Sleep Fragments

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Waxing and Waning Breathing

Contributed by John Kimoff, MD

What nocturnal symptom is likely in this patient?

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Paroxysmal nocturnal dyspnea. The first tracing shows characteristic central sleep apnea – Cheyne-Stokes respiration (CSA-CSR) with waxing and waning ventilatory effort and airflow and a symmetric pattern of oxygen desaturation-resaturation. Microarousals typically occur during the incremental hyperpnea phase of the CSA-CSR cycle. In some cases, a full awakening may occur, such that the patient arouses at the peak of ventilatory drive and therefore experiences dyspnea, as was the case with the awakening shown on the second slide. Paroxysmal nocturnal dyspnea in a patient with congestive heart failure is an important clinical clue suggesting the presence of CSA-CSR.


  1. Bradley TD & Floras JS. Sleep apnea and heart failure: Part II: central sleep apnea. Circulation 2003; 107:1822-6
  2. Javaheri, S. Central sleep apnea in congestive heart failure: prevalence, mechanisms, impact, and therapeutic options. Semin Crit Care Med 2005; 26(1):44-55.
  3. BradleyTD, Logan AG, Kimoff RJ, Series F, et al Continuous positive airway pressure for central sleep apnea and heart failure. NEJM 2005; 353:2025-33.
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