Electroencephalographyand Clinical Neurophysiology,1975,39:575-585 :i~"ElsevierScientificPublishingCompany.Amsterdam Printedin The Netherlands

CHEYNE-STOKES POLYGRAPHIC

RESPIRATION

575

AND SLEEP: A DIURNAL

STUDY

B. A. SCHWARTZ1 AND M. F. EPRINCHARD Laboratoire d'EEG. H6pital Broussais. 96, rue Didot, 75674 Paris Cedex 14 (France)

(Accepted for publication:June30, 1975)

Respiratory modifications occurring during et al. 1966; Schwartz et al. 1967). The complete sleep in normal subjects were described during pattern typically comprises four aspects (Fig. the first years which followed the introduction of 1, A ~, A 2): a short decrescendo series of respirathe polygraphic study of sleep (Bulow 1963; tory movements while the subject begins to fall Aserinsky 1965). In more recent years the im- asleep, his mouth slowly opens and his subportance of hypnic respiratory modifications in mental EMG activity decreases; a short respipatients has also become increasingly apparent ratory pause which lasts about 10 sec during (Kales and Tjiauw-Ling 1969; Bergman et al. which sleep deepens (this central apnoea can be 1970; Broughton 1972; Steinschneider 1972; missing, as in Fig. 1, A2); a long crescendo series Guilleminault et al. 1973; Fischer et al. 1974; of ineffective breathing efforts, first of moderate Weitzman and Graziani 1974). Although striking intensity while sleep continues to deepen and observations have been made in the Pickwickian EMG activity to decrease, then of more marked syndrome (hypersomnia with hypnic respiratory intensity during which sleep lightens and inperiodicity, HRP) since 1965 (Jung and Kuhlo spiratory EMG activity increases (the ineffec1965; Gastaut et al. 1966; Schwartz et al. 1967: tive breathing efforts are clinically accompanied Lugaresi et al. 1972b; Tassinari et al. 1972) the by simultaneous lowering of the lower jaw, raismost widely known respiratory periodicity (RP), ing of the shoulders, strong abdominal contracCheyne-Stokes breathing, has only rarely been tion and small forward movements of the studied with polygraphic methods (Karp et al. tongue); the last and most intense breathing 1961). As the Cheyne-Stokes RP is observed in efforts are often accompanied by a strong rasping a great variety of pathological states (Brown and noise in the throat as if air were struggling to get Plum 1961 ; Karp et al. 1961 ; Rout et al. 1971 ; through the narrowed upper-airways (the inCherniack and Longobardo 1973) and as it has effective respiratory movements correspond to sometimes been confused with the RP of the obstructive apnoea); finally, a violent snore Pickwickian syndrome (Karp et al. 1961 ; Specht and Fruhman 1972) the purpose of the present work is to observe whether criteria, and more particularly polygraphic criteria, which are accepted as characteristic of HRP can be applied to the study of the still somewhat mysterious Bib Cheyne-Stokes respiration and thus contribute to a better understandin~ of RPs (Karp et al. 1961; Hornbein 1972; Cherniack and LongoFig. 1. A~and A2: Pickwiekianrespiratoryperiodicity(RP) bardo 19731. In HRP, breathing is normal in wakefullness with and without central apnoea; obstructive apnoea inand modified as soon as sleep sets in (Gastaut dicatedby brokenlines.B~.and B2,:Cheyne-StokesRP with and without central apnoeas. Bib and B2b: the same with i Charg6ede Recherches/tI'INSERM. Contrat 742175 ineffective respiratory movements during the respiratory 06. crescendo.

576

B, A. S C H W A R F Z AND M. F. EPRINCHARD

followed by spontaneous hyperventilation appears, with an intense awakening reaction (a large K complex followed by a brief period of alpha activity) and the mouth is closed until the next respiratory decrescendo. The total duration of the obstructive apnoea lengthens as slow wave sleep (SWS) deepens but the longest periods of obstructive apnoea occur in REM sleep (Schwartz e t al. 1967: Lugaresi e t al. 1972b). When a stimulus is sufficient to awaken a patient during ineffective breathing, normal breathing is immediately resumed, replaced by hyperventilation if the apnoea has been long enough Schwartz et al. 1967).

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Thirty-four patients (27 men and 7 women) aged between 45 and 97 (Fig. 2, B) were selected for study because they presented an RP other than that typical of the Pickwickian syndrome in at least one of their records (patients whose apnoea occurred only while attentive to orders or only in the period following voluntary hyperventilation in wakefulness were not included). They provided a total of 72 records (47 routine morning records, 25 polygraphic afternoon records). Fourteen patients were recorded only once but the others were recorded 2-8 times each on nonconsecutive days over periods of up to 29 months.

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Fig. 2. Comparison of the ages of group A 159 patients) with hypersomnolence and sleep-linked respiratory periodicity (the typical Pickwickians are md|cated by stippling) and group B (34 patmnts} with Cheyne-Stokes respiration in at least one of their records.

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Fig. 3. Arterial blood gases (PCO 2 and PO2)and haematocrit (Ht) in 18 Pickwickians (A) and 11 patients with Cheyne Stokes respiration (B). W h e n there were more than two evaluations in a patient, only the highest and lowest figures observed are indicated.

In 11 cases blood gases and/or haematocrit were evaluated as often as possible on the day a record was obtained (Fig. 31. All patients were recorded in the laboratory, which meant that the group did not include any dramatic cases, patients in coma or who needed intensive care. Eighteen patients had been prescribed an EEG for a neurological condition (of these 4 had strokes, and 10 strokes accompanied by a cardiovascular condition), 8 tbr a cardiovascular condition alone, the remainder tbr a cardiovascular condition together with another pathological problem (cirrhosis, hypothyroidism, obesity, etc.). In 8 patients Cheyne-Stokes breathing had been clinically observed before the EEG was prescribed. Routine morning records lasted an average of 30 min with 15 rain of partial polygraphy (EEG, ECG, respiratory rhythm) in a quiet but not sound proof laboratory; the patient was supine; voluntary hyperventilation was obtained in patients who could cooperate; the record ended with photic stimulation. Polygraphic afternoon records lasted 60-100 min in a sound attenuated laboratory. Polygraphy included EEG, ECG, EOG, submental EMG, respiratory rhythm (respiratory move-

577

CHEYNE--STOKES RESPIRATION AND SLEEP

ments were recorded with a belt set at the abdomino-thoracic junction so that effective or ineffective respiratory movements could not be missed; a microphone at 5-10 cm in front of the mouth and nose recorded breathing sounds so that effective respiration with air flow could not be missed; ineffective respiratory movements

were also clinically observed and annotated, as described above) ; standard recording and scoring methods were used (Schwartz 1968). The patient was supine and, whenever possible, also in lateral recumbency; 5 min of voluntary hyperventilation was required when sleep onset did not occur spontaneously after 15-30 min of recording. Efforts were made to render the laboratory situation and apparatus the least aggressive possible. The EEG aspects recorded were divided into wakefulness with occipital alpha rhythms of 8-12 c/sec (W), wakefulness with slow occipital rhythms (5-7 c/sec) sometimes accompanied by low voltage slow waves ("W") and the five normal sleep stages. W was considered to be full wakefulness; " W " was duller wakefulness or presleep. Subjects with borderline sleep patterns (dominant slow waves immediately at sleep onset)

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Fig. 4. A completeCheyne-Stokesrespiratory]period(the two halvesof the figure are continuous). Note that the respiratory crescendo starts with eight ineffectiverespiratory movementsfollowed by spontaneoushyperventilation (loud inspiration followed by loud expiration). In this example there is EEG slowing during decrescendo, an awakening reaction on order to open and close the eyes (O and C) without respiratory modification, gradual return to sleep, and awakening with hyperventilation only. EM, horizontal eye movements; S, breathing sounds; i, inspiration; EKG, cardiogram; RM, respiratory movements. EMG, submental myograms (recorded at C a and C 2 as indicated in inset). Calibration: 1 sec and 50/~V; time constant: 0.3 sec for the EEG, 0.7 sec for EM.

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Fig. 6. Patient G.C. Record IV. A complete period of Cheyne-Stokes respiration (type B2) in R E M sleep. The two halves of the figure are continuous. Note that spontaneous hyperventilation is not sufficiently intense to show breathing sounds on S and how ditterent this respiratory phenomenon is fi:om the Cheyne-Stokes-like breathing which can be observed in a control subject's REM sleep in which the reduced respiratory amplitude occurs during REM bursts only (Aserinsky 1965). For abbreviations see Fig. 4.

579

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* RP did not exist in these records, whereas it was present in the patient's three other records. ** R E M S was preceded by stages 3 and 4 but B 2 only appeared briefly in W and sleep stages 1 and 2 of the same record. (Fig. 4, V). *** R E M S was preceded by stages 3 and 4 with RP but RP was only briefly of type B 1 in R E M S itself; it was then replaced by B 2 which was not continuous throughout this stage (Fig. 8, IV).

were not excluded. The data obtained were compared with those observed in a group of 59 hypersomnolent

patients aged between 19 and 83 (Fig. 2, A), 18 of whom were Pickwickians. They had been recorded and followed up in a similar fashion to

580

the present patients, and the results were published elsewhere (Schwartz and Granelet-Eprinchard 1972, 1974).

B.A. SCHWARTZ AND M. F. EPRINCHARD (20 see per~odsj

The two classical types of Cheyne-Stokes respiration were observed (Fig. 1, Bla, B2a; Fig. 4-6). They typically comprised four parts: a short series of decrescendo respiratory movements; a long respiratory pause which usually lasted 15-40 sec (this central apnoea, which was not constant, characterizes type B1 and is missing in type B2); a short series of crescendo respiratory movements; a more or less prolonged period of spontaneous hyperventilation; EMG activity decreased during decrescendo and pause, increased during crescendo and hyperventilation (Fig. ~-, 7).

Sleep and wakefulness Sleep was recorded in all but 19 routine records (Table 1) and in 7 of these W alternated with "W". The lighter stages of SWS were those most frequently present and REM sleep was only recorded twice, both times in the same patient (Fig. 8). In 26 patients RP was observed in both wakefulness and sleep; in 8 patients it was observed in sleep only. RP was present in all but 11 records (Table I), 9 of which contained only wakefulness; in the 2 others sleep reached stages 2 and 3 respectively; it was also absent in the REM sleep period of a record which had reached stage 4 and had contained transitory RP at sleep onset (Fig. 8, V).

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Modulation of respiratory periodiciO, B1 and B 2 w e r e observed in wakefulness and in sleep but B 2 was not recorded beyond stage 3 sleep. BI was recorded in all stages of SWS but only briefly in REM sleep (see Table III for example of a case). When RP existed in wakefulness it was usually little influenced by stimuli so that orders to open the eyes were readily executed (phenomenon P:, Fig. 4 and 5) without interrupting the characteristically long central apnoea. On occasions P~ only occurred in the wakefulness

Fig. 8. Patient G.C., aged 69 (see Tables II, III). Graphs indicate the sleep stage reached, or the type of wakefulness observed in each 20 sec period. I, the only routine morning record for this patient (partial polygraphy is indicated by a double line). W(EO), wakefulness with eyes open, W(EC) with eyes closed. REMS, rapid eye movement sleep. BI and B2, Cheyne-Stokes respiration of types B L and B2. Arrow down, change from the supine position to lateral recumbency; arrow up, return to the supine position. The patient was hospitalized for records I, II and III (respectively 19-2-73, 23-2-73 and 2-3-73); he was an outpatient for records IV, V and VI {respectively 29-5-73, 26-9-73 and 18-2-74). Time scale: each block corresponds to five 20 see units.

CHEYNE--STOKES RESPIRATION AND SLEEP

581

which followed sleep. When stimuli did influence waking RP, B2 disappeared or B1 pauses became shorter or disappeared for a time. Central apnoeas were shorter in wakefulness and grew longer as SWS deepened (Fig. 8). In 2 patients, in lateral recumbency and in the sitting position, central apnoeas were shorter

and sleep became deeper and more stable (awakening reactions were more discrete at the onset of spontaneous hyperventilation) than when they were recorded supine (Table II). Type B 2 respiration prevailed in wakefulness, light SWS and REMS and in lateral recumbency (Tables II and

III).

TABLE II Patient G.C. aged 69 (moderate hypertension; angina pectoris). Percent number of 20 sec periods of recording (total of 6 records) in which the different stages of sleep or wakefulness were reached. Periods of wakefulness with eyes open (EO) were distinguished from those with eyes closed (EC). In brackets: percent of total recording time (I, 68 periods; 11, 168 periods ; III, 216 periods; IV, 269 periods; V, 249 periods; VI, 253 periods). I, routine record; II-VI, polygraphic afternoon records. Recumbency

Wakefulness ( % total waking time)

Sleep stages ( % total sleep time)

EO

EC

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64

100 (26.5)

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3

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40.8

29.8

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36 (73.5)

Records I1- VI

Supine

10.3 (40.6)

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TABLE Ill Patient G.C., aged 69. Percent number of respiratory periods (RPs) of types B 1 and B 2 occurring in each stage of sleep or wakefulness (see Table II lor abbreviations). There were 167 RPs of type B 1 and 60 RPs of type B 2 in records II-VI. There had been 14 RPs of type B~ in record I. Recumbency

Respiratory Periodicity

Wakefulness

Sleep stages

EO

EC

1

2

3

4.5 3.1

21.9

22.7 46.9

47.3 21.9

25.5 6.2

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21 7.4

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Records II- VI

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3 1.7

11.7

582

When RP only existed in sleep, the first few periods were of type B 2, the following of type B1 (Fig. 8). In certain patients, it was clear that sleep onset occurred during the respiratory calm of decrescendo or pause, while spontaneous hyperventilation caused awakening and the patient exclaimed in irritation, clenched his fists and teeth, thus manifesting great annoyance at his sleep being interrupted time and time again (these patients were often considered agitated by the attending physician and were given sedatives). Except on occasions when RP occurred in sleep stages 3 or 4 (Fig. 7), spontaneous hyperventilation was accompanied by W or at most " W " , but not by sleep when the patient was supine. When this was observed in consecutive records over a period of days, moments of wakefulness became shorter, waking alpha rhythms became slower, the patient had more and more difficulty keeping his eyes open and respiratory pauses became inevitably accompanied by sleep. Progressive sleep deprivation due to the periodic awakenings, themselves due to hyperventilation, was obvious. In 15 patients, ineffective respiratory movements (phenomenon P2) were observed during the crescendo phase o f RP (Fig. 1, Bjb, Bzb) in sleep only, particularly when E M G activity dropped sharply (Fig. 4). In most of these cases this phenomenon occurred briefly or sporadically but in 7 cases ineffective respiratory movements were recorded in unusually long crescendo series and in repeated periods o f sleep RP so that, although they could be preceded by long central apnoeas, they greatly resembled the Pickwickian RP (Table I--A l ?, A 2 ? and B z + B 1 + A , + A 2 ?). Four o f these patients were obese and 3 under sedatives. In all the different groups of pathological conditions RP could be of one type or another (or even absent) from one moment to the next or from one record to another. In the 20 patients who were recorded more than once the RP pattern was stable throughout follow-up in only 5 cases and, on the whole, it was clear that RP was the more stable as the patient's general condition was less satisfactory and as his wakefulness was less steady (this happened, for example, close to the onset of the pathological situation

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POz levels were less low and PCOz levels lower than in the Pickwickian population (Fig. 3). Haematocrits could be lower than in the

CHEYNE--STOKES RESPIRATION AND SLEEP

Pickwickian population but also reached polycythaemic levels in certain cases. In these patients, obese or not, the haematocrit often dropped parallel to decreased diurnal somnol-. ence and to weight loss.

583

in lateral recumbency and the presence of transitional forms when the phenomenon is at a minimum (B 2 type RP in Cheyne-Stokes respiration, hypopnoea as described by Kurtz er a l 1072 and Lugaresi et al. 1972b in HRP). The main differences between t~e two RPs DISCUSSION (besides those linked with wakefulness) are the greater length of the central apnoeas in CheyneThe influence of sleep on RP is now known to Stokes breathing, the constant presence of be an important problem at all ages (Stein- obstructive apnoeas in HRP (whereas in the schneider 1972; Guilleminault et al. 1973; Cheyne-Stokes RP ineffective respiratory moveSchwartz and Granelet-Eprinchard 1974; Weitz- ments are only occasional), the opposite influman and Graziani 1974) but this study shows ence of REM sleep on both these RPs (the that RPis often missed by the attending physician periodicity is at a maximum during this sleep (in the present series only 8 out of 34 cases of stage in HRP, at a minimum in CheyneRP were known before the patient was sent to Stokes breathing) and finally a tendency to the EEG laboratory) because he does not ob- hypocapnia in Cheyne-Stokes respiration, to serve his patient in sleep, because in wakefulness hypercapnia in HRP. Another characteristic of the Cheyne-Stokes he mistakes periodic spontaneous hyperventilation for dyspnoea or because in certain cases RP RP is the variability of its precise tyl~e, even its can be disrupted by such common stimuli as possible absence in a patient who is recorded on clinical examination and talking (Harrison et al. diverse occasions in comparable clinical and 1934a, b). biological states. On the whole, with clinical RP, however, can often be discovered during improvement the Cheyne-Stokes RP changes routine EEG recording provided it is accom- from type B1 to B2, to disappearance, from the panied by recording of the respiratory rhythm. presence of RP both in wakefulness and in sleep Of 18 cases of RP observed during routine EEG to its presence in sleep alone, and lastly to total sessions in this series, 16 were certainly patho- disappearance. All this makes it unlikely that logical. The Cheyne--Stokes RP can therefore one particular neurological lesion or biological often be discovered with simple minimum poly- imbalance should suffice to explain Cheyne-Stokes respiration. Among the several concurrent graphic methods. Unlike HRP Cheyne-Stokes respiration is factors which may be responsible for its occurnot strictly sleep-linked. It can be observed in rence must be the patient's own physiological wakefulness. However, it is influenced by sleep personality (all the patients in the same clinical (to the point of being revealed by sleep when it and biological state do not have Cheyne-Stokes does not exist during wakefulness) and it can in respiration; men with this RP outnumber turn influence sleep: the regularly occurring women), the way his sleeo modifies his breathing phases of spontaneous hyperventilation can and perhaps some as yet unidentified factors definitely lead to sleep deprivation and ultimately (Said et al. 1974). to exhaustion (this is a similar phenomenon to Conflicting evidence is given to explain that hypothesized to explain the diurnal byper- Cheyne-Stokes respiration with its periodicity, somnolence of H R P by Gastaut et al. 1966, apnoeas and hyperventilation (Brown and Plum Lugaresi et al. 1972a and Tassinari et al. 1972). 1961 ; Karp et al. 1961 ; Rout et al. 1971 ; HornCheyne-Stokes respiration is therefore dif- bein 1972; Cherniack and Longobardo 1973). ferent from H R P but it does have points in This study shows, at least in those records in common with the Pickwickian and related RPs, which the Cheyne Stokes RP is spontaneous The main points of similarity are the lengthening and sleep-linked, that if the first central apnoea of the periods with deepening SWS, the accentu- is indeed preceded by the spontaneous hyperation of the phenomenon with weight gain and ventilation of B 2, the very first sign of the bethe administration of sedatives, its attenuation ginning of RP is neither a central apnoea nor

584 hyperventilation but occurs after normal waking respiration and is the decrescendo of type B2 Cheyne-Stokes respiration. It also shows that the swings of arterial PO2 and PCO2 cannot always suffice to perpetuate the respiratory cycles in those cases in which the Cheyne-Stokes RP is seen to disappear promptly with awakening. Brown and Plum (1961) noted cases in which RP was only present in sleep but considered their sleepy patients as "obtunded" and this to be a sign of the presence of a neurological lesion. The present study shows that in patients with no known neurological lesion the Cheyne-Stokes RP can persist or disappear according to the case, once diurnal somnolence has disappeared. Would those in whom it persists have been part of the normal population with RP in sleep if they had been recorded before they were ill (Bulow 1963) ? On the other hand, although in the present study the series of REM sleep periods was too limited to make it certain, the observed influence of REM sleep on the two types of RP underlines how closely the Pickwickian RP, with its characteristic obstructive apnoeas, is primarily linked to the hypnic loss of muscle tone (Schwartz and Escande 1967) whereas the Cheyne-Stokes RP is not. SUMMARY

Thirty-four adult patients with CheyneStokes respiration provided 47 routine EEG records and 25 polygraphic afternoon records. These records were analysed and compared with those of 18 Pickwickian patients previously studied. The main points of difference between these two groups of patients were: the CheyneStokes patients were older and their respiratory periodicity (RP) was not strictly sleep-linked; it could be observed in wakefulness as well as sleep (in that case opening and closing the eyes often did not interrupt the ongoing RP); it tended to disappear in REMS. The main points of resemblance were the frequent appearance of Cheyne-Stokes RP at sleep onset and the presence of occasional ineffective respiratory movements during the crescendo phase of RP in sleep.

B. A. SCHWARTZ AND M. F. EPRINCHARD RESUME RESPIRATION DE CHEYNE--STOKES ET SOMMEIL: ETUDE POLYGRAPHIQUE D1URNE

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