NEONATAL APNEA - DIAGNOSIS AND MANAGEMENT

Algorithm for Management of Apnea of Prematurity ©IAP

 (1) POSSIBLE ETIOLOGIES:

• anemia
• sepsis
• hypoxemia
• seizure d/o
• GER
• electrolyte imbalance, etc....

(2) Initial THEOPHYLLINE/AMINOPHYLLINE Dosing: no adjustment in dosing is necessary when swithching between Theo and Amino in neonates

• Loading Dose: 6mg/kg
• Maintenance Dose: 4mg/kg/d divided Q8h (consider Q12h for infants <1500gms)

(3) Weight Adjust Dose: Adjust the dose to the equivalent mg/kg/day amount at which the patient was previously controlled (or to 4mg/kg/day)

(4) Checking Levels:

• If patient continues to have persistent apnea and bradycardia spells
• If patient is exhibiting signs/symptoms of toxicity (irritability, tachycardia, fededing intolerance, etc.)
• Order as trough levels.
• Therapeutic ranges:
  • Theophylline: 6-10mcg/ml
  • Caffeine: 8-20 mcg/ml

  Adjusting Doses:

  • if steady state level ( Theo level 72h or Caffeine level 5 days after dose changes), calculate new dose (per pharmacy)
  • if non-steady state level, consider a partial loading dose and increase maintenance dose by 20% (notify pharmacy)

(5) Initial CAFFEINE (CITRATE) Dosing: 2mg affeine citrate contains 1mg caffeine base.

• A caffeine level is not necessary prior to discharge (see (4) above for checking levels)
• Loading Dose:
  • for discharge:
    • Caffeine Citrate 30mg/kg (15mg/kg Caffeine base)
  • for inpatients (max theo dosing first):
    • Caffeine Citrate 20mg/kg (10mg/kg Caffeine base)
• Maintenance Dose: Cafffeine Citrate 6mg/kg/day (given at 8am)

Pneumograms (CR-scan, MMU)

All infants less than 34 weeks gestational age and any infant (regardless of gestational age) who has experienced clinical apnea should have a pneumogram (12-hour recording of heart rate, respiration, and O2 saturation) performed prior to discharge. A Cardiorespiratory Scan (CR Scan) is a continuous recording of heart rate, breathing pattern, nasal airflow, and oxygen saturation (by pulse-ox); this type of scan is particularly useful if there is concern over oxygenation, as in infant with BPD and/or on supplemental oxygen. A Memory Monitor Unit (MMU) recording only records when monitor limits are violated (therefore only giving a brief "snapshot" of the monitored variables); the advantage to this type of scan is that the results are available the same day. The MMU is the routine type of scan, but ask the attending what type of scan is desired before it is ordered.

A pneumogram is not a test for SIDS. It does document the presence of absence of significant apnea or bradycardia. Clinically significant events may occur before or after a pneumogram. Therefore, a normal pneumogram does not necessarily mean a monitor can be discontinued.

When ordering a pneumogram you need to specify which type (MMU or CR Scan), and, in the case of an MMU, you need to specify the duration (usually a minimum of 12 hours, although if a patient is admitted at night to the Apnea Center, it may end up being less than 12 hours until morning).

Treatment of Apnea with Methylxanthines (Theophylline, Caffeine)

Indications:

To treat infants who are having frequent (5 or more episodes per day) or severe (requiring vigorous stimulation or CPR) apnea or bradycardia. Prior to prescribing theophylline or caffeine, treatable causes of apnea should be excluded, i.e., anemia, seizures, sepsis, hypoxemia, metabolic abnormalities, or gastroesophageal reflux.

1. To normalize an abnormal pneumogram prior to discharge.
2. To facilitate weaning from ventilatory support.

Scans while Patients are receiving Theophylline or Caffeine

If an infant has experienced no clinical apnea for 5-7 days while receiving theophylline or caffeine at therapeutic levels and discharge is anticipated within 2-3 weeks, theophylline and caffeine should be discontinued. A pneumogram can be obtained within 48-72 hours of discontinuing theophylline and within 72-96 hours of discontinuing caffeine.

Apnea of Prematurity or Abnormal Scans

If the pneumogram is abnormal and the infant is otherwise ready for discharge, caffeine is started and the infant is referred to the Infant Apnea Program who does outpatient management of apnea of prematurity, home apnea monitors, and also gastroesophageal reflux. An infant discharged home on caffeine will also be placed on a home apnea monitor. Parents will be instructed by the Infant Apnea Program nurses in administration of caffeine, infant CPR, and use of a home monitor.

Infants receiving theophylline should be changed to caffeine prior to discharge. Twenty mg/kg/day of caffeine citrate as a loading dose should be given, followed by 6 mg/kg/day maintenance dose. A caffeine serum level should be obtained prior to the second maintenance dose; if the infant is discharge before that time, at least one trough level (prior to a maintenance dose) needs to be obtained.

Home Monitoring

Infants who are discharged home with a monitor are under the care of the Infant Apnea Program. An order must be written for a home cardiorespiratory monitor. Instructors of the Infant Apnea program should be notified 4-5 days prior to discharge, so that the parents can be instructed in CPR and in the use of the monitor.

Guidelines for Studies: CR Scans, MMUs and Polysomnograms (PSG)

MMU Recordings

Indications

• This is the most routine type of scan and can easily be done overnight or over several days, with the results usually available within hours of downloading. For infants in the NICU who have had "spells" and for any outpatient admitted with a diagnosis of "apnea", this is the type of scan that would be ordered.

CR Scans with Saturation

Indications

• This type of scan is a continuous recording of HR, respiratory pattern, oxygen saturation and nasal airflow. It would be appropriate for infants on supplemental oxygen or with BPD where O2 saturation is a concern. Because it measures airflow, it can suggest (but can not definitively diagnose) obstructive apnea. It can also be done in conjunction with a pH probe to help determine the significance of gastroesophageal reflux (i.e., is reflux associated with apnea, bradycardia or desaturation).

Polysomnograms (sleep studies):

Indications

• Infants with unexplained significant clinical events suggesting a problem with respiratory drive or profound airway obstruction.

Relative indications

1. Infants who had an abnormal saturation study or CR scan and need additional evaluation.
2. Infants who need close observation of apneic, bradycardic, or cyanotic spells without obvious etiology.
3. Further evaluation of infants who have cyanotic or bradycardic episodes with feedings.
4. Suspected Munchausen by proxy.

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