain adjusts ventilation. In Cheyne-Stokes respiration, this control system becomes unstable.
A period of increased breathing can lower carbon dioxide below the person's apnea threshold, the level at which the drive to breathe briefly stops during sleep. Carbon dioxide then rises during the pause, breathing restarts, and the response can overshoot again. Clinicians sometimes call this an abnormally high loop gain, meaning the system reacts too strongly to a disturbance.
Heart failure can add a delay because blood takes longer to travel between the lungs and the sensors that help regulate breathing. Pulmonary congestion can also promote hyperventilation. The combination of an overly sensitive response and delayed feedback can produce the long, regular cycles associated with Cheyne-Stokes breathing 1.
Carbon dioxide context matters. A low or low-normal carbon dioxide level fits the common hyperventilation-driven form of Cheyne-Stokes breathing. Central events can also occur with inadequate ventilation and elevated carbon dioxide in neuromuscular, lung, medication-related, or other disorders. Those are different mechanisms and may need different treatment.
How it differs from similar breathing patterns
| Pattern | What is happening | Main distinction |
|---|---|---|
| Cheyne-Stokes respiration | Breathing smoothly waxes and wanes around central apneas or hypopneas | The cycles are gradual, repetitive, and usually long |
| Other central sleep apnea | Airflow and effort stop during central events | Central events may be irregular or lack the Cheyne-Stokes shape |
| Obstructive sleep apnea | The upper airway closes while breathing effort continues | Chest and abdominal effort persists or increases during an apnea |
| High-altitude periodic breathing | Central pauses alternate with increased breathing after ascent | It is an altitude-triggered pattern and can occur in otherwise healthy people |
| Biot or ataxic breathing | Breath depth and timing are irregular, with unpredictable pauses | There is no orderly crescendo-decrescendo sequence |
| End-of-life breathing changes | Breathing may become irregular, shallow, noisy, or interrupted by pauses | Not every end-of-life change is Cheyne-Stokes respiration, and the setting determines its meaning |
Cheyne-Stokes respiration is not the whole of central sleep apnea
Central sleep apnea is a broader group of sleep disorders. It includes central events related to heart failure, medications or substances, high altitude, another medical condition, PAP treatment, or no identified cause. Cheyne-Stokes respiration is one recognizable pattern within that broader group 1.
A person can have central sleep apnea without Cheyne-Stokes breathing. A person can also have obstructive and central events on the same night. The shape of one airflow trace cannot establish which disorder predominates.
Biot breathing is irregular, not smoothly periodic
Biot breathing and ataxic breathing are terms used for an irregular pattern with pauses and no consistent order in breath depth or timing. The terminology has not always been used consistently, but the core distinction is the absence of Cheyne-Stokes respiration's stereotyped rise and fall 2.
This difference is especially relevant with opioids. In a retrospective sleep-clinic cohort, chronic opioid use was associated with central apnea and an irregular or ataxic pattern distinct from Cheyne-Stokes breathing 3. A medication history is therefore part of the evaluation, not a reason to label every central pause Cheyne-Stokes respiration.
High-altitude periodic breathing can be a normal response to low oxygen
Periodic breathing during sleep is almost universal among lowlanders spending time at high altitude, and it generally becomes more pronounced as sleeping altitude increases. It can persist during acclimatization without clear adverse consequences in otherwise healthy people 4.
This altitude response may resemble Cheyne-Stokes breathing on a simple airflow or oxygen trace, but it has a different context and is classified separately. Symptoms of acute mountain illness, severe low oxygen, or breathing difficulty still need prompt attention. A new sea-level pattern should not be dismissed because someone once had periodic breathing at altitude.
Conditions associated with Cheyne-Stokes respiration
Finding the cause is more important than naming the pattern alone. Several conditions can create unstable breathing, and more than one may be present.
Heart failure
Heart failure is the major medical association. Reduced cardiac output can delay respiratory feedback, while congestion and increased sensitivity to carbon dioxide can push breathing below the apnea threshold after a period of hyperventilation.
In studies of people with heart failure with reduced ejection fraction, central sleep apnea and Cheyne-Stokes breathing are associated with more severe disease and worse outcomes. This is a group-level association. The pattern does not reveal an individual's ejection fraction, prove that heart failure has worsened, or predict how long someone will live 1.
A new Cheyne-Stokes pattern may therefore prompt a cardiac assessment even if heart failure has not been diagnosed. In someone with known heart failure, it may justify reviewing symptoms, fluid status, heart rhythm, current treatment, and the most recent measure of heart function.
Stroke and other neurologic disease
Acute stroke, brain injury, tumors, and other neurologic conditions can affect respiratory control. Cheyne-Stokes breathing may be seen in some people during acute neurologic illness, including while awake.
It is inaccurate to assume that central sleep apnea is common after every stroke. In a cohort of 1,346 people tested shortly after ischemic stroke, 1.4 percent met the study's criteria for central sleep apnea 5. Earlier reports of periodic breathing in selected, severely ill stroke populations measured different patterns and populations. New breathing changes accompanied by weakness, facial droop, speech trouble, confusion, or loss of balance are an emergency, not a sleep-study question.
Chronic kidney disease
Central sleep apnea has been reported in chronic kidney disease and dialysis populations, but the evidence is limited. A systematic review found only eight eligible studies with 313 participants, inconsistent definitions, and a wide range of estimates. Some participants also had heart failure 6.
Kidney disease can affect fluid balance, acid-base status, and other parts of respiratory control. It belongs in the clinical workup, but kidney disease alone does not prove that an observed pattern is Cheyne-Stokes respiration or explain its mechanism.
Medications and substances
Opioids and other respiratory depressants can cause central apnea, hypoventilation, or irregular breathing. This usually belongs to the medication-related central sleep apnea category rather than Cheyne-Stokes breathing. Sedatives, alcohol, recent dose changes, and combinations of depressant drugs can alter both the pattern and the immediate risk.
Do not stop an opioid, sedative, or cardiac medicine abruptly because a breathing pattern was noticed. Sudden withdrawal or loss of disease control can be dangerous. A prescriber should plan any change, except when emergency services are treating a suspected overdose.
What a bed partner may notice
A bed partner may see several breaths become steadily larger and louder, then smaller and quieter, followed by a pause. The sequence may repeat with a similar rhythm. The sleeper may briefly stir when breathing resumes.
These observations are useful to report, but they do not identify the mechanism. Snoring can occur alongside central events and does not prove obstruction. A person with heart failure may have little daytime sleepiness despite substantial sleep-disordered breathing, while fatigue or breathlessness may come from the heart condition itself 1.
If it is safe to do so, a short video that includes the chest and abdomen can help a clinician understand what prompted concern. Record when it happened, whether the person was awake or asleep, recent altitude, medication or alcohol exposure, and any associated breathlessness, chest symptoms, confusion, or weakness. Do not delay emergency care in order to record.
How Cheyne-Stokes breathing is confirmed
An attended polysomnogram provides the clearest sleep-specific assessment. It records sleep and arousals along with airflow, chest and abdominal effort, oxygen saturation, heart rhythm, and other signals. The effort channels help separate central apneas from obstructive apneas. Sleep staging shows whether events occurred during sleep rather than wakefulness.
Carbon dioxide monitoring is not part of every sleep study, but end-tidal or transcutaneous carbon dioxide may be added when hypoventilation, medication effects, neuromuscular disease, or another carbon dioxide problem is suspected. An arterial or venous blood gas may be selected in some clinical settings. These measurements answer a different question from oxygen saturation: whether ventilation is keeping carbon dioxide within an appropriate range.
For the diagnostic evaluation of suspected sleep apnea, the American Academy of Sleep Medicine recommends polysomnography rather than basic home sleep apnea testing when significant cardiorespiratory disease, possible sleep-related hypoventilation, chronic opioid use, or a history of stroke makes the case more complex 7.
A clinician may still choose an appropriately equipped home study for a specific person. Some medical home systems record airflow, effort, and oxygen and can flag central or Cheyne-Stokes events. A negative, inconclusive, or technically limited home test does not settle the question when clinical concern remains.
What consumer devices cannot confirm
- A phone video can show the visible rhythm but cannot reliably measure airflow, sleep stage, carbon dioxide, or whether effort stopped.
- A pulse oximeter can show oxygen changes, but similar rises and falls can occur with central events, obstructive events, movement, poor sensor contact, circulation problems, or altitude.
- A wearable may estimate breathing rate or oxygen from indirect signals. It does not provide the full set of channels used to classify the mechanism.
- A PAP download can flag periodic breathing or a clear-airway event, but the machine primarily analyzes flow and pressure rather than the complete polysomnogram.
In a study that compared one PAP device with simultaneous polysomnography, device-detected airway status was useful but could not be equated with a specific respiratory-event type 8. A rising periodic-breathing percentage or new central-event flag is a reason to send the data to the treating sleep clinician, not a reason to change pressure or mode without guidance.
What the medical workup may include
The workup starts with the setting in which the pattern appeared. Clinicians may ask about waking and sleeping symptoms, altitude, recent illness, known heart or neurologic disease, kidney function, PAP use, and every prescription drug, over-the-counter medicine, supplement, alcohol product, or other substance that could affect breathing.
Testing is chosen to answer the likely cause rather than ordered as one fixed panel. Depending on the history and examination, it may include:
- an electrocardiogram and cardiac imaging to assess rhythm, structure, and left ventricular ejection fraction
- kidney function, electrolytes, acid-base status, and selected blood tests
- oxygen and carbon dioxide assessment
- neurologic examination and imaging when a new neurologic problem is suspected
- review of PAP settings and detailed flow data for someone already receiving treatment
A breathing pattern alone should not be used to diagnose heart failure, stroke, kidney failure, or an overdose. It helps clinicians decide which questions need answers.
Treatment starts with the cause
The 2025 AASM central sleep apnea guideline says care should be individualized using clinical features, associated conditions, and polysomnography. It prioritizes treating contributing conditions and improving symptoms and quality of life rather than chasing a zero event count. Persistent central events after treatment should trigger a review of the cause and the treatment choice 9.
Treat the associated condition
- Heart failure: The cardiology team should optimize evidence-based heart failure treatment and assess rhythm, congestion, and cardiac function. Do not adjust a diuretic, beta blocker, or other cardiac medicine based on a breathing video or PAP report.
- Neurologic disease: Acute problems need urgent treatment. A stable post-stroke or brain-injury pattern may be reassessed as recovery and other medical factors change.
- Kidney disease: Fluid, dialysis, metabolic, and medication issues are managed with the kidney-care team. Sleep treatment does not replace renal care.
- High altitude: Mild periodic breathing may not need treatment, and returning to a lower altitude removes the trigger. Acclimatization does not necessarily eliminate the pattern. Symptoms of altitude illness require a separate safety assessment.
- Medication-related central apnea: The prescriber may reduce, substitute, or more gradually change a contributing drug when the benefits and withdrawal risks have been reviewed. Do not make an abrupt change independently.
Positive airway pressure is selected by mechanism
CPAP is one conditional option for several forms of central sleep apnea, including heart-failure-related CSA. It may improve breathing events, oxygenation, or symptoms in some people, but suppressing the event count has not been shown to guarantee better survival.
Bilevel PAP is not one treatment with one effect. The 2025 AASM guideline conditionally supports bilevel PAP with a backup rate for selected CSA causes, but suggests against bilevel PAP without a backup rate for CSA because it can fail to support breathing appropriately or worsen instability 9.
These modes require a prescription, appropriate titration, and follow-up. A person using PAP should not copy another user's settings or switch modes to treat a suspected waveform.
ASV needs a current cardiac assessment
Adaptive servo-ventilation, or ASV, changes pressure support from breath to breath to stabilize ventilation. It can markedly reduce central events, but heart-failure safety requires special attention.
In the SERVE-HF trial, ASV increased all-cause and cardiovascular mortality in participants with symptomatic systolic heart failure, a left ventricular ejection fraction of 45 percent or less, and predominantly central sleep apnea 10. The result applies to that trial population and device strategy, not to every person with central apnea.
The 2025 AASM guideline conditionally suggests ASV for several CSA causes, including heart failure, but states that use in heart failure with reduced ejection fraction should be limited to experienced centers with close monitoring and follow-up 9. A current ejection fraction, the exact CSA cause, symptoms, device type, and cardiology input all matter. ASV is not a mode to start or change from a home-device menu.
Oxygen, acetazolamide, and implanted stimulation are cause-specific
The AASM guideline conditionally suggests low-flow oxygen for CSA due to heart failure or high altitude and acetazolamide for several CSA causes. The evidence certainty is low or very low, and these are not universal home treatments 9.
Oxygen needs a prescription and a reason. It can improve oxygen levels without resolving every breathing mechanism, and unmonitored oxygen can be inappropriate in conditions involving carbon dioxide retention. Acetazolamide has medication interactions, kidney and electrolyte considerations, and side effects that need clinical review.
Transvenous phrenic nerve stimulation is an implanted treatment conditionally suggested for selected adults with primary or heart-failure-related CSA, usually after less invasive options have been considered. It requires specialist assessment, a procedure, and long-term follow-up 9.
When to seek urgent help
Call emergency services for severe or rapidly worsening trouble breathing, blue or gray lips, severe chest pain or pressure, fainting, inability to awaken, or new severe confusion 11.
Also treat sudden facial droop, one-sided weakness or numbness, speech difficulty, loss of balance, vision change, or an unexplained severe headache as possible stroke signs. Call emergency services even if the symptoms improve 12.
If someone who may have taken an opioid cannot be awakened, has slow or shallow breathing, makes choking or gurgling sounds, has discolored lips or nails, or has pinpoint pupils, treat it as a possible overdose. The CDC advises giving naloxone if available, calling emergency services, keeping the person breathing if possible, placing them on their side, and staying with them until help arrives 13.
Arrange prompt medical review for a newly observed repeating pattern without emergency symptoms, especially with:
- waking breathlessness or shortness of breath when lying flat
- new swelling or worsening heart-failure symptoms
- recurrent nighttime oxygen drops
- new central or periodic-breathing flags on PAP data
- marked daytime sleepiness, near-misses, or drowsy driving
- a recent medication or dose change that can affect breathing
Do not drive if sleepiness makes it hard to stay alert.
Does Cheyne-Stokes breathing mean someone is dying?
No, not by itself. The pattern can occur in people living with heart failure, during sleep, after neurologic illness, or at altitude. It should not be used alone to estimate life expectancy.
Cheyne-Stokes breathing can also occur during the final days of life in a person already known to be dying. In prospective studies of people with advanced cancer, the National Cancer Institute lists it as one of several late signs associated with impending death, while also emphasizing that predicting the timing of death remains difficult 14.
Context changes the response. If a person is receiving hospice or end-of-life care, contact the care team for guidance about comfort and what the breathing change means in that person's situation. If the pattern is new and the person is not in an expected dying process, seek medical evaluation rather than assuming it is an end-of-life sign.
The bottom line
Cheyne-Stokes respiration is a specific waxing-and-waning breathing pattern with central pauses or reductions. It is narrower than central sleep apnea as a whole and different from airway obstruction, irregular ataxic breathing, and ordinary altitude-related periodic breathing.
The pattern points clinicians toward an explanation, especially heart failure, but it cannot diagnose the cause or predict an individual's outcome. Polysomnography, respiratory-effort signals, relevant oxygen and carbon dioxide context, and a cause-focused medical assessment are what turn an observation into a useful diagnosis and treatment plan.
