Académique Documents
Professionnel Documents
Culture Documents
Apnea of Prematurity
Eric C. Eichenwald, MD, FAAP, COMMITTEE ON FETUS AND NEWBORN
Apnea of prematurity is one of the most common diagnoses in the NICU. abstract
Despite the frequency of apnea of prematurity, it is unknown whether
recurrent apnea, bradycardia, and hypoxemia in preterm infants are
harmful. Research into the development of respiratory control in immature
animals and preterm infants has facilitated our understanding of the
pathogenesis and treatment of apnea of prematurity. However, the lack
of consistent definitions, monitoring practices, and consensus about
clinical significance leads to significant variation in practice. The purpose
of this clinical report is to review the evidence basis for the definition,
epidemiology, and treatment of apnea of prematurity as well as discharge
recommendations for preterm infants diagnosed with recurrent apneic
events.
PEDIATRICS Volume 137, number 1, January 2016:e20153757 FROM THE AMERICAN ACADEMY OF PEDIATRICS
DEFINITION AND CLASSIFICATION 38 weeks’ PMA is higher in infants Preterm infants with resolved apnea
who were 24 to 26 weeks’ gestational also may have clinically unapparent
An apneic spell is usually defined
age at birth compared with those intermittent hypoxia events. In a
as a cessation of breathing for 20
born at ≥28 weeks’ gestation.8 recent study in former preterm
seconds or longer or a shorter pause
Infants with bronchopulmonary infants after discontinuation of
accompanied by bradycardia (<100
dysplasia may have delayed medical therapy for apnea, the mean
beats per minute), cyanosis, or pallor.
maturation of respiratory control, number of seconds/hour of oxygen
In practice, many apneic events in
which can prolong apnea for as long saturation less than 80% was 20.3
preterm infants are shorter than 20
as 2 to 4 weeks beyond term PMA.8 at 35 weeks’ PMA, decreasing to 6.8
seconds, because briefer pauses in
In most infants, apnea of prematurity seconds/hour at 40 weeks’ PMA.12
airflow may result in bradycardia
follows a common natural history,
or hypoxemia. On the basis of
with more severe events that require
respiratory effort and airflow,
intervention resolving first. Last to MONITORING FOR APNEA/
apnea may be classified as central
resolve are isolated, spontaneously BRADYCARDIA
(cessation of breathing effort),
resolving bradycardic events of
obstructive (airflow obstruction
uncertain clinical significance.8 Most infants in NICUs are
usually at the pharyngeal level),
continuously monitored for
or mixed. The majority of apneic
Most studies examining the time heart rate, respiratory rate, and
episodes in preterm infants are
course to resolution of apnea oxygen saturation. Cardiac alarms
mixed events, in which obstructed
of prematurity have relied on are most commonly set at 100
airflow results in a central apneic
nurses' recording of events in beats per minute, although lower
pause, or vice versa.
the medical record; however, alarm settings are acceptable in
several studies have shown a lack convalescent preterm infants.
of correlation with electronically Apnea alarms are generally set
EPIDEMIOLOGY AND TIME COURSE TO
RESOLUTION recorded events.9,10 Standard at 20 seconds. However, apnea
NICU monitoring techniques are detection by impedance monitoring
In an observational study, is potentially misleading. Impedance
unable to detect events that are
Henderson-Smart3 reported that monitoring is prone to artifact
primarily obstructive in nature. With
the incidence of recurrent apnea attributable to body movement or
continuous electronic recording,
increased with decreasing gestational cardiac activity and is unable to
it is evident that some preterm
age. Essentially, all infants born detect obstructive apnea. Practices
infants continue to have clinically
at ≤28 weeks’ gestation were differ as to when continuous
unapparent apnea, bradycardia, and
diagnosed with apnea; beyond 28 oximetry is discontinued. In a study
oxygen desaturation events even
weeks’ gestation, the proportion of investigating the age at last recorded
after discharge. The Collaborative
infants with apnea decreased, from apnea and age at discharge from the
Home Infant Monitoring Evaluation
85% of infants born at 30 weeks’ hospital in 15 different NICUs, the
Study examined the occurrence of
gestation to 20% of those born at 34 duration of use of pulse oximetry was
apnea/bradycardia events in >1000
weeks’ gestation. This relationship significantly different among hospital
preterm and healthy term infants
has important implications for NICU sites.5 Later discontinuation of pulse
monitored at home.11 “Extreme
policy, because infants born at less oximetry was associated with a later
events” (apnea >30 seconds and/or
than 35 weeks’ gestation generally PMA at recorded last apnea and
heart rate <60 beats per minute for
require cardiorespiratory monitoring longer length of stay, suggesting that
>10 seconds) were observed most
after birth because of their risk oximetry may detect events that
frequently in former preterm infants,
of apnea. As expected with a cardiorespiratory monitoring does
decreasing dramatically until about
developmental process, some infants not.
43 weeks’ PMA. After 43 weeks’ PMA,
born at 35 to 36 weeks’ gestation
“extreme events” in both preterm There are no data to suggest that a
may have respiratory control
and term infants were very rare. diagnosis of apnea of prematurity is
instability, especially when placed in
a semiupright position.7
In Henderson-Smart’s study, apneic TABLE 1 Factors Implicated in the Pathogenesis of Apnea of Prematurity
spells stopped by 37 weeks’ PMA in Central Mechanisms Peripheral Reflex Pathways
92% of infants and by 40 weeks’ PMA Decreased central chemosensitivity Decreased carotid body activity
in more than 98% of infants.3 The Hypoxic ventilatory depression Increased carotid body activity
proportion of infants with apnea/ Upregulated inhibitory neurotransmitters Laryngeal chemoreflex
Delayed central nervous system development Excessive bradycardic response
bradycardia events persisting beyond