Clinical Guidelines (Nursing)

Apnoea (Neonatal)


  • Introduction

    Apnoea is a common problem in preterm infants that may be due to an underlying illness or most commonly to idiopathic apnoea of prematurity. In term infants apnoea is almost always due to a pathological cause but they may rarely experience apnoea of prematurity as well. There are 3 types of apnoea, all of which present quite differently.

    Aim

    The aim of this guideline is to ensure that health carers are aware of:

    • The variety of causes of apnoea and how to manage them both in an acute situation and longer term
    • The different types of apnoea, how each one presents and which type of management is most appropriate

    Definition of terms

    Apnoea:No respiratory effort for greater than 20 seconds. No respiratory effort for shorter periods of time may also be classified as apnoea if accompanied by cyanosis or bradycardia

    Neonate:A newborn, up to 28 days of age (post-term)

    Incidence

    The most common cause of apnoea is apnoea of prematurity; the incidence depends on the neonate's gestational age

    • 10% at 34-35 weeks or above
    • 50% at 30-31 weeks
    • >60% at below 28 weeks

    Types of Apnoea

    • Central apnoea:(40%) Caused by decreased central nervous system stimuli to respiratory muscles. Both the respiratory effort and airflow cease simultaneously. (Absence of chest wall movement and airflow).
    • Obstructive apnoea:(10%) Caused by pharyngeal instability / collapse, neck flexion or nasal obstruction.  Absence of airflow in presence of inspiratory efforts. (Presence of chest wall movement but no airflow).
    • Mixed apnoea:(50%) Has a mixed aetiology. Central apnoea is either preceded (usually) or followed by obstructed respiratory effort

    NB:Short episodes of apnoea are usually central whereas prolonged ones are often mixed

    Differential diagnosis

    • Periodic breathing:Defined as three or more periods with no respiratory effort lasting 3 seconds or more in a 20 second period. This is a normal neonatal breathing pattern and does not involve changes in heart rate or colour
    • Subtle seizures:Apnoea is an uncommon presentation of a neonatal seizure

    Causes

    • Apnoea of prematurity:The most common cause of apnoea is that due to immaturity of the respiratory centre of the brain. Onset is from days 2-7 of life.  Apnoea beginning immediately after birth suggests another cause. Term or near term babies may rarely experience apnoea of prematurity but a pathological cause should be sought before making this diagnosis in this group
    • Infections:Sepsis, necrotising enterocolitis, meningitis
    • Cardiovascular:Anaemia, hypo / hypertension, patent ductus arteriosus, cardiac failure, hypovolaemia
    • Pain:Acute and chronic
    • Central nervous system:Intraventricular haemorrhage, seizures, hypoxic injury, neuromuscular disorders, brainstem infarction or anomalies, birth trauma, congenital malformations
    • Respiratory:Pneumonia, intrinsic / extrinsic mass or lesions causing airway obstruction, upper airway collapse, atelectasis, phrenic nerve paralysis, respiratory distress syndrome, pneumothorax, hypoxia, malformations of chest, pulmonary haemorrhage, aspiration
    • Gastrointestinal:Oral feeding, bowel movement, oesophagitis, intestinal perforation, gastro oesophageal reflux, abdominal distension
    • Metabolic:Hypoglycaemia, hypocalcaemia, hypo / hypernatraemia, hyperammonaemia, low organic acids, high ambient temperature, hypo / hyperthermia
    • Drugs:Maternal drugs (consider narcotic abstinence syndrome), opiates, prostin, high levels of phenobarbitone, chloral hydrate or other sedatives, general anaesthetic
    • Head and neck poorly positioned

    Management

    • All neonates less than 34 weeks gestation should be routinely monitored with cardio-respiratory and oxygen saturation monitors for at least the first week of life or until there has been an absence of apnoeic episodes for at least 7 days.
    • Above 34 weeks gestation neonates only need to be monitored if they are unstable: all neonates in the NICU, PICU and Cardiac Ward at the RCH are monitored for this reason. Continuous cardio-respiratory and pulse oximetry monitoring should occur as per Observation and Continuous Monitoring Clinical Guideline

    Acute management

    • Positioning:Ensure the neonate's head and neck are positioned correctly (head and neck in neutral position) to maintain a patent airway.
    • Tactile stimulation:Gentle rubbing of soles of feet or chest wall is usually all that is required for episodes that are mild and intermittent. 
    • Clear airway:Suction mouth and nostrils.
    • Provision of positive pressure ventilation:May be required until spontaneous respirations resume. If positive pressure ventilation is required to treat apnoeic episodes, CPAP or mechanical ventilation should be considered. RCH Basic Life Support reading package is available viawww.learningseat.com/rch (intranet only) 

    Ongoing management

    • Pulse oximeter / cardiorespiratory monitor:Detect changes in the heart rate, respiratory rate and oxygen saturation due to apnoeic episodes.
    • Identify cause:If apnoea is not physiologic, investigate to identify underlying cause and treat appropriately. Differential diagnoses are outlined above.
    • Apnoea monitor:This detects abdominal wall movement and may alarm falsely with normal periodic breathing. It will not detect obstructive apnoea. They are used routinely in some perinatal nurseries but at the RCH only used for home monitoring by parents who have undergone resuscitation training.
    • Caffeine citrate:from the methylxanthine group of drugs; it can be given orally or intravenously and is usually routinely given to neonates <34 weeks gestation. It acts as a smooth muscle relaxant and a cardiac muscle and central nervous system stimulant.
    • High flow nasal cannula (HFNC):This is especially effective with mixed and obstructive apnoeas. Often used when treatment with caffeine has failed.
    • Nasal CPAP:As with HFNC, this is effective with mixed and obstructive apnoeas and when caffeine has failed.
    • Mechanical ventilation:This is used when caffeine and HFNC and CPAP have been tried and there are still significant apnoeas. It is effective in all types of apnoea.

    Documentation

    Ensure all episodes are clearly documented with the intervention that was required to correct them.

    Family centred care

    • Ensure that parents are aware of the cause of the apnoeas and how it is being treated e.g. antibiotics for infection
    • Ensure the parents of premature babies are aware that Apnoea of Prematurity is a normal occurrence and will resolve by the time 34 weeks gestation is reached
    • Explain all interventions and why they are necessary e.g. caffeine, CPAP or full ventilation

    Companion documents

    References

    1. Aggarwal, R., Singhal, A., Deorari, A., Paul V.K. (2009). Apnoea in the newborn. All India Institute of Medical Sciences. (12), 550-554.

    2. Atkinson, E. & Fenton, A. (2009). Management of apnoea and bradycardia in neonates. Paediatrics and Child Health. 19
    3. Doherty Chantal, MD. Causes and management of apnoea in the newborn. Powerpoint Presentation.
    4. Gray, P.H., Flenady, V.J., Charles, B.G., & Steer, P.A. (2011). Caffeine citrate for very preterm infants: effects on development, temperament and behavior. Journal of Paediatrics and Child Health. 47, 167-172.
    5. Henderson-Smart, D.J., Steer, P.A. (2010). Caffeine versus theophylline for apnea in preterm infants. Chochrane Database Syst Rev. Jan 20; (1)
    6. Johnson, P.J. (2011). Caffeine Citrate Therapy for Apnoea of Prematurity. Neonatal Network 30(6), 408-412.
    7. Mohammed, S., Nour, I., Shabaan, A.E., |Shouman, B., Adbel-Hady, H., Nasef, N. (2015). High vs low-dose caffeine for apnea of prematurity: a randomized controlled trial. Eur J Pediatrics. Jul; 174(7): 949-956
    8. Sreenan, C., Lemke, R.P., Hudson-mason, A., & Osiovich, H. (2001). High-flow nasal cannulae in the management of apnoea of prematurity: A comparison with conventional nasal continuous positive airway pressure. Pediatrics 107, 1081-1083. 

    Evidence table

    Please remember to read the disclaimer

    The development of this clinical guideline was originally coordinated by Alec Barrett, Associate Nurse Unit Manager, Butterfly Ward. The review of the guideline was coordinated by Trudy Holton, Clinical Nurse Educator, Butterfly Ward. Approved by the Clinical Effectiveness Committee. Authorised by Bernadette Twomey, Executive Director Nursing Services. First published July 2012, and reviewed July 2015.