DO NOT USE FOR CLINICAL PRACTICE
Please use current guidelines available on the UHNM intranet for patient treatment
Please use current guidelines available on the UHNM intranet for patient treatment
RECOGNITION AND ASSESSMENT
Apnoea
Pause(s) in breathing >20 sec (or less, when associated with bradycardia or cyanosis)
Bradycardia
Heart rate <100 bpm, associated with desaturation
Types
Central
- Caused by poorly developed neurological control
- Respiratory movements absent
Obstructive
- Caused by upper airway obstruction, usually at pharyngeal level
- Respiratory movements continue initially but then stop
Mixed
-
Initially central, followed by obstructive apnoea
Significance
- Most babies born <34 weeks’ gestation have primary apnoea of prematurity (PAP). Hence babies born <34 weeks should have SpO2 monitoring until ≥34 weeks’ post conceptional age (PCA)
- multiple aetiologic factors can exacerbate apnoea in preterm babies
- sudden increase in frequency warrants immediate action
- Consider causes other than apnoea of prematurity if occurs:
- in term or near-term baby (>34 weeks’ gestation)
- on first day after birth in preterm baby
- onset of apnoea after aged 7 days in a preterm baby
Causes
Infection
-
Sepsis
-
Necrotising enterocolitis
-
Meningitis
Respiratory
- Inadequate respiratory support
- Upper airway obstruction
- Surfactant deficiency
CNS
- Intracranial haemorrhage
- Seizure
- Congenital malformations
CVS
-
Patent ductus arteriosus
Other
- Metabolic abnormalities, especially hypoglycaemia
- Haematological: anaemia
- Inherited metabolic disorders e.g. non-ketotic hyperglycinaemia
MANAGEMENT
Terminate episode
- If apnoea not self-limiting (clinician to agree threshold to intervene), perform the following in sequence to try to terminate episode:
- ensure head in neutral position
- stimulate baby by tickling feet or stroking abdomen
- if aspiration or secretions in pharynx suspected, apply brief oropharyngeal suction
- face mask ventilation
- emergency intubation
- Once stable, perform thorough clinical examination to confirm/evaluate cause
Screen for sepsis
- If apnoea or bradycardia increasingly frequent or severe, screen for sepsis as apnoea and bradycardia can be sole presenting sign
TREATMENT
- Treat specific cause, if present
- Primary apnoea of prematurity is a diagnosis of exclusion and may not require treatment unless pauses are:
- frequent (>8 in 12 hr) or
- severe (>2 episodes/day requiring positive pressure ventilation)
Pharmacological treatment
- Caffeine citrate 20 mg/kg loading dose oral/IV (over 30 min) followed, after 24 hr, by maintenance dose of
5 mg/kg oral/IV (over 10 min) once daily, increasing to 20 mg/kg if required until 34 weeks’ PCA - If desaturations and bradycardias persist, may continue beyond 34 weeks’ PCA. If so, review need for treatment regularly
Non-pharmacological treatment
- CPAP, SiPAP/BiPAP [see Ventilation: continuous positive airway pressure (CPAP) guideline]
- If above fails, intubate and ventilate