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Apnea of Prematurity

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Apnea of Prematurity

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  1. Apnea of Prematurity Dr.C.S.N.Vittal

  2. Apnea Definition • Cessation of breathing for ≥20 sec or for any duration if accompanied by cyanosis (SpO2 ≤ 80% for ≥4 s) and bradycardia (heart rate < 2/3 of baseline for ≥4 s) in infants born less than 37 weeks of gestation. • Moriette G, Lescure S, El Ayoubi M, Lopez E. Apnea of prematurity: what's new? Arch Pediatr. 2010;17(2):186–190

  3. Types of Apnea 1 Central apnea • complete cessation of respiration (10-25%) • inspiratory efforts are absent 2 Obstructive apne • cessation of airflow (usually at the pharyngeal level.) in the presence of continued respiratory effort. (10-25%) 3 Mixed apnea • elements of both central and obstructive apnea, either within the same apneic pause or at different times during a period of respiratory recording (50-75%). inspiratory efforts precedes or follows central apnea

  4. What causes apnea of prematurity? • Developmental immaturity of central respiratory drive • May correlate with brainstem neural function. Apneic spells occur more frequently in REM sleep • Chemoreceptor response - immaturity of peripheral chemoreceptors • Hypoxemia might play a role in prolonging the spell. • Ventilatory response to increased carbon dioxide is decreased in preterms • Reflexes. • Active reflexes invoked by stimulation of the posterior pharynx, lung inflation, fluid in the larynx, or chest wall distortion can precipitate apnea • Eg.vigorous use of suction catheters in the pharynx or with fluid in the upper airway during feeding. • Enhanced sensitivity to inhibitory neurotransmitters, such as gamma-aminobutyric acid (GABA), adenosine, serotonin, and prostaglandin

  5. Other Factors which may have a role? • Elevated body temperature • Presence of a patent ductus arteriosus with a large shunt • Narcotic analgesics and magnesium sulfate,  • Anemia • Gastroesophageal reflux • Neck flexion, • Nasal obstruction, and • Delayed gastric emptying

  6. Clinical • Bluish color to the skin (cyanosis) • Decrease in heart rate • Low oxygen levels

  7. Evaluation of an Infant with Apnea

  8. Treatment • General: • Specific therapy : for underlying cause • Optimal oxygenation • Avoid reflexes that may trigger apnea • Positions of extreme flexion or extension of the neck should be avoided • Respiratory stimulants (eg, caffeine) • Continuous positive airway pressure (CPAP)

  9. Management • General care.  • This includes control of body temperature, proper body position, and extra oxygen. • Nasal continuous positive airway pressure (CPAP).  • A steady flow of air is delivered through the nose into the airways and lungs. Nasal intermittent positive pressure ventilation may be added to CPAP. • Medicines.  • Methylxanthine is used to stimulate breathing.

  10. Mechanism of action of proposed interventions for the treatment of apnea of prematurity Nasal continuous positive airway pressure (nCPAP, 3-5 cm H2 O) and heated humidified high-flow nasal cannula (HHHFNC, 1-4 L/min) are appropriate therapies for mixed or obstructive apnea

  11. Nonpharmacological treatment • Posture: avoid both hyperextension and hyperflexion of the neck, which can trigger obstructive apnea. • In the prone position (face down), • the chest wall is stable and • thoracoabdominal asynchrony is reduced; in neonates with respiratory distress, the prone position • increases ventilation, • reduces the incidence of gastric reflux, and • decreases the apnea rate • Only be considered for infants in neonatal intensive care during cardiopulmonary monitoring, whereas the supine sleeping position (face up) should be recommended in the normal newborn nursery and to all parents at discharge.

  12. Noninvasive ventilation support • Nasal continuous positive airway pressure (nCPAP) • prevents obstruction of the upper airway by splinting the pharynx; • reduces the work of breathing; • stabilizes the rib cage and thus reduces neuronal inhibitory signals to the respcenter; • prevents hypoventilation by improving functional residual capacity and expansion of the alveoli • Nasal flow-synchronized intermittent positive pressure ventilation (nSIPPV) • Improve patency of upper airway by creating intermittently elevated pharyngeal pressure • High flow nasal cannula: .  • can deliver a mixture of heated, humidified, and blended oxygen and air via a nasal cannula at variable flow rates. Due to the potential for delivery of a positive, continuous, distending pressure and to keep the upper airway open • Kangaroo mother care •  reduction in apnea and bradycardia in infants receiving kangaroo care • Mechanical Ventilation • If significant apnea persists despite both pharmacotherapy and CPAP PIP 10-12 cm H20 and PEEP 3-5 cm H20 , short Ti of 0.35 to 0,40 sec and low FiO2 of 0.21 to 0.3 are required

  13. Noninvasive ventilation support • Supplementation with branched-chain amino acids • Oral sucrose • Tactile stimulation: special mattress with embedded actuators that deliver small stochastic displacements achieved a 65% reduction in duration of oxygen desaturation • Olfactory stimulation: it was found that exposure to 15 drops of saturated vanillin solution applied on the periphery of the infant’s pillow led to a 45% reduction in the frequency of apnea associated with bradycardia • Red blood cell transfusion:Transfusion of packed cells was followed by a statistically significant reduction in number of apneas.

  14. Pharmacological treatment • Caffeine citrate: • Loading dose: 20 mg/kg (10 mg/kg of Caffeine alkaloid) • Maintenance dose: 5-10 mg/kg/d • Methylxanthines: Theophylline: • Loading dose: 5-6 mg/kg • Maintenance dose: 1.5- 3 mg/kg q 8-12h • increase the output of the respiratory center, which determines an increase in ventilation • Discontinued at 33 to 34 weeks' PMA if no apneic spells have occurred for 5 to 7 days

  15. Pharmacological treatment • Doxapram: potent stimulator of breathing, stimulating peripheral chemoreceptors at low doses and central chemoreceptors at high doses.  • The dose of doxapram reported to be effective for apnea is 2.5 mg/kg/hour given by continuous intravenous infusion • Possible side effects during infusion include jaundice, convulsions, myoclonus, irritability, increased blood pressure, and increased gastric residuals. Three cases of atrioventricular block • Should not be employed in treating neonates with AoP

  16. Consequences of AOP • Short term • Decrease in systemic blood pressure leading to cerebral hypoperfusion > hypoxic ischemic injury in immature brain • Long term • Increased number of AOP days associated with neurodevelopmental impairment as cerebral palsy, blindness at 3 yrs age. • SIDS

  17. Thank You • Dr.C.S.N.Vittal

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