Introduction

Apnoea is the absence of breathing in a neonate for a period of >15 seconds often associated with bradycardia and/or desaturation. Apnoea is a common occurrence in preterm neonates that is often due to idiopathic apnoea of prematurity. Both preterm and term neonates may have apnoea related to underlying illness or pain. There are 3 types of apnoea, central, obstructive and mixed, all of which present differently. Potential causes or exacerbating factors need to be considered and identified/or excluded. 

Aim

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

• The variety of causes of apnoea and how to manage them.
• The different types of apnoea, how each one presents, and which type of management is most appropriate.

This guideline relates to the management of neonatal apnoea and will apply to neonates being nursed on Butterfly and on the wards at RCH.  If older infants and children are apnoeic, a MET call should be made immediately.   

Definition of terms

• Apnoea: Absence of breathing for a period of >15 seconds often associated with a bradycardia and/or desaturation. 
  
• Neonate: A newborn, up to 28 days of age (post-term).
  
• Periodic breathing: 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.
  
• Seizures: Apnoea is an uncommon presentation of a neonatal seizure.
  

Incidence

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

• >60% when born at 28 weeks or below.
  
• 50% when born between 30-31 weeks.
• 14% when born between 32-33 weeks.
• 10% when born at 34-35 weeks or above.
  

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 (There is 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.

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

Periodic breathing may be mistaken for apnoea. Apnoea may be a symptom of seizure activity.

Causes

• Apnoea of prematurity: The most common cause of apnoea, attributable to the immaturity of the respiratory centre in the brain. Onset is from day 1-7 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.
  
• Airway obstruction: Assess position of head and neck to ensure neutral alignment.
  
• Cardiovascular: Anaemia, hypotension, hypertension, patent ductus arteriosus, cardiac failure, hypovolaemia.
  
• Central nervous system: Intraventricular haemorrhage, seizures, hypoxic injury, neuromuscular disorders, brainstem infarction or anomalies, birth trauma, congenital malformations.
  
• Drugs: Maternal drugs (consider neonatal abstinence syndrome), opiates, prostin, high levels of phenobarbitone, chloral hydrate or other sedatives, general anaesthetic.
  
• Gastrointestinal: Oral feeding, bowel movement, oesophagitis, intestinal perforation, gastro oesophageal reflux, abdominal distension.
  
• Infections: Sepsis, necrotising enterocolitis, meningitis.
  
• Metabolic: Hypoglycaemia, hypocalcaemia, hyponatraemia, hypernatremia, hyperammonaemia, low organic acids, high ambient temperature, hypothermia, hyperthermia.
  
• Pain: Acute and chronic.
  
• 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.

Management

• Assess for an underlying factor that may be causing the apnoeic episodes. Does the apnoea appear to be obstructive, central or mixed? Is the apnoea self-limiting or will the infant require intervention? 
• If an episode of apnoea/bradycardia does not resolve spontaneously, gentle tactile stimulation may be required. If response is slow and if the neonate  is cyanotic then bag and mask ventilation may be required. 
• Escalation of Care should be initiated for neonates which require bag mask ventilation which includes a MET call for neonates in the ward environment (see Medical Emergency Response Procedure)
• Cardio-respiratory and oxygen saturation monitoring is required. Refer to Observation and Continuous Monitoring guideline.
• Ensure the infants head and neck are positioned correctly (neutral position) to maintain patent airway. Gently suction mouth and nostrils if necessary.
• Consider prone positioning as this can stabilise the chest wall, potentially reducing the frequency of apnoea. 
• Non – invasive positive pressure ventilation (NIPPV) may be required (CPAP or HFNP). Intubation and ventilation should be considered if apnoeic episodes continue despite non-invasive ventilation. 
• Caffeine is a potent respiratory and central nervous system (CNS) stimulant and is the pharmalogical agent of choice. It has been shown to decrease apnoea and reduce the need for ventilator support.  For dosage and side effects of caffeine refer to Neonatal Formulary Neonatal Formulary 8th Edition
• Refer to BLS pathway if apnoeic episode doesn’t resolve. RCH Resuscitation guidelines.
• Neonates nursed on the ward who are apnoeic will require a MET call

Documentation

Ensure all episodes are clearly documented within the EMR observation flowsheet to reflect the time of the event. Select yes on the Apnoea and Bradycardia row and complete the relevant information. Include the intervention that was required to correct them.

Family centered care

• Ensure that parents are aware of the cause of the apnoea and how it is being treated e.g. Apnoea of prematurity treated with Caffeine.
• Explain all interventions and why they are necessary e.g. Caffeine, Antibiotics, CPAP or Ventilation.
  
• Ensure the parents of premature neonates are aware that Apnoea of Prematurity is a normal occurrence and should resolve with age.

Companion documents

• RCH Nursing Guidelines
  • Observation and Continuous Monitoring Guideline
  • Apnoea Monitoring Post Operatively in Infants Guideline
• Departmental Guidelines (RCH access only)
  • Acute Pain Management CPMS
• Learning Hero (RCH access only)
  • RCH Basic Life Support Learning Package  
  • Butterfly BLS Resources and Quiz
    
• RCH Policy Procedures (RCH access only)
  • Medical Emergency Response Procedure (rch.org.au)

Evidence table

You can view the evidence table for this guideline here: Apnoea (Neonates) Evidence Table

Please remember to read the disclaimer

The revision of this nursing guideline was coordinated by Jaimee Musial, RN, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated February 2023.