Which type of respirations would the nurse expect to identify in a healthy newborn

Note: This guideline is currently under review. 

Introduction

Aim

Definition of Terms

Incidence 

Types of Apnoea

Causes

Management

Documentation

Family Centered Care

Companion Documents

References

Evidence Table

Introduction

Apnoea is a common occurrence in preterm infants that is often due to idiopathic apnoea of prematurity but may also be due to underlying illness or pain. 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 (central, obstructive and mixed), all of which present differently. 

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 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 or if cessation of breathing lasts for more than 10 seconds and is accompanied by 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 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.
  
• Airway obstruction: Assess position of head and neck to ensure neutral alignment.
  
• Infections: Sepsis, necrotising enterocolitis, meningitis.
  
• Cardiovascular: Anaemia, hypotension, 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, hyponatraemia, hypernatremia, hyperammonaemia, low organic acids, high ambient temperature, hypothermia, hyperthermia.
  
• Drugs: Maternal drugs (consider neonatal abstinence syndrome), opiates, prostin, high levels of phenobarbitone, chloral hydrate or other sedatives, general anaesthetic.
  

Management

• All neonates less than 34 weeks completed 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 completed 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 Nursing Guideline.
  

Acute management

1. Observe event: Assess. Does the apnoea appear to be obstructive, central or mixed? Is the apnoea self-limiting or will the infant require intervention?
   
2. Tactile stimulation: Gentle rubbing of soles of feet or chest is usually all that is required for episodes that are mild and intermittent. 
   
3. Position airway: Ensure the neonate's head and neck are positioned correctly (neutral position) to maintain a patent airway. Gently suction mouth and nostrils if necessary. Be mindful that deep suction may stimulate a vagal response.
   
4. Provision of PEEP or positive pressure ventilation: May be required until spontaneous respirations resume. If PEEP or positive pressure ventilation is required to treat apnoeic episodes, CPAP or mechanical ventilation should be considered. 
   
5. Refer BLS pathway if apnoeic episode doesn’t resolve after steps 1-4. RCH Resuscitation guidelines
   
6. Document event.

NB: It is important to note that although there are different types of Apnoeas, acute management is always the same.

Ongoing management

• Pulse oximeter / cardiorespiratory monitor: Allows for observation of heart rate, respiratory rate and oxygen saturation. As well as monitoring trends and patterns. 
• 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.
• Prone positioning: Has been shown to improve thoracoabdominal synchrony and stabilize the chest wall. Several studies have demonstrated that prone position reduces apnoea of prematurity.
  
• 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): As treatment for mixed and obstructive apnoeas. Often used when caffeine has failed.
• Nasal CPAP: As a treatment for mixed and obstructive apnoeas and when caffeine and or HFNC 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 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.
  
• Ensure the parents of premature babies are aware that Apnoea of Prematurity is a normal occurrence and should resolve with age.
  
• Explain all interventions and why they are necessary e.g. Caffeine, Antibiotics, CPAP or Ventilation.
  

Companion documents

• Observation and Continuous Monitoring Clinical Guideline 
• RCH Basic Life Support Learning Package (intranet only)   

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. Elder, D. E., Campbell, A. J. and Galletly, D. (2013), Definitions for neonatal apnoea. J Paediatr Child Health, 49: E388-E396. doi:10.1111/jpc.12247
   
5. 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.
   
6. Henderson-Smart, D.J., Steer, P.A. (2010). Caffeine versus theophylline for apnea in preterm infants. Chochrane Database Syst Rev. Jan 20; (1)
   
7. Johnson, P.J. (2011). Caffeine Citrate Therapy for Apnoea of Prematurity. Neonatal Network 30(6), 408-412.
   
8. 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
   
9. Powell MB, Ahlers-Schmidt CR, Engel M, Bloom BT. (2017). Clinically significant cardiopulmonary events and the effect of definition standardization on apnea of prematurity management. J Perinatol. 37:88–90. (PubMed: 27684421)
   
10. Schmidt B, Roberts RS, Anderson PJ, et al. (2017). Academic Performance, Motor Function, and Behavior 11 Years After Neonatal Caffeine Citrate Therapy for Apnea of PrematurityAn 11-Year Follow-up of the CAP Randomized Clinical Trial. JAMA Pediatr. 171(6):564–572. doi:10.1001/jamapediatrics.2017.0238
    
11. 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. 
    
12. Zhao, J., Gonzalez, F. & Mu, D. (2011) Apnea of prematurity: from cause to treatment. Eur J Pediatr 170: 1097. https://doi.org/10.1007/s00431-011-1409-6
    

Evidence table

• Apnoea (Neonates) Evidence Table

Please remember to read the disclaimer

The development of this nursing guideline was coordinated by Jenna Rhodes, RN, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated February 2019.  

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