Periodic Breathing, Pediatric

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Periodic Breathing, Pediatric

Basics

Description

Chest x-ray: usually normal findings

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

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 infantsAmount of periodic breathing usually <4% of total sleep timeAmount 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 infantsAmount of periodic breathing is higher than in full-term infants.Amount correlates inversely with gestational age.

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.

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 etiologiesA delay in detecting changes in blood gas values by the chemoreceptorsIncreased chemoreceptor gain

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 infancyFamilial history of sudden infant death syndrome (SIDS)Anemia of prematurityHypoxemiaHypochloremic 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

Apnea of prematurity or infancy
Familial history of sudden infant death syndrome (SIDS)
Anemia of prematurity
Hypoxemia
Hypochloremic alkalosis

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

Diagnostic Tests & Interpretation

PolysomnographyAssesses the extent of periodic breathing episodesDetermines if there is accompanying hypoxemia, hypercarbia, or bradycardia with the eventsDistinguishes between periodic breathing and obstructive and/or central apneaUseful 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 pneumogramGives less information than polysomnographyCan document periodic breathing, but it may miss episodes of obstructive apneaMonitors heart rate and respiratory effort (If oxygen saturation monitoring is desired, an additional channel is required).

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)

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 apneaMixed apneaObstructive apnea (or hypopnea)
Other forms of periodic breathing:Cheyne-Stokes respirationsBiot breathingKussmaul respirations
Normal irregular respiration seen in infants

Central apnea
Mixed apnea
Obstructive apnea (or hypopnea)

Cheyne-Stokes respirations
Biot breathing
Kussmaul respirations

Treatment

Medication

StimulantsCaffeine IV or PO (based on caffeine base; multiply dosage by 2 for caffeine citrate salt)Loading dose: 10 mg/kgMaintenance dose: 2.5 mg/kg/24 hTherapeutic level: 5 " 20 mg/LTheophylline PO (if using aminophylline IV, divided dosage by 0.79)Loading dose: 4 " 5 mg/kgMaintenance dose: 3 " 5 mg/kg/24 h divided t.i.d.Therapeutic level: 6 " 10 mg/L

Caffeine IV or PO (based on caffeine base; multiply dosage by 2 for caffeine citrate salt)Loading dose: 10 mg/kgMaintenance dose: 2.5 mg/kg/24 hTherapeutic level: 5 " 20 mg/L
Theophylline PO (if using aminophylline IV, divided dosage by 0.79)Loading dose: 4 " 5 mg/kgMaintenance dose: 3 " 5 mg/kg/24 h divided t.i.d.Therapeutic level: 6 " 10 mg/L

Loading dose: 10 mg/kg
Maintenance dose: 2.5 mg/kg/24 h
Therapeutic level: 5 " 20 mg/L

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

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 ascentMedication (acetazolamide most commonly used)
Duration of therapyDepends on the underlying cause of the periodic breathingTreatment 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.

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 ascentMedication (acetazolamide most commonly used)

Acclimation (if tolerated)
Descent to lower altitude, then gradual ascent
Medication (acetazolamide most commonly used)

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 breathingAccompanying apneaAssociated hypoxia and/or bradycardiaHistory of a significant ALTEParental anxiety

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

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

R06.3 Periodic breathing

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.