A 3-day-old boy is evaluated in the neonatal intensive care unit for intermittent episodes of bradycardia and desaturation for the past 12 hours. He was born at 29 weeks gestation and had a birth weight of 1,050 g (2 lb 5 oz). The patient had respiratory distress syndrome initially, for which he was intubated and given endotracheal surfactant therapy. He was then extubated to continuous positive airway pressure on day of life 1 and has been stable since. Antibiotics were discontinued at age 36 hours when cultures remained sterile. During examination, the patient has cessation of respiratory effort that lasts about 25 seconds. The heart rate decreases to 85/min, and the oxygen saturation decreases to 72%. The patient recovers spontaneously, and the vital signs normalize. Physical examination after the episode is normal. Chest x-ray reveals resolving granular opacities bilaterally. Which of the following is the best next step in management of this patient?

Question

A 3-day-old boy is evaluated in the neonatal intensive care unit for intermittent episodes of bradycardia and desaturation for the past 12 hours.  He was born at 29 weeks gestation and had a birth weight of 1,050 g (2 lb 5 oz).  The patient had respiratory distress syndrome initially, for which he was intubated and given endotracheal surfactant therapy.  He was then extubated to continuous positive airway pressure on day of life 1 and has been stable since.  Antibiotics were discontinued at age 36 hours when cultures remained sterile.  During examination, the patient has cessation of respiratory effort that lasts about 25 seconds.  The heart rate decreases to 85/min, and the oxygen saturation decreases to 72%.  The patient recovers spontaneously, and the vital signs normalize.  Physical examination after the episode is normal.  Chest x-ray reveals resolving granular opacities bilaterally.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d723_62b7_bc81_8157465f87d0_MD0003_00 This patient has intermittent episodes of apnea, defined as periods of >20 seconds without respiratory effort. In a preterm infant with a normal physical examination who appears well between episodes, the most likely cause is apnea of prematurity (AoP). AoP is a type of central apnea (ie, no respiratory effort) caused by immature central respiratory centers in the brainstem. These respiratory centers are responsible for normal respiratory drive; in AoP, the signal to breathe intermittently fails to generate. AoP may not be evident immediately after birth but typically presents in the first few days of life with episodic respiratory pauses (often with associated bradycardia and desaturation) that may initially increase in frequency. Diagnosis is generally clinical; however, chest x-ray may be performed to exclude pulmonary pathology. AoP does not cause abnormalities on x-ray, but concomitant lung disease caused by prematurity may be seen, as in this patient with bilateral granular opacities from resolving respiratory distress syndrome. Mild apneic episodes may not require treatment; however, spells that are prolonged, frequent, or associated with bradycardia or hypoxia (as seen in this patient) can cause repeated "watershed" insults to the brain white matter, which can result in cerebral palsy. Therefore, treatment with caffeine therapy and/or noninvasive respiratory support (eg, high-flow nasal cannula, continuous positive airway pressure) is warranted. Caffeine is a methylxanthine that chemically stimulates the respiratory drive and is given until the respiratory centers mature, which is usually at 34-37 weeks postmenstrual age. (Choices A and C) Albuterol dilates the airways, and dexamethasone reduces inflammation in the airways and the alveolar-capillary interstitial space. These treatments can be used for obstructive apnea caused by severe bronchopulmonary dysplasia, which occurs after age 28 days and can cause chronic (not episodic) hypoxia. Albuterol and dexamethasone have no effect on AoP. (Choice D) Infants who continue to have significant AoP episodes despite caffeine therapy and noninvasive ventilation may need to be intubated and ventilated, but caffeine should be tried first. (Choice E) Although sepsis can present with apnea, this infant has a normal physical examination and appears well between apneic episodes, making additional antibiotic therapy unnecessary. Educational objective: Apnea of prematurity is caused by immature central respiratory centers and presents with respiratory pauses, often with bradycardia and desaturation. Treatment involves noninvasive ventilation and caffeine. References: Caffeine therapy for apnea of prematurity. (http://www.ncbi.nlm.nih.gov/pubmed/16707748) Neurobehavioral outcomes 11 years after neonatal caffeine therapy for apnea of prematurity. (http://www.ncbi.nlm.nih.gov/pubmed/29643070)

A 3-Day-Old Boy Is Evaluated in the Neonatal Intensive Care