| ID | 356 |
|---|---|
| Name | APNOEA IN THE NEWBORN |
| Cause | Apnoea of prematurity: The most common cause of apnoea, attributable to the immaturity of the respiratory centre in the brain. Onset is from day 1-7 of life. Apnoea beginning immediately after birth suggests another cause. Term or near term babies may rarely experience apnoea of prematurity but a pathological cause should be sought before making this diagnosis in this group. Airway obstruction: Assess position of head and neck to ensure neutral alignment. Cardiovascular: Anaemia, hypotension, hypertension, patent ductus arteriosus, cardiac failure, hypovolaemia. Central nervous system: Intraventricular haemorrhage, seizures, hypoxic injury, neuromuscular disorders, brainstem infarction or anomalies, birth trauma, congenital malformations. Drugs: Maternal drugs (consider neonatal abstinence syndrome), opiates, prostin, high levels of phenobarbitone, chloral hydrate or other sedatives, general anaesthetic. Gastrointestinal: Oral feeding, bowel movement, oesophagitis, intestinal perforation, gastro oesophageal reflux, abdominal distension. Infections: Sepsis, necrotising enterocolitis, meningitis. Metabolic: Hypoglycaemia, hypocalcaemia, hyponatraemia, hypernatremia, hyperammonaemia, low organic acids, high ambient temperature, hypothermia, hyperthermia. Pain: Acute and chronic. Respiratory: Pneumonia, intrinsic / extrinsic mass or lesions causing airway obstruction, upper airway collapse, atelectasis, phrenic nerve paralysis, respiratory distress syndrome, pneumothorax, hypoxia, malformations of chest, pulmonary haemorrhage, aspiration |
| Signs Symptoms | The primary symptom of sleep apnea in infants and newborns is a pause in breathing that lasts for at least 20 seconds during sleep which may be observed by a caregiver. Although infants with less severe sleep apnea may have few or no visible symptoms, caregivers may notice one or several signs of apnea |
| Diagnosis | Diagnostic approach to apnoeic patient: A. A good history & physical examination- 1. Gestational age 2. Maternal drugs 3. Maternal bleedings 4. Risk factors for infection (sepsis) 5. Foetal asphyxia 6. Evidence of Cardiorespiratory disease. 7. Temperature (patient & environment) 8. Association of apnoea with feedings, stooling, suctioning. B. Laboratory workup- minimal- 1. Hematocrit values. 2. Radiological screening (viz. chest) 3. Blood glucose, calcium, sodium. 4. Arterial PH, PCO2 , PO2 5. Blood culture 6. Spinal tap. 7. Urine culture C. Laboratory workup- more extensive- 1. Urine for metabolic screening (amino acids, organic acids). 2. Serum ammonia level. 4. EEG 5. CAT scan of head. |
| Investigations | |
| Management | The first step in the management of apnoea is to determine the underlying cause. The above approach might be a key to reach an acurate diagnosis of the problem. 1. Treatment of underlying cause-Such as, Sepsis, Hyaline membrane disease, Hypoglycemia, Hypocalcemia, PDA, Seizure etc. 2. Temperature control-By using room heater or incubator, if available temperature should be maintained in between 85-900F. 3. Maintain pO2 slightly high (70-80mm Hg)- by O2 inhalation or incubator, if available. 4. Maintain hematocrit greater than 40%- Some infants have apnoea if their hematocrit is less than 40%. Transfusion to a hematocrit greater than 40% may be therapeutic, particularly if the infant requires supplemental oxygen, has a very low birth wt. or has a PDA. 5. Frequent stimulation-Cutaneous stimulation on the sole has been found to be very effective to recover from apnoea. 6. Avoid triggering reflexes- - Suction catheters - Tube feed instead of nipple - Avoid hyperinflation during bagging - Avoid cold stimulus to face. All these may lead to development of apnoea. 7. Nasal Continuous Positive Airway Pressure (CPAP)- this has been shown to be very effective in the treatment of apnoea. 8. Theophylline & caffeine (methylxanthines): theophylline & caffeine are found effective on treating apnoea of prematurity. The most significant effect of these are to increase the sensitivity of the respiratory centre to CO2. The recommended dose- Theophyhlline, a loading dose of 5mg/kg & maintenance dose of l-2mg/kg i.v every 6-12 hours; or, 5mg/kg/day orally in 2 or 3 divided doses. Caffeine, a loading dose of 20mg/kg & maintenance dose of 5-10mg/kg every 24 hours. Doxapram Img/kg/h by i.v infusion for 48 hours is found effective in some cases of methylxanthine-refractory apnoea. 9. Bag & mask ventilation: Whenever an infant is at high risk for apnoea, a resuscitation bag should be at the side of the incubator or radiant warmer. It is important that this bag can be connected to an oxygen line equipped with an O2 blender that provides approx. the same pO2 the infant usually receives. 10. Mechanical ventilation. |
| Introduction | Apnoea is defined as the cessation of breathing for greater than 20 seconds or the cessation of breathing with a concomitant decrease in heart rate &/or the presence of cyanosis. (Approx. 25% of all infants <1800gms & 80% of all infants <1000gms experience apnoea when monitored using conventional methods) |
| History | |
| Etiology | Etiology: A. Temperature instability - 1. Infant- increased or decreased temperature. 2. Environment- increased or decreased temperature. B. Sepsis- Apnoea in the first 24 hours of life should always be considered secondary to sepsis until proved otherwise. One of the most common presentations of group B streptococcal sepsis. C. Metabolic- 1. Hypocalcemia. 2. Hypoglycemia. 3. Hyponatremia/Hypernatremia 4. Other (inborn errors of metabolism). D. Cardiorespiratory - 1. Hypoxia 2. Acidosis 3. Hypotension 4. Severe anemia. 5. Upper airway obstruction 6. Pneumonia 7. Respiratory distress syndrome (RDS) 8. Patent ductus arteriosus. 9. Pulmonary hemorrhage. E. CNS - 1. Congenital malformation. 2 Seizures. 3. Asphyxia. 4. Intracranial hemorrhage. 5. Meningitis. 6. Congenital infections (TORCH). 7. Drugs (maternal narcotics, analgesics etc.) F. G.I system - 1. Necrotizing enterocolitis (NEC). G Apnea of prematurity. (Diagnosis by exclusion of above causes). Note: It is important to remember that any infant who experiences apnoea for the first time, or who has apnoea in the first 24 hours of life should always be considered to have a pathologic disorder, never ‘physiologic’ apnoea of prematurity. Although apnoea may be a consequence of an infants immature physiology; it is never a benign disorder. A complete diagnostic evaluation for underlying problems is required. Therefore, a systematic approach to the management of the apnoeic infant is essential. |
| Clinical Features | Reffer under ig |
| Preventions | Consider prone positioning as this can stabilise the chest wall, potentially reducing the frequency of apnoea |
| Treatment | Treatment is with respiratory stimulants for central apnea and head positioning for obstructive apnea. Prognosis is excellent; apnea resolves in most premature neonates by 37 weeks postmenstrual age and in almost all premature infants by 44 weeks postmenstrual age |
| Complications | |
| Prognosis | |
| Types | Central apnoea:(40%) Caused by decreased central nervous system stimuli to respiratory muscles. Both the respiratory effort and airflow cease simultaneously (absence of chest wall movement and airflow). Obstructive apnoea:(10%) Caused by pharyngeal instability / collapse, neck flexion or nasal obstruction. Absence of airflow in presence of inspiratory efforts (There is presence of chest wall movement but no airflow). Mixed apnoea:(50%) Has a mixed aetiology. Central apnoea is either preceded (usually) or followed by obstructed respiratory effort. |
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| Observation | |
| Pathology |
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