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ALTE,. APNEA,. and SIDS. Valerie Vickers RNC Apnea Program Coordinator UMC. APNEA is a nonspecific indicator of distress. Failure of a system Early indicator of deterioration. Many known causes of apnea can be diagnosed and treated. Thought to be benign PB  Apnea  SIDS???.

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apnea

ALTE,

APNEA,

and SIDS

Valerie Vickers RNC

Apnea Program Coordinator UMC

apnea is a nonspecific indicator of distress
APNEA is a nonspecific indicator of distress
  • Failure of a system
  • Early indicator of deterioration

Many known causes of apnea can be diagnosed and treated.

periodic breathing

Thought to be benign

PB Apnea  SIDS???

PERIODIC BREATHING

These should not be considered linear events. They overlap but one is not causative to the next.

Definition of Periodic Breathing: 3 or more pauses for greater than 30 seconds duration with less than 20 seconds of respiration between pauses.

apnea cessation of respiratory airflow
APNEACessation of respiratory airflow
  • CENTRAL (40-45%)
    • No respiratory effort, no nasal airflow
    • Developmental phenomenon
  • OBSTRUCTIVE (10-15%)
    •  respiratory effort, no nasal airflow,  HR
    • Caused by aspiration, laryngospasm or poor airway control
  • MIXED (40-45%)
    • Both obstructive and central
reflex effects of apnea
Reflex Effects of APNEA
  • sinus bradycardia
  • drop in blood pressure
  • change in cerebral blood flow

Apnea and periodic breathing are common in premature infants after the first 24 to 48 hours of life.

Premature infants sleep 80% of the time, term infants 50%. Apnea only occurs with active sleep.

factors contributing to decreased inspiratory effort
Factors contributing to decreased inspiratory effort:
  • CNS immaturity -  # of synaptic connections   sensitivity to CO2
  •  activity of protective respiratory reflexes (conserve, rather than breath)
  •  minute ventilation
  • diaphragmatic fatigue
  • soft compliant chest
therefore
THEREFORE:

Mixed apnea occurs frequently in premature infants due to:

  • increased CNS immaturity (central apnea)
  • softer chest, weaker diaphragms (obstructive apnea)
pathologic apnea
PATHOLOGIC APNEA

Apnea > 20 seconds with cyanosis, abrupt, marked pallor or hypotonia, or bradycardia < 100 bpm

apnea of prematurity aop
APNEA OF PREMATURITY (AOP)

AOP is probably caused by abnormality in the central control for breathing:

Decreased inspiratory effort and blunted response to CO2 and O2 plus prolonged brainstem conduction times result in hypoventilation and hypercarbia

  • Developmental characteristics are the primary cause due to poor development of both CNS and airway control
  • Most common form of apnea in premies
  • Diagnosis of exclusion
  • Usually resolves by 37 weeks post conception but occasionally persists for several weeks past term
apnea is associated with many clinical conditions
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
    • Bacterial (GBS, staph. Proteus, Listeria, Coliforms
    • Viral (RSV, paraflu, herpes, CMV
    • Chlamydial
    • NEC
slide11
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
    •  blood viscosity and  blood flow to CNS
    • begins at 2-4 hours of age
slide12

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
    • Myelomeningocele
    • Meningitis
slide13
ALTE

“APPARENT LIFE THREATENING EVENT”

  • Frightening event to the observer
  • Combination of apnea
  • Color change
  • Marked change in muscle tone
  • Over 37 weeks conceptual age
careful evaluation of episode
Careful Evaluation of Episode
  • Obtain accurate report including feeding and sleeping history
  • Physical exam, vital signs
  • Temperature of isolette
  • CBC, lytes, ABG’s, pulse ox
  • Blood and viral cultures
  • Chest xray
  • Cranial ultrasound
  • Echocardiogram
  • pH probe, barium swallow
  • Placement of feeding tubes (OG/NG)
  • Computer monitor reports if available
  • Sleep study
treatment of apnea or alte
TREATMENT OF APNEA OR ALTE
  • Dependent on Etiology
    • Least invasive
    • Treat underlying causes
    • Non-pharmacologic vs pharmacologic
treatment of apnea non pharmacologic
TREATMENT OF APNEA: NON-PHARMACOLOGIC
  • Tactile stimulation
  •  neutral ambient temperature
  • Address feeding issues / GER
  • Oxygen
  • Mechanical CPAP / ventilation
    • CPAP markedly reduces apneic episodes with an obstructive component
    • Improves patency of upper airway by activation of dilator muscles or by passive splinting
treatment of apnea pharmacologic
TREATMENT OF APNEA: PHARMACOLOGIC
  • May treat more severe AOP with methylxanthines.
  • Methylxanthines effect neurotransmitters and increase the transmission of impulses across nerves and synapses.
methylxanthines
METHYLXANTHINES
  • CAFFEINE
    • 2.5 - 5 mg /kg / day once per day (therapeutic range 8-15 mcg/ml)
  • THEOPHYLLINE
    • 3-6 mg/kg/day divided in 2 doses per day

(therapeutic range 6-12 mcg/ml)

methylyxanthines cont
METHYLYXANTHINES (cont.)
  • Caffeine is often preferable:
    • More centrally active
    • Not metabolized by the liver
    • However - many pharmacies do not carry it
  • Methylxanthines can exacerbate GER - use the right drug for treatment

NOTE: Neither drug has had controlled study for efficacy

goal for home
GOAL FOR HOME

Goal is to discharge without methylxanthines or monitor

  • For AOP/Apnea:
    • No apneic events for 5 days
    • If discharge on methylxanthines, standard in this community is also discharge with monitor
    • May discharge with monitor only if no other treatment indicated
  • For ALTE:
    • May discharge sooner than 5 days if work-up negative and no events
home monitors
HOME MONITORS

At Risk Group:

  • Infants with BW less than 1000 grams
  • Infants with continued apnea and bradycardia
  • Infants requiring methylxanthines to control apnea
  • Infants with severe gastroesophageal reflux
  • Infants with tracheostomies
  • Less risk but for family’s peace of mind
    • Infants with severe BPD requiring oxygen
    • SIDS sibling or twin of SIDS
    • Infants with non-repeated ALTE, no cause found
criteria for success of home monitoring
CRITERIA FOR SUCCESS OF HOME MONITORING
  • Training is crucial!
    • Apnea class including CPR
    • Caregivers have adequate time to use equipment prior to discharge
  • Support is imperative!
    • Support system includes: medical, technical, psychosocial, community support
  • Choose the right monitor!
termination of monitor use
TERMINATION OF MONITOR USE
  • Usually by 6 months of age
  • No significant apnea or repeat of ALTE event for 2 months
  • If on methylxanthines, 1-2 weeks after discontinuation of medications and not significant apnea
  • Resolution of primary problem

MONITORING CANNOT GUARANTEE SURVIVAL

monitors
MONITORS
  • Monitors heart rate and respirations
  • Common settings: Low HR 70 bpm for premie, 60 for term; high HR off; apnea delay 20 seconds
  • Has a memory, can be printed/analyzed
  • ON/OFF switch: child-proof, sometimes nurse proof 
  • Belt must be tight – pad touches skin always
  • Clean pads with water only

Parents are the best monitor; use only when the baby is not observed.

sudden infant death syndrome sids
SUDDEN INFANT DEATH SYNDROME (SIDS)

Sudden death of any infant or young child which is unexplained by history and in which a thorough post mortem fails to demonstrate and adequate cause of death.*

*Definition taken from the NIH Consensus Development Conference on Infantile Apnea and Home Monitoring

sids statistics
SIDS STATISTICS
  • Currently, 0.6 death per 1000
    • 1-2 deaths per 1000 live births per year until the Back to Sleep campaign in the US -  by 40%.
    • leading cause of death in infants older than one month
  • Most common age for SIDS is 2-4 months
    • 99% of deaths before 6 months
    • 1 % of deaths 6-12 months
    • extremely rare in the 1st month of life
    • infants have a change in response to hypoxia around 6 months of age
sids facts
SIDS FACTS
  • SIDS risk for an infant with AOP or who has had an ALTE is at no greater risk than the general population
  • Premature infants have a slightly greater risk which increases as their gestational age decreases
  • Home monitoring of infants has NOT decreased the incidence of SIDS
  • The SIDS sibling is not at greater risk of SIDS than the general population
sids research
SIDS RESEARCH
  • Research findings:
    • Supine sleeping position most protective, side lying better than prone but not protective as supine
    • Overheating contributory
    • Smoking contributory
    • Any breastfeeding is protective
    • Pacifier use is protective
    • Sleeping in the same place every night is protective
    • Research indicates SIDS is a malfunction in arousal
    • CHIME study indicates that normal infants have apnea, bradycardia and desaturations into the 70’s (question then is why they can recover and the infant who dies of SIDS does not)
slide29

SIDS PHYSIOLOGICAL CHARATERISTICS

Research indicates that SIDS is more complex than a single abnormality in a single system.

  • tachycardia then bradycardia prior to fatal event – not necessarily proceeded by apneic event
  • diminished # of breathing pauses
  •  heart rate variation related to respirations
  • profuse sweating
slide30

SIDS PREVENTION

  • Failure of arousal mechanism
  • Ethnicity is a factor ( in blacks)
  • Back to Sleep campaign
  • AAP discourages the use of monitors
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