Cheyene Stokes - Dying pt

[NurseyPoo7]

I was always under the assumption a pt with cheyene stokes is considered to be entering the last phases of dying. I had a pt today who had a "large" brainstem hemorrhage, expected to pass. This is on a med surg/CVA floor. He was a DNR/comfort care, and after he was made comfort care, he was transferred from ICU to my unit.

He had labored breathing this morning along with the "death rattle", lungs sounded very very congested. I suctioned him as best I could, but didnt get much up - wife also requested we keep him as comfortable as possible , so I didnt want to harass him with suction too much.

Towards the end of my shift, he had cheyne stokes resp. Also on a morphine drip - could the morphine be causing this or is it death taking over?

I couldnt tell if he was mottling really b/c he has severe PVD and his legs are very dark anyway.

How long before death do you see cheyene stokes? My charge today said she had a pt who had cheyene stokes for 13 days before he passed! I never thought it would be that long

[CoffeeRTC, BSN, RN]

Personal experience with this one. My dad went almost 2 days taking 1-3 breaths per minute. Mom and I (both nurses) knew what this meant and we were very okay with managing his pain levesl with the morphine. Stubborn man was waiting for my sister to come up from Tx.

Yes...it happens.

[Pedi-Gree, BSN, RN]

I think maybe we need some definitions here.

Kussmaul respirations have a regular rate and rhythm with a large tidal volume and pauses at end-inspiration and end-expiration. This pattern is seen most often in diabetic ketoacidosis and results in blowing off carbon dioxide to try to neutralize the acidosis.

Cheyne-Stokes respirations are regularly irregular. They follow a pattern of waxing and waning, that is to say that they start out very shallow and quickly become deeper and deeper, then begin to become shallower and shallower again, followed by a pause. Then the pattern starts again. Some references liken this to periodic breathing, but the oscillatory pattern is absent in periodic breathing, which is often seen in infants whose nervous systems are immature. This pattern is more one of irregular pauses in breathing with a normal rate and rhythm in between.

Central neurogenic hyperventilation is brainstem mediated and has no relation to oxygenation or gas exchange from a regulatory sense. The rate and rhythm are regular but very rapid and shallow, almost like panting.

Biot's respirations are also called cluster breathing. They're characterized by a cluster of rapid, shallow breaths followed by a variable period of apnea.

Apneustic respirations are irregular, gasping and include a full pause at end-inspiration.

Ataxic respirations are very irregular in rate, rhythm and volume, with irrgeular pauses and progressively longer periods of apnea. They often progress to agonal respirations: irregular and very infrequent breaths often seen just before death.

Most of these respiratory patterns can be related to brain injuries from taruma, stroke or some other mechanism and are often associated with other signs and symptoms of brain injury such as loss of airway protective reflexes. But some of these patterns may be related to metabolic conditions, which when treated, resolve.

This should eliminate some of the confusion.