Apnea in the newborn

Prepared by Nasir Salaam

 Introduction
About 30-45% of preterm babies exhibit a periodic
breathing pattern characterized by 3
or more respiratory pauses of greater than 3 seconds
duration with less than 20 seconds
respiration between pauses. Periodic breathing is a
normal event, is usually not associated with any
physiological changes in the infant and does not merit
any treatment. Apnea is a
pathological cessation of breathing tha results in
physiological changes (decrease in central drive,
peripheral perfusion, cyanosis, bradycardia, hypotonia)
and merits treatment.
 Definition

Apnea is defined as cessation of respiration

for >20 sec or cessation of respiration of any
duration accompanied by bradycardia (HR
<100/min) and/or cyanosis.
 Incidence
Apne in preterms is usually related to
immaturity of the central nervous system and
is called Apnea of Prematurity (AOP). It may
be secondary to other causes and is common
manifestation of most neonatal diseses. AOP
is related inversely to gestational age with
25% of preterm below 34 weeks needing
either pharmacological or ventilatory for
repeated apnic episodes.
 Causes of Apnea

1. Apnea of prematurity

2. Secondary causes
 Apnea of prematurity
Apnea of prematurity is defined as cessation
of breathing by a premature infant that lasts
for more than 20 seconds and/or is
accompanied by hypoxia or bradycardia.

This may result from central nervous system

immaturity, or from the effects of medications or
illness.
 Pathophysiology of AOP

Ventilatory drive is primarily dependent on

response to increased levels of carbon dioxide
(CO2) and acid in the blood. A secondary
stimulus is hypoxia. Responses to these stimuli
are impaired in premature infants due to
immaturity of specialized regions of the brain
that sense these changes.
 Secondary causes
• Secondary causes of apnea include:
• 1_ Temperature problems: Hypothermia and
hyperthermia,
•
• 2_ Neurological: Birth trauma, drugs, intracranial
infections, intracranial hemorrhage, perinatal
asphyxia, anesthetic drugs.
•
• 3_Pulmonary: Respiratory distress syndrome (RDS),
pneumonia, chronic lung disease, pulmonary
hemorrhage, obstructive airway lesion,
pneumothorax.
 Continue.......
4_ Cardiac: Congenital cyanotic heart disease,
hypo/hypertension, congestive heart failure, patent ductus
arteriosus.

5_Gastro-intestinal: Gastro esophageal reflux, esophagitis.

6_ Hematological: Anemia, polycythemia.

7_ Infections: Sepsis, necrotizing enterocolitis

8_ Metabolic Hypoglycem a hypocalcemia, hyponatremia,
hypernatremia and.

9_Inborn errors of metabolism.

 Continue....

Apnea of prematurity is a diagnosis of

exclusion and should be considered only
after secondary causes of apnea have
been excluded. Common causes of
secondary apnea in lude sepsis,
pneumonia, asphyxia, temperature
instability and anemia.
 Types of Apnea

1. Central apnea(40%)

2. Obstructive apnea(10%)

3. Mixed apnea(50%)
 Central apnea

Both the inspiratory effort and

airflow cease simultaneously in
this type of apnea (Absence of chest
wall movement and airflow).
 Obstructive apnea

Obstructive apnea: (10%) This type is

characterized by absenc of airflow in the
presence of inspiratory efforts (Presence of
chest wall movement but no airflow).
 Mixed apnea

Mixed apnea: (50%) Central apnea is

either preceded or followed by airway
obstruction.
 Monitoring

Monitoring :All babies less than 34

weeks gestation should be monitored
for at least the first week of life or till
absence of apneic episodes for at least
7 days. Babies ≥34 weeks gestation
should be monitored if they are sick .
 Apnea monitoring

1. Movement sensors

2. Thoracic impedence
based monitor

3. Pulse oximeter
Movement sensors:

(Ripple type mattress) These monitors

interpret chest/ abdominal movements
as respiration. In general, these monitors
will fail to diagnose obstructive apnea
and may not distinguish body movements
from breathing.
Thoracic impedence based monitors:

These monitors translate changes in

thoracic impedence that occur with
breathing, as respiratory activity. These
monitors will also fail to diagnose
obstructive apnea
Puls oximeters:
These are commonly used for
monitoring of apnea. These monitors
detect changes in heart rate and/ or
saturation due to apneic episodes.
Facility for detecting chest wall
movement is absent in these monitor
 Continue......

Apnea monitors based on chest wall

movement are likely to miss obstructive
apnea.
Monitors with facilities for measuring
heart rate and oxygen saturation would be
useful in the monitorning of significant
apnea in preterm infants
 DDx
1 _Periodic breathing: It consists of breathing for
10-15 seconds, followed by apnea for
5-10 sec without change of heart rate or color. It
does not occur within the first 2 days of
life.
2_Subtle seizures: Apnea is an uncommon
presentation of a neonatal seizure. Sudden
alteration in muscl tone, twitching movements,
vacant stare and up rolling of eyes suggests a
seizure. Also tachycardia preceding/ accompanying
an apneic attack usually suggests seizures activity.
Evalvuation of child with apnea

1. Emergency treatment

2. Clinical examination

3. Investigation
 Emergency treatment
1. The neonate should be checked for bradycardia,
cyanosis and airway obstruction.

2_The neck should be positioned in slight extension.

3_oro-pharynx gently suctioned and tactile

stimulation should be given. Most apneic spells
respond to tactile stimulation.

4_Provide oxygen f patient is hypoxic (maintain

saturation 92-95%) by head box or nasal cannula
 Continue....
5_If the newborn continues to remain apneic and
does not respond to tactile stimulation,
ventilation with bag and mask (BMV) using 100%
oxygen hould be initiated.

6_If BMV fails to initiate spontaneous

respiration in the newborn, then the
infant should be managed with positive
pressure ventilation
 Clinical examination

1_After stabilization, the infant should be

evaluated for a possible underlying cause.

2_History Should be reviewed for possible

causes of secondary apnea including perinatal
asphyxia , maternal drugs, features of neonatal
sepsis and feeding intolerance.
 Continue.....

3_The infant should be examined for

temperature instability, hypotension, jaundice,
pallor, cardiac murmur and
poor perfusion.

4_Onset of apnea within the first 7 days in a

premature baby (gestation < 34
weeks) would be suggestive of apnea of
prematurity (AOP).
 Investigation
• Neonates with apnea should be investigated to
exclude common causes of secondary apnea
• investigations depending on the history and
physicalexamination.
• Investigations that should be considered include:

blood glucose, hematocrit, electrolytes,

septic screen, blood culture, arterial blood
gas, chest x-ray, abdominal x-ray,
ultrasound.
 Treatment

1. General measures

2. Specific measures
General measures:

• Maintain airway, breathing and circulation (ABC)

• Avoid vigorous suctioning of the oro-pharynx
• Avoid oral feeds for at least 24 hours.
• Decrease environmental temperature to lower
end of thermo-neutral range.,Avoid swings in
environmental temperature.
• Treatment of the underlying cause: sepsis, anemia,
polycythemia, hypoglycemia,
hypocalcemia, respiraory distress syndrome (RDS)

• Transfuse packed cells if hematocrit <30%.

• Specific measures :Specific measures
include:

• Drugs including aminophylline, caffeine,

doxapram

• Continuous positive airway pressure(CPAP).

•
• Mechanical ventilation.

• Kinesthetic stimulation: no role

 Pharmacotherapy

Aminophylline, caffeine and doxapram have been

used in the treatment of apnea.

• The indications for starting drugs are:

• First line of treatment for apnea of

prematurity
• .
• Post extubation to reduce the incidence of
apnea.
 Theophylline and Aminophylline
• The loading dose of Aminophylline is 5-7
mg/kg administered IV followed by a
maintenance dose of 1.5-2.0 mg/kg/dose Q6-
8H given IV or PO.
• For apnea of prematurity,
Aminophyline should be continued till 34 weeks
corrected gestational age and stopped there
after if no episodes of apnea have occurred in
the last 7 days.
• Adverse effects include
tachycardia, jitteriness, irritability,
feed intolerance, vomiting and
hyperglycemia.
The drug is available as:

Injection: Aminophylline ampoule 250 mg per

10-ml ampoule.
Oral: Theophylline 50 mg/5 ml in Theoped
syrup
 Caffeine
• Caffeine also belongs to the methylxanthine
group and is considered as an alternative to
aminophylline. It is associated with fewer side
effects than aminophylline.
• The loading dose is 10 mg/kg IV or PO (20-
mg/kg caffeine citrate) followed by a
maintenance dose of 2.5 mg/kg OD IV or PO,
24 hours after loading dose (5 mg/kg of
caffeine citrate).
 Doxapram
• Doxapram is associated with serious side
effects and hence should be used with
caution or preferably avoided.
• At present, indications for doxapram include a
failure to respond to both methylxanthine and
CPAP therapy.
• Doxapram infusion is started at 0.5 mg/kg/hour and
increased gradually to a maximum of
• 2-2.5 mg/kg/hr. Doxapram may be tried for a period of
48 hours before weaning the drug.
 Continue.....

• Adverse effects include seizures,

hypertension, hyperactivity, hyperglycemia
and abdominal distension.

• It should be avoided in the initial few days since

hypertensive episode may be associated with an
increase risk of intraventricular hemorrhage
(IVH).
 CPAP

Indications for using continuous positive

airway pressure (CPAP) in the treatment of
apnea include a failure to respond to
methylxanthine therapy.
 Continue....

Indications for starting CPAP in a neonate on

aminophylline therapy include :

(a)>1 episode of apnea pnea needing either

BMV or oxygen supplementation within 24
hours.

(b)>12 episodes in 24 hours (or >6 within in 12

hours) needing tactile stimulation.
 Continue.....

(c)>1 episode of apnea (spontaneous)

every hour for 12-24 hours.

CPAP may also be used to reduce post-

extubation apnea in preterm infants.
 Continue....

Continuous positive airway pressure (CPAP)

improves oxygenation, splints the upper irway
during respiration and prevents collapse of the
pharynx during expiration. Hence
CPAP is effective in the management of all types
of apnea.

• CPAP of 3-5cm H2O is usually used. CPAP

may be delivered by nasal prongs or
nasopharyngeal tube.
 Mechanical ventilation

• The infant should be ventilated if both

pharmacotherapy and CPAP have been tried
and significant apneas continue to occur.
 If the lungs are normal, the infant should
be ventilated :
1_at minimum pressures (peak inspiratory pressure
of 13-14 cm of water nd
positive end expiratory pressure of 4-5 cm of water),

2_, low rate (20-25 per minute)

3_ small time (0.35-0.40 seconds)
4_and low FiO2 (0.4-0.5)
This method is effective in all forms of
apnea.
 Kinesthetic stimulation

• Kinesthetic stimulation Water bed,

oscillating bed mattress. Present evidence
does not support any role for this mode of
therapy either in the prevention or
treatment of apnea.
 Persistent apnea

• Persistent apnea :Apneic episodes may persist

beyond 37-40 weeks in some infants,
especially those born before 28 weeks.

• Methylxanthine therapy should be continued if

apneic episode continue to occur beyond 34
weeks of corrected gestational age.
 Continue....

• The neonate should be

• re-evaluated for secondary causes of apnea
especially neurological problems and
gastro-esophageal reflux.

• These infants would require NICU care

until drugs can be weaned and stopped.
 SIDS and Apnea

Sudden Infant Death Syndrome (SIDS) and Apnea:

There is evidence to suggest that AOP is not an

independent risk factor for SIDS.

Only 2-4% of patients with SIDS have a history of

AOP.
THANKS