Apnea is defined as the cessation of breathing for 20 seconds or longer, representing a severe medical emergency in a child. A shorter pause is also classified as apnea if accompanied by concerning signs like cyanosis, paleness, or a slowed heart rate (bradycardia). Prompt intervention is necessary because a child’s oxygen reserves are smaller than an adult’s, leading to rapid deterioration when breathing stops. This information outlines medical protocols for managing pediatric apnea and is intended for educational purposes, not as a substitute for professional medical care.
Recognizing Apnea and Initial Non-Invasive Steps
The initial response to a child who is not breathing begins with a rapid assessment for signs of respiratory distress or failure. Observable signs of true apnea include the absence of chest wall movement or breath sounds, often coupled with a change in the child’s color. In infants, a heart rate below 80 beats per minute frequently accompanies an apneic event, signaling a significant lack of oxygen.
Once apnea is recognized, the first non-invasive intervention is gentle tactile stimulation to prompt spontaneous breathing. Techniques include gently rubbing the child’s back or flicking the soles of their feet. This stimulation must be brief and gentle, as excessive rubbing can cause injury and delay the start of mechanical ventilation if the child does not respond immediately.
Simultaneously, the airway must be opened and maintained using specific positioning techniques. Placing the child in the “sniffing position,” which involves slight neck extension, helps align the airway axes and lift the tongue away from the throat. For a child with suspected neck trauma, a jaw-thrust maneuver must be used instead of the head tilt-chin lift to avoid moving the cervical spine. If breathing does not resume after these maneuvers, intervention must escalate quickly.
Essential Airway and Ventilation Support
When non-invasive maneuvers are unsuccessful, the immediate next step is to provide mechanical ventilation using a bag-mask device with supplemental oxygen. A self-inflating bag appropriate for the child’s size must be used, typically 450 to 500 milliliters for infants. Correct mask fit is necessary for effective ventilation, requiring the device to cover both the mouth and nose without obscuring the eyes.
The ventilation rate depends primarily on the presence of a pulse. For a child who has a pulse but is not breathing, rescue breaths should be delivered at a rate of 12 to 20 breaths per minute (one breath every three to five seconds). Each breath should be delivered gently over one second, using just enough volume to cause a visible rise of the chest. Maintaining a tight seal with the face mask is necessary for air to enter the lungs effectively and avoid forcing air into the stomach.
To bypass an obstruction or facilitate ventilation, basic airway adjuncts like oropharyngeal (OPA) or nasopharyngeal (NPA) airways may be inserted. An OPA is a curved device inserted into the mouth to keep the tongue from blocking the airway, but its use is restricted to unconscious children due to the risk of triggering the gag reflex. An NPA is a soft tube inserted into the nostril, which is often better tolerated in conscious or semi-conscious children. Choosing the correct size for either device is paramount; the length must be carefully measured against the child’s anatomy to ensure effectiveness and prevent injury.
Advanced Resuscitation Procedures
If apnea is prolonged and the child’s heart rate drops below 60 beats per minute despite effective oxygenation and ventilation, intervention must progress to include chest compressions. A severely slowed heart rate often indicates impending cardiac arrest, which is frequently preceded by respiratory failure in children. High-quality chest compressions must be delivered hard and fast, at a rate of 100 to 120 compressions per minute.
If two rescuers are present, the compression-to-ventilation ratio is 15 compressions for every two breaths; a single rescuer uses a 30:2 ratio. These cycles are performed with minimal interruption to maximize blood flow to vital organs. Advanced airway management is initiated by trained providers, typically involving the placement of a supraglottic device, such as a Laryngeal Mask Airway (LMA), or an endotracheal tube (ETT).
While the ETT is the most secure method for controlling the airway, the LMA is a valuable rescue device that is quicker and easier to place, providing comparable ventilation. Once an advanced airway is secured, the ventilation strategy changes to continuous compressions with one breath administered every six seconds (10 breaths per minute), without pausing compressions. Pharmacological support is given concurrently, with epinephrine being the primary medication administered to increase heart rate and blood pressure. The standard dose of epinephrine (0.01 mg/kg) is given intravenously or intraosseously and can be repeated every three to five minutes.
Stabilization and Post-Emergency Care
After a successful resuscitation, defined by the return of spontaneous circulation (ROSC), immediate stabilization is necessary to prevent a secondary collapse. Continuous monitoring is required to manage ventilation and oxygenation, utilizing devices like pulse oximetry and capnography. Pulse oximetry measures blood oxygen saturation to ensure adequate oxygen delivery while avoiding hyperoxia, which can cause secondary injury.
Capnography measures the carbon dioxide in exhaled breath, which is necessary for confirming the correct placement of an advanced airway and assessing the effectiveness of chest compressions and ventilation. A critical part of post-resuscitation care is identifying and correcting the underlying cause of the apnea. The list of potential causes, often summarized by the mnemonic “H’s and T’s,” must be systematically investigated and addressed.
Targeted temperature management (TTM) is considered for children who remain comatose following cardiac arrest to improve neurological outcomes. TTM involves maintaining the child’s core temperature within a controlled range (normothermia) or, in some cases, mild therapeutic hypothermia. Following initial stabilization, the child requires urgent transfer to a specialized pediatric facility, such as a pediatric intensive care unit (PICU). This transfer is often facilitated by a specialized transport team to ensure access to higher levels of care and continuous subspecialty consultation.