Apnea, Pediatric, Emergency Medicine

Basics

Description

Absence of respiratory airflow for a period of 20 sec, with or without decreased heart rate:
- Central apnea:
  - Disruption in the generation or propagation of respiratory signals in the brainstem and descending neuromuscular pathways
- Obstructive apnea:
  - Respiratory effort is present, but there is no airflow
  - Structural airway obstruction, often with paradoxical chest wall movement
  - Functional obstruction from airway collapse
- Mixed
Apparent life-threatening event (ALTE):
- Episode that is associated with a combination of apnea, color change, change in tone, choking, or gagging
- A clinical presentation, not a diagnosis

Etiology

Infection:
- Sepsis
- Meningitis or encephalitis
- Pneumonia
- Pertussis/chlamydia
- RSV and other viral respiratory infections
Respiratory:
- Obstructive airway lesions
  - Enlarged tonsils and adenoids
  - Vocal cord dysfunction
  - Laryngotracheomalacia
  - Vascular ring
  - Foreign body
  - Craniofacial abnormality
  - Choanal atresia or stenosis
- Functional obstruction from airway collapse
- Infection
- Immaturity/prematurity
- Abnormal ventilatory response to hypoxia/hypercarbia
Neurologic:
- Seizure
- Intracranial hemorrhage
- Increased intracranial pressure
- Tumor
- Arnold-Chiari or other CNS malformation
- Ingestion
- Toxin
- Carbon monoxide
- Hypoxic injury
- Neuromuscular disorder
- Central hypoventilation syndrome
Cardiac:
- Dysrhythmia
- Congenital heart disease
- CHF
- Myocarditis
- Cardiomyopathy
GI:
- GERD
- Volvulus
- Intussusception
Child abuse
Endocrine/metabolic:
- Hypoglycemia
- Electrolyte disorders
- Inborn errors of metabolism
Other:
- Transient choking episode
- Laryngospasm
- Periodic breathing
- Breath-holding spell

Diagnosis

If the patient is apneic, treatment must commence at once.

Signs and Symptoms

Apnea may be current, historical, or impending.
History

Duration of apnea
State:
- Asleep, awake, crying
- Relationship to feeds and position (supine, prone)
Respiratory effort:
- None, shallow breathing, increased work of breathing, struggling to breathe, choking
Presence and location of any color change
Position of eyes
Description of movements and muscle tone
Interventions done by the caregiver
Antecedent symptoms such as fever or cough
Antecedent trauma
Past medical history, including prematurity, cardiopulmonary, GI, or neurologic conditions
Any past history of ALTEs in this patient or family members

Physical Exam

Vital signs with temperature
Growth parameters:
- Weight pattern
- OFC (head circumference) pattern
Pulse oximetry
Exam of airway and lungs:
- Assess impending apnea
- Stridor or other evidence of upper airway obstruction
- Fast or slow respirations
- Use of accessory muscles
- Adventitial lung sounds
Exam of heart:
- Irregular rhythm
- Murmur
- Evidence of CHF
Neurologic exam:
- Assess mental status
- Assess for trauma, seizure, or toxidrome
- Muscle tone and reflexes
- Funduscopic exam

Essential Workup

Complete history and physical exam
The historical factors and exam will direct the diagnostic evaluation and treatment
Check/clear out upper airway as appropriate.
Remove or suction any obstruction as appropriate
Ensure proper head positioning with special consideration for occult trauma

Diagnosis Tests & Interpretation

Lab
Perform as appropriate for presentation:

Dextrostix
CBC
Urinalysis
CSF studies
Blood, urine, and CSF cultures
Electrolytes (including calcium)
BUN, creatinine
Blood gas
RSV and respiratory viral studies
Pertussis and chlamydia tests
Consider toxicologic screen (including toxic alcohols and acetaminophen)
Consider LFTs and ammonia

Imaging
Perform as appropriate for presentation:

CXR
Head CT or MRI
ECG
UGI or swallowing study
Polysomnography in follow-up in patient with suspected central or obstructive sleep apnea
EEG in follow-up
0 Bone survey and other studies as indicated

Differential Diagnosis

Multiple etiologies as previously noted
Special considerations:
- Breath-holding spells:
  - Reflexive cessation of respiratory effort during expiration
  - Cyanotic and pallid types
  - Paroxysmal event occurring in 0.1-5% of healthy children 6 mo-6 yr of age
- Periodic breathing may be seen in neonates:
  - 3 or more respiratory pauses lasting >3 sec with <20 sec of respiration between pauses
  - May be normal event

In a neonate, strongly consider occult sepsis.

Treatment

Pre-Hospital

Respiratory support as indicated
- High-flow oxygen if breathing resumes
- Check/clear out upper airway
- Bag-mask ventilation
- Endotracheal intubation if continued apnea
IV access, cardiac monitoring
Look for signs of an underlying cause:
- Medications
- Document a basic neurologic exam:
  - GCS
  - Pupils
  - Extremity movements
- Gross signs of trauma
- Talk with family/pre-hospital personnel for information

Initial Stabilization/Therapy

Establish unresponsiveness
Check/clear out upper airway
Remove or suction any obstruction
Ensure proper head positioning

Ed Treatment/Procedures

If currently apneic, ventilate with the bag-valve-mask device and high-flow oxygen
Endotracheal intubation is required if apnea persists
Resuscitation medications and antibiotics as indicated
Support and counseling if breath holding suspected

Medication

Antibiotic doses in ED
- Ceftriaxone: 50 mg/kg IV
- Vancomycin: 15 mg/kg IV
- Neonates:
  - Ampicillin: 50 mg/kg IV
  - Gentamicin: 2.5 mg/kg IV
Dextrose: 2-4 mL/kg D25W IV or 5-10 mL/kg D10W IV
- Neonates: 1 mo 2-4 mL/kg D10W IV
Naloxone: 0.01-0.1 mg/kg IV/IM/SC/ET
- Caution: May precipitate withdrawal symptoms in patients with chronic opiate use

Follow-Up

Disposition

Admission Criteria

Patients who were or may become apneic should be admitted to an inpatient unit for appropriate monitoring. Those with persistent abnormal vital signs need intensive care monitoring.
Variables that identify most children requiring admission include those with an obvious need for admission including abnormal vital signs or a medical history, or >1 apparent ALTE event in 24 hr.
Recommend referral for pediatric evaluation and follow-up as indicated. Interventions may include further studies (i.e., EEG), antireflux medications or caffeine, and home monitoring.

Discharge Criteria
In patients without true apnea who are low risk and have no abnormalities noted during the period of observation and evaluation, discharge may be considered, assuming that parents are compliant and comfortable with their child and follow-up and support are definitively established.
Issues for Referral
Primary care physician and subspecialist, reflecting suspected etiology

Pearls and Pitfalls

Consider occult sepsis, especially in a neonate
Consider occult trauma

Additional Reading

Brand AD, Altman RL, Purtill K, et al. Yield of diagnostic testing in infants who have had an apparent life-threatening event. Pediatrics. 2005;115:885-893.
Claudius I, Keens T. Do all infants with apparent life-threatening events need to be admitted? Pediatrics. 2007;119(4):679-683.
De Piero A, Teach SJ, Chamberlain JM. ED evaluation of infants after an apparent life-threatening event. Am J Emerg Med. 2004;22(2):83-86.
Kahn A; European Society for the Study and Prevention of Infant Death. Recommended clinical evaluation of infants with an apparent life-threatening event. Consensus document of the European Society for the Study and Prevention of Infant Death, 2003. Eur J Pediatr. 2004;163(2):108-115.
Kaji AH, Claudius I, Santillanes G, et al. Apparent life-threatening event: Multicenter prospective cohort study to develop a clinical decision rule for admission to the hospital. Ann Emerg Med. 2013;61:379-387.
McGovern MC, Smith MB. Causes of apparent life threatening events in infants: A systematic review. Arch Dis Child. 2004;89(11):1043-1048.

Codes

ICD9

327.23 Obstructive sleep apnea (adult)(pediatric)
770.81 Primary apnea of newborn
786.03 Apnea

ICD10

G47.33 Obstructive sleep apnea (adult) (pediatric)
P28.4 Other apnea of newborn

SNOMED

13094009 Apnea in the newborn (finding)
276545006 Obstructive apnea of newborn (disorder)

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