Derivation of Candidate Clinical Decision Rules to Identify Infants at Risk for Central Apnea.
OBJECTIVE
Central apnea complicates, and may be the presenting complaint in, bronchiolitis. Our objective was to prospectively derive candidate clinical decision rules (CDRs) to identify infants in the emergency department (ED) who are at risk for central apnea.


METHODS
We conducted a prospective observational study over 8 years. The primary outcome was central apnea subsequent to the initial ED visit. Infants were enrolled if they presented with central apnea or bronchiolitis. We excluded infants with obstructive apnea, neonatal jaundice, trauma, or suspected sepsis. We developed 3 candidate CDRs by using 3 techniques: (1) Poisson regression clustered on the individual, (2) classification and regression tree analysis (CART), and (3) a random forest (RF).


RESULTS
We analyzed 990 ED visits for 892 infants. Central apnea subsequently occurred in the hospital in 41 (5%) patients. Parental report of apnea, previous history of apnea, congenital heart disease, birth weight ≤2.5 kg, lower weight, and age ≤6 weeks all identified a group at high risk for subsequent central apnea. All CDRs and RFs were 100% sensitive (95% confidence interval [CI] 91%-100%) and had a negative predictive value of 100% (95% CI 99%-100%) for the subsequent apnea. Specificity ranged from 61% to 65% (95% CI 58%-68%) for CDRs based on Poisson models; 65% to 77% (95% CI 62%-90%) for CART; and 81% to 91% (95% CI 78%-92%) for RF models.


CONCLUSIONS
All candidate CDRs had a negative predictive value of 100% for subsequent central apnea.
Pediatric Emergency Medicine, Sutter Medical Center, Sacramento, California; Department of Emergency Medicine, University of California Davis, Sacramento, California; Department of Emergency Medicine, Kern Medical Center, Bakersfield, California; Walshp@sutterhealth.org.
Paul
P
Walsh
School of Computer Science, University College Dublin, Belfield, Dublin, Ireland; and.
Pádraig
P
Cunningham
Department of Emergency Medicine, Kern Medical Center, Bakersfield, California;
Sabrina
S
Merchant
Department of Emergency Medicine, Kern Medical Center, Bakersfield, California;
Nicholas
N
Walker
Department of Emergency Medicine, Kern Medical Center, Bakersfield, California;
Jacquelyn
J
Heffner
Department of Emergency Medicine, Kern Medical Center, Bakersfield, California;
Lucas
L
Shanholtzer
Instituto Nacional de Salud Pública, Centro de Investigación en Salud Poblacional, Cuernavaca, Morelos, Mexico.
Stephen J
SJ
Rothenberg
D001988:Bronchiolitis / Q000453:epidemiology; D000066491:Clinical Decision-Making / Q000379:methods*; D015897:Comorbidity; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012372:ROC Curve; D020182:Sleep Apnea, Central / Q000175:diagnosis* / Q000453:epidemiology