APNEA

Cessation of respiration for longer than 20 sec, or shorter duration

in presence of cyanosis or bradycardia(<100/min)
3 types
1. CENTRAL APNEA : Total cessation of inspiratory efforts with no
evidence of obstruction.
2. OBSTRUCTIVE APNEA : occurs when inspiratory efforts persist
in the presence of airway obstruction, usually at the
pharyngeal level
3. MIXED APNEA : occurs when airway obstruction with
inspiratory efforts precedes or follows central apnea
Etiology
1. Apnea of prematurity(AOP)
 Immaturity of the central nervous system
 Usually presents after 1-2 days of life and within the first 7 days
 AOP is a diagnosis of exclusion and should be considered only
after secondary causes of apnea have been excluded.
2. Secondary apnea
 Common causes : common causes -sepsis, pneumonia,
asphyxia, temperature instability and anemia
 Temperature instability, Neurological, Pulmonary, Cardiac, Gastro-intestinal,
Hematological, Infections , Metabolic, Inborn errors of metabolism

 Apnea in Term /Near term infants -Always abnormal and are

nearly always associated with serious, identifiable causes,

MONITORING AND EVALUATION

 All infants <35 weeks' gestational age should be monitored for apneic spells for at
least the first week
 Monitoring should be continue until no significant apneic episode has been
detected for at least 7 days
 Apnea monitor , HR, SPO2
Differential diagnosis
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.
 2. Subtle seizures: tachycardia preceding/ accompanying an
apneic attack usually suggests seizure activity.
Evaluation of a child with apnea
Emergency treatment
 Checked for Bradycardia, Cyanosis and Airway obstruction
 neck should be positioned in slight extension;
 Oro-pharynx gently suctioned, (if required , secretions,
obstruct)
 Tactile stimulation
 maintain saturation between 90-93%
 Not respond to tactile stimulation , should be ventilate with
bag and mask using 100% oxygen
 All NBNs with apneic spell evaluate for underlying cause , if
identified give specific treatment
 Evaluation should include a history and physical examination and may include
ABG , CBC , RBS, Ca , SE investigated to exclude common causes of secondary
apnea.

Evaluation of an Infant with Apnea

Potential Associated History or Evaluation
Cause Signs
Infection Feeding intolerance, Complete blood count,
lethargy, cultures
temperature instability
Impaired Desaturation, tachypnea, Continuous SPO2
oxygenation respiratory distress monitoring,
ABG measurement,
chest x-ray examination
Metabolic Jitteriness, poor feeding, Glucose, calcium,
disorders lethargy, CNS depression, electrolytes
irritability

Drugs CNS depression, Magnesium; screen for

 hypotonia, toxic substances in urine
maternal history
Temperatur Lethargy Monitor temperature of
e patient and environment
instability

Intracranial Abnormal neurologic Cranial USG examination

pathology examination, seizures

 Treatment
General measures:
 Maintain airway, breathing and circulation
 Avoid vigorous suctioning of oro-pharynx
 Avoid oral feeds in case of repeated episodes of apnea
requiring BMV.
 Decrease environmental temperature to lower end of thermo-
neutral range.
 Avoidswings in environmental temperature.
 Avoid Positions of extreme flexion or extension of the neck
 Treatment of the underlying cause: sepsis, anemia,
polycythemia, hypoglycemia,hypocalcemia, respiratory
distress syndrome (RDS).
 Transfuse packed cells if hematocrit <30%.

Specific measures for AOP

• Drugs including aminophylline, caffeine, doxapram
• Continuous positive airway pressure (CPAP)
• Mechanical ventilation
• Kinesthetic stimulation

 Caffiene :
o loading dose of 20 mg/kg of caffeine citrate (10 mg/kg caffeine base)
orally or intravenously >30 minutes,
o followed by maintenance doses of 5 to 10 mg/kg in one daily dose
beginning 24 hours after the loading dose.
 o An additional dose of 10 mg/kg caffeine citrate and increase the
maintenance dose by 20%.may given if apnea continues with above
maintenance dose
o Discontinued at 33 to 34 weeks' PMA if no apneic spells have occurred for
5 to 7 days
o AMINOPHYLLIN
o loading dose:m intravenous aminophylline is 5 to 6 mg/kg
o followed by 1.5 to 3 mg/kg every 8 to 12 hours. Oral theosphylline can be
administered once the infant becomes stable in the same dose
 Nasal continuous positive airway pressure (CPAP): at moderate levels (4 to 6
cm H2O) can reduce the number of mixed and obstructive apneic spells.
 Discharge
Preterm infants have no apnea spells recorded for 5 to 7 days prior to discharge

Transient Tachypnea of the Newborn

 Characterized by tachypnea with signs of mild respiratory distress
including retractions and cyanosis; decreased oxygen saturation is
usually alleviated by supplemental oxygen with FiO2 <0.04.
 benign and self-limited, symptoms resolve in 12 to 72 hours.
 Incidence : 0.3% to 0.6% of term deliveries and 1% of preterm deliveries.
 Risk factors : cesarean delivery with or without labor, precipitous birth, and
preterm birth.
  Clinical features
o usually present within the first 6 hours after birth
o with tachypnea; respiratory rates are typically 60 to 120 breaths per
minute.
o The tachypnea may be associated with mild to moderate respiratory distress
with retractions, grunting, nasal flaring, and/or mild cyanosis that
o usually responds to supplemental oxygen at <0.40 FiO2.
o increased anteroposterior diameter of the chest (barrelshaped) due to
hyperinflation, which may also push down the liver and spleen, making
them palpable.
o Auscultation : good air entry, and crackles may or may not
o Signs of TTN usually persist for 12 to 24 hours in cases of mild disease but
can last up to 72 hours in more severe cases.

Meconium Aspiration