Prediction of Postdischarge Complications by Predischarge Event Recordings in Infants With Apnea of Prematurity

Abstract

OBJECTIVE:To determine whether predischarge event recording (PDER) can accurately identify preterm infants with resolving apnea of prematurity (AOP) at risk for postdischarge complications. DESIGN:PDER was performed on infants with resolving AOP on caffeine, ready for discharge. The outcome of infants with normal recordings was compared with that of infants with abnormal recordings. Follow-up data were obtained for outcome. RESULTS:Of the 106 infants, 74 had a normal PDER and 32 had an abnormal PDER (apneas lasting for Ͼ20 seconds and/or a heart rate of Ͻ80 beats per minute for Ͼ5 seconds). Birth weight, gestational age at birth, length of stay, discharge weight, and duration of caffeine treatment after discharge were no different between groups. None of the normal PDER infants (0 of 74) had postdischarge complications, whereas 4 of 32 infants with an abnormal PDER had complications (p Ͻ 0.05, power ϭ 0.7). The positive predictive value of a normal PDER and no postdischarge complications was 100%. The positive predictive value of an abnormal PDER and an adverse outcome was 12.5%. CONCLUSION:Normal PDER accurately identifies infants at low risk for an adverse outcome. Journal of Perinatology 2000; 2:92-95.Apnea of prematurity (AOP) is a common diagnosis in the premature infant, occurring in up to 85% of infants of Ͻ34 weeks' gestation.1 Timing of discharge for infants with AOP in a safe and expedient manner is a challenge faced by many neonatologists. Criteria for discharge of these infants may include an apnea-free interval, 2 usage of medications (methylxanthines), 3,4 gestational age (GA) at birth, or corrected age at discharge.Documented event recording has been used to evaluate the compliance of monitor usage at home 5,6 and to document efficacy of treatment;7,8 in addition, documented event recording has been shown to result in a shorter duration of home monitoring compared with a nonrecording monitor. 9 We use predischarge recordings as a tool for determining the need for home apnea monitoring at hospital discharge.Event-recording apnea monitors record cardiorespiratory waveforms with pulse oximetry; the user sets the parameters that define an event.5-13 For example, in-hospital "test" parameters in our institution record apneas lasting for Ͼ10 seconds and heart rates of Ͻ90 beats per minute. Smith and Hoy 14 reported a positive correlation between an abnormal predischarge event recording (PDER) performed for 1 week and continued apneas at home. We sought to determine whether a 24-hour PDER in preterm infants treated with caffeine could accurately identify infants who are at greater risk of an adverse outcome [15][16][17][18][19][20] (apparent life-threatening event [ALTE], rehospitalization, and death). METHODSThe medical records of all preterm infants followed by the Infant Apnea Program at University Medical Center and Hospital at Stony Brook during the period of January 1, 1996 to January 13, 1999 were reviewed retrospectively. Only those infants discharged with caffeine citrate were included. Informed...

Clinical associations of immature breathing in preterm infants: part 1—central apnea

“…These events may have been self-resolved or occurred during feeding or stressors such as immunization, ( 39 ) Most infants were sent home without a monitor and very few were readmitted to our hospital within 2 months for apnea or ALTE, which is in keeping with other reports. ( 40 ) Our unit protocol of discharging infants after a week free of needing stimulation to resolve an apneic spell has not changed based on our studies to date, and further work in larger patient populations is needed to establish criteria for safe NICU discharge, since the cost of additional hospital days simply for an “apnea countdown” is substantial. ( 41 )…”

A Primer on Apnea of Prematurity

“…75 Predischarge event recording is sometimes used as a way to evaluate the extent of persisting apnea episodes and determine the need for a home apnea monitor. 6,76 Event-recording monitors register heart rate, respiratory rate, pulse oximetry, and, in some cases, nasal airflow oscillimetry, providing more objective data than can be obtained from nursing documentation. 6,76 In the absence of event recordings, nursing documentation based on clinical observations of apnea and bradycardia events is the primary means of formulating discharge decisions for individual infants.…”

“…6,76 Event-recording monitors register heart rate, respiratory rate, pulse oximetry, and, in some cases, nasal airflow oscillimetry, providing more objective data than can be obtained from nursing documentation. 6,76 In the absence of event recordings, nursing documentation based on clinical observations of apnea and bradycardia events is the primary means of formulating discharge decisions for individual infants. 75 When infants are otherwise ready for discharge (have achieved full oral feedings, are maintaining body temperature in an open crib, etc), persistence of apnea and/or bradycardia will delay discharge.…”

Oximetry for preterm infants at neonatal discharge: What is current practice in New Zealand and Australia?

“…Many preterm infants experience pauses in breathing (‘apnoea’) and drops in blood oxygen saturation levels. As an infant matures towards term corrected age, these events become less frequent, however, clinically unapparent events may still occur up to and beyond discharge home . The long‐term implications for infants experiencing these persistent respiratory events are not completely clear.…”

“…The long‐term implications for infants experiencing these persistent respiratory events are not completely clear. Some studies have shown an association between episodes of intermittent hypoxia and both reduced initial weight gain after discharge and longer term neurodevelopmental delay . Therefore, when assessing a preterm infant's readiness for discharge from the neonatal intensive care unit (NICU), it is important to establish that the infant is stable from a cardiorespiratory perspective.…”