Medical Mystery of the Week

On your morning rounds, your team reaches the bedside of the patient imaged in the video below. Your attending asks the following questions: what is your diagnosis, what test(s) would you order to confirm your suspicions, and what treatment, if any, do you recommend?

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DIAGNOSIS: Cheyne-stokes respirations (CSR). CSR is characterized by periods of apnea followed by progressive hyperpnea and then apnea.

CSR is a form of central sleep apnea and is do to either decreased circulation time (as seen in patients with left ventricular systolic dysfunction) and/or diminished hypothalmic sensitivity to pCO2 levels. Hence, arterial CO2 levels build to abnormally high levels causing hyperpnea and then to abnormally low levels causing apnea. CSR only occurs during sleep and "dozing" is a frequent sign in patients with low left ventricular ejection fractions. Hence, when examining a patient with systolic congestive heart failure, it is important to note the respiratory rate and depth when the patient is awake and repeat your observations if the patient falls asleep. CSR occurs normally in babies and in persons climbing to altitudes of 10,000 feet above sea level.