Apnea

Apnea: Excerpt from In A Page: Pediatric Signs and Symptoms

Apnea is defined as the cessation of breathing; how long a pause is physiologically significant depends on age. History will often be more helpful than physical exam. Central apnea refers to a lack of respiratory effort accompanied by a lack of air flow; obstructive apnea refers to a lack of air flow in the face of a respiratory effort. “Central apnea” may be due to muscle weakness and failure despite CNS activation.

Differential Diagnosis

• Much apnea is physiologic and normal
  –Post-sigh apnea is normal
  –Newborns, especially premature babies, may have irregular breathing as their respiratory control center matures
  –Periodic breathing at high altitude
• Prolonged apnea is respiratory arrest, and inadequate ventilation is respiratory failure, and both require immediate intervention
• Apnea may be divided into central, obstructive, and mixed apnea; etiologies vary by age
• Central apnea in infants
  –Apnea of prematurity
  –Congenital central hypoventilation syndrome (CCHS, or Ondine curse)
  –CNS depression (sepsis, shock, drug effect, RSV, seizure or postictal state)
  –Respiratory muscle failure (e.g., myotonia, infantile botulism)
  • Obstructive apnea in infants
    –Upper airway obstruction (severe laryngomalacia, choanal atresia, macroglossia, micrognathia, subglottic stenosis or web, laryngospasm)
    –Lower airway: Rarely causes obstructive apnea (tracheal stenosis, rings, slings)
  • Central apnea in children
    –CNS (drug-induced CNS depression, CCHS, abnormal CNS brainstem anatomy and function, sepsis/septic shock)
    –Respiratory muscle failure (muscular dystrophy, myotonia, myasthenia gravis)
  • Obstructive apnea in children
    –Upper airway obstruction, obstructive sleep apnea syndrome (OSAS), tonsillar and adenoidal hypertrophy, macroglossia, micrognathia, subglottic stenosis, laryngospasm
  • Mixed apnea
    –CNS depression and decreased upper airway tone
    –Gastroesophageal reflux leading to increased parasympathetic activity and/or laryngospasm
    –Respiratory muscle failure and adenoidal hypertrophy
  • Apparent life-threatening events (ALTE)
  • Trauma may cause apnea at any age

  Workup and Diagnosis

  • Acute or prolonged apnea must be treated immediately with life-support protocols
  • History may determine if apnea is central or obstructive
    –Snoring, stridor, gasps are consistent with obstructive apnea
    –Pauses are consistent with central apnea
    –Ingestion of raw honey can cause infantile botulism
    –Apnea/ALTE may occur in a familial pattern, but such a history should provoke a search for intentional injury
    • Apnea is most often associated with sleep and/or change in stage of sleep, so obtaining data during sleep may be needed to diagnose the cause of the apnea
    • CCHS may be associated with hypoventilation while awake, but is primarily a sleep-related disorder
    • Neuromuscular disease may be accompanied by structural disease (e.g., arthrogryposis, scoliosis)
    • Obstructive disease may have an obvious etiology (e.g., micrognathia), but consider central or CNS disease
    • Radiographic studies not as helpful as physiologic studies; fluoroscopy may diagnose malacia
    • A pneumogram examines heart rate, respiratory rate, chest wall movement, and oxygen saturation, but may miss obstructive disease
    • Preferred test is polysomnography, which adds measures of sleep stage and body movement, EEG, pH, and CO2
    • Covert videotaping in hospital may be needed for suspected abuse

    Treatment

    • Central apnea therapy depends on cause; an infant may need no more than monitoring or supplemental O2.
    • Severe central apnea, especially with respiratory muscle failure, may need to be treated with artificial respiration (via nasal/face mask or tracheotomy tube)
    • CCHS may be treated long term with diaphragmatic pacing
    • Other causes of central apnea require targeted therapy (i.e., antibiotics for sepsis, O2 for severe hypoxia)
    • Severe obstruction is bypassed with tracheostomy, or overcome with positive pressure ventilation
    • Weight loss is an important adjunct in treating severe OSAS
    • Respiratory stimulants (e.g., caffeine) may help some babies with apnea of prematurity
    • Vigorously treat causative factors (e.g., GERD)
    • Apnea monitors are of little proven value in the management or treatment of apnea, yet frequently used

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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• Back to disease: Asphyxia: Introduction
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

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