Cheyne-Stokes respiration

CSR typically arises in the context of congestive heart failure, stroke, or brain injury. CSR has also been described in sleep-disordered breathing and in the dying process.

Modern criteria include:

• A central apnea–hypopnea index (AHI) ≥5/hour
• A crescendo–decrescendo pattern of breathing
• No evidence of obstructive respiratory effort during events
• Often diagnosed via polysomnography

It is thought to reflect instability in respiratory control feedback loops, including prolonged circulation time and hypersensitive chemoreflexes.

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History of Cheyne-Stokes respiration

~400 BCE – Hippocrates appears to have made a proto-description of periodic respiration in Epidemics, Case I, involving a febrile patient named Philiscus. He writes:

Respiration throughout like that of a man recollecting himself, and rare, and large.
(Original Greek: πνοὴ διὰ τέλος, ὥσπερ ἀνακαλουμένῳ, ἀραιὸν, μέγα.)

This quote is suggestive of irregular, infrequent, deep breathing, though not explicitly cyclic or apnoeic. This was interpreted by later scholars such as Galen (“besoin de respirer“), Daremberg (“rare comme chez quelqu’un qui ne respire que par souvenir“) to signify a pattern where the need to breathe seems “forgotten” and then suddenly “recollected“—resonant with the waxing-waning nature of Cheyne-Stokes respiration.

1786 – Jean-Baptiste Nicolas (1745–1832) in Histoire des maladies épidémiques described what appears to be a pattern of periodic breathing in a general officer

a complete cessation of the movement of the lungs for 25 to 30 seconds… followed by a gradual restoration of respiration to its ordinary strength, then again cessation.

While the ascending phase is well captured, the descending component is not clearly described, making this a partial match for what would later become known as Cheyne–Stokes breathing.

1818 – In Dublin Hospital Reports, John Cheyne (1777–1836) documented a patient with apoplexy and fatty heart degeneration. He observed a peculiar periodic breathing pattern:

The only peculiarity in the last days of his illness, which lasted nine days, was in the state of the respiration: for several days his breathing was irregular; it would entirely cease for a quarter of a minute, then it would become perceptible, though very low, then by degrees it became heaving and quick, and then it would gradually cease again: this revolution in the state of his breathing occupied about a minute, during which there were about thirty acts of respiration.

Cheyne 1818

Cheyne also notes a second patient with a similar pattern but without post-mortem verification, so the report focuses on the first, where autopsy revealed cardiac fatty degeneration.

1854 – William Stokes (1804–1878) in The Diseases of the Heart and Aorta, Stokes described this pattern again in the context of heart failure and CNS depression.

Stokes provided a broader and more physiologically reasoned description. He observed the same periodic respiratory pattern and connected it with advanced heart failure and neurological disease, cementing its pathophysiological basis and linking the two names.

…the peculiar rhythmical type of respiration, in which a series of gradually increasing respirations is succeeded by a series of gradually diminishing ones, and this again by a pause, which is followed by a renewal of the respiratory acts in the same order.

Stokes, 1854

1889 – George Alexander Gibson (1854-1913) coined the term Cheyne–Stokes respiration and used it explicitly as a diagnostic label throughout his multi-part article, “An Examination of the Phenomena in Cheyne–Stokes Respiration.”

Gibson published a series of articles in the Edinburgh Medical Journal, An Examination of the Phenomena in Cheyne–Stokes Respiration and later a monograph Cheyne-Stokes respiration (1892), exploring the pathophysiology, patterns, and differentials of the phenomenon. He reviewed historical origins and attempted the first systematic analysis of the mechanism.

1953 – On March 4, 1953, the Soviet press announced that Joseph Stalin (1878–1953) was ill and had ‘Cheyne-Stokes respiration‘. The following day he died. Stalin’s final hours marked by Cheyne-Stokes respiration as his condition deteriorated after cerebral haemorrhage, featured prominently in political and medical analyses of his death. Details were publicized post facto in various biographies and dramatisations and often referred to as the first mention of the condition.

The breathing pattern was cited as a clinical marker of neurological decline, reinforcing its historical association with catastrophic brain injury.

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Associated Persons

• Hippocrates (c. 460 – c. 370 BCE) – His work Epidemics is retrospectively interpreted as possibly alluding to CSR-like patterns.
• Jean-Baptiste Nicolas (1745–1832) – Provided an earlier case description in 1786.
• John Cheyne (1777–1836) – First described the apnoea-hyperpnoea cycle clinically in a case of apoplexy.
• William Stokes (1804–1878) – Expanded and clinically associated the phenomenon with cardiac disease.
• George Alexander Gibson (1854–1913) – Conducted the first detailed analysis and discussion of Cheyne-Stokes breathing as a named clinical entity.

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References

Original references

• Cheyne J. A case of apoplexy in which the fleshy part of the heart was converted into fat. Dublin Hospital Reports. 1818; 2: 216-223. Reprinted: Cardiac Classics. 1941;1:317-320 [Cheyne-Stokes Respiration]
• Stokes W. Fatty degeneration of the heart. In: The Diseases of the heart and the aorta. 1854:302-340
• Gibson GA. An examination of the phenomena in Cheyne-Stokes respiration. Edinburgh medical journal. 1889; 34(2): 585-596, 681-692, 801-813, 887-900, 1020-1030, 1105-1118
• Gibson GA. Cheyne-Stokes respiration. 1892

Review articles

• Gessen M. “The Death of Stalin” Captures the Terrifying Absurdity of a Tyrant. The New Yorker. March 6 2018

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