The use of nasal CPAP in children

Infant Mandibular Distraction for Upper Airway Obstruction: A Clinical Audit

Background:

Mandibular distraction osteogenesis (MDO) is an effective method of treating upper airway obstruction (UAO) in micrognathic infants. The short-term outcomes include relief of UAO, avoidance of tracheostomy, and prompt discharge from hospital. However, it is a significant surgical procedure with potential associated morbidities. This study describes a cohort of infants managed using MDO over a twelve-year period.

Methods:

A retrospective chart review was undertaken for children who had MDO before the age of 5 years between 2000 and 2012. This was followed by a clinical review of the same cohort specifically looking for dental anomalies, nerve injuries, and scar cosmesis.

Results:

Seventy-three children underwent MDO at a mean age of 2 months [interquartile range (IQR), 1.7–4.2] for nonsyndromic infants and 3.3 months (IQR, 2.1–7.4) for those with syndromes. Infants were discharged from hospital, on average, 15 days after procedure. After MDO, of the 9 who were previously tracheostomy dependent, 5 (56%) were decannulated within 12 months and none of the nontracheostomy-dependent children required further airway assistance. The majority of children required supplemental feeding preoperatively but, 12 months postoperatively, 97% of the nonsyndromic infants fed orally. Thirty-nine children (53%) were reviewed clinically [median age, 5.1 y (IQR, 3.9–6.5)] with 18 being syndromic. Many of the mandibular first permanent and second primary molars had developmental defects, but there was a low rate of neurosensory deficit and good scar cosmesis.

Conclusions:

This study contributes further to the evidence base underpinning the management of micrognathic infants with UAO.

Domiciliary noninvasive positive airway pressure therapy in children

There has been a dramatic increase in the past few decades in the number of children receiving noninvasive positive airway pressure (PAP) therapy at home. Although PAP therapy was first prescribed for children with obstructive sleep apnea, the indications have rapidly widened to include treatment for central hypoventilation syndromes, neuromuscular and chest wall disorders as well as primary respiratory diseases. Given the rapidly expanding use of PAP therapy in children, pediatric pulmonologists need to be familiar with the indications, technical and safety considerations as well as potential complications and challenges that may arise when caring for children using PAP therapy. This review article covers the definition of PAP therapy, modes, interfaces, devices, indications, contraindications, suggested settings, complications as well as the factors influencing the adherence.

Assessment and treatment of obstructive sleep-disordered breathing

Obstructive sleep-disordered breathing (OSDB) is a condition that affects 1% to 3% of the pediatric population. These disorders are difficult to diagnosis and left untreated may be serious, including not only medical comorbidities but also cognitive, academic, behavioral, and emotional sequelae. This article is designed to bring awareness of the severity and prevalence to family physicians and pediatricians. It reviews detailed information concerning OSDB, including the predisposing factors, assessment of presenting features, and treatment.

Long-term non-invasive positive airway pressure ventilation in infants

AIM

To evaluate the clinical application of long-term non-invasive ventilation (NIV) in infants with life-threatening ventilatory failure with regard to: diagnosis, age at initiation, indication for and duration of treatment, clinical outcome and mortality and adverse effects.

PATIENTS AND METHODS

The medical records of 18 infants treated in a home setting during a 7-year period were reviewed. The criteria for ventilatory support were: (a) transcutaneous partial pressures of carbon dioxide (TcPCO(2)) >6.5 kPa and oxygen (TcPO(2)) < 8.5 kPa and (b) decreased cough ability and/or recurrent chest infections.

RESULTS

The median age at initiation was 4 months (range 1-12). NIV was initiated because of hypoventilation in 12 infants and because of reduced cough ability and/or recurrent infections in six infants. Tracheotomy was eventually needed in two infants. The median duration of treatment was 24 months (range 1-84). NIV produced significant improvements, with median TcPCO(2) falling from 9.9 to 6.1 kPa, and median TcPO(2) rising from 9.8 to 11.1 kPa.

CONCLUSION

NIV can be successfully and safely used in infants with prolonged life-threatening ventilatory failure, potentially avoiding intubation and tracheotomy.

Preoperative continuous positive airway pressure compliance in children with obstructive sleep apnea syndrome: assessed by a simplified approach

INTRODUCTION

The frequency of diagnoses of obstructive sleep apnea syndrome (OSAS) in children is increasing and more and more adenotonsillectomies (A&T) are being performed on severely ill children who have a higher perioperatory risk. The objective of the present study was to describe preoperative compliance in the use of continuous positive airway pressure (CPAP) in children with OSAS, when this treatment was prescribed as a means of preventing complications.

PATIENTS AND METHODS

We describe data from children with severe OSAS caused by hypertrophy of the adenoids and tonsils, but with no craniofacial abnormalities. CPAP pressure was adjusted either during diurnal polysomnography with sleep deprivation or by self-adjusting devices. Follow-up was conducted through weekly interviews and the downloading of data recorded by the equipment.

RESULTS

48 children were included; 73% of them used a CPAP machine > or =3h per night, and 31% used it for > or =6h per night. The variables associated with good equipment compliance included higher BMI, higher pressure levels in the devices, and a higher number of episodes of apneas and hypopneas. Children who weighed > or =30kg used CPAP for > or =3h per night more often (OR 16, 95% CI 1.9-137). Compliance levels with fixed and self-adjusting CPAP were similar, and side effects in both cases were slight and limited to those caused by the pressure of the masks on patients' skin. One case of excessive bleeding was the only complication reported during A&T.

CONCLUSIONS

The mean preoperative use of CPAP equipment by children with severe OSAS was 4.5+/-2.6h. Seventy-three percent of subjects used the equipment for >/=3h.

The effect of adenotonsillectomy on children suffering from obstructive sleep apnea syndrome (OSAS): the Negev perspective

OBJECTIVE

To present the Negev perspective in recent decades as to the effect of adenotonsillectomy regarding clinical and polysomnographic features, cardiopulmonary morbidity, growth, neurocognitive function, health care services utilization, and enuresis by reviewing current related literature.

METHODS

All relevant published data by the Soroka University Medical Center and related community medical services were reviewed and compared to MEDLINE linked literature regarding aspects of childhood obstructive sleep apnea published through November 2005.

RESULTS

Published data support a significant effect of adenotonsillectomy on the associated co morbidities: adenotonsillectomy resulted in the reduction of pulmonary hypertension, improved growth as a result of an increase in growth hormone secretion, improvement of neurocognitive function to the normal range, reduction in nocturnal enuresis, as well as reducing general morbidities, as reflected by the reduction in health care utilization. However, there are still uncertainties relating to major aspects. There is no specific definition for OSAS grading, or for generating a guideline for surgical treatment and refinement of the indications of T&A.

CONCLUSIONS

Adenotonsillectomy has a beneficial effect on children with OSAS, however, further research is required before recommendations for the treatment of OSAS in children can be formulated.

Continuous positive airway pressure for children: A discussion on how to maximize compliance

As pediatric sleep facilities and resources expand, increasing numbers of children with sleep-disordered breathing requiring continuous positive airway pressure (CPAP) treatment are being identified. Despite extensive expertise in treating adults with CPAP, many centres have little experience using CPAP in the pediatric population. The successful initiation and continued effective treatment with CPAP requires a unique and specialized approach to the pediatric patient and their family. Nearly, half of children needing CPAP will be uncooperative upon initial exposure to this unusual treatment. This review aims to outline an approach to the successful initiation of CPAP treatment in children including some trouble-shooting strategies to maximize initial and ongoing compliance with prescribed therapy.

Diagnostic approach to obstructive sleep apnea in children

Obstructive sleep apnea syndrome (OSAS) in childhood is a disorder of breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction that disrupts normal ventilation during sleep and normal sleep patterns. A spectrum of severity related to the degree of upper airway resistance, to the duration of the disease, to the presence or absence of hypoxemia episodes, and to certain clinical features can be described. Symptomatic children may not fit the criteria for diagnosis established for OSAS in adults; age-specific standards are needed. Both anatomical factors that increase upper airway resistance, e.g. adenotonsillar hypertrophy, and functional processes that decrease upper airway tone, e.g. REM sleep, contribute to the pathogenesis of pediatric OSAS. Sequelae of OSAS in children include neurobehavioural abnormalities, stunting of growth, and cor pulmonale. Both the history and physical examination should target the sleeping child; parents often report loud snoring, difficulty breathing, and obstructive apneas. The gold standard investigation to establish the diagnosis and to quantitate disease severity is overnight polysomnography. Home cardiopulmonary sleep studies have been shown to be an accurate and practical alternative to overnight laboratory polysomnography for routine evaluation of non-complex children with adenotonsillar hypertrophy. Children with documented severe OSAS are at increased post-operative risk for airway compromise and should be observed and monitored carefully. Adenotonsiliectomy is the most common therapy for OSAS in children; as a second-line treatment, the use of nasal CPAP in children with OSAS has been very successful in experienced hands.

The use of nasal continuous positive airway pressure to treat obstructive sleep apnoea

AIM

To review 66 children with obstructive sleep apnoea (OSA) for whom a trial of nasal continuous positive airway pressure (nCPAP) was proposed.

METHODS

Baseline sleep studies were performed to assess OSA severity; a trial of nCPAP was performed where moderate to severe OSA, not relieved by adenotonsillectomy, was found. The nCPAP trial was considered either technically successful (ST), if the child accepted the mask for sufficient time to determine nCPAP efficacy, or a technical failure (FT) if otherwise. Patients with an initial FT were offered a period of home acclimatisation to familiarise them with wearing the mask during sleep. ST patients in whom nCPAP was effective were established on long term therapy.

RESULTS

Nasal CPAP trials were successful (ST) in 49/66 (74%) patients. Nasal CPAP efficacy could not be determined in the remaining 17 FT patients (26%), generally because of their poor nCPAP tolerance. These patients were subsequently considered for other treatment. A total of 42/49 (86%) ST patients were established on long term nCPAP therapy, 2/49 (4%) derived no benefit from nCPAP, while 5/49 (10%) refused long term nCPAP therapy. Of patients on long term nCPAP, the most frequently reported side effects were skin irritation and nasal dryness; however, these were not serious enough to require any patients to discontinue therapy. A period of home acclimatisation was found to be effective in increasing nCPAP acceptance, with 26% of FT children being subsequently successfully reassessed for nCPAP.

CONCLUSION

The use of nCPAP was feasible in a significant proportion of a paediatric OSA population. Failure was usually because of the child's intolerance of the nCPAP equipment. Nasal CPAP was an effective treatment in the majority of patients where it could be assessed, and was adopted as a long term therapy in most cases. We have successfully used nCPAP to treat OSA across a wide range of ages. Motivated parents and skilled support staff have proved essential for the success of nCPAP in a paediatric setting.

Effects of OSA, inhalational anesthesia, and fentanyl on the airway and ventilation of children

To assess effects of anesthesia and opioids, we studied 13 children with obstructive sleep apnea (OSA, age 4.0 +/- 2.2 yr, mean +/- SD) and 24 age-matched control subjects (5.8 +/- 4.0 yr). Apnea indexes of children with OSA were 29.4 +/- 18 h-1, median 30 h-1. Under inhalational anesthetic, closing pressure at the mask was 2.2 +/- 6.9 vs. -14.7 +/- 7.8 cmH2O, OSA vs. control (P < 0.001). After intubation, spontaneous ventilation was 115.5 +/- 56.9 vs. 158.7 +/- 81.6 ml x kg-1 small middle dot min-1, OSA vs. control (P = 0.02), despite elevated PCO2 (49.3 vs. 42.1 Torr, OSA vs. control, P < 0.001). Minute ventilation fell after fentanyl (0.5 microg/kg iv), with central apnea in 6 of 13 OSA cases vs. 1 of 23 control subjects (P < 0.001). Consistent with the finding of reduced spontaneous ventilation, apnea was most likely when end-tidal CO2 exceeded 50 Torr during spontaneous breathing under anesthetic. Thus children with OSA had depressed spontaneous ventilation under anesthesia, and opioids precipitated apnea in almost 50% of children with OSA who were intubated but breathing spontaneously under inhalational anesthesia.

Postoperative bilevel positive airway pressure ventilation after tonsillectomy and adenoidectomy in children--a preliminary report

Obstructive sleep apnea (OSA) in children, characterized by hypoventilation secondary to upper airway obstruction, often results from tonsil and adenoid hypertrophy. Adenotonsillectomy is the standard therapy in this patient population. The immediate postoperative period is complicated occasionally by respiratory difficulties that may require intubation and mechanical ventilation. Recently, physicians have provided temporary airway support using continuous and bilevel positive airway pressure (BiPAP) devices. Reported complications of positive airway pressure devices include local abrasions to the nose and mouth; dryness of the nose, eyes, and mouth; sneezing; nasal drip, bleeds, and congestion; sinusitis; increased intraocular pressure; non-compliance; and pneumocephalus. Subcutaneous emphysema following facial trauma, dental extractions, adenotonsillectomy, and sinus surgery has been reported. There is also a hypothetically increased risk of subcutaneous emphysema following the use of positive airway pressure ventilation in the tonsillectomy patient. Between January 1997 and July 1998, 1321 patients underwent tonsillectomy and/or adenoidectomy at our institution. In reviewing the records of all pediatric intensive care unit admissions during that time period, we identified nine patients, of the 1321, who required BiPAP postoperatively. Of these, four children were obese, four had preexisting neurological disorders, and one underwent endoscopic sinus surgery and adenoidectomy. Three children were asthmatic, and three were less than 3 years of age. Two obese children were discharged with home BiPAP, one of whom had been on BiPAP prior to surgery. All patients tolerated BiPAP without complications. This preliminary report suggests that BiPAP is a safe and effective method of respiratory assistance in the adenotonsillectomy patient with preexisting conditions who is predisposed to postoperative airway obstruction. Furthermore, with BiPAP, the risks of intubation and ventilator dependence are avoided.

The effect of adenotonsillectomy on serum insulin-like growth factor-I and growth in children with obstructive sleep apnea syndrome

OBJECTIVE

Obstructive sleep apnea syndrome (OSAS) in children is frequently associated with growth interruption. The objective of this study was to evaluate the effect of OSAS and adenotonsillectomy on the insulin-like growth factor-I (IGF-I) axis in children.

STUDY DESIGN

Thirteen prepubertal children (mean age, 6.0 +/- 2.8 years) were studied before and after adenotonsillectomy (T&A). Weight, height, overnight polysomnography, and IGF-I and IGF-binding protein-3 levels were evaluated before and 3 to 12 months after T&A. The children's weights and heights were monitored for 18 months.

RESULTS

The respiratory disturbance index improved from 7.8 +/- 9.1 events/h to 1.0 +/- 2.1 events/h after T&A (P <.02). Slow-wave sleep increased from 29.1% +/- 7.2% to 34.6% +/- 9.8% after T&A (P <.02). The weight standard deviation score increased from 0.86 +/- 1 to 1. 24 +/- 0.9, 18 months after T&A (P <.01). Serum IGF-I levels increased from 146.3 +/- 76.2 ng/mL before T&A to 210.3 +/- 112.5 ng/mL after surgery (P <.01), but IGF-binding protein-3 levels did not change significantly.

CONCLUSION

The respiratory improvement after T&A in children with OSAS is associated with a significant increase in serum IGF-I levels and weight. We conclude that the IGF-I axis is affected in children with OSAS.

Treatment of obstructive sleep apnoea using nasal CPAP in children with craniofacial dysostoses

We studied a group of children (aged 2.2-15 years) with craniofacial dysostosis and obstructive sleep apnoea to assess the use of nasal continuous positive airway pressure (n-CPAP) as a palliative form of treatment. A variable period of time was allowed for acclimatisation to n-CPAP (1 day to 2 months), depending on the patient. Patients were then admitted for their first CPAP trial. Baseline breathing difficulty and the effectiveness of n-CPAP were assessed by respiratory sleep studies. Successful results were obtained with n-CPAP in five of the eight patients, with marked clinical and polygraphic improvements of the respiratory pattern immediately after n-CPAP was established. Of the remaining three cases, one child needed a prolonged period of acclimatisation to the n-CPAP system, one was withdrawn from the study, and one failed to respond to n-CPAP and was found to have complete blockage of the upper airways as a result of enlarged adenoids. Our results confirm that n-CPAP can be tolerated even by young patients and can be effective, and that it may be a useful alternative palliative treatment for obstructive sleep apnoea in children with craniofacial syndromes.