Apnoea of Prematurity

Introduction

Apnoea of prematurity is defined as sudden cessation of breathing that lasts for at least 20 seconds or is accompanied by bradycardia, oxygen desaturation (cyanosis) or pallor in an infant younger than 37 weeks' gestational age.

  • Apnoea of prematurity is a developmental disorder in preterm infants, which occurs as a direct consequence of immature respiratory control.
  • Monitoring for apnea of prematurity and associated bradycardia and hypoxemia generally includes continuous cardiac monitoring and continuous pulse oximetry.
Epidemiology of apnoea of prematurity
Apnoea of prematurity resolution normally occurs between 36 to 40 weeks' postconceptual age.
  • Some neonates, especially younger gestational age patients, may require longer courses of treatment.



Classification

Apnoea may be classified as

  • Obstructive - related to decreased airflow with functioning breathing mechanics (chest wall motion)
  • Central - related to decreased stimulation from the central nervous system to the respiratory musculature.
  • Mixed central and obstructive - the most common type



Treatment

Nonpharmacologic treatments are often initiated prior to starting or in combination with pharmacologic options.

Nonpharmacologic treatment options include

  • Manual stimulation
    • e.g. Rubbing on the neonate's chest, back or extremities.
  • Airway patency maintenance
    • e.g. Ensuring proper head and neck positioning, limit nasal suctioning
  • Maintaining a stable thermal environment.
  • Supplemental oxygen therapy
    • Preventing hypoxemia (a cause of apnoea); May cause retinopathy of prematurity.
  • Respiratory support
    • e.g. Continuous positive airway pressure (CPAP) or endotracheal intubation in severe cases.
  • Red blood cell transfusions
    • Warranted in neonates with anaemia who have frequent and/or severe apnoea despite caffeine therapy.

Pharmacologic treatment class of choice is methylxanthines. Efficacy is similar between the 3 agents.

  • Aminophylline
  • Caffeine
    • Medication of choice in practice due to a favourable adverse event profile, wide therapeutic index and administration advantages (once daily).
  • Theophylline

In anticipation of discharge, treatment may be discontinued at earlier gestational ages. To ensure resolution of AOP, neonates may be observed 5 to 7 days off treatment due to medication prolonged half-lives in preterm neonates.



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