Management of Apnea

Aims of Management

1. Maintain Adequate Oxygenation: The primary goal is to ensure the infant receives a sufficient supply of oxygen. This prevents hypoxemia, a dangerous condition of low blood oxygen, and its potential complications.

2. Support Respiratory Function: Providing support to the infant’s breathing mechanisms is crucial to maintain effective respiration and minimize or prevent further episodes of apnea.

3. Prevent Complications: A key objective is to reduce the risk of complications associated with Apnea of Prematurity (AOP), such as potential brain damage, developmental delays, and long-term respiratory difficulties.

Assessment

• Initially, observe the infant for visible signs of breathing and assess their skin color. If the infant is not breathing (apneic), appears pale, has cyanosis (bluish skin), or exhibits bradycardia (slow heart rate), provide tactile stimulation.

• Gather information about the frequency and duration of apneic episodes, the degree of hypoxia (low oxygen levels) experienced, and the intensity of stimulation required to prompt the infant to breathe.

  • Note: If the infant does not respond to tactile stimulation, immediate intervention is necessary. This includes using bag-and-mask ventilation to assist breathing, along with suctioning to clear the airway and ensuring the airway is open through proper positioning.

• For all infants born before 34 weeks of gestation (premature infants), continuous monitoring of heart rate, breathing patterns, and oxygen saturation levels is essential for at least the first week of life. This close monitoring continues until the infant has been free from any apneic pauses for a full week.

• Neonates born at or after 34 weeks gestation generally only require continuous monitoring if they exhibit signs of instability or respiratory distress.

Acute Management

• Positioning: Ensuring the neonate’s head and neck are in a neutral position is critical for maintaining an open and unobstructed airway. Avoid excessive flexion or extension of the neck.

• Tactile stimulation: For mild and infrequent episodes of apnea, gentle stimulation, such as lightly rubbing the soles of the feet or the chest wall, is often sufficient to stimulate breathing.

• Clear airway: Suctioning the mouth and nostrils removes any mucus or secretions that could be blocking the airway.

• Provision of positive pressure ventilation: If spontaneous breathing does not resume quickly, providing breaths using a bag and mask may be necessary. If positive pressure ventilation is frequently required to treat apneic episodes, mechanical ventilation should be considered for more sustained respiratory support.

• Continuous Positive Airway Pressure (CPAP): CPAP is an effective treatment option for both mixed and obstructive apnea, but it is generally not effective for central apnea. It is typically delivered through nasal prongs or an endotracheal tube. CPAP works by increasing the volume of air in the lungs and reducing the duration of each inhalation, which helps to prevent airway collapse. It also provides support and stability to the muscles of the chest wall.

Ongoing Management

• Pulse oximeter: Continuous monitoring with a pulse oximeter allows for the detection of changes in heart rate, respiratory rate, and oxygen saturation levels that may occur due to apneic episodes.

• Identify cause: If the apnea is not attributed to the normal physiological immaturity of prematurity, a thorough investigation is needed to identify and treat any underlying medical conditions contributing to the apnea.

• Apnea monitor: This device detects movement of the abdominal wall associated with breathing. However, it’s important to note that apnea monitors may trigger false alarms with normal periodic breathing patterns seen in infants.

• Caffeine citrate: Caffeine citrate can be administered either orally or intravenously and is commonly given routinely to neonates born before 34 weeks gestation. It acts as a smooth muscle relaxant, a stimulant for the heart muscle, and a stimulant for the central nervous system, which helps to regulate breathing.

• High flow nasal Cannula (HFNC): HFNC can be particularly effective for managing mixed and obstructive apneas. It is often used when treatment with caffeine alone is not sufficient.

• Mechanical ventilation: When other treatments like caffeine, HFNC, and CPAP have been tried and the infant continues to experience significant apneic episodes, mechanical ventilation may be necessary to provide full respiratory support. It is effective for all types of apnea.

Medical Management

• Methylxanthines: This class of medications is frequently used in the medical management of apnea. Examples include caffeine, theophylline, and theobromine. These drugs work by blocking adenosine receptors in the body. Adenosine is a naturally occurring substance that inhibits the drive to breathe. By blocking these receptors, methylxanthines stimulate respiratory neurons, thereby improving ventilation.

• Two commonly used methylxanthines are:

  • Caffeine Citrate: Due to its longer duration of action in the body (longer half-life) and lower risk of toxicity compared to other methylxanthines, caffeine citrate is often the preferred choice for the routine management of AOP, especially in premature infants.

    • Loading Dose: A starting dose of 20 mg per kilogram of body weight (20 mg/kg) is typically administered, either intravenously (IV) or orally (P.O.).

    • Maintenance Dose: A daily maintenance dose of 5 mg per kilogram of body weight per day (5 mg/kg/day) is usually given after the loading dose.

  • Theophylline: Theophylline also acts as a bronchodilator, which can be particularly beneficial for neonates who have bronchopulmonary dysplasia (BPD), a chronic lung condition common in premature infants. This dual action helps manage both apnea and airway constriction (bronchospasm).

    • Loading Dose: A starting dose of 6 mg per kilogram of body weight per dose (6 mg/kg/dose) is administered either intravenously (IV) or orally (P.O.).

    • Maintenance Dose: A daily maintenance dose of 6 mg per kilogram of body weight per day (6 mg/kg/day), divided into doses given every six hours, is usually prescribed.

Documentation and Family-Centered Care

• Documentation: Thorough documentation of all apnea episodes is essential. This should include the interventions that were required to resolve the episode, the frequency of episodes, and their duration.

• Parental Education:

  • Provide clear explanations to parents about the underlying cause of apnea in their infant and the rationale behind the chosen treatment approaches, such as the use of antibiotics for suspected infections.

  • Reassure parents that Apnea of Prematurity is a common condition in premature infants and typically resolves as the infant matures, usually by around 34 weeks gestation.

  • Offer clear and detailed explanations of all medical interventions being used, such as caffeine administration, Continuous Positive Airway Pressure (CPAP), or mechanical ventilation, and emphasize the importance of these interventions in managing their infant’s condition.