Apnea

Definition: Apnea is cessation of airflow.

Apnea is pathologic ( Apneic spell) :
when absent air flow is prolonged (20 second or more)
or accompanied by bradycardia( heart rate less than 100 beats)
or central cyanosis.
Bradycardia and and cyanosis occure more rapidly in premature baby. After
30 – 45 second  pallor and hypotenia and infant unrespensive to tactile
stimulation.

Classification:
Central apnea: occure when resp. efford are absent.
Obstructive apnea: Airway obstruction, Insp. efford are present.
Mixed apnea: airway obstruction with insp. Efford preceed or follow central
apnea.

Incidence:
25 % of Neonates ≤ 34 weeks gestation age have at least 1apneic spell,
and almost all 28 weeks have apnea.

Onset: 25% of 1 – 2 days after birth, if does not occure after 7 days of
Age unlikely to occure.

Duration: Usually stopped by 37 week gestation ,

But in premature baby less than 28 weeks Apnea may persist
beyond term ,
Up to gestation 43 weeks in 20 %,of these prematuate babies.

N.B.: Apneic spell in term infant always abnormal or associated with

 Birth asplyxia, IC Hge, seizure, sepsis, electrolyte disturbance, maternal
medication as magnesium.

Evaluation of infant with apnea:

1.sepsis evaluation.
2.Electrolyte disturbance: glucose,calcium,electrolytes.
3.CNS depression: Maternal medication or drug addict(urine toxic screening)
4.Temprature instability
5.Intracranial pathology: cranial ultrasound
6. Impaired Oxygenation: tachypnea,Res.distress,chest infection.

Pathogenesis:
1. Developmental immaturity of central respiratory drive
2. Hypoxia make premature babies less responsive to increase level of CO2
3. Active reflexes involve by stimulation of post-pharynex (vigorous
suction) or fluid in phaynx (during feeding).
4. Gastro esophageal reflux : However not yet proven
5. Airway obstruction: obstructive or mixed apnea esp. upper pharynx esp.
in REM sleep or with position of neck flexion.
Also nasal obstruction esp. premature baby who cannot switch to oral
breathing after nasal obstruction.

N.B.: 1.All infant less than 35 weeks should be monitor to apneic spell
At least in the 1st week.
2. Heart rate as monitor for apnea cannot diff. bet resp. efford
During airway obstruction from normal breath.

N.B.: Most apneic spells respond to tactile stimulation, If not → bag and
mask ventilation with FiO2 40% or less.
Measure blood glucose ,Ca and electrolyte level + complete blood picture
for sepsis.
Treatment:
a) General measures:
i. Avoid reflexes that may trigger apnea as vigorous suction and stop
oral feeding.
ii. Position : extreme flexion or extension should be avoided.
iii. Decrease environmental Temp. To lower end of normal, may decrease
apneic spells.
iv. Blood transfusion may decreased apneic spells
esp. if Hct less than 25 %.
b) Nasal CPAP at 4 – 6 cm H2O may decreased apnea esp. obstructive or
mixed.

c) Methylxanthine therapy:
Mechanism:
i. Resp. center stimulation
ii. Improvement of diaphragmatic contraction
iii. Antagonized adenosine (neuro transmitter) that can cause resp.
depression.

I. Theophylline:
Caffeine is more safe, less toxic, well tolerated.
Loading: 4-6 mg/Kg dose over 20-30 minute
Maintenance:1-2 mg/kg/dose every 8 hours
Adverse Effects:peak serum level ≤ 20mcg/ml
Tachycardia,irritability,seizure,diarrhea,vommitig,tremor,diureses .
Serum level ≥30mcg/ml:Acute myocardial infarction,Siezure(resist to
anticonvulsants),Urinart retention.
II. Caffein Citrate:
Loading 20 mg. / kg of caffeine citrate (10 mg. /Kg of caffeine base) orally
or I.V over 30 minute.
Followed by maintenance dose of 5 – 8 mg. / kg of caffein citrate (2.5 – 5
mg/Kg caffeine base). If apnea continue → give addition dose
of 10 mg. / kg of caffeine citrate and increased maintenance by 20 %.

N.B,
Caffein serum level of 5 – 20 µg. / ml. considered therapeutic.
Discontinue at 34 – 36 weeks gestation age, if no apnea for 5 – 7 days.

N.B.:
Effect of caffeine persist for 1 week after stop of caffeine.

Persistent apnea: esp. in Premture babies less than 28

weeks that may persist at40- 43 weeks gestation:
a) Pneumogram and continuous ECG for 12 or 24 hours to detect apnea
or bradycardia.(but didn’t predict risk for SIDS)
b) Continue use of caffeine and attempt to withdraw over 2 months with
close observation.
Strategies to prevent SIDS:
Sleeping position: prone position increased SIDS
No smoking
No overheating
Encourage breast feeding.