What type of apnea is characterized by perioral cyanosis and episodes of stopped breathing for 15 seconds multiple times per hour in a preterm newborn?

Central Apnea

This preterm newborn is experiencing central apnea, characterized by cessation of respiratory effort without airway obstruction, as evidenced by the complete cessation of breathing for 15 seconds multiple times per hour. 1, 2

Pathophysiology in Preterm Infants

Central apnea in preterm neonates results from immaturity of the central nervous system's respiratory control centers, leading to:

• Decreased respiratory center output with depressed ventilatory response to CO2, as demonstrated in studies showing significantly reduced alveolar ventilation (96 vs 129 mL/kg/min) and elevated PaCO2 (45.4 vs 35.6 mm Hg) in apneic infants compared to controls 2
• Altered ventilatory responses to hypoxia and hypercapnia during different sleep states, which is a hallmark of physiologic immaturity 1
• Complete absence of respiratory effort during the apneic episode, distinguishing it from obstructive or mixed types 3

Distinguishing Central from Other Apnea Types

The clinical presentation clearly indicates central apnea because:

• Central apnea involves cessation of breathing with no respiratory effort and no chest wall movement 1, 4
• Obstructive apnea would show continued chest wall movement against a closed airway, which is not described in this case 3
• Mixed apnea begins with a central component but then develops obstruction, typically showing an initial pause followed by obstructed breathing efforts 1, 3

Clinical Significance

• Central apnea episodes ≥10 seconds associated with bradycardia <100 bpm and oxygen desaturation <80% are nearly universal among very preterm infants 5
• The frequency and duration of apnea events decrease with increasing gestational age and postmenstrual age 5
• Perioral cyanosis indicates significant hypoxemia resulting from the prolonged cessation of breathing, confirming the pathological nature of these episodes 4

Management Implications

Understanding this as central apnea is critical because:

• Methylxanthine therapy (caffeine) is the mainstay of treatment for central apnea by stimulating the central nervous system and respiratory muscle function 6, 1, 4
• CPAP is NOT effective for pure central apnea, as studies demonstrate that CPAP entirely fails to affect central apnea episodes ≥5 seconds (P value not significant), while it markedly reduces obstructive and mixed apnea 3
• Continuous monitoring with pulse oximetry and heart rate assessment is essential, as bradycardia often accompanies apneic episodes 6

Common Pitfall

Do not assume all apnea in preterm infants is mixed type. While mixed apnea is common, the absence of any obstructive component (no continued respiratory effort during the pause) clearly identifies this as central apnea, which requires different therapeutic considerations than obstructive apnea 1, 3.