and Science of Home Infant Apnea Monitoring in the 1990s

Transcription

1 C A I A I S S U 1 s and Science of Home Infant Apnea Monitoring in the 1990s Sarah Whitaker, MSN, RNC The use of home apnea monitoring (HAM) continues as an accepted or recommended intervention for infants with certain signs and symptoms or medical diagnoses. Results of HAM in terms of case outcomes versus cost-effectiveness and efficacy remain matters of controversy in relation to the limited number of studies that show conflicting results. There are no studies that document the effectiveness of apnea monitoring. When an apnea monitor is prescribed, nursing can provide quality care through education and emotional support of families using HAM. Infants often are placed on apnea monitors in home programs to facilitate early discharge, which allows the infants to go home, where bonding and normal stimulation for growth and development can occur. A pproximately 11 to 12.4 infants per 1,000 live births are placed on home apnea monitoring (HAM) each year in the United States (Ahmann, 1989). There are approximately 45,000 monitors in use in the United States, according to the federal Food and Drug Administration. The rate varies in other countries in relation to the technology available and the recognized indications for monitoring. This article reviews the current theory and nursing care undergirding the home infant apnea monitoring programs. What Is Home Apnea Monitoring? Home apnea monitoring (HAM) involves the use of an apnea monitoring machine to detect apnea events. If the monitor detects a symptom of a possible apnea event, an alarm sounds, alerting the caregiver that observation is needed and intervention may be required. However, false alarms also may occur, which require observation and intervention with the machine. Infants frequently are placed on apnea monitors in home programs to facilitate early discharge, which allows the infant to be with his/her parents and family in the home environment, where bonding and normal stimulation for healthy growth and development can occur. In addition to being more emotionally suitable for most parents and infants, the home monitoring program is less costly than keeping the infant in the hospital to be monitored. There are three major types of monitors. One type detects apnea only. Another type detects apnea and bradycardia or heart rate changes. Depending on the type of monitor, the alarm responds to apnea, bradycardia, apnea and bradycardia, tachycardia, loose lead, dry lead, and weak battery signals (Webb & Duncan, 1983). The third type of monitor has a memory to record cardiorespiratory patterns and alarms for what the machine senses as an apnea event. This system of monitoring is called documented monitoring. Documented monitoring records not only the apnea event but also basic data before and after the event, such as transient pulse deceleration, bradycardia, apnea, and desaturation in the form of oximetry in some monitor models. The documented monitor records the time the monitor is turned on and off. This feature can help the health-care providers to assess compliance with the monitoring program (Weese-Mayer & Silvestri, 1992). The memory feature in documented monitoring ensures accuracy in reporting to the health-care provider. The newest models of the third type are able to record in computer memory electrocardiography waveforms, heart rate trend, respiratory effort waveforms, oxygen saturation levels, pulse waveforms, and airflow, straingage or C02 physiologic signal. Some new models are capable of doc- 84 J O C N N Volume 24, Number 1

2 Home Care umenting the infant s body position as prone or nonprone. Apnea Defined An apnea event occurs when there is a respiratory pause. The length of the respiratory pause is a matter of controversy in the literature and research studies (Ahmann, 1986). Aranda et al. (1983) recognize apnea as a respiratory pause greater than seconds. Most literature recognizes more than 20 seconds as the length of respiratory pause indicating apnea. A few studies identify 15. seconds for the length of respiratory pause. A longer than 20-second respiratory pause is the most recognized definition during clinical practice. Apnea can be defined in two ways (Nelson, 1992). The first definition states that apnea is a respiratory pause that exceeds three standard deviations of the mean breath time for an infant of a particular age. This definition does not have physiologic value. The second definition of apnea associates it with cardiovascular and neurophysiologic changes, such as skin color turning cyanotic and muscle tone loss or muscle rigidity. Clinically the second definition has meaning and can be applied to clinical practice. The nurse needs to be aware of two major types of apnea: idiopathic apnea of prematurity and obstructive apnea. Obstructive apnea is characterized by absent air flow while chest wall movement is occurring. Infants rarely have obstructive apnea. An obstructive apnea index used by Marcus, Glomb, Basinski, Ward, and Keens (1994) recognizes obstructive apnea as an absence of breathing for two or more respiratory cycles. The cause is not known. Some theories to explain this condition are: upper airway obstruction related to pharyngeal instability; neck flexion; and nasal occlusion. These anatomic features would produce a reduction in the size of the upper airway or increased compliance or collapsibility of the upper airway structures (Nelson, 1992). Another theory for obstructive apnea is that reflexes affect the crosssectional air passages and may close or reduce the size of the passages and prevent air exchange. The other type of apnea, idiopathic apnea of prematurity, is related to gestational age and reduced central nervous system stimulus. Apnea events need to be differentiated from normal periodic breathing in premature infants. Periodic breathing is a respiratory pattern that has cyclic brief pauses of 5-10 seconds that are followed by a burst of respirations at the rate of a minute within a time frame of seconds. Periodic breathing is not associated with a change in skin color or heart rate. There are several terms used for the description of apneas in infants. The National Institutes of Health held a consensus conference on infantile apnea and home monitoring in October The conference statement (National Institutes of Health Consensus Development Conference Statement, 1986) provided definitions of ap- Table 1. Definitions of Apnea ~ Apnea: cessation of respiratory air flow. The respiratory pause may be central or diaphragmatic (i.e., no respiratory effort), obstructive (usually caused by upper airway obstruction), or mixed. Short (15 seconds), central apnea can be normal at all ages. Pathologic apnea: a respiratory pause is abnormal if it is prolonged (20 seconds) or associated with cyanosis, abrupt marked pallor, hypotonia, or bradycardia. Periodic breathing: a breathing pattern in which there are three or more respiratory pauses of greater than 3 seconds duration with less than 20 seconds of respiration between pauses. Periodic breathing can be a normal event. Apnea of prematurity (AOP): period breathing with pathologic apnea in a premature infant. Apnea of prematurity usually ceases by 37 weeks gestation but occasionally persists to several weeks past term. Apparent life-threatening event (ALTE): an episode that is characterized by some combination of apnea, color change, marked muscle tone change, choking, or gagging. Apnea of infancy (AOI): an unexplained episode of cessation of breathing for 20 seconds or longer, or a shorter respiratory pause associated with bradycardia, cyanosis, pallor, or marked hypotonia. The infants usually are older than 37 weeks gestational age at onset of pathologic apnea. The term is reserved for the infants for whom no specific cause of ALTE can be identified. nea (Table 1). These are the definitions that are becoming recognized worldwide and are used in most research. signa$cance of Apnea Respiratory pauses are cause for concern because infants have a higher oxygen consumption rate, a smaller lung volume, and lower oxygen stores than do adults. The infant is more vulnerable and sensitive to a lack of oxygen. The significance of apnea in the infant, especially a premature infant, can have serious health implications. The infant may experience lack of oxygen, resulting in brain and organ damage. On autopsy, sudden infant death syndrome (SIDS) victims have had tissue markers that indicate chronic hypoxia and hypoxemia (National Institutes Respiratory pauses are cause for concern because infants have a higher oxygen consumption rate, a smaller lung volume, and lower oxygen stores than do adults. January 1995 JOG 85

3 C L I N I C A L I S S U E S of Health Consensus Development Conference, 1987). It was believed that if one could identify an infant who has apnea, one could treat and prevent SIDS with an apneamonitoring protocol. However, it has not proven to be that simple as apparent life-threatening events and SIDS are explored. Apparent Life-threatening Events Another term in the literature that is described as an event of severe apnea is an apparent life-threatening event (ALTE). The older literature identifies what we call ALTE as a near miss SIDS. ALTE is more accurate, and with known etiology, has no relationship to SIDS. An ALTE is characterized by the symptoms of apnea, cyanosis, altered muscle tone, choking, or gagging (Little & Peterson, 1990). ALTE describes a clinical syndrome that may have multiple causes that may or may not be identified. When the cause cannot be identified, the infant may be at increased risk for dying of SIDS (Steinschneider, Weinstein, W Diamond, 1982). In the work done by Keens and Ward (1993), treatable etiologies were found in approximately 30% of the infants with a history of ALTE. Keens and Ward found that episodes of ALTE that occurred while the infant was awake were more likely to be secondary to a treatable underlying condition. When a treatable cause of ALTE cannot be found, the diagnosis of apnea of infancy is made. SIDS and Apnea The literature often assumes a relationship between apnea and SIDS. This is not a correct assumption. An epidemiologic study conducted through the National Institute of Child Health and Human Development revealed no difference in the incidence of neonatal apnea in SIDS victims compared with non-sids infants in a control group. However, there was an increased incidence of ALTE occurring in postterm SIDS victims (7%) as compared with non-sids infants in the control group. SIDS is defined as: The sudden death of an infant under one year of age which remains unexplained after the performance of a complete postmortem investigation, including an autopsy, an examination of the scene of death and review of the case history (Valdez-Dapena, 1992, p. 133). SIDS is associated with age, nutrition, viral infection (Influenza A), anemia, and maternal cigarette smoking and drug abuse. Infants of 8-9 weeks of age and weeks of age most often experience SIDS. The number of SIDS cases varies geographically, from 0.9 to 1.2 per 1,000 in Canada (Fetus and Newborn Committee, 1992) and 2 per 1,000 in the United States, to a high of per 1,000 in Tasmania and southern New Zealand (Little W Peterson, 1990). It remains unclear whether apnea may be a symptom or contributing cause of SIDS because 93% of SIDS deaths had no history of a prior observed apnea event. However, it has been shown that infants with unexplained apnea events are at an increased risk of SIDS (Davidson et al., 1986). Major Indicators for HAM In the United States, HAM may be prescribed if the infant: is a survivor of ALTE, which usually occurs during sleep; is a newborn sibling of two or more SIDS infants; is premature and has symptoms of idiopathic apnea of prematurity but is otherwise ready for hospital discharge; has a tracheostomy; has a sleep apnea syndrome caused by a neurologic disorder, periodic breathing, upper airway abnormality, or idiopathic syndromes (Hanley, 1992). In Canada, a position paper was published by the Canadian Paediatric Medical Association (Fetus and Newborn Committee, 1992) that states that the following criteria are used to recommend the use of HAM: Infants with a history of severe ALTE requiring resuscitation or vigorous stimulation and for which no cause has been identified and infants with a condition having an inherent risk of recurring apnea. Preterm infants beyond 37 weeks of gestational age who have symptomatic apnea with no identified underlying cause. Infants with conditions such as central hypoventilation. According to the Canadian position paper, the following infants may or may not be monitored because research has not been conclusive, and the decision to monitor is made on an individual basis: siblings of infants who died of SIDS; infants with a tracheostomy; infants with bronchopulmonary dysplasia; infants of women who abuse opiates or cocaine. The indicators for HAM are without consensus in North America. Randomized controlled clinical studies of adequate size have not been done. The conditions to conduct such a study would be difficult to meet because of the number of infants required for the sample population, the emotional and ethical issues of not providing HAM to some infants, and the legal ramifications if an infant does not receive HAM (Fetus and Newborn Committee, 1992). In the United States, the National Institute of 86 JOG" Volume 24, Number 1

4 Home Care The family s stress level may heighten with the use of home apnea monitoring. Child Health and Development is sponsoring a collaborative study for home infant monitor efficacy (Neuman, 1994). The five centers that have been located for the study are in Chicago, Cleveland, Honolulu, Los Angeles, and Toledo. The collaborative study allows the inclusion of a large enough sample from which to gather data to make generalization meaningful beyond the sample. The new monitors provide the opportunity to more accurately document events and utilization compliance to assess the incidence of clinically important apnea events in the study population. However, HAM is increasingly prescribed, even without an established standard of medical care (Meadows, Mendez, Lantos, Hipps, & Ostrowski, 1992). Nursing has a newly established standard of care for HAM from the National Association of Apnea Professionals. The standards are based on the nursing process framework and are available from the association. There is a wide variance in level of participation, role, and clinical interventions on the part of nursing in HAM programs. At one end of the spectrum, the nurse makes a referral to a social worker or respiratory therapist, who assumes care at discharge under a physician s supervision. At the other end of the spectrum, after receiving the physician s order for HAM on discharge, a transition program in the hospital is begun by nurses. The transition program emphasizes education of the parents in care of the infant and equipment required for HAM. After discharge, nurses continue to provide emotional support, education and assessment, and appropriate intervention and referrals. Other HAM programs include various other levels of nursing participation between these two ends of the spectrum. Nursing care Nurses can be part of transdisciplinary teams to facilitate care of the infant. The family requires team effort to provide support physically, psychosocially, financially, and spirituahy. The family, life-style, and stress level should be assessed. Life-style adjustment, monitoring, and monitoring equipment need to fulfill as many of the family s needs as possible for attainment of a satisfying parenting experience and to meet the needs of the infant. For example, a busy life-style requires a lightweight, batteryoperated monitor to allow for mobility. The family s stress level may heighten with the use of HAM. The first week of HAM has been identified as particularly stressful. Families with prior serious problems or who lack social support are at increased risk for experiencing higher levels of stress related to the de- mands of care for an infant requiring HAM (Ahmann, 1993). Nursing intervention should focus on providing extra support to those families and all families during the first week of HAM. Anticipatory guidance of the family that they may experience a perceived increase in stress gives the family the opportunity to plan ways of coping with the adjustment of having an infant on HAM. Anticipatory guidance allows the nurse time to better assess the family, to reassure the family that nursing is there to help incorporate their infant on HAM into their life-style, and to refer to a nurse psychiatric clinician, counselor, or lay support group. Contact with the family after discharge by telephone, letter, and home and clinic visits provides the family with physical care and social and emotional support. By experience, nurses have had some families with low cornpliance to HAM programs. It appears logical to associate the type and amount of care and parent education with compliance rate. However, the literature does not support this because research is lacking with regard to this nursing issue. Teaching the family care of the infant and monitor before discharge is imperative. The nurse can ensure understanding of the HAM process on the part of parents and promote an appropriate response to the infant s condition. Although the family observes the nurse giving care to their infant, the nurse is teaching by role modeling. During the in-hospital transition time, the nurse can help the family to assume that role in a supportive, safe environment and foster their feeling of comfort in performing tasks for the care of infant and monitor. Grandparents or baby-sitters may need to be included in the teaching plan as extra resources and support system for the family. Teaching objectives should include safety information for the use of the monitor. The information will vary according to the manufacturer s directions. Important safety instructions include: Do not sleep in the same bed as a monitored infant because the cables might become disconnected or choke the infant. Keep children and pets away from the monitor because they may accidentally disconnect the monitor. Keep the infant and monitor dry. Check that the monitor is working on a regular basis by performing the monitor self-test according to the manufacturer s directions and keep a log. Be sure that you can hear the alarm when working in another part of the house. Check batteries as necessary and keep a log. Keep the monitor 3-4 feet away from sources of electrical interference, such as heated waterbeds, radios, remote telephones, televisions, electric blankets, and air conditioners. The monitor may become confused and miss an apneic episode. January 1995 JOG 87

5 C L I N I C A L I S S U E S Report any problems immediately. Keep the cofltact telephone number on or by the home telephone unit to facilitate quick contact. Response to Alarm The caregivers need information about how to respond to the alarm. The use of multimedia audiovisuals helps to meet the learning needs and styles of the parents. Films, demonstrations, return demonstrations, and printed materials facilitate learning how to respond to an alarm. The caregiver should respond to the alarm within 10 seconds (Phoenix Children s Hospital, 1992). The infant should be observed for color in good lighting. If the infant s color is pink, observation should be done of chest movement and air passage from the nose. The activity level of the infant also should be assessed for movements signifying sleeping, eating, stretching, or being alert and awake. Troubleshooting the machine should be considered if the infant is pink and there appears to be no apneic event. If the caregiver finds the infant to be pale or blue, the infant should be gently stimulated. If the infant does not respond, more vigorous stimulation should be done by rubbing the back or briskly tapping the infant s feet. The caregiver needs to initiate cardiopulmonary resuscitation (CPR) for an infant who does not respond to stimulation and begin respiration spontaneously. All of the caregivers for the infant should be trained in CPR by a certified instructor for infant resuscitation. The training should be done before the child leaves the hospital. On the follow-up care, the nurse making the first contact should assess the caregiver s understanding of CPR. Caregivers who do not understand the process should attend another CPR class recommended to them and documented on their record. A 24-hour-a-day contact number must be available to the caregiver in the event that questions and problems arise. The caregiver should understand when to call for emergency assistance and not waste time calling a provider who cannot give timely assistance. Knowing whom to call and when to call for specified signs and symptoms can save frustration and access the best health care for the infants as it is needed. An example would be that the caregiver should cat1 for emergency assistance when CPR is needed. A cardiorespiratory event log should be maintained by the caregiver. The date, time, and time length of the event should be recorded in the log. The activity level and color of the infant should be noted. The type of alarm (apnea alarm, low heart rate alarm, fast heart rate alarm) that the monitor is triggering should be documented. The caregiver might find that a false alarm occurred. False alarms also should be recorded. The intervention, if any, should be entered into the log. Some examples are: real alarm and the infant self-corrected; the infant was gently stimulated; the infant was vigorously stimulated; or CPR was required. Other information that would be helpful is the time of the last feeding before the event and muscle tone of infant during the event (hypotonic or hypertonic). Proper skin care training to maintain proper hygiene and deal with the monitor leads can make the infant more comfortable and decrease the chance of infection. The monitor leads need to be disconnected, and the infant should be given a bath on a regular basis. The sight w.here the leads attach to the body need to be monitored for any skin irritation and lesions. The electrodes should be changed when they become dry. The leads do not have to be changed daily; it could be irritating to the skin to have adhesive pulled off and reapplied every day. Some caregivers become intimidated by the equipment and need to be encouraged to keep care as normal as possible for the infant and not treat the infant as an object or part of a mechanical device that is untouchable. The nurse should demonstrate, role model, and encourage return demonstrations of skin care and general hygiene. The infant stays on monitoring until the physician changes the order. Physicians tend to rely on the criteria first described by Ariagno (1984). He recommended that the infant be free of ALTE for 3 months or for 2 months if there have not been serious problems with an apnea alarm setting of 20 seconds and a heart rate setting of 60 beats/minute. It remains a matter of controversywhether or not the infant should have been through the stress of having had an upper respiratory tract infection, diptheria, pertussis, and tetanus (DPT) immunization, or another illness before discontinuing the monitor. The stress of the immunization or illness must have occurred without a recurrence of cardiorespiratory symptoms. If there was an underlying cause of the cardiorespiratory symptoms, the condition must be resolved before the monitor can be discontinued. Some physicians are requiring two normal event recordings at 2- to 3-month intervals in addition to Ariagno s described criteria. The family needs to be helped to make the transition away from using the monitor. Anticipatory guidance, opportunity for verbalizations of fear (if any), support, and education from the nurse are required during this period. The caregiver should keep a record of the date of the discontinuance of the monitor and the physician who wrote the order to discontinue the monitor. The monitor needs to be picked up by the vendor or returned to the provider. Follow-up appointments with the primary physician and consultants, if any, should be arranged. A follow-up call from the nurse from the apnea management program team should be made after 1 and 4 weeks to assess progress and encourage participation in the follow-up program. This action also lends support to the family emotionally. In conclusion, HAM, basic terminology, and current theory regarding clinical practice have been reviewed. Standard nursing care has been established for HAM but has not been widely distributed and used by the nursing community. There is a lack of nursing research regarding the care and use of apnea monitors and infants who are placed on the monitors. The families that are experiencing the use of an apnea monitor on their infant have not 88 J O G N N Volume 24, Number 1

6 Home Care been studied enough to generalize any study findings. Channels of communication for nurses working in apnea management programs need to be established and collaborative research done to produce studies with reliability and validity upon which to base future nursing practice. References Ahmann, E. (1986). Home care of the infant on an apnea monitor. In E. Ahmann (Ed.), Home care for the high risk infant: A holistic guide to using technology (pp ). Rockville, MD: Aspen. Ahmann, E. (1989). Home apnea monitoring and patterns of family life. Unpublished doctoral dissertation, The Johns Hopkins University School of Hygiene and Public Health, Baltimore. Ahmann,,E. (1993). Family impact of home apnea monitoring: An overview of research and its clinical implications. Neonatal Intensive Care, 5, Ariagno, R. L. (1984). Evaluation and managment of infantile apnea. Pediatric Annuals, 13, 217. Aranda, J. V., Davis, J., Trippenbach, T., Grondin, D., Zinman, R., &? Watters, G. (1983). Apnea and control of breathing in newborn infants. In L. Stern, (Ed.), Diagnosis and mangement of respiratoy disorders in the newborn (p. 135). Reading, MA: Addision- Wesley Publishing Co. Davidson, W., Bautista, D., & Chan, L. (1986). Sudden infant death syndrome in infants evaluated by apnea programs in California. Pediatrics, 77, Fetus and Newborn Committee, Canadian Paediatric Society. (1992). The infant home monitoring dilemma. Canadian Medical Association Journal, 147, Hanley, P. (1992). Mechanisms and management of central sleep apnea. Lung, 170,1017. Keens, T., &Ward, S. (1993). Apnea spells, sudden death, and the role of the apnea monitor. Pediatric Clinics of North America, 40, Little, R., & Peterson, D. (1990). Sudden infant death syndrome epidemtology: A review and update. Epidemiology Review, 12, Marcus, C. L., Glotnb, W. B., Basinski, D. J., Ward, S. L. D., & Keens, T. G. (1994). Developmental pattern of hypercapnic and hypoxic ventilatory responses from childhood to adulthood. Journal ofapplied Physiology. In press. Meadows, W., Mendez, D., Lantos, J., Hipps, R., & Ostrowski, M. (1992). What is the legal standard of medical care when there is no standard of medical care? Neonatal Intensive Care, 5 (3),43. National Institutes of Health (NIH) Consensus Development Conference on Infantile Apnea and Home Monitoring. (1987). NIH publication Bethesda, MD: US Department of Health and Human Services. National Institutes of Health Consensus Development Conference Statement. (1986). Infantile apnea and home monitoring. Volume 6, Number 6,1-2. Nelson, W. E. (Ed.) (1992). Nelson textbook ofpediatrics (14th ed.; pp ). Philadelphia: WB Saunders. Neuman, M. R. (1994). Collaborative home infant monitor evaluation (CHIME): Comparison of technologies and interrate reliability. Podium presentation January 21, Apnea of Infancy Twelfth Conference. Annenberg Center at Eisenhower, Palm Spring, California. Phoenix Children s Hospital. (1992). Apnea managementprogram caretaker handout. Phoenix: Author. Steinschneider, A., Weinstein, S., & Diamond, E. (1982). The sudden infant death syndrome and apnea: Obstruction during neonatal sleep and feeding. Pediatrics, 70, Valdez-Dapena, M. (1992). A patholgist s perspective on the sudden infant death syndrome Pathology Annual, 27, Webb, L., & Duncan, J. (1983). Selecting the right home apnea monitor. Pediatric Nursing, Weese-Mayer, D., & Silvestri, D. (1992). Documented monitoring: An alarming turn of events. Clinical Perinatology, 19, Address for correspondence: Sarah E. Whttaker, MSN, RNC, 7209 Canyon Road, El Paso, TX Sarah Whitaker is a lecturer at The University of Texas at El Paso and a doctoral candidate in nurstng at the Untuerstty of San Diego. January 1995 J O C N N 89