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Cassibba J, Aubertin G, Martinot JB, Le Dong N, Hullo E, Beydon N, Dupont-Athénor A, Mortamet G, Pépin JL. Analysis of mandibular jaw movements to assess ventilatory support management of children with obstructive sleep apnea syndrome treated with positive airway pressure therapies. Pediatr Pulmonol 2024. [PMID: 38593278 DOI: 10.1002/ppul.27005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND The polysomnography (PSG) is the gold-standard for obstructive sleep apnea (OSA) syndrome diagnosis and assessment under positive airway pressure (PAP) therapies in children. Recently, an innovative digital medicine solution, including a mandibular jaw movement (MJM) sensor coupled with automated analysis, has been validated as an alternative to PSG for pediatric application. OBJECTIVE This study aimed to assess the reliability of MJM automated analysis for the assessment of residual apnea/hypopnea events during sleep in children with OSA treated with noninvasive ventilation (NIV) or continuous PAP (CPAP). METHODS In this open-label prospective non-randomized multicentric trial, we included children aged from 5 to 18 years with a diagnosis of severe OSA. The children underwent in-laboratory PSG with simultaneous MJM monitoring and at-home recording with MJM monitoring 3 months later. Agreement between PSG and MJM analysis in measuring the residual apnea-hypopnea index (AHI) was evaluated by the Bland-Altman method. The treatment effect on residual AHI was estimated for both PSG and MJM analysis. RESULTS Fifteen (60% males) children were included with a median age of 12 years [interquartile range 8-15]. Two (17%) were ventilated with NIV and 13 (83%) with CPAP. There was a good agreement between MJM-AHI and PSG-AHI with a median bias of -0.25 (95% CI: -3.40 to +2.04) events/h. The reduction in AHI under treatment was consistently significant across the three measurement methods: in-laboratory PSG and MJM recordings in the laboratory and at home. CONCLUSION Automated analysis of MJM is a highly reliable alternative method to assess residual events in a small population treated with PAP therapies.
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Affiliation(s)
- Julie Cassibba
- Pediatric Department, Grenoble Alpes University Hospital, Grenoble, France
| | - Guillaume Aubertin
- Pediatric Pulmonology Department and Reference Center for Rare Respiratory Diseases, RespiRare, Armand Trousseau Hospital, APHP, Sorbonne University, Paris, France
| | - Jean Benoit Martinot
- Sleep Laboratory, CHU University Catholique of Louvain (UCL) Namur Site Sainte-Elisabeth, Namur, Belgium
| | | | - Eglantine Hullo
- Pediatric Department, Grenoble Alpes University Hospital, Grenoble, France
| | - Nicole Beydon
- Sorbonne-Université, Hôpital Trousseau, Unité Fonctionnelle de Physiologie - Explorations Fonctionnelles Respiratoires et du Sommeil, Paris, France
| | - Audrey Dupont-Athénor
- Pediatric Pulmonology Department and Reference Center for Rare Respiratory Diseases, RespiRare, Armand Trousseau Hospital, APHP, Sorbonne University, Paris, France
| | - Guillaume Mortamet
- Pediatric Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble, France
- HP2 Laboratory, INSERM U1300, Grenoble Alpes University Hospital, Grenoble, France
| | - Jean Louis Pépin
- HP2 Laboratory, INSERM U1300, Grenoble Alpes University Hospital, Grenoble, France
- EFCR Laboratory, Thorax and Vessels Division, Grenoble Alpes University Hospital, Grenoble, France
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Valika T. Fluoroscopic-Assisted Tongue Suspension: Advancement and Innovation in the Management of Complex Pediatric Obstructive Sleep Apnea. Laryngoscope 2024; 134 Suppl 6:S1-S9. [PMID: 37823584 DOI: 10.1002/lary.31107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 08/07/2023] [Accepted: 09/28/2023] [Indexed: 10/13/2023]
Abstract
OBJECTIVES The primary aim of this study is to describe a novel surgical technique developed for tongue base suspension (TBS). The second aim of this study is to assess the efficacy of the developed procedure by quantifying preoperative and postoperative polysomnographic outcomes for pediatric patients undergoing fluoroscopic-assisted tongue suspension (FATS) with the Encore System. Our hypothesis is that our FATS technique will provide at least a 50% reduction in the Apnea/Hypopnea Index (AHI), including in the medically complex pediatric population. STUDY DESIGN Retrospective case series. METHODS An electronic medical record review was conducted of patients who underwent FATS by a single surgeon at a tertiary care medical center between December 2019 and June 2022. Inclusion criteria included all patients <18 years old with evidence of OSA or sleep-disordered breathing and who had glossoptosis on sleep endoscopy. Data extracted from the medical record included age, gender, medical comorbidity history, reason for referral, history of airway surgeries, length of hospital stay, surgical complications data, and preoperative and postoperative polysomnographic data. Surgical success was defined by at least a 50% reduction in AHI. RESULTS Thirty patients (53.3% male) with a mean age of 6.3 (±5.3, 0.16-17) years underwent FATS over the study period. Most patients (93%) had an underlying comorbidity: cerebral palsy (37%), chromosomal abnormalities (23%), Down syndrome (13%), Pierre-Robin sequence (10%), and obesity (10%). The majority of patients (77%) were explicitly referred for tracheostomy placement secondary to failed management of OSA. 21 patients completed both preoperative and postoperative polysomnograms. The mean preoperative AHI, obstructive AHI (oAHI), and respiratory disturbance index (RDI) were 28.8 (±19.8), 30.8 (±19.6), and 30.5 (±19.3), respectively. The mean postoperative AHI, oAHI, and RDI were 7.3 (±9.2), 7.5 (±9.1), and 7.9 (±9.3), respectively. The mean change in AHI was -21.5 (±21.4) events/h (p < 0.01, 95% CI -29.0 to -11.4 events/h). The mean percentage decrease in AHI was 74.7%. The mean change in oAHI and RDI were -23.3 (±21.9) events/h (p < 0.01 95% CI- 39.9 to -21.4 events/h) and -22.5 (±21.5) events/h (p < 0.01, 95% CI- 31.5 to -12.4 events/h), respectively. The mean percentage decrease in oAHI and RDI was 75.6% and 73.8%, respectively. Surgical success occurred in 16 of the 21 (76%) patients. Of the 23 patients referred explicitly for tracheostomy placement, 21 (91%) were able to avoid tracheostomy placement secondary to improvements in OSA. CONCLUSIONS Patients undergoing fluoroscopic-assisted TBS revealed statistically significant improvements in AHI, oAHI, and RDI, with an overall surgical success rate of 76%. Complication rates were minimal, despite the complex nature of the study population. FATS should be considered a viable surgical approach in pediatric patients with an identified base of tongue obstruction and OSA. LEVEL OF EVIDENCE 4 Laryngoscope, 134:S1-S9, 2024.
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Affiliation(s)
- Taher Valika
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, U.S.A
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Israelsson-Skogsberg Å, Palm A, Lindahl B, Markström A, Ekström M. Young adults' narratives about living with home mechanical ventilation - a phenomenological hermeneutical study. Disabil Rehabil 2023:1-8. [PMID: 37933171 DOI: 10.1080/09638288.2023.2278187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 10/28/2023] [Indexed: 11/08/2023]
Abstract
PURPOSE An increasing number of children and young adults with complex medical conditions and respiratory failure are treated with home mechanical ventilation (HMV). The current study aimed to describe how young adults using HMV experience their everyday life with the ventilator, their physical impairments and their opportunities for an educational and professional career. MATERIALS AND METHODS Data were collected via narrative interviews with nine young HMV users (3 females and 6 males, aged 18-31 years) in their homes. Two were ventilated invasively, six were ventilated non-invasively and one was treated with continuous positive airway pressure (CPAP) via facemask. Data were analysed using a phenomenological hermeneutical method. RESULT A multi-professional team contributed to participants' safety and ability to participate in society through higher education and professional work. A good and valuable life, mostly feeling healthy were experienced but also prejudice and stiffened social society structures. CONCLUSION The findings of this study prove the importance of having long-standing access to a competent and supportive available multi-professional healthcare team when living with a long-term complex condition. These teams provided well-functioning human and technological support in everyday lives.
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Affiliation(s)
- Åsa Israelsson-Skogsberg
- Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
- Faculty of Medicine, Department of Health Sciences, Lund University, Lund, Sweden
| | - Andreas Palm
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Berit Lindahl
- Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
| | - Agneta Markström
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
- Department of Women's and Children's Health, Neuropediatric Karolinska Institutet, Stockholm, Sweden
| | - Magnus Ekström
- Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine, Allergology and Palliative Medicine, Lund University, Lund, Sweden
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Wolter NE, Scheffler P, Li C, End C, McKinnon NK, Narang I, Amin R, Chiang J, Matava C, Propst EJ. Adenotonsillectomy for obstructive sleep apnea in children with cerebral palsy: Risks and benefits. Int J Pediatr Otorhinolaryngol 2023; 174:111743. [PMID: 37748322 DOI: 10.1016/j.ijporl.2023.111743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 07/24/2023] [Accepted: 09/20/2023] [Indexed: 09/27/2023]
Abstract
OBJECTIVES To determine outcomes following adenotonsillectomy for obstructive sleep apnea (OSA) and the impact of motor and swallowing impairment on respiratory complications in children with Cerebral Palsy (CP). METHODS A retrospective review of children with CP and sleep disordered breathing (SDB) who underwent adenotonsillectomy (2003-2021) was performed. Children with CP were age-matched to children without CP. Motor and swallowing function was assessed using the Gross Motor Functional Classification System (GMFCS) and the Eating and Drinking Ability Classification System (EDACS). The primary outcome was postoperative obstructive apnea-hypopnea index (OAHI). Secondary outcomes were cure rate, complications, and need for additional interventions. RESULTS Ninety-seven children with CP were assessed for SDB, and 74 underwent polysomnography. Moderate or severe OSA was found in 49% (36/74). Adenotonsillectomy was performed in 30% (29/97). All children who underwent adenotonsillectomy experienced an initial reduction in OAHI (31.7/h to 2.9/h, p < 0.0001). Children with CP were less likely to achieve an OAHI<1 compared with children without CP (62.5% vs 81.8%, p = 0.23). Children with CP had more postoperative complications (43.5% vs. 8.7%) and greater odds of respiratory complications compared with children without CP (OR 8.9 95% CI 2.1-37.9). Children with CP and a GMFCS score of 5 and EDACS score between 3 and 5 had more respiratory complications post-adenotonsillectomy compared to those with GMFCS<5 (p = 0.002) and EDACS<3 (p = 0.031). CONCLUSION Children with CP had an improved OAHI initially following adenotonsillectomy but had higher rates of post-adenotonsillectomy complications. Respiratory complications after adenotonsillectomy were more common in children with motor and swallowing impairment. Findings may provide better preoperative planning for caregivers.
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Affiliation(s)
- Nikolaus E Wolter
- Department of Otolaryngology - Head and Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
| | - Patrick Scheffler
- Phoenix Children's Hospital, Division of Otolaryngology - Head and Neck Surgery, Phoenix, AZ, USA
| | - Chantal Li
- Department of Otolaryngology - Head and Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Christopher End
- Department of Otolaryngology - Head and Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nicole K McKinnon
- Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Indra Narang
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Reshma Amin
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jackie Chiang
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Clyde Matava
- Department of Anesthesia and Pain Medicine, Department of Anesthesia, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Evan J Propst
- Department of Otolaryngology - Head and Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Lackey TG, Tholen K, Pickett K, Friedman N. Residual OSA in Down syndrome: does body position matter? J Clin Sleep Med 2023; 19:171-177. [PMID: 36081330 PMCID: PMC9806788 DOI: 10.5664/jcsm.10288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 09/06/2022] [Accepted: 09/06/2022] [Indexed: 01/07/2023]
Abstract
STUDY OBJECTIVES To examine children with Down syndrome with residual obstructive sleep apnea (OSA) to determine if they are more likely to have positional OSA. METHODS A retrospective chart review of children with Down syndrome who underwent adenotonsillectomy at a single tertiary children's hospital was conducted. Children with Down syndrome who had a postoperative polysomnogram with obstructive apnea-hypopnea index (OAHI) > 1 event/h, following adenotonsillectomy with at least 60 minutes of total sleep time were included. Patients were categorized as mixed sleep (presence of ≥ 30 minutes of both nonsupine and supine sleep), nonsupine sleep, and supine sleep. Positional OSA was defined as an overall OAHI > 1 event/h and a supine OAHI to nonsupine OAHI ratio of ≥ 2. Group differences are tested via Kruskal-Wallis test for continuous variables and Fisher's exact tests for categorical. RESULTS There were 165 children with Down syndrome who met inclusion criteria, of which 130 individuals had mixed sleep. Patients who predominately slept supine had a greater OAHI than mixed and nonsupine sleep (P = .002). Sixty (46%) of the mixed-sleep individuals had positional OSA, of which 29 (48%) had moderate/severe OSA. Sleeping off their backs converted 14 (48%) of these 29 children from moderate/severe OSA to mild OSA. CONCLUSIONS Sleep physicians and otolaryngologists should be cognizant that the OAHI may be an underestimate if it does not include supine sleep. Positional therapy is a potential treatment option for children with residual OSA following adenotonsillectomy and warrants further investigation. CITATION Lackey TG, Tholen K, Pickett K, Friedman N. Residual OSA in Down syndrome: does body position matter? J Clin Sleep Med. 2023;19(1):171-177.
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Affiliation(s)
- Taylor G. Lackey
- Department of Otolaryngology and Head and Neck Surgery, University of Colorado Denver, Aurora, Colorado
| | - Kaitlyn Tholen
- Louisiana State University Health Shreveport School of Medicine, Shreveport, Louisiana
| | - Kaci Pickett
- Center for Research Outcomes in Children’s Surgery, Center for Children’s Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Norman Friedman
- Department of Pediatric Otolaryngology, Children’s Hospital Colorado, Aurora, Colorado
- Department of Pediatric Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado
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Oyegbile-chidi T. Continuous Positive Airway Pressure Use for Obstructive Sleep Apnea in Pediatric Patients. Sleep Med Clin 2022; 17:629-638. [DOI: 10.1016/j.jsmc.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Morrison L, Suresh S, Leclerc MJ, Kapur N. Symptom care approach to non-invasive ventilatory support in children with complex neural disability. J Clin Sleep Med 2021; 18:1145-1151. [PMID: 34928205 DOI: 10.5664/jcsm.9836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Sleep-disordered breathing (SDB) is a major cause of morbidity and mortality among pediatric patients with severe neurological disabilities such as cerebral palsy. Despite increasing use of non-invasive ventilation (NIV) in this group, there remains a lack of consensus about its role and indications. We aim to explore the indications, acceptability, and outcomes of a cohort of children with severe, complex neurological disability and SDB, managed with NIV. METHODS Data was retrospectively extracted on children with severe neurological disabilities (GMFCS V equivalent) initiated on NIV in Queensland over a 5-year period. Demographic, clinical, hospitalization, and polysomnography data was collected, as well as caregiver-reported side effects and NIV adherence. RESULTS Fourteen (median age 9.1 years; 6F) children were included, 8 with cerebral palsy and 6 with other complex neurological disabilities. Obstructive sleep apnea was the most common indication for NIV (n=12). The median (IQR) apnea-hypopnea index improved on NIV [Pre-NIV 21.3 (IQR 10.0-28.2) vs. Post-NIV 12.2 (IQR 2.8-15.2)], although this was not statistically significant. There was significant improvement in proportion of time spent with SpO2<95% (22.2% Pre-NIV vs. 7.85% Post-NIV; p<0.05). Reported side effects were minimal. There was no reduction in hospital admissions in the 12 months post-NIV initiation. CONCLUSIONS Our findings suggest that NIV improves polysomnography parameters among children with severe neurological disability. Long-term outcomes and overall impact on quality of life remain unclear. Ethical issues and overall benefit must be considered before embarking on this mode of therapy.
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Affiliation(s)
| | - Sadasivam Suresh
- Department of Respiratory & Sleep Medicine, Queensland Children's Hospital, School of Medicine, University of Queensland
| | - Mary Josee Leclerc
- Department of Respiratory & Sleep Medicine, Children's Health Queensland Hospital and Health Service
| | - Nitin Kapur
- Department of Respiratory & Sleep Medicine, Queensland Children's Hospital, School of Medicine, University of Queensland
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Abstract
Obstructive sleep apnea (OSA) is common in infants and children with craniofacial malformations. Continuous positive airway pressure (CPAP) represents an effective noninvasive treatment for severe upper airway obstruction in these children, reducing the need of surgery or a tracheostomy. The decision to start CPAP should be discussed by a multidisciplinary team in order to decide the optimal individualized treatment strategy. CPAP initiation depends on patients' clinical characteristics and local practices, with an increase tendency towards an outpatient program. Follow-up and monitoring strategy varies among centers but benefits from the analysis of built-in software data in order to assess objective adherence and breathing parameters, reducing the need of in-hospital sleep studies. The possibility to wean CPAP should be periodically checked after surgical treatment or when spontaneous resolution is suspected. Finally, these infants with craniofacial malformations should have a long term follow up because of the risk of OSA recurrence over time.
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Affiliation(s)
| | - Lucie Griffon
- Pediatric Noninvasive Ventilation and Sleep Unit, Hôpital Necker-Enfants Malades, F-75015, Paris, France; Université de Paris, VIFASOM, F-75004, Paris, France
| | - Brigitte Fauroux
- Pediatric Noninvasive Ventilation and Sleep Unit, Hôpital Necker-Enfants Malades, F-75015, Paris, France; Université de Paris, VIFASOM, F-75004, Paris, France
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End C, Propst EJ, Cushing SL, McKinnon NK, Narang I, Amin R, Chiang J, Al-Saleh S, Matava C, Wolter NE. Risks and Benefits of Adenotonsillectomy in Children With Cerebral Palsy With Obstructive Sleep Apnea: A Systematic Review. Laryngoscope 2021; 132:687-694. [PMID: 34032299 DOI: 10.1002/lary.29625] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/24/2021] [Accepted: 05/07/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVES/HYPOTHESIS Assess the risks and benefits of adenotonsillectomy (AT) for obstructive sleep apnea (OSA) in children with cerebral palsy (CP). STUDY DESIGN Systematic review. METHODS We conducted a systematic review of Medline, Embase, and Cochrane Central Registry from 1946 to 2021. Broad search concepts included cerebral palsy, pediatric, tonsillectomy/adenoidectomy, and sleep. Additional articles were identified by searching reference lists. Studies on the safety and efficacy of AT for OSA management in children with CP were included. RESULTS Fifteen articles met inclusion criteria. Articles were classified into one or more of four themes: intraoperative risk (n = 1), postoperative risk (n = 3), postoperative care requirements (n = 6), and surgical outcomes (n = 7). No intraoperative anesthetic complications were reported. Postoperatively, respiratory complications including pneumonia were common and necessitated additional airway management. Following AT, children with CP required close postoperative observation, experienced increased lengths of stay, and had increased odds of unplanned intensive care unit (ICU) admission. Benefits following AT were improvement in OSA as measured by a reduction in obstructive apnea-hypopnea index (OAHI) as well as improved quality of life in some; however, many patients went on to require tracheostomy due to persistent OSA. CONCLUSIONS Children with CP who undergo AT have a significant risk of developing a postoperative respiratory complication. Realistic counseling of families around increased perioperative risks in this population is imperative and close postoperative monitoring is critical. Many children will obtain a reduction in OAHI, but additional surgical management is often required, including tracheostomy. Further research is needed to determine the best management strategy for OSA in children with CP. Laryngoscope, 2021.
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Affiliation(s)
- Christopher End
- Department of Otolaryngology-Head and Neck Surgery, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Evan J Propst
- Department of Otolaryngology-Head and Neck Surgery, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sharon L Cushing
- Department of Otolaryngology-Head and Neck Surgery, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nicole K McKinnon
- Department of Critical Care Medicine, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Indra Narang
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Reshma Amin
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jackie Chiang
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Suhail Al-Saleh
- Division of Respiratory Medicine, Department of Paediatrics, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Clyde Matava
- Department of Anesthesia and Pain Medicine, Department of Anesthesia, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nikolaus E Wolter
- Department of Otolaryngology-Head and Neck Surgery, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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