Basics
Description
- A respiratory pattern consisting of regular oscillations in breathing amplitude
- Typically, a respiratory pattern in which ≥3 apneas lasting ≥3 seconds occur, separated by <20 seconds of respiration
Alert
Don 't confuse periodic breathing with obstructive and/or central apnea.
Epidemiology
- Usually absent in the 1st 48 hours of life
- More frequent during rapid eye movement (REM or active) sleep versus non-REM (quiet) sleep
- Less common in prone versus supine position
- In full-term infants
- Amount of periodic breathing usually <4% of total sleep time
- Amount gradually decreases through the 1st year of life.
- By 1 year of age, the mean amount of periodic breathing is <1% of total sleep time.
- In premature infants
- Amount of periodic breathing is higher than in full-term infants.
- Amount correlates inversely with gestational age.
Pathophysiology
- No common pathologic finding
- Abnormalities, when they exist, are related to the underlying disorder causing the periodic breathing.
Etiology
- Periodic breathing can be seen in healthy infants, children, and adults.
- Abnormalities, in any component of the breathing control system, may result in an increased amount of periodic breathing.
- Possible etiologies
- A delay in detecting changes in blood gas values by the chemoreceptors
- Increased chemoreceptor gain
Commonly Associated Conditions
- Periodic breathing in infants is associated with the following:
- Apnea of prematurity or infancy
- Familial history of sudden infant death syndrome (SIDS)
- Anemia of prematurity
- Hypoxemia
- Hypochloremic alkalosis
- Periodic breathing with adults is associated with the following:
- Cardiac abnormalities (especially congestive heart failure [CHF])
- Neurologic dysfunction (meningitis, encephalitis, brainstem dysfunction)
- Exposure to high altitudes
Diagnosis
History
- In most cases, parents notice periodicity in the child 's respiratory pattern.
- An apparent life-threatening episode (ALTE) might precipitate an evaluation in which periodic breathing is documented.
- In otherwise healthy premature or term infants, there are no other symptoms.
Physical Exam
In otherwise healthy premature or term infants, the physical exam is normal.
Diagnostic Tests & Interpretation
Imaging
Chest x-ray: usually normal findings
Diagnostic Procedures/Other
- Polysomnography
- Assesses the extent of periodic breathing episodes
- Determines if there is accompanying hypoxemia, hypercarbia, or bradycardia with the events
- Distinguishes between periodic breathing and obstructive and/or central apnea
- Useful for following response to treatment (i.e., normalization of polysomnography)
- pH probe done in combination with the polysomnogram (if gastroesophageal reflux is suspected): Record for a minimum of 6 hours.
- 2-channel pneumogram
- Gives less information than polysomnography
- Can document periodic breathing, but it may miss episodes of obstructive apnea
- Monitors heart rate and respiratory effort (If oxygen saturation monitoring is desired, an additional channel is required).
Differential Diagnosis
- Other forms of apnea:
- Central apnea
- Mixed apnea
- Obstructive apnea (or hypopnea)
- Other forms of periodic breathing:
- Cheyne-Stokes respirations
- Biot breathing
- Kussmaul respirations
- Normal irregular respiration seen in infants
Treatment
Medication
- Stimulants
- Caffeine IV or PO (based on caffeine base; multiply dosage by 2 for caffeine citrate salt)
- Loading dose: 10 mg/kg
- Maintenance dose: 2.5 mg/kg/24 h
- Therapeutic level: 5 " 20 mg/L
- Theophylline PO (if using aminophylline IV, divided dosage by 0.79)
- Loading dose: 4 " 5 mg/kg
- Maintenance dose: 3 " 5 mg/kg/24 h divided t.i.d.
- Therapeutic level: 6 " 10 mg/L
Additional Treatment
General Measures
- Therapy should be directed at treating the underlying primary disease:
- If periodic breathing is associated with apnea, hypoxemia, and/or other sleep disturbances, appropriate treatment of the underlying etiology should be instituted.
- In cases secondary to CHF, appropriate cardiac interventions need to be instituted.
- In cases associated with high altitude, treatment options include the following:
- Acclimation (if tolerated)
- Descent to lower altitude, then gradual ascent
- Medication (acetazolamide most commonly used)
- Duration of therapy
- Depends on the underlying cause of the periodic breathing
- Treatment does not change the natural course of periodic breathing in otherwise healthy infants.
- Therapy should continue until the periodic breathing resolves or is no longer clinically significant.
Additional Therapies
- Supplemental oxygen: useful if periodic breathing is secondary to hypoxemia
- Nasal continuous positive airway pressure (CPAP): very effective in eliminating periodic breathing
- Home monitoring should be considered (although not absolutely indicated) in the following cases:
- Significant amount of periodic breathing
- Accompanying apnea
- Associated hypoxia and/or bradycardia
- History of a significant ALTE
- Parental anxiety
Ongoing Care
Follow-up Recommendations
- Time to improvement depends on the underlying cause of the periodic breathing.
- Improvement is anticipated as the infant ages.
- When treatment is started, a decrease in the amount of periodic breathing should be seen almost immediately.
Prognosis
- Excellent in otherwise healthy premature or term infants
- Governed by primary process in patients with an underlying cardiac or neurologic disorder
Complications
Relationship between periodic breathing and SIDS is controversial.
Additional Reading
- Carroll JL, Agarwal A. Development of ventilatory control in infants. Paediatr Respir Rev. 2010;11(4):199 " 207. [View Abstract]
- Horemuzova E, Katz-Salamon M, Milerad J. Breathing patterns, oxygen and carbon dioxide levels in sleeping healthy infants during the first nine months after birth. Acta Paediatr. 2000;89(11):1284 " 1289. [View Abstract]
- Hunt CE, Corwin MJ, Lister G, et al. Longitudinal assessment of hemoglobin oxygen saturation in healthy infants during the first 6 months of age. J Pediatr. 1999;135(5):580 " 586. [View Abstract]
- Miano S, Castaldo R, Ferri R, et al. Sleep cyclic alternating pattern analysis in infants with apparent life-threatening events: a daytime polysomnographic study. Clin Neurophysiol. 2012;123(7):1346 " 1352. [View Abstract]
- Poets CF. Apnea of prematurity: what can observational studies tell us about pathophysiology? Sleep Med. 2010;11(7):701 " 707. [View Abstract]
- Schechter MS, Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome. Technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2002;109(4):e69. [View Abstract]
- Sterni LM, Tunkel DE. Obstructive sleep apnea in children: an update. Pediatr Clin North Am. 2003;50(2):427 " 443. [View Abstract]
Codes
ICD09
- 786.09 Other respiratory abnormalities
ICD10
SNOMED
- 271824009 Respiration intermittent (finding)
FAQ
- Q: What is the risk of the patient dying of SIDS?
- A: The relationship between periodic breathing and SIDS is not clear, although most studies have not found a higher frequency of SIDS among patients with periodic breathing.