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Apnea, Pediatric, Emergency Medicine

Basics

Description

- 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

- 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

- Duration of apnea - State: - Asleep, awake, crying - Relationship to feeds and position (supine, prone)

- 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

- 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

- 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

- 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

  • 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 pathwaysObstructive apnea:Respiratory effort is present, but there is no airflowStructural airway obstruction, often with paradoxical chest wall movementFunctional obstruction from airway collapseMixed
  • Apparent life-threatening event (ALTE):Episode that is associated with a combination of apnea, color change, change in tone, choking, or gaggingA clinical presentation, not a diagnosis

Etiology

  • Infection:SepsisMeningitis or encephalitisPneumoniaPertussis/chlamydiaRSV and other viral respiratory infections
  • Respiratory:Obstructive airway lesionsEnlarged tonsils and adenoidsVocal cord dysfunctionLaryngotracheomalaciaVascular ringForeign bodyCraniofacial abnormalityChoanal atresia or stenosisFunctional obstruction from airway collapseInfectionImmaturity/prematurityAbnormal ventilatory response to hypoxia/hypercarbia
  • Neurologic:SeizureIntracranial hemorrhageIncreased intracranial pressureTumorArnold-Chiari or other CNS malformationIngestionToxinCarbon monoxideHypoxic injuryNeuromuscular disorderCentral hypoventilation syndrome
  • Cardiac:DysrhythmiaCongenital heart diseaseCHFMyocarditisCardiomyopathy
  • GI:GERDVolvulusIntussusception
  • Child abuse
  • Endocrine/metabolic:HypoglycemiaElectrolyte disordersInborn errors of metabolism
  • Other:Transient choking episodeLaryngospasmPeriodic breathingBreath-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, cryingRelationship 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 patternOFC (head circumference) pattern
  • Pulse oximetry
  • Exam of airway and lungs:Assess impending apneaStridor or other evidence of upper airway obstructionFast or slow respirationsUse of accessory musclesAdventitial lung sounds
  • Exam of heart:Irregular rhythmMurmurEvidence of CHF
  • Neurologic exam:Assess mental statusAssess for trauma, seizure, or toxidromeMuscle tone and reflexesFunduscopic 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 expirationCyanotic and pallid typesParoxysmal event occurring in 0.1-5% of healthy children 6 mo-6 yr of agePeriodic breathing may be seen in neonates:3 or more respiratory pauses lasting >3 sec with <20 sec of respiration between pausesMay be normal event

In a neonate, strongly consider occult sepsis.

Treatment

Pre-Hospital

  • Respiratory support as indicatedHigh-flow oxygen if breathing resumesCheck/clear out upper airwayBag-mask ventilationEndotracheal intubation if continued apnea
  • IV access, cardiac monitoring
  • Look for signs of an underlying cause:MedicationsDocument a basic neurologic exam:GCSPupilsExtremity movementsGross signs of traumaTalk 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 EDCeftriaxone: 50 mg/kg IVVancomycin: 15 mg/kg IVNeonates:Ampicillin: 50 mg/kg IVGentamicin: 2.5 mg/kg IV
  • Dextrose: 2-4 mL/kg D25W IV or 5-10 mL/kg D10W IVNeonates: 1 mo 2-4 mL/kg D10W IV
  • Naloxone: 0.01-0.1 mg/kg IV/IM/SC/ETCaution: 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.

See Also (Topic, Algorithm, Electronic Media Element)

  • Sudden Infant Death Syndrome
  • Neonatal Sepsis

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)