Pri nedonošenčkih so dihalni premori skoraj edini klinični odraz nezrelega nadzora dihanja. Splošno je sprejeto, da je centralni nadzor glavni dejavnik za njihov nastanek in da gre pri nedonošenčkih ne glede na različne dejavnike za eno entiteto, za katero se je uveljavil izraz apneja zaradi nedonošenosti (angl. Apnea of Prematurity, AOP). Ločimo tri tipe AOP: centralno, obstruktivno in mešano. Najpomembnejša posledica AOP so ponavljajoči se hipoksemični dogodki, ki so povezani s številnimi neugodnimi izidi, kot so retinopatija zaradi nedonošenosti (ROP), bronhopulmonalna displazija (BPD) ter razvojni zaostanek. Na nastanek AOP vplivajo številni dejavniki: nezrelost ali zavora dihalnega centra, stanje budnosti in spanja, vpliv kemoreceptorjev, Hering-Breuerjev refleks, gastroezofagealni refluks in dinamična podajnost zgornjih dihalnih poti, ki so v članku podrobno opisani. Zdravljenje AOP je farmakološko, ki temelji na metilksantinih, in nefarmakološko, kot so uporaba stalnega pozitivnega nadtlaka v dihalnih poteh, nadzorovano mehansko senzorično draženje in uravnavanje primerne zasičenosti krvi s kisikom. Preiskava za opredelitev dihalnih premorov je polisomnografija (PSG), saj vključuje tudi možnosti opredelitve obdobja spanja. Pri nedonošenčkih uporabljamo zmanjšan nabor signalov: EKG, nosni termistor ali kanilo, pulzno oksimetrijo in torakalno induktivno pletizmografijo, kar imenujemo kontinuirano zapisovanje kardiorespiratornih funkcij (CMCRF) ali kar kardiorespiratorna poligrafija (CRPG). V zadnjem delu članka predstavljamo izkušnje s CRPG pri nedonošenčkih v EINT Porodnišnice Ljubljana. Najpogostejše indikacije za CRPG v EINT so pogoste desaturacije, potreba po zdravljenju s kisikom pri otrocih z BPD in ukinitev metilksantinskih preparatov. Med otroki z AOP v EINT pa s 43 % prevladuje obstruktivni tip apneje, mešani tip se pojavlja pri 33 %, centralni pa v 14 %.
Breathing disorders and cardiorespiratory polygraphy in preterm infants – our experiences
In preterm infants, apnoea is a universal manifestation of immature respiratory control. It is widely accepted that central control is the main factor in their occurrence. In preterm infants regardless of various factors, it is a single entity for which the term Apnoea of Prematurity (AOP) has been established. There are three types of AOP: central, obstructive, and mixed. The most important consequence of AOP are intermittent hypoxemic events that are associated with many poor outcomes, such as retinopathy of prematurity, bronchopulmonary dysplasia, and developmental delay. Many factors play a role in the pathogenesis of AOP, including immaturity or inhibition of the respiratory centre, wake-sleep state, chemoreceptors, the Hering-Breuer reflex, gastro-oesophageal reflux, and dynamic compliance of the upper airway. AOP is treated pharmacologically with methylxanthines and non-pharmacologically, using continuous positive airway pressure, of mechanosensory input optimization, and blood gas status optimization. Polysomnography (PSG) is a multichannel test used in sleep-related breathing disorders. A reduced set of signals is used in preterm infants: EKG, nasal thermistor or cannula, pulse oximetry, and thoracic inductive plethysmography, referred to as continuous monitoring of cardiorespiratory functions (CMCRF) or cardiorespiratory polygraphy (CRPG). The final section of the article discusses experiences with CRPG in preterm infants at Ljubljana Maternity Hospital’s NICU. The most common indications for CRPG are frequent desaturations, the need for oxygen therapy in children with BPD, and withdrawal of methylxanthine therapy. Among infants with AOP, the obstructive type of apnoea predominates in 43%, mixed type in 33 %, and central type in 14%.
Tomaž Križnar
