CPAP is sometimes necessary
(the baby may already be on this if weaned from ventilation or recovering from
respiratory distress).
If the baby remains unstable on
CPAP and caffeine, consider IMV.
There are no fixed guidelines
on the initiation of any of these treatments, as the assessment of apnoea
tends to be subjective, and each baby needs individual assessment.
In general, exercise caution in
giving caffeine to babies with acute respiratory problems; apnoea often
indicates respiratory deterioration needing respiratory support, not caffeine.
Monitoring
the Baby
Babies with apnoea severe
enough to consider treatment should be monitored by a cardio-respiratory
monitor and pulse oximeter.
Once the baby becomes more
stable, discuss changing to an apnoea mattress on the ward round.
Usually this is at >32
weeks gestation.
Apnoea mattresses are
less sensitive at picking up apnoeas and do not detect bradycardias or
desaturations.
Monitoring
Caffeine
It is not necessary to do
routine levels on stable babies.
Serum concentrations should be
obtained either if toxicity is suspected or if a baby continues to have apnoea
and has not previously had an optimal level documented.
Note that the assay is not
very accurate and has a coefficient of variation of 15%, so that a
reported level of 165 mmol/L has a 95% chance of being between 115 and
215 mmol/L.
Levels should not be
checked within 6 hours of previous dose.
Order levels the day before
assay is to be done (clearly dated with the next day’s date). Levels to
be done at 0830 hours.
Therapeutic range is:
135-200 m mol/L, toxicity is unlikely at <400 m mol/L.
Discontinuing
When
In most babies, caffeine
can be stopped between 32 and 34 weeks gestation, as apnoea ceases to be
an ongoing problem. At the latest, it should be discontinued several days
before the baby goes home.
How
Continue apnoea monitoring
for several days after stopping caffeine. Depending on the clinical
situation, this can be either by an apnoea mattress or cardio-respiratory
monitor plus pulse oximetry.
For babies about to go
home, monitoring is usually for 4 days, with a further day off an apnoea
monitor before discharge.
