A 65-year-old comatose man with metastatic melanoma developed rapidly cycling breathing, with clusters of approximately 10 abdominal excursions within 3 seconds, interspersed by 10 seconds of apnea (video 1 and figure), mimicking abdominal myoclonus. Introduced by Plum and Posner1 as a respiratory pattern associated with lesions in the low pons or high medulla, cluster breathing can occur without pontomedullary lesions when respiratory alkalosis accompanies bihemispheric lesions.2 It differs from the constant tachypnea of central neurogenic hyperventilation, also associated with respiratory alkalosis, and from the crescendo-decrescendo breathing pattern of Cheyne-Stokes. Combined cerebellar and cerebral lesions may suffice to affect brainstem-mediated respiratory control in the absence of brainstem lesions.
Video 1
Cluster breathing. Rapid, rhythmic, and shallow breathing cycles were demonstrated after sedation was removed and ventilatory assistance placed in continuous positive airway pressure mode using a tracheostomy. Download Supplementary Video 1 via http://dx.doi.org/10.1212/011215_Video_1
Postcontrast sagittal and coronal T1-weighted brain MRI demonstrated nodular bihemispheric lesions as well as contrast-enhancing bilateral cerebellar lesions with no mass effect on the brainstem. Screenshots of the respiratory monitor at the bottom document the cluster-breathing waveforms in the mean airway pressure (Paw, in cm H2O) and volume (flow, in L/min).
Study Funding
No targeted funding reported.
Disclosure
R.M. Meza, H. Schulz, and D. Alva report no disclosures. A.J. Espay has received grant support from the NIH and the Michael J Fox Foundation; personal compensation as a consultant/scientific advisory board member for AbbVie, Neuroderm, Neurocrine, Amneal, Adamas, Acadia, Acorda, InTrance, Sunovion, Lundbeck, and USWorldMeds; publishing royalties from Lippincott Williams & Wilkins, Cambridge University Press, and Springer; and honoraria from USWorldMeds, Acadia, and Sunovion. Go to Neurology.org/N for full disclosures.
Appendix Authors
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Teaching slides links.lww.com/WNL/B277
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