Disorders of the Control of Breathing
QUICK LOOK AT THE CHAPTER AHEAD
This chapter discusses common causes of apnea in the pediatric population.
PEDIATRIC SLEEP APNEAObstructive sleep apnea, defined as the attempt to breathe through an obstructed airway, most commonly occurs in children with craniofacial abnormalities (Crouzon’s syndrome, etc.), in those with neuropathies, and in those medicated with hypnotics, sedatives, and anticonvulsants. Central apnea, defined as the lack of effort to breathe, occurs mainly in premature infants. Sleep apnea can be life threatening in infants. In toddlers it may present as failure to thrive, hyperactivity, and behavior problems. Mood changes and lethargy may be the presenting symptoms in teenagers.
Sleep apnea can be life threatening in infants.Pediatric sleep disorder clinics are able to provide testing and treatment. Adenotonsillectomy relieves obstructive sleep apnea in many children. Other treatment choices include the use of a Bi-Pap (bilevel positive airway pressure) apparatus during sleep.
APPARENT LIFE-THREATENING EVENTS IN INFANCYInfants who have apparent life-threatening events (ALTEs) commonly do so because of a combination of obstructive and central apnea. During the episode they stop breathing, become cyanotic or very pale, become limp, and may choke or gag. If no apparent reason for the event is discovered the infant is diagnosed as having apnea of infancy. This condition is most common in infants 2 to 4 months of age. The risk for sudden infant death syndrome rises if the child has apnea of infancy. The exact cause of ALTEs is unknown. Because these events do not occur past infancy, immaturity of the nervous system, reflexes, and responses to apnea during sleep may be causes (Table 53-1).
Once the cause of ALTEs is identified, therapy is individualized (Table 53-2). Antibiotics are administered for bacterial respiratory infections. Anticonvulsant medications are given to help control a seizure disorder. Structural abnormalities are corrected with surgery. Home monitoring is used to detect bradycardia and apnea when no specific cause for the episodes is found. Parents and caregivers should be taught infant cardiopulmonary resuscitation techniques. If the alarm is not triggered for several months, monitoring is usually discontinued. Other treatments
include oxygen therapy to increase serum oxygen saturation and respiratory stimulants such as caffeine and aminophylline to counteract central sleep apnea.
include oxygen therapy to increase serum oxygen saturation and respiratory stimulants such as caffeine and aminophylline to counteract central sleep apnea.
Table 53-1 Causes of ALTEs | ||||||||||||||||
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SUDDEN INFANT DEATH SYNDROMESudden infant death syndrome (SIDS) occurs when an infant less than 12 months of age dies suddenly from an unexplained cause. Most SIDS cases occur between ages 2 and 4 months and between midnight and 8 AM when both the infant and caregivers are sleeping. Infants up to 6 months of age are at greater risk of SIDS than infants 6-12 months of age. All SIDS cases are investigated in-depth by performing a complete
autopsy, examining the death scene, and reviewing the infant’s clinical history. Eighty percent of SIDS cases cannot be explained by autopsy results.
autopsy, examining the death scene, and reviewing the infant’s clinical history. Eighty percent of SIDS cases cannot be explained by autopsy results.
Table 53-2 Diagnostic Tools for ALTEs | ||||||||||||||||
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Factors associated with SIDS include exposure to maternal smoking, male gender, African-American or Native American ethnic and/or racial group, having a low socioeconomic status, low birth weight, born to a teenage or to a drug-addicted mother, and a family history of SIDS. Recent immunization has not been shown to be a risk factor.
Since 1994 the “Back-to-Sleep” campaign has focused on educating caregivers about SIDS risk factors. Those risk factors that can be modified include infant sleeping positions, mattress firmness, bottle-feeding, prenatal maternal smoking, exposure to smoke after birth, and infant overheating. The recommended sleep position is supine on a firm mattress in a crib that does not contain soft bedding. Both side-lying and prone positions may increase the risk of SIDS because they contribute to decreased arousal during hypoxia and/or sleep, rebreathing of carbon dioxide, or effects on the autonomic nervous system, which in infants is immature.
Both side-lying and prone positions may increase the risk of SIDS.Infants born to mothers who smoked during pregnancy have an increased risk of SIDS due to the effects smoking has on the developing autonomic nervous system and on pulmonary growth. Exposure to smoke after birth has also been shown to increase the risk of SIDS. Studies concerning the risk reduction effects of breast-feeding versus bottle-feeding are inconclusive. Data point to other factors associated with breast-feeding that may reduce the risk of SIDS rather than a component of breast milk that is protective. Overheating infants by tightly swaddling them is also discouraged.
Infants born to mothers who smoked during pregnancy have an increased risk of SIDS due to the effects smoking has on the developing autonomic nervous system and on pulmonary growth.SECTION XXII ♦ REVIEW QUESTIONS
1. The functions of the respiratory system include (select all that apply):
a. Removing carbonic acid from the bloodstream
b. Providing oxygen to cells
c. Regulating serum pH
d. Producing ATP (adenosine triphosphate)
View Answer
1. The answers are b and c. Rationale: Carbon dioxide is removed from the bloodstream, and mitochondria produce ATP by oxidative phosphorylation.
2. Which of the following statements correctly explains the functional anatomy of the respiratory system?
a. Turbinates provide moisture to inspired air.
b. Approximately 200 cc of fluid is lost each day in expired air.
c. The sinuses are air-filled spaces.
d. The epiglottis open during swallowing.
View Answer
2. The answer is c. Rationale: Turbinates provide air turbulence, approximately 1 pint (2 cups or 480 ml) of fluid is lost via ventilation each day, and the epiglottis closes over the trachea during swallowing.
3. Surfactant is produced by:
a. Alveolar type II cells
b. Pulmonary capillaries
c. The basement membrane
d. Pulmonary epithelium
4. Johnny, a 21/2-year-old, has frequent temper tantrums during which time he holds his breath. His father asks the nurse if Johnny can have permanent damage from one of these episodes. The nurse correctly replies that:
a. If Johnny holds his breath to the point of unconsciousness, he may develop brain damage.
b. At his age Johnny cannot hold his breath long enough to become unconscious and harm himself.
c. General cell damage may occur because of lack of oxygen.
d. Johnny will lose consciousness if he holds his breath long enough but at that time ventilation will automatically start.
View Answer
4. The answer is d. Rationale: If a child holds his or her breath long enough, he or she will become unconscious at which time breathing will automatically resume; cell damage will not occur.
5. Ventilation occurs because of a:
a. Rise in serum pH
b. Buildup of serum carbon dioxide
c. Elevation of serum oxygen
d. Reduction in carbonic acid production
View Answer
5. The answer is b. Rationale: Ventilation is stimulated by a rise in serum carbon dioxide, decrease in serum pH, a drop in arterial oxygen, or a drop in cerebrospinal fluid pH.
6. In contrast to an adult airway, the airway of an infant or child has a (select all that apply):
a. Larynx that is more posterior
b. Floppy epiglottis
c. Longer trachea
d. Larger tongue
View Answer
6. The answers are b and d. Rationale: In contrast to the airway of an adult, the infant or child has a long floppy epiglottis, larger tongue, shorter trachea and neck, and a larynx that is more anterior.
7. Conditions that cause oxygen to be released easily from hemoglobin include:
a. Acidosis
b. Below sea-level altitude
c. Alkalosis
d. Subnormal body temperature
View Answer
7. The answer is a. Rationale: Acidosis, high altitude, heart failure, anemia, and hypercapnia all cause hemoglobin desaturation easily.
8. The enzyme carbonic anhydrase:
a. Is found in alveoli
b. Buffers hydrogen ions
c. Facilitates carbonic acid production
d. Ionizes red blood cells
View Answer
8. The answer is c. Rationale: Carbonic anhydrase causes 60% of the carbon dioxide produced by cells to combine with water to form carbonic acid.
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