M.

Noori-Shadkam, MDMPH
Neonatologist

Cessation of airflow for at least

20 seconds or accompanied by
bradycardia or cyanosis.
Bradycardia and cyanosis are
usually present after 20 sec. of
apnea. After 30 to 45 sec., pallor
and hypotonia are seen, and
infant may be unresponsive to
tactile stimulation.

Apnea is Associated with

Many Clinical Conditions:
Intraventricular bleed
May see hypoventilation, apnea or respiratory
arrest
Subtle seizures

Along with fluttering eyelids, drooling or sucking,

tonic posturing
Sepsis

V Vickers 2006

Bacterial (GBS, staph. Proteus, Listeria,

Coliforms
Viral (RSV, paraflu, herpes, CMV
Chlamydial
NEC

 Congestive Heart Failure

PDA and CHD

Due to decreased lung compliance
Respiratory muscle fatigue
Chest wall distortion
Hypoxemia

Respiratory Distress Syndrome

Due to atelectasis, work of breathing, fatigue

May lead to chronic lung disease

Anemia

oxygen carrying capacity of blood

Arterial pressure perfusing CNS

Polycythemia

V Vickers 2006

blood viscosity and blood flow to CNS

begins at 2-4 hours of age

 High temperature of environment

Feeding problems

overdistention of stomach
aspiration
GER (gastroesphogeal reflux) with or without
aspirations
due to laryngospasm
stimulation of irritant receptors in lower esophagus
causing reflux apnea
some reflux is common (laundry issue only?)

Metabolic conditions

Hypoglycemia
Hypocalcemia
Hypernatremia
Alkalosis

Others

V Vickers 2006

Myelomeningocele
Meningitis

Causes
CNS:
(Abnormality,Encephalitis,Meningitidis,ICH,
)
Upper & lower Air way:
(choanal A.,congestion, RDS,pneumonia,)
Cardiovascular:
(Malformation,hypotention,hypertention,)
Digestive system:(GER,NEC,Distention,)
Other:
(Sepsis,Anemia,Hypothermia,Hyperthermia
,pain,metabolic disorder,)

 Recurrent sequences of
pauses in respiration
lasting for 5-10
seconds and followed
by 10-15 seconds of
rapid respiration.

 As many as 25% of all

preterm infants who
weigh <1800 g (34
Week) have at least one
apneic episode.
Essentially all infants
<28 Week have apnea.

PREMATURITY
Impaired
Inhibitory
Oxygenation
Reflexes
APNEA
Infection
pathology

CNS
Metabolic disorders
Specific causes of apnea

Preterm infants respond

to a fall in inspired
oxygen with a transient
hyperventilation followed
by hypoventilation and
sometimes apnea.

The Respiratory
Pump
The neonatal
diaphragm
The ribcage and
chest wall muscles

The Neonatal
Diaphragm

In the relaxed state

is located higher in
the
Thorax
Inc. insp. pressure

The Neonatal
Diaphragm
Muscle fibers
Type I: fast-oxidative, 20%
fatigue resistant
Type IIa: fast-oxidative,
fatigue sensitive
Type IIb: slow oxidative,
fatigue resistant

The Neonatal
Diaphragm

Is attached to a more pliable

chest wall
Distortion
Dec. tidal volume

The Newborn is
Predisposed to Fatigue of
Resp.
The reduced
number
of fatigue
Muscles
Because
of:

resistant fibers in the diaphragm

A pliable chest wall
The rapid RR, which minimizes
relaxation time for perfusion of
the diaphragm
The work of breathing associated
with CL and CW

Consequences of
Apnea
Gas
exchange is
compromised due to:
PA CO2, PAO2
Extrapulmonary
shunting
Muscle relaxation

Types of Neonatal
Apnea
1.Central
(diaphragmatic)
2.Peripheral
(obstructive)
3.Mixed

 All preterm infants below 35

WG must be monitored for
at least the first week after
birth. Monitoring should
continue until no significant
apneic episode has been
detected for at least 5 days.

 Because impedance apnea

monitors may not
distinguish respiratory
efforts during airway
obstruction from normal
breaths, heart rate should
be monitored in addition to,
or instead of, respiration.

 BP should be measured
frequently and
hypotension with
oliguria< 2 mL/kg/h
should be treated
accordingly
Hct should be> 45% ???

1.Prevent hyperflexion of the neck

2.Nurse the baby in prone position
3.Set the thermal environment to
obtain a central temperature of
36.5-37 C
4.Minimize the duration and rate
of pharyngeal suction
contd

5. Place the orogastric tube

carefully
6. Avoid sudden gastric distension
7. Continuous gastric feeding if
apnea occurs with gavage
8. Warm air and oxygen to
incubator temperature

Nursing
Management
1.
Check
infant
at
once
During Apneic
2.Cancel alarm
Episode
3.Stimulate if there is
no obvious vomit
4.Suction

contd

Nursing
Management
5. Give O2 via face mask in
During
Apneic
same concentration as infant
had
been
receiving
Episode
6. Summon help if infant does
not respond
7. Document and report
8. Intubation if indicated

Management of
Idiopathic Apnea

When apneic spells are

repeated and prolonged,
(i.e., more than 2 to 3
times/h.) or when they
require frequent bag and
mask ventilation, treatment
should be initiated.
contd

Management of
Idiopathic Apnea

Diagnosis and treatment of specific

causes
Nursing care
Nasal CPAP (4-6 cm H2O)
Methylxanthine therapy
Increased environmental O2 only as
necessary to maintain adequate baseline
O2 saturation. Often associated with
treatment of anemia
Assisted ventilation if all else fails

Management of
Idiopathic Apnea

A.General measures
1. Diagnosis and treatment of
specific causes
2. SO2 : 85-95%
3. Avoid reflexes that may trigger
apnea. Suctioning of the pharynx
should be done carefully, and oral
feeding should be avoided.
contd

Management of
Idiopathic Apnea

4. Position of extreme flexion

or extension of the neck
should be avoided, to reduce
the likelihood of airway
obstruction.
5. Avoid swings in
environmental temperature.
contd

Management of
Idiopathic Apnea

6. Consider a transfusions of
PRBCs if the Hct is <25% and the
infant has episodes of apnea and
bradycardia that are frequent or
severe while methylxanthine
levels are therapeutic.
contd

Management of
Idiopathic Apnea
B. Nasal CPAP (4-6 cm H2O) can reduce
the number of mixed and obstructive
apneic spells.
C. Methylxanthine (caffeine of
theophylline) therapy, commencing
with a loading dose followed by
maintenance therapy, and serum level
monitoring, especially for theophylline.
D. Assisted ventilation if all else fails

PaO2 with increased lung

volume & C
Work of breathing
Splitting of the upper
airways
Elimination of the intercostal
inspiratory- inhibitory reflex

Pharmacologic
Mechanisms for
Competitive effect on adenosine receptors
Methylxanthine
Sensitivity of respiratory center to CO2

Afferent nerve traffic to brain stem

Catecholamine response
Central stimulation (inspiratory drive)
Improved skeletal muscle contraction
Improved metabolic homeostasis
Improved oxygenation via increased
cardiac output and decreased hypoxic
episodes

Signs of Toxicity in
Infants Receiving
Failure to gain weight
10-20 g/mL
Theophylline
Sleeplessness

Irritability
Tachycardia
Hyperglycemia
Vomiting
20 g/mL
Diuresis/dehydration
Jitteriness
> 20 g/mL
Hyperreflexia
Cardiac arrhythmias
> 40 g/mL
Seizures