Apnea in the Newborn (Nursing)

00:01 Hi, welcome to apnea in the pediatric patient.

00:04 This is a lecture that covers terms and definitions, the types of apnea you'll see in pediatrics and the basic treatments for them.

00:11 Let's start with terms and definitions.

00:14 Normal newborn breathing can be anything but normal.

00:18 Have you ever tried to take a respiratory rate in a newborn? It can be super frustrating and difficult.

00:23 Usually you have to listen for a full minute to get an accurate rate.

00:28 The reason why it's so frustrating is because they don't breed like we do.

00:33 When they're newborns, they sometimes have to learn to breathe like we do.

00:37 So they might be periodically pausing in their breaths.

00:40 As long as these pauses aren't longer than 10 seconds, and aren't accompanied by any cyanosis or other changes in respiratory status, like hypoxia or respiratory distress.

00:53 It's okay.

00:56 Apnea or the definition of apnea is a cessation of breathing for 20 seconds or more, or a smaller cessation of breathing that's accompanied by distress of some sort, which might include decreased heart rate, decrease O2 sat, or other signs of respiratory distress such as cyanosis.

01:17 Remember that if you're assessing a newborn or an older child, with darker skin, you may need to really check the mucous membranes to see changes in color such as cyanosis.

01:29 If you take care of infants in a hospital during nursing school, or after nursing school, when you're a nurse.

01:35 You may notice that many young infants are admitted to hospitals because of a brief resolved unexplained event called a BRUE.

01:43 You may wonder what that means.

01:45 Basically, it means that something happened when they were at home or with a caregiver.

01:49 That's unexplainable.

01:51 If this is not something that was witnessed by a healthcare provider, this is something that happened outside of the hospital, and caused enough concern to have the caregiver bring them to the hospital.

02:03 So, it has a special term, this is actually the diagnosis that's used.

02:07 And these infants are usually admitted to the hospital for a day or two for observation, to rule out anything serious.

02:15 Usually, these events involve some combination of what's described as apnea, color change, choking or gagging, or bradycardia, that's less likely to be reported because usually caregivers are not counting their heart, the child's heart rate.

02:32 Another term you may still see, in the medical literature or even hospitals is Apparent Life-Threatening Event or ALTE.

02:40 That's the classic word for BRUE, that was changed a few years ago by the American Academy of Pediatrics, but it means the same thing.

02:48 Let's talk about central apnea first.

02:51 Central apnea just means that there's a neurological cause for the apnea in the infant or child.

02:57 This can be a result of infection in the brain, head trauma, birth asphyxia, maternal drug use, such as narcotic use and the mother or a metabolic disorder.

03:09 Apnea of prematurity is the most common form of central apnea.

03:13 And it's seen in infants born under 28 weeks gestation, because these infants do not have normally developed neurological or respiratory systems.

03:25 By about 37 weeks gestation, these systems are developed and this is no longer a problem usually.

03:34 Alright, let's talk about obstructive apnea.

03:37 But first, let's compare the pediatric to the adult airway.

03:40 Newborns are born with various small airways compared to the adults.

03:45 They grow, and they strengthen, and they widen as they get older.

03:48 And often they grow out of airway problems because of this.

03:52 Newborns are also born with a larger tongue in proportion to their mouth, and a larger and floppier epiglottis.

04:00 And that is, those are both things that also contribute to increased risk of airway obstruction in a newborn, infant, or a child.

04:10 So a little more pathophysiology.

04:13 This is how easy airflow is supposed to happen in a normal, healthy human.

04:17 Basically, the air goes through the nose, or the mouth, goes past the adenoids and tonsils and down the trachea, and then it makes its way into the lungs.

04:26 So, now you can see how swollen tissue somewhere along the airway, which is often adenoid tissue or large tonsils, if it's upper airway problem, can cause difficult airflow.

04:40 That's something that's often seen in what we call sleep apnea.

04:43 These tissues sometimes collapse when somebody's sleeping and obstruct the airway either partially or all the way.

04:50 Certain cranial facial abnormalities that children are born with can also cause abnormal tissue along the airway that can cause this obstruction.

04:58 And lastly, the malacia, the airway malacia, which we cover in a different lecture can cause obstruction and a different way along the airway.

05:06 Because malacia's involve a weak or a very flexible and collapsing airway area that basically also obstructs airflow in a different way.

05:20 All right.

05:21 Let's talk about some different causes of obstructive apnea, which is basically any blockage within the airway that impedes that adequate ventilation from happening in the lungs, in the alveoli of the lungs.

05:34 Certain causes, certain specific causes include some airway infections.

05:39 So, for example, epiglottitis would cause a swollen epiglottis and the epiglottis is already pretty big to begin with.

05:46 So if it gets even bigger and more inflamed, it can be life threatening.

05:50 Some congenital problems such as the malacia's, large adenoids or tonsils, which is seen more in older children.

05:58 Newborns are not usually born with large adenoids and tonsils.

06:02 And obesity is also a risk factor for obstructive apnea just because people who are obese are more likely to have excess tissue or inflamed tissue.

06:12 All right, let's talk about mix apnea.

06:14 The last one we're going to cover and this one's a quick one.

06:16 Basically, it's what it sounds like.

06:19 It's a combination of central apnea, and some kind of obstructive apnea occurring at the same time or one right after the other.

06:27 It could be because a premature infant is born without a neurological system fully developed, and without the respiratory system fully developed.

06:35 So they're just not talking to each other at all.

06:38 And at the same time, they may have some sort of abnormality in their airway, such as weak tissue or very immature tissue that collapses.

06:47 So you can see how both these things could contribute to apnea, and sometimes could happen together.

06:52 Another condition that can cause mixed apnea and a premature infant especially, but really, in any infant is an infection that really affects the lungs and airways, such as bronchial itis or pertussis.

07:05 All right, now let's review the common treatment for apnea.

07:09 The treatment, as with most conditions depends on the type, the source and the severity of apnea, and any related symptoms.

07:18 So if there's an underlying cause that can be treated or fixed or corrected, it will be, but for instance, was central apnea, sometimes there's not.

07:27 If an infant has central apnea, because they were very premature.

07:31 Sometimes they just need their lungs and their brains to develop more fully.

07:34 And so they may need to be supported in an ICU setting until that point.

07:39 Some but not all, infants and children with apnea might need some supplemental oxygen.

07:47 And some might need breathing assistance, such as mechanical ventilation or CPAP, or BiPAP.

07:52 Those things are usually done in an ICU setting as well.

07:56 Medications such as caffeine maybe use.

07:59 It's actually given a lot in NICUs, or newborn intensive care units because it stimulates the breathing and it helps prevent apnea.

08:08 And finally, if an infant or child does not grow out of their apnea, with normal development and growth of the airway, surgery is an option.

08:19 The NCSBN Clinical Judgment Measurement Model is the framework being used now, in many NCLEX exam questions and case studies.

08:27 You may also hear about it in class, or see it in your nursing school exams.

08:31 So, we're gonna connect some of the content from this lecture to the first two important steps of that model.

08:38 In order to recognize cues and analyze cues, and an infant or child with apnea, you have to understand what apnea is and also understand what periodic breathing of the newborn is.

08:49 Remember, apnea means a cessation in breathing for 20 or more seconds, or a smaller sensation or breathing with signs of respiratory distress of some sort.

09:03 Periodic breathing of the newborn means that the newborn might have pauses of up to 10 seconds, but they do not come with any accompanying respiratory distress.

09:15 Recognizing cues and analyzing cues in these children also means that you have to know what are signs of respiratory distress, especially in pediatrics.

09:25 And actually the good news is they're this very similar or the same no matter what the condition are.

09:30 So, they may involve nasal flaring, or the opening of the nares to try to get more air.

09:37 They may include retractions, that could go anywhere from the neck down to under the sternum.

09:43 So, supraclavicular, suprasternum, intercostal between the ribs or substernum.

09:51 They could include airway noise, abnormal airway noise some sorts such as wheezing, or strider, or even decreased breath sounds, and they could include color change.

10:02 Remember that seeing color change and cyanosis and a child or infant who has darker skin can be very challenging.

10:09 And you have to be really careful to make sure you assess things like mucous membranes or nail beds and might be more likely to show those color changes.