Apnea monitoring is a vital component of modern respiratory care, particularly in the management of vulnerable patient populations such as premature infants, newborns with underlying conditions, and patients at risk of breathing irregularities.
By providing early alerts to potentially life-threatening events like apnea, bradycardia, and hypoxemia, apnea monitors serve as a safety net for patients and peace of mind for caregivers. For respiratory therapists, understanding how these devices work, their clinical applications, and their role in patient outcomes is crucial for effective practice.
What is Apnea Monitoring?
Apnea monitoring involves the continuous assessment of a patient’s breathing and heart rate to detect abnormal pauses in respiration. Apnea, defined as a cessation of breathing for at least 20 seconds (or shorter if associated with oxygen desaturation or bradycardia), is particularly common in premature infants due to immature respiratory control mechanisms.
Most apnea monitors are equipped with sensors that measure both respiratory effort and heart rate. When breathing stops, becomes irregular, or falls outside preset limits, the device activates audio and visual alarms to alert clinicians or caregivers. This rapid response system allows immediate intervention, which can prevent hypoxic injury or even death.
Clinical Indications for Apnea Monitoring
Apnea monitors are used across various settings, from neonatal intensive care units (NICUs) to patients’ homes. Some of the key indications include:
- Prematurity: Infants born before 37 weeks often experience apnea of prematurity due to immature brainstem function.
- High-Risk Infants: Babies with a history of apparent life-threatening events (ALTEs) or brief resolved unexplained events (BRUEs).
- Underlying Conditions: Infants with congenital heart disease, chronic lung disease, or neurological disorders.
- Post-Discharge Monitoring: Some infants are sent home with apnea monitors to ensure ongoing safety after hospital discharge.
Note: By detecting apnea and associated events, these devices allow healthcare providers to track progress and adjust care plans accordingly.
How Apnea Monitors Work
Apnea monitors typically use impedance pneumography, where electrodes placed on the chest detect changes in electrical resistance as the lungs fill and empty with air. Some models also incorporate pulse oximetry for oxygen saturation measurement.
When a pause in breathing is detected or heart rate falls below preset thresholds, the monitor generates alarms. Many models include memory functions that record alarm events. This stored data can be downloaded or reviewed remotely, giving respiratory therapists and physicians valuable insight into the frequency and severity of apnea episodes.
The Role of Respiratory Therapists
Respiratory therapists play a critical role in apnea monitoring at nearly every stage of care. Their responsibilities include:
- Setup and Calibration: RTs ensure that the monitor is properly set up, sensors are correctly placed, and alarm limits are tailored to the patient.
- Family and Caregiver Education: When apnea monitors are prescribed for home use, RTs provide extensive training for caregivers. This includes responding to alarms, performing basic resuscitation techniques, and troubleshooting equipment.
- Follow-Up Visits: RTs conduct regular follow-up visits, particularly after hospital discharge, to evaluate both the infant’s progress and the caregivers’ confidence in using the device.
- Data Interpretation: Reviewing recorded events helps RTs determine whether alarms reflect true apnea episodes or false triggers such as movement artifacts.
- Care Transition: RTs are involved in decisions about when to discontinue apnea monitoring, often after sleep studies or when the device’s memory shows no significant events over a period of 2–4 months.
Note: Through these responsibilities, respiratory therapists serve as the bridge between technology and patient safety.
Advancements in Apnea Monitoring Technology
Modern apnea monitors have become more sophisticated with the integration of digital recording and wireless connectivity. Some advanced systems allow continuous remote monitoring via the internet, enabling healthcare providers to review patient data in real time. This not only improves patient safety but also reduces caregiver anxiety and unnecessary hospital visits.
Additionally, the use of integrated monitors that combine apnea detection with pulse oximetry provides a more comprehensive assessment of respiratory and cardiovascular stability. Such advancements align with the growing emphasis on home-based care and telemedicine.
Relevance to Respiratory Care
Apnea monitoring is not just about detecting abnormal breathing; it is about ensuring long-term respiratory health. In the field of respiratory care, these devices contribute to:
- Early Intervention: By alerting caregivers to apnea events, interventions such as stimulation, repositioning, or resuscitation can occur immediately.
- Reducing Mortality and Morbidity: Monitoring reduces the risk of hypoxic brain injury and sudden infant death syndrome (SIDS).
- Family Empowerment: Training caregivers in equipment use and emergency response helps build confidence and improves home care outcomes.
- Professional Growth for RTs: Apnea monitoring highlights the specialized knowledge and critical thinking skills respiratory therapists bring to patient care.
Note: In short, apnea monitors not only save lives but also underscore the essential role of RTs in managing complex respiratory conditions.
Discontinuation of Apnea Monitoring
Apnea monitoring is typically discontinued when:
- The infant has a negative pneumocardiogram (sleep study).
- Recorded data over a prescribed period (often 2–4 months) shows no events.
- The infant has reached a developmental stage where the risk of apnea is minimal.
Note: The decision to stop monitoring is made collaboratively by physicians and RTs, balancing patient safety with the psychological relief of caregivers.
Apnea Monitoring Practice Questions
1. What is the principle behind how an apnea monitor detects respirations?
Electrode pads placed on the chest detect changes in distance during chest expansion; some monitors also measure heart activity via ECG.
2. Where are electrode pads placed for apnea monitoring in adults?
LA: Left midclavicular line, 2nd intercostal space, RA: Right midclavicular line, 2nd intercostal space, and RL: Right side of the abdomen, below the ribs.
3. Where are electrode pads placed for apnea monitoring in infants?
RA: Right midaxillary line, at or two finger widths below the nipple line, LA: Left midaxillary line, at or two finger widths below the nipple line, and RL: Along the outer right thigh.
4. When is the use of an apnea monitor clinically indicated?
To detect central apnea or apnea of prematurity, where there is no chest or air movement
5. When is an apnea monitor NOT clinically useful?
In cases of obstructive or mixed apnea, where chest movement continues despite no airflow
6. What clinical conditions can interfere with the accuracy of apnea monitoring?
Patient movement, diaphoresis causing electrode loss, choking, interference with wires, and accidental disconnections
7. What are the common limitations of apnea monitors?
False alarms, missed events, user inexperience, noisy environments, and electrical interference
8. How often should a patient be assessed during continuous apnea monitoring?
Whenever an alarm activates, and typically every 1 to 4 hours based on patient condition
9. Why is there a specific method to turn off an apnea monitor?
To prevent accidental shutdowns, especially by other children in the home
10. How should alarm parameters be set on an apnea monitor based on patient age?
Respiratory rate: ±5–10 breaths from baseline, Heart rate: ±10–15 beats from baseline, Apnea interval: 20 sec (adult), 15 sec (child), 10 sec (infant), and Alarm volume: Loud enough to be heard clearly.
11. What life-threatening events can apnea monitors alert caregivers to?
Recurrent apnea, bradycardia, and hypoxemia
12. Why are at-risk infants often placed on apnea monitors in the hospital?
To continuously monitor for apnea and cardiorespiratory events due to immaturity or illness
13. What occurs before an infant is discharged home with an apnea monitor?
The family receives thorough training in monitor use and infant resuscitation procedures.
14. What additional feature do many apnea monitors include for tracking?
Memory to record alarm events, which can be monitored remotely or downloaded
15. When is an apnea monitor typically discontinued?
After a negative pneumocardiogram (sleep study) or no recorded events for 2 to 4 months
16. True or False: Infant apnea monitoring is indicated when apnea lasts longer than 20 seconds.
True
17. An infant who experiences apnea, cyanosis, choking, or lifelessness requiring CPR may be evaluated for what syndrome?
Sudden Infant Death Syndrome (SIDS)
18. What are three key indications for infant apnea monitoring?
Sibling of a SIDS victim, Preterm infants with significant apnea, and Snoring infants with suspected airway obstruction.
19. What is Impedance Apnea Monitoring?
A method where chest electrodes detect changes in electrical impedance caused by lung expansion and contraction
20. What is another term for Impedance Apnea Monitoring?
Impedance Pneumograph
21. What are three common issues with Impedance Apnea Monitoring?
False alarms, poor electrode-skin contact, and the inability to detect obstructive apnea if chest movement is present.
22. During which activities should apnea monitoring tests be conducted?
While napping, while riding in a car, and while in a stroller.
23. What are two appropriate times when apnea monitor electrodes may be temporarily disconnected?
During breastfeeding, and when the infant is being continuously observed.
24. What should the low heart rate alarm be set to for infant apnea monitoring?
Between 60 and 80 beats per minute
25. Before an infant is discharged with an apnea monitor, what life-saving skill must the parents be trained in?
Infant CPR
26. When can apnea monitoring typically be discontinued for an infant?
After 2 months without any recorded apnea or bradycardia events
27. What alarm conditions must be absent for a prolonged period before discontinuing an apnea monitor?
No apnea alarms for events >20 seconds and no heart rate drops below 60 bpm
28. True or False: If an infant remains symptom-free after DPT immunizations and a case of nasopharyngitis, the apnea monitor may be discontinued.
True
29. What are the main indications for infant apnea monitoring?
Infants at risk for prolonged apnea (>20 seconds) or sudden infant death syndrome (SIDS)
30. What are the key risk factors for SIDS that may indicate a need for monitoring?
Apparent life-threatening episodes (ALTEs), having a sibling who died of SIDS, premature birth with apnea episodes, and snoring in infants.
31. What is an impedance apnea monitor (also called an impedance pneumograph)?
A monitor that uses chest electrodes to detect changes in impedance as the lungs expand and contract.
32. What are common issues with impedance apnea monitoring?
False alarms, poor electrode contact (e.g., oily skin), may miss obstructive apnea, must be used during sleep or when unsupervised, and can be disconnected briefly during breastfeeding or direct observation.
33. Why is it important to determine the cause of apnea in infants?
To guide and implement proper treatment strategies
34. When is it appropriate to send an infant home with an apnea monitor?
After the parents have been trained in CPR and are comfortable using the equipment
35. What are the criteria for discontinuing apnea monitoring in infants?
Two months with no events, no apnea >20 seconds, no bradycardia <60 bpm, no recurrence after illness or immunization, and normal follow-up sleep study (pneumogram).
36. How is apnea defined in a clinical setting?
A cessation of breathing for more than 15 to 20 seconds
37. What must accompany a breathing pause of less than 15 seconds to be considered apnea?
Bradycardia and oxygen desaturation
38. What type of apnea can standard bedside or impedance monitoring detect?
Central apnea and bradycardia
39. What type of apnea cannot be detected by standard impedance monitoring?
Obstructive apnea caused by upper airway blockage.
40. Recurrent hypoxemia has been associated with which complications?
Retinopathy of prematurity (ROP), necrotizing enterocolitis (NEC), and periventricular leukomalacia (PVL)
41. What may cause prolonged oxygen desaturation without apnea or bradycardia?
Obstructive apnea, hypoventilation, or intrapulmonary right-to-left shunting
42. What is central apnea?
A complete cessation of breathing due to a lack of respiratory effort
43. What is obstructive apnea?
When the infant attempts to breathe, but airflow is blocked due to upper airway obstruction.
44. What is mixed apnea?
A combination of obstructive and central apnea, where breathing stops after attempting to breathe against an obstruction; it is the most common type
45. Where is the most common site of upper airway obstruction in infants?
The pharynx
46. When does apnea of prematurity typically occur?
In infants born at or before 28 weeks of gestational age
47. True or False: Apnea in infants with respiratory distress syndrome (RDS) may be delayed by several days.
True
48. What type of developmental immaturity does apnea in infants typically reflect?
Physiological immaturity of respiratory control
49. During what conditions do ventilatory responses become blunted in infants?
Hypoxia (low oxygen to tissues) and hypercapnia (elevated carbon dioxide levels)
50. True or False: Most infants become hypoxic before apnea begins.
False
51. Why are premature infants more prone to apnea?
Their baseline CO₂ level is close to the apneic threshold, so even small changes can trigger apnea.
52. What occurs during REM sleep that may cause apnea in infants?
Loss of upper airway muscle tone, leading to pharyngeal collapse and obstruction
53. Who is at increased genetic risk for apnea in infancy?
Infants with first-degree consanguineous parents (second cousins or closer)
54. What neurological disorders can contribute to apnea in infants?
Intraventricular hemorrhage (IVH), hypoxic-ischemic encephalopathy (HIE), and brain malformations
55. What clinical conditions may cause new or worsening apnea episodes in infants?
Sepsis, anemia, hypoglycemia, hypocalcemia, electrolyte imbalances, temperature instability, and metabolic acidosis
56. Which medications are known to precipitate apnea in infants?
Benzodiazepines, opioids, magnesium sulfate, and prostaglandin E1 (Prostin)
57. How does CPAP therapy (4–6 cm H₂O) help manage apnea in infants?
It splints the upper airway to reduce pharyngeal collapse and prevent obstruction.
58. What is the mechanism of action of xanthine therapy (e.g., caffeine, theophylline) in treating apnea?
Increases minute ventilation, improves CO₂ sensitivity, reduces hypoxic respiratory depression, enhances diaphragmatic activity, and decreases periodic breathing
59. Which xanthine therapy is most commonly used in NICUs to treat apnea of prematurity?
Caffeine
60. Which methylxanthine has demonstrated anti-inflammatory effects on the lungs?
Caffeine
61. At what age does apnea of prematurity typically resolve?
Between 36 and 40 weeks postconceptional age
62. What is the peak age range for sudden infant death syndrome (SIDS)?
2 to 4 months of age
63. What is the most common type of apnea observed in preterm infants?
Mixed apnea
64. Which methylxanthine is preferred in the treatment of apnea of prematurity?
Caffeine
65. What is a common side effect of methylxanthines used to treat apnea?
Tachycardia
66. What therapy is considered safe and effective for apnea of prematurity with an obstructive component?
Nasal continuous positive airway pressure (nCPAP)
67. What is a key mechanism of action of methylxanthines in apnea treatment?
They increase minute ventilation.
68. How is central apnea best defined?
Total cessation of respiratory effort
69. In cases of severe hypoxia and agonal gasping during delivery, what is the final stage called?
Terminal apnea
70. Theophylline or caffeine is used to treat apnea of prematurity after ruling out other causes. Which of the following is LEAST accurate?
Theophylline diffuses more rapidly than caffeine in the central nervous system.
71. If an infant has pauses in breathing lasting 5–10 seconds followed by 10–15 seconds of rapid respirations, what condition is present?
Periodic breathing
72. What is periodic breathing in infants, and how is it different from apnea?
It consists of brief pauses in breathing (5–10 seconds) followed by rapid respirations without associated bradycardia or desaturation.
73. What is the primary cause of apnea of prematurity?
Immature central respiratory control in the brainstem
74. What is the recommended apnea interval alarm setting for infants on apnea monitors?
10 seconds
75. Which part of the brain is underdeveloped in infants with apnea of prematurity?
The medulla oblongata, which controls automatic breathing.
76. What is the role of the diaphragm in apnea events?
Diaphragmatic fatigue can contribute to failure to initiate or maintain adequate respirations.
77. Which hormone-related drug can be used to reduce the risk of apnea in premature infants?
Caffeine (a central nervous system stimulant)
78. Which type of apnea may still show chest movement but no airflow?
Obstructive apnea
79. What should be done if an infant’s apnea monitor alarm sounds?
Assess the infant immediately for breathing, color, and responsiveness.
80. Why is continuous apnea monitoring important in premature infants?
It detects life-threatening episodes of apnea and bradycardia early.
81. What parental education is critical before discharging an infant with an apnea monitor?
CPR training, alarm response procedures, and proper equipment use
82. What is the purpose of the memory feature on apnea monitors?
To record events for review and adjustment of therapy
83. What is one sign that an apnea episode may be clinically significant?
It is associated with bradycardia and/or oxygen desaturation.
84. What follow-up test is often used to evaluate whether apnea monitoring can be discontinued?
A pneumocardiogram or sleep study
85. True or False: Mixed apnea begins as obstructive apnea and progresses to central apnea.
False — it begins as central and progresses to obstructive or vice versa.
86. What is the most common respiratory pattern in premature infants?
Periodic breathing
87. What is the major concern with frequent apnea episodes in neonates?
Risk of hypoxia-induced organ damage, including to the brain
88. What complication can arise if apnea is not promptly treated in neonates?
Sudden infant death, developmental delays, or oxygen deprivation injuries
89. What is one disadvantage of impedance-based apnea monitors?
They may miss obstructive apnea if chest movement is still present.
90. How can body temperature affect apnea in preterm infants?
Hypothermia can increase the risk and frequency of apnea episodes.
91. Which electrolyte disturbances are commonly associated with apnea in neonates?
Hypocalcemia and hypoglycemia
92. What is the typical duration of caffeine therapy for apnea of prematurity?
Until the infant reaches 34–36 weeks postconceptional age
93. Why is nasal CPAP preferred over intubation for managing obstructive apnea in preemies?
It is less invasive and helps maintain airway patency without mechanical ventilation
94. What should the high heart rate alarm be set to on an infant apnea monitor?
10–15 bpm above the infant’s normal resting heart rate
95. What are the benefits of caffeine therapy beyond apnea treatment?
Reduced need for mechanical ventilation and decreased incidence of bronchopulmonary dysplasia
96. Which non-respiratory condition can mimic apnea in infants?
Seizures or gastroesophageal reflux
97. What does a sudden increase in apnea frequency typically indicate in a previously stable infant?
An underlying medical issue, such as an infection or metabolic imbalance
98. What is the first-line pharmacologic treatment for recurrent central apnea?
Caffeine citrate
99. What environmental factor can help reduce apnea episodes in preterm infants?
Maintaining a neutral thermal environment
100. What is the risk of long-term apnea monitoring without clear indications?
Parental anxiety, unnecessary alarms, and over-monitoring without clinical benefit
Final Thoughts
Apnea monitoring is a cornerstone of care for infants and other patients at risk of life-threatening respiratory events. By combining technology with expert oversight from respiratory therapists, these devices safeguard patients, reduce complications, and support families during critical stages of care.
For respiratory therapists, apnea monitoring represents both a clinical responsibility and an opportunity to demonstrate their expertise in patient education, equipment management, and long-term respiratory health.
As respiratory care continues to evolve, apnea monitoring remains a key example of how vigilance, technology, and professional skill come together to protect the most vulnerable patients.
Written by:
John Landry is a registered respiratory therapist from Memphis, TN, and has a bachelor's degree in kinesiology. He enjoys using evidence-based research to help others breathe easier and live a healthier life.
References
- Horne RS, Nixon GM. The role of physiological studies and apnoea monitoring in infants. Paediatr Respir Rev. 2014.