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Stefan Johansson

Post-discharge apnea monitoring in extr preterm infants?

Do you routinely recommend apnea monitor as post-discharge surveillance in post-extremely preterm infants?   

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This is a practical question that surfaces in my hoods from time to time - whether to routinely recommend an apnea monitor when discharging extremely preterm infants, and use it during the first months of life (or not!)?

Would be great to see how you would do it?

Do you have guidelines, or do you decide from family to family?

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We generally don't, for a combination of economic, physiologic and logistical reasons (in the USA).  The reality is that our payers (private and even state insurance) will cover prolonged hospitalization for apnea so there is no financial pressure to discharge while apnea is a serious concern.  Given this, we have a unit protocol that waits 5 days after any (unprovoked) clinically significant cardiopulmonary event (CSCPE) and 2 days after provoked events (usually feeding related).  See https://www.ncbi.nlm.nih.gov/pubmed/27684421 for our standardized definition of CSCPE.  There is weak evidence that there may be recurrent 'spells' even if a baby is spell free for 5 days (I can't find it at the moment, but there was a creative study from Virginia and Dartmouth a number of years ago that found recurrent spells unto 7-8 days after the previous event) but we've not seen this in practice.  Finally, there are logistical barriers in our current environment: Our NICU clinic does not have staff/equipment/training to interrogate these devices.  Our pulmonology colleagues do but they are very uncomfortable managing apnea of prematurity.  The end result is that if we send babies on on such monitors and they go off the parents have no one to speak with who both understands the monitor and the underlying pathology and if they come to the ED no one will be able to interrogate the device in a timely manner.  Furthermore, if the baby goes home on room air, there is no intervention the parents can offer if the monitor goes off except perhaps stimulation.  Are they expected to stare at the monitor around the clock and swim the baby when it goes off?  This way madness lies!  When you combine these, I can recall sending ONE patient in 3 years home with such a device (not counting babies on home O2 who go home with a monitor for somewhat different reasons).  It was at parents insistence and some deal brokered with the primary team that the covering weekend attending would discharge on a monitor.  The baby was readmitted to our quaternary referral NICU for a blue spell at home within a week and it was a huge issue; I honestly cannot ever see myself sending a baby home on RA and with a monitor.

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Very rarely, we send a baby home on home apnea/cardiorespiratory monitor, just for post-discharge monitoring for apnea. I don't think that, there is adequate evidence

to support that practice on a routine basis (2016-AAP Guidelines). From our Level IV NICU, more than 90% of babies that go home on home apnea / CR monitors have

O2 dependent chronic lung disease / BPD (That number is dwindling down). Remaining infants  tend to belong to the following groups- a) babies that are otherwise

ready to be sent home, but unable to be weaned off caffeine by 36 weeks PMA. We attempt weaning off caffeine by 32 to 34 weeks babies that had no "true apneic

episodes" for a week (will stop caffeine if maintenance dose is 4 to 6 mg/kg/day, Or will decrease by 50% for 4 days, and stop it if remained asymptomatic, when the

maintenance dose is 7 to 10 mg/kg/day, b) babies that are symptomatic at >36 weeks GA (apnea of infancy and other causes are ruled out), c) ALTE (apparent life

threatening event- other cause are ruled out), and d) miscellaneous- babies that have very high potential upper airway obstruction, such as upper airway anomalies,

severe GE reflux, CNS anomalies, central hypoventilation syndrome, s/p trach etc.

 

Once on home apnea / CR monitor, we use the following criteria for discontinuing-- a) at 44 weeks (or more) corrected GA, and apnea free for 1 month, b) the reasons

for using the monitors, have resolved, and c) off caffeine for 7 to 10 days, and remained asymptomatic.

 

Yes, we have guidelines, but compliance is unsure. I guess, it tends to be individualized.

 

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We send them on small spo2 monitor..we teach mother some basic resuscitation...we have kmc well established...kmc started at around 1 kg weight..so mother gets good time spent with baby under observation..and she gets good time to learn basics like what to do in case of apneas...we have very less rate of BPD and very less babies sent on o2...

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@all: So how trustworthy do you find your current equipment in determining apneas prior to discharge? What are recurring issues?

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On 7/23/2018 at 5:01 AM, HSchn said:

@all: So how trustworthy do you find your current equipment in determining apneas prior to discharge? What are recurring issues?

I'm not sure whether the issue is equipment vs. us not really understanding what sorts of 'events' it is safe to have at home.  The CHIMES study clearly shows that even well past term corrected many babies will have minor events that no one really ever notices because they aren't looking.  There is reasonable evidence that you can ignore brief events without compromising safety (probably because many brief events reflect monitor limitations as opposed to actual biology) [see https://www.researchgate.net/publication/308756008_Clinically_significant_cardiopulmonary_events_and_the_effect_of_definition_standardization_on_apnea_of_prematurity_managementfor example].  My experience has been that the biggest issues are not, at their heart, technological but social and professional: We get parents who stare at the bedside monitor for weeks on end and are terrified to go home and we also get bedside nurses who either document every time the monitor alarms (often without enough context overnight for the team the next morning to figure out if the baby is actually any different) or nurses who document only the most severe episodes when a kid is getting ready to go home.  One of my prior units started a program to standardize the approach of our nurses to these cases and, from a physician perspective, it Wass an unbelievably positive change 

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Sorry for slow input from my side, have been either off-work (vacation :)) or very much on-work (summer schedule...). And sorry that I did not extend my thoughts in the first post.

The questions we debate is 1) to what extent have very and extremely preterm infants an increased risk of Sudden Infant Death (SIDS/SUID) and 2) shall we use apne monitor for an extended period at home (like a few months corrected term age)?

Although I interpret research on gestational age and SIDS/SUID prone to bias (mainly confounding) I think this paper in Pediatrics (http://pediatrics.aappublications.org/content/140/1/e20163334.long) is rather convincing that rates and relative risks increase as gestational age shorten, despite adjustments for factors like parental smoking.

The critical question is of course whether apnea monitors reduce the risk of SIDS/SUID - but THAT question is hardly possible to investigate given low baseline risks etc.

In our unit (Sachs Chuildren's /Stockholm) we don't have guidelines on paper, but we tend to follow the guidelines at Karolinska Univ Hospital; where extremely preterm infants are monitored at home until the age of 3 months corrected age.

@bimalc Thanks for sharing that paper, will read it more carefully. I feel we have some degree of "overmonitoring" in our unit, and suffer from some "alarm fatigue" as well... With regard to home monitoring with an apnea sensor monitor, my experience is that the monitors are working well (i.e. either true or false alarms) and most parents report that they felt good to have it. But maybe that is a false feeling of "safety".

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Agree for SIDS risk; Eran Alhaij,adversarial chilhood events are associated with SIDS:an ecological study,

But it's not easy in our country to monitor at home till 3 months corrected age ; medicine is private, even post-dischqrge follow up by ''home care'' is expensive.

WE only monitor BPD leaving the unit with nasal oxygen .

 

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