Vol. 11 •Issue 1 • Page 10
Infant Home Apnea Monitors Provide Technological Bridge
Apnea events are sources of tremendous anxiety for parents of premature and term infants. A brief course of home apnea monitoring can help reduce parents’ stress and serve as a technological bridge in the transition from hospital to home.
The use of home monitors has greatly expanded in the last five to 10 years. An estimated 70,000 to 100,000 newborns are discharged from hospital nurseries each year with home apnea monitors. The potential for even greater numbers of infants on monitors is increasing as a result of improved neonatal intensive care and home care services that allow infants to be discharged at lower weights and ages.
Monitors are used to alert caretakers if an infant stops breathing for longer than a set period of time, usually 20 seconds. In addition, they alert caretakers if an infant has an episode of bradycardia, where the heart rate dips under 80 beats per minute. However, false alarms are frequent, so families must be educated about the devices’ purpose, limitations and interpretation.
Several categories of infants have been identified as potentially benefiting from home monitoring. They include:
• premature infants less than 35 weeks gestational age
• infants with apparent life-threatening events
• subsequent siblings of sudden infant death syndrome victims
• infants with other home care needs
• infants with severe gastroesophageal reflux
• infants of substance-abusing mothers.
Historically, infants in these groups are evaluated for apnea and bradycardia,1,2 and they may be at an increased risk for SIDS as well, although there is no evidence that they are at any greater risk than those without apnea.
In particular, premature infants may experience a prolonged apneic spell that causes bradycardia and death if the event is not properly interrupted. Despite these risks, many infants will still go home prior to the resolution of their apnea of prematurity; therefore home monitoring is key for these infants.
HISTORY OF HOME MONITORING
The work of Alfred Steinschneider, MD, in the 1970s was instrumental in setting up a standard of care in home monitoring.3 Back then, home monitors simply alerted families to apnea and bradycardia events in the home. Families and physicians had no idea whether these alarms signified true, serious events.
When a family had alarms, physicians asked durable medical equipment (DME) companies to perform recordings in the home of heart rate and chest wall movement, called pneumograms, over a 12- to 24-hour period. In this fashion, they could see if the child had continued serious apnea. Because of the uncertainty about the exact cause of the event at home and whether it was even a real event, up to 30 percent of infants at home on monitors were re-hospitalized at least once before the monitor was discontinued.
In the early 1990s, event recorders, known as documented monitors, came into use. These devices continuously record heart rate and respiration and mark any unusual events. They also have the capability to be periodically downloaded to assess the nature of any alarms. Through the use of these monitors, clinicians discovered that more than 94 percent of all alarms were false, caused by artifacts of movement, equipment trouble or cardiac activity.
This new technology has spawned a “download” industry in which physicians ask DME vendors to provide multiple downloads and visits on patients with multiple alarms. This trend has contributed to spiraling costs of care for patients on monitors, though home monitoring still costs substantially less than a continued hospitalization. It costs approximately $400 per month for rental of equipment. Some insurance companies allow one download per month included in this rental cost. Others pay additionally for interpretations of downloads to physician groups, who on average charge anywhere from $75 to $200.
Recently, however, technology has again improved so that modems are now being integrated into the monitors. Physicians can directly download information from monitors into their offices, without the need to involve the DME vendor. The technology is inexpensive and easy to use, so it can dramatically cut costs and expedite good patient care. Instant access to information allows doctors to give immediate reassurance to families in the event of a false alarm. In the case of real events, they can direct families on how to the best approach the situation.
Along with technological advances, many physicians developed apnea programs and clinics through the years. One such initiative is the Infant Apnea Program at Thomas Jefferson University Hospital, Philadelphia, which enrolls more than 1,000 infants per year. The program began in 1978 with two physicians, a respiratory therapist and a nurse coordinator. As more children started to go home on monitors, it has expanded to include a nurse practitioner, a clinical nurse specialist, two nurse coordinators and a program administrator.
The event recording monitors the program uses mostly measure transthoracic impedance, atrial and ventricular repolarizations and depolarizations (QRS complexes) of an eletrocardiogram, plus heart rate trends. It’s set to record a one-minute window triggered by central apnea greater than or equal to 16 seconds or a heart rate of less than 80 beats per minute. False alarms from movement, loose lead condition or from a low-impedance signal also are recorded. The monitor reports the date, time and duration of all events.4,5
A database tracks a tremendous amount of detail regarding the infants. It charts demographic information, specific problems related to the home monitoring (eating difficulties, alarms, color changes, etc.), management, physician and parent contacts and the child’s health record, including readmissions to the hospital, physical wellness and medications the child is taking during the monitoring course.
Further information recorded includes infant breathing pattern evaluation through cardiorespiratory monitoring during sleep times, parents’ initial reactions to the infant’s need for a home monitor, parents’ anxiety and how they handle the stress of the monitor and alarms throughout the entire home monitoring period.
The program assists in the evaluation and treatment of neonatal apnea in the intensive care nursery and pediatrics on-site at Jefferson and in the surrounding tri-state area through health system affiliations and contractual agreements of third-party payers. It provides a screening tool at discharge that can be useful to clinicians in conjunction with the infant’s clinical course in determining the need for home monitoring.
DEVELOP FAMILY RELATIONSHIPS
Before discharge, family and caretakers must understand the basic physiology of apnea and the risks associated with this diagnosis. In addition, if home monitoring is prescribed, caretakers must be well trained in its operation, as well as resuscitation. Nurses explain the diagnosis, and if a monitor is needed, a respiratory therapist teaches the family about the device and CPR.
An important lesson families must learn is that, even though there is a long history of home monitors being used as SIDS prevention devices, no hard evidence exists to support that practice. As a result, families are advised not to use them in that regard. Rather, monitors should be used to help recognize events in the home that may be cause for concern and discussion with a physician.
Once the patient is discharged, neonatal and pediatric nurses specializing in home infant apnea monitoring manage the infant’s care through close telephone contact with caretakers. The nurses, supervised by the program’s medical director, work closely with the infant’s pediatrician to support the family through the first month or two of life at home. Infants are seen on an emergency basis if needed.
Through frequent contact and development of close relationships with families, the program tries to smoothly guide caregivers through a brief course of monitoring, the ultimate goal being a comfortable transitioning of newborns off the device. The program performs and interprets additional studies at home to determine when the monitor can be discontinued. Home monitor downloads are routinely done four to six weeks after discharge from the hospital or at the infant’s post-conceptual age of 40 weeks.
Depending upon the severity of the apnea and factors such as medication, illnesses and oxygen requirement at discharge, the duration of monitoring can be from 6 weeks to 6 months of age. Approximately 71 percent of all program patients are discontinued from their monitors within three months and 88 percent by four months. (See Sidebar.) A recent study suggests that the duration of monitoring can be reduced from 136 days to 89 days by using a comprehensive program that emphasizes the use of apnea monitors as a bridge to home from the hospital, rather than a SIDS prevention device.6
Families need to recognize that most of them have taken home healthy infants who don’t yet have fully developed respiratory control because of a slight disturbance in their rate of maturation. Most of these infants will mature rapidly, but meanwhile a brief course of monitoring can help to assuage parents’ stress.7 Ongoing improvements in technology and increased education likely will further enhance parents’ views of in home apnea monitors.8,9,10,11 n
Epstein is the associate director of the Infant Apnea Program and the administrative nurse practitioner of the Children’s Rehab Unit at Thomas Jefferson University Hospital, Philadelphia. Dr. Gibson is the director of the Infant Apnea Program at the same facility.
For a list of references, please call Mike Bederka at (800) 355-5627, ext. 1128 or visit Respiratory-care-sleep-medicine.advanceweb.com/mrreflist.html.