APNEA OF PREMATURITY MEDICAL CARE
Category: Child Health
Abstract : apnea of prematurity - Medical Care: • Stimulation o Tactile stimulation usually is sufficient to terminate an apneic event. o Gently elevate the infant's jaw if the upper airway is obstructed. • Oxygen administration o Supplemental oxygen administration or bag-mask ventilation is indicated for infants with signs of bradycardia or desaturation. o Medical treatment is indi
apnea of prematurity - Medical Care:
• Stimulation
o Tactile stimulation usually is sufficient to terminate an apneic event.
o Gently elevate the infant's jaw if the upper airway is obstructed.
• Oxygen administration o Supplemental oxygen administration or bag-mask ventilation is indicated for infants with signs of bradycardia or desaturation.
o Medical treatment is indicated when apneic episodes number 6-10 or more per day or when the infant does not respond to tactile stimulation or requires bag-mask ventilation.
• CPAP use
o CPAP has been used to treat apnea in preterm neonates, and it is indicated when the infant continues to have apneic episodes despite a therapeutic methylxanthine serum level.
o CPAP is delivered with nasal prongs, a nasal mask, or a face mask with 3-6 cm of water pressure.
o CPAP is used to effectively treat mixed and obstructive apnea, but it has little or no effect on central apnea. This limitation suggests that CPAP may reduce the frequency of apnea by means of several mechanisms, including stabilization of PaO2 by increasing the functional residual capacity (FRC), by altering the influence of stretch receptors on respiratory timing, or by splinting the upper airway in an open position.
apnea of prematurity - MEDICATION
Methylxanthine administration may help reduce the incidence of events in a child with central apnea, although apnea in 15-20% of children does not respond to methylxanthines. Home monitoring after discharge always is necessary for an infant whose apneic episodes continue despite methylxanthine administration. Infants undergoing methylxanthine therapy should rarely be sent home without a monitor because apnea may recur once they outgrow their therapeutic level. Some families, however, cannot manage a monitor in the home, and, in these cases, caffeine administration may be the only possible therapy. For more about follow-up care, see Follow-up Care. Doxapram use should be reserved for infants in whom appropriate methylxanthine therapy and CPAP fail to control severe apneic events.
Drug Category: Methylxanthines -- These appear to stimulate skeletal and diaphragmatic muscle contraction, increase the ventilatory center's sensitivity to carbon dioxide, and stimulate the central respiratory drive.
apnea of prematurity - Further Inpatient Care:
• Most neonatologists agree that babies should be apnea-free for 2-10 days before discharge. The minimum length of this apnea-free period has been subject to debate among clinicians. Darnall et al concluded that otherwise healthy preterm neonates continue to have periods of apnea separated by as many as 8 days before the last one before discharge. Infants with longer apnea intervals often have risk factors other than AOP.
• Home monitoring after discharge is necessary for an infant whose apneic episodes continue despite methylxanthine administration. Infants undergoing methylxanthine therapy rarely are sent home without a monitor because apnea may recur once they outgrow their therapeutic level. Without a monitor, caregivers may not know when apnea reappears.
• Some families, however, cannot manage a monitor in the home, and, in these cases, caffeine administration may be the only possible therapy. Seriously consider frequent follow-up for such infants, and readmit them for further study when blood levels approach the subtherapeutic range.
apnea of prematurity - Further Outpatient Care:
• Home monitors
o Among the several types of monitors now available for home use in the United States, the most common combines impedance pneumography with assessment of the average heart rate to provide cardiorespiratory monitoring. The most significant drawback of impedance monitors is their inability to detect obstructive apnea.
o Standard home monitors detect respiratory signals and heart rates. Electrodes are placed directly on the infant's chest or inside an adjustable belt secured around his or her chest
o Recently developed units store records of events, which help the physician to evaluate home events. These devices also provide a record of compliance to show monitor use. The event recorder has a computer chip that continuously records respiratory and cardiac signals. Normal signals are erased, but any event that violates preset alarm parameters activates the monitor to save records of that event, as well as records of activities 15-75 seconds before and 15-75 seconds after the event. Additional channels are available to record pulse oximetry, nasal airflow, and body position (eg, prone, supine) findings. The monitor records are downloaded within 24 hours after a parent's report of an event or after excessive alarms.
o Many units now have computer modems that instantly transmit data to the physician's office for evaluation. These easily installed devices are especially useful for families who have had problems with events or alarms.
o Some devices, such as pulse oximeters, piezo belts, and pressure capsules, have been impractical to use or have had limited applications. Newer technologies and software programs, however, may soon make oximeters and similar devices more practical.
o All monitoring devices are associated with false alarms, which occur when no true cardiorespiratory event has occurred. False alarms worry parents and, if they occur often, may discourage monitor use. Excessive false alarms usually can be minimized by alternative electrode placement and parental education.Image 4 illustrates an approach to apnea monitoring in the premature neonate. Monitoring depends on the frequency of observed events during hospitalization of the premature neonate, the size and stability of the infant at the time of discharge, and the degree of parental anxiety.
o Careful follow-up is needed with all home monitoring of premature neonates. Physicians who have limited experience with home monitoring or who cannot interpret downloaded monitor recordings should seek assistance from a center or program with expertise in these areas.
o Parents of infants with home monitors must have a clearly designated person to contact on a regular basis and during emergencies. Many programs or centers provide 24-hour assistance for families of children with home monitors.
o The mean duration of home monitoring for premature neonates usually is less than 6 weeks. Reserve extended monitoring for infants whose recordings show significant cardiorespiratory abnormalities. Only in the rarest of circumstances should any child be monitored beyond age 1 year. Most often, children who require monitoring in such circumstances have other conditions that require additional technology, such as bronchopulmonary dysplasia with home mechanical ventilation.
o For infants who require methylxanthine, stop drug therapy after 8 weeks without true events, but continue monitoring for 4 additional weeks. If no events are noted in that period, monitoring can be discontinued.
• Indications for home monitoring
o Historical evidence of significant apnea or an apparent life-threatening event (ALTE)
o Documentation of apnea on recording monitor or multichannel evaluation
o GER with apnea
o Sibling or twin of patient who died from sudden infant death syndrome (SIDS) or other postneonatal cause of death
�� The National Institutes of Health (NIH) consensus conference recommends monitoring the siblings of infants with SIDS only after 2 SIDS-related deaths have occurred in a family. Siblings of patients who died from SIDS routinely are monitored until 1 month past the sibling's age at death.
�� Monitoring to prevent SIDS in infants older than 1 year is not indicated, although proponents believe such monitoring reduces anxiety in parents of high-risk infants. Opponents of monitoring cite a lack of evidence that monitoring reduces the SIDS rate and argue that monitors are an intrusion into family life that is poorly tolerated by the family.
apnea of prematurity - Complications:
• Infants born prematurely have increased risk for apnea and bradycardia after general anesthesia (or ketamine administration for sedation), regardless of their history of apnea.
• Because of this increased risk, defer elective surgery, if possible, until the infant's respiratory control mechanism is more mature (ie, approximately 52-60 weeks after conception).
apnea of prematurity - Prognosis:
• The natural history of apnea in infants born prematurely shows a gradual decrease in the frequency of all types of apnea during the first month of postnatal life.
• In some infants, however, apnea may persist until they are aged 42 weeks after conception.
apnea of prematurity - Patient Education:
• Family members and others involved in the care of an infant with AOP should be well trained in cardiopulmonary resuscitation (CPR).
• Many of the pitfalls of home monitoring can be avoided by providing 24-hour telephone access (ideal level of service) to a designated physician or nurse who is involved in the infant's care. In addition to this access, families should have frequent, regularly scheduled telephone calls from health care providers and home visits by a nurse or respiratory technician or follow-up appointments at a clinic.
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