Apnea

Apneas represent another important group of respiratory/ventilation dysfunctions in newborns (apart from perinatal asphyxia and respiratory distress syndrome). They are generally defined as a cessation of breathing movements and air flow for more than 20 seconds, thus often being accompanied by desaturation and bradycardia.

Division of apneas

  • central
    → prematurity
    → injury to respiratory control centre in medulla oblongata and pons (brainstem)
  • peripheral
    → airway obstruction (muscle hypotonia, meconium)
  • mixed
    → central and peripheral features

Mixed apneas are typical and highly frequent in preterm infants => apnea of prematurity (AOP). Special attention is given to recurrent apneas that endanger a newborn by severe and/or prolonged desaturations/bradycardia, thus causing hypoxic injury and cerebral reperfusion damage.

DIAGNOSIS

Causes of Apnea

  • seizures (especially in term infants)
  • apnea of prematurity
  • congenital upper airway defects (orofacial cleft, stenosis, atresia)
  • congenital pulmonary (lower) airway malformation (CPAM)
  • respiratory distress syndrome (RDS)
  • neurologic issues (PIVH, HIE, meningitis)
  • sepsis (EOS, LOS)
  • gastro-esophageal reflux (GER)
  • anemia
  • circulation issues (PDA – rare cause of apneas)
  • disturbed homeostasis (hypothermia, hyperthermia, hypoxemia, hypoglycemia, hyponatremia, hypocalcemia)
  • inherited metabolic disorders
  • medication (phenobarbital, opioids)
  • inappropriate handling and positioning

THERAPY

General

  • Appropriate handling and positioning
  • Upper airways suctioning
  • Elevated position (GER)
  • Slow infusion of enteral feeds or continuous enteral feeding (GER)
  • Oxygen (maintain normoxemic oxygenation)

Specific

  • Caffein citrate
  • Ventilation support (CPAP or mechanical ventilation)

Caffein citrate (PEYONA®)

→ stimulates respiratory control centre in the brainstem
→ prevention from apnea of prematurity
Loading dose: 20 mg/kg i.v. (30 minute infusion)
Maintenance dose: 5-10 mg/kg/day i.v./p.o. (given once daily and titrated as per clinical effect)
Adverse effect: tachycardia

REFERENCES

① Koch G, Datta AN, Jost K, Schulzke SM, van den Anker J, Pfister M. Caffeine Citrate Dosing Adjustments to Assure Stable Caffeine Concentrations in Preterm Neonates. J Pediatr. 2017 Dec;191:50-56.e1. doi: 10.1016/j.jpeds.2017.08.064

② Sweet DG, Carnielli V, Greisen G, et al. European Consensus Guidelines on the Management of Respiratory Distress Syndrome – 2019 Update. Neonatology. 2019;115(4):432-450. doi:10.1159/000499361