Average Volume-assured Pressure Support as Rescue Therapy after CPAP Failure in Pediatric Obstructive Sleep Apnea: A Retrospective Case Series Study

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Abstract

Background

Continuous positive airway pressure (CPAP) is frequently prescribed for patients with residual obstructive sleep apnea (OSA) following adenotonsillectomy.

Objectives

The goal was to examine the efficacy of noninvasive ventilation with average volume-assured pressure support (AVAPS) as a potential option for children with failed CPAP titration.

Methods

In a single-center retrospective study, we included children aged 1-17 years, with polysomnographically confirmed OSA who underwent AVAPS titration following failed CPAP titration. In addition to describing the clinical characteristics of the included patients, we compared polysomnographic parameters before and after AVAPS.

Results

Nine patients met the inclusion criteria; out of them, 8 (89%) were males with an age range of 6.7 ± 3.9 years and a body mass index percentile of 81.0 ± 28.9. Reasons for failed CPAP titration were: 3 (33%) patients due to inability to control apnea-hypopnea index (AHI), 3 (33%) patients due to sleep-related hypoventilation, 2 (22%) patients due to treatment-emergent central sleep apnea, and 1 (11%) patient due to intolerance to CPAP. AVAPS resulted in a greater reduction in AHI than CPAP (reduction following CPAP = 24.6 ± 29.3, reduction following AVAPS = 42.5 ± 37.6, p = 0.008). All patients had resolution of the problems which caused CPAP failure.

Conclusion

In this case a series of children with OSA and with failed CPAP titration, AVAPS resulted in a greater reduction in AHI compared with CPAP as well as resolution of the problems which caused CPAP failure.

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Most cited references 27

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Diagnosis and management of childhood obstructive sleep apnea syndrome.

C Marcus, L. Brooks, K. Draper … (2012)

This revised clinical practice guideline, intended for use by primary care clinicians, provides recommendations for the diagnosis and management of the obstructive sleep apnea syndrome (OSAS) in children and adolescents. This practice guideline focuses on uncomplicated childhood OSAS, that is, OSAS associated with adenotonsillar hypertrophy and/or obesity in an otherwise healthy child who is being treated in the primary care setting. Of 3166 articles from 1999-2010, 350 provided relevant data. Most articles were level II-IV. The resulting evidence report was used to formulate recommendations. The following recommendations are made. (1) All children/adolescents should be screened for snoring. (2) Polysomnography should be performed in children/adolescents with snoring and symptoms/signs of OSAS; if polysomnography is not available, then alternative diagnostic tests or referral to a specialist for more extensive evaluation may be considered. (3) Adenotonsillectomy is recommended as the first-line treatment of patients with adenotonsillar hypertrophy. (4) High-risk patients should be monitored as inpatients postoperatively. (5) Patients should be reevaluated postoperatively to determine whether further treatment is required. Objective testing should be performed in patients who are high risk or have persistent symptoms/signs of OSAS after therapy. (6) Continuous positive airway pressure is recommended as treatment if adenotonsillectomy is not performed or if OSAS persists postoperatively. (7) Weight loss is recommended in addition to other therapy in patients who are overweight or obese. (8) Intranasal corticosteroids are an option for children with mild OSAS in whom adenotonsillectomy is contraindicated or for mild postoperative OSAS.

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A randomized trial of adenotonsillectomy for childhood sleep apnea.

Carole L Marcus, Renee Moore, Carol L Rosen … (2013)

Adenotonsillectomy is commonly performed in children with the obstructive sleep apnea syndrome, yet its usefulness in reducing symptoms and improving cognition, behavior, quality of life, and polysomnographic findings has not been rigorously evaluated. We hypothesized that, in children with the obstructive sleep apnea syndrome without prolonged oxyhemoglobin desaturation, early adenotonsillectomy, as compared with watchful waiting with supportive care, would result in improved outcomes. We randomly assigned 464 children, 5 to 9 years of age, with the obstructive sleep apnea syndrome to early adenotonsillectomy or a strategy of watchful waiting. Polysomnographic, cognitive, behavioral, and health outcomes were assessed at baseline and at 7 months. The average baseline value for the primary outcome, the attention and executive-function score on the Developmental Neuropsychological Assessment (with scores ranging from 50 to 150 and higher scores indicating better functioning), was close to the population mean of 100, and the change from baseline to follow-up did not differ significantly according to study group (mean [±SD] improvement, 7.1±13.9 in the early-adenotonsillectomy group and 5.1±13.4 in the watchful-waiting group; P=0.16). In contrast, there were significantly greater improvements in behavioral, quality-of-life, and polysomnographic findings and significantly greater reduction in symptoms in the early-adenotonsillectomy group than in the watchful-waiting group. Normalization of polysomnographic findings was observed in a larger proportion of children in the early-adenotonsillectomy group than in the watchful-waiting group (79% vs. 46%). As compared with a strategy of watchful waiting, surgical treatment for the obstructive sleep apnea syndrome in school-age children did not significantly improve attention or executive function as measured by neuropsychological testing but did reduce symptoms and improve secondary outcomes of behavior, quality of life, and polysomnographic findings, thus providing evidence of beneficial effects of early adenotonsillectomy. (Funded by the National Institutes of Health; CHAT ClinicalTrials.gov number, NCT00560859.).

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Sleep disordered breathing in children in a general population sample: prevalence and risk factors.

Edward Bixler, Alexandros N Vgontzas, Hung-Mo Lin … (2009)

Assess the prevalence based on clinically meaningful criteria (i.e., blood pressure) and identify risk factors of sleep disordered breathing (SDB) in a representative sample of elementary school children. A random sample of the local elementary school children (K-5) were assessed using a two-phased strategy. In phase I a brief questionnaire was completed by a parent of each child in local elementary schools (N = 5,740), with a response rate of 78.5%. In phase II, randomly selected children and their parent spent a night in our sleep laboratory (N = 700) with a response rate of 70.0%. University sleep laboratory. Children enrolled in local elementary schools. None. Each child was assessed with a full polysomnogram and completed a history/physical examination including an electrocardiogram, otolaryngology examination, and pulmonary evaluation. The prevalence of moderate SDB (apnea-hypopnea index > or = 5) was 1.2%. The independent risk factors included nasal abnormalities and minority associated only with mild (1 or = 5 was 1.2% in a representative sample of elementary school children. Risk factors for SDB included waist circumference, nasal abnormalities (e.g., chronic sinusitis/rhinitis), and minority. The strong linear relationship between waist circumference and BMI across all degrees of severity of SDB suggests that, as in adults, metabolic factors may be among the most important risk factors for SDB in children.

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Author and article information

Journal

Journal ID (publisher-id): TORMJ

Journal ID (nlm-ta): Open Respir Med J

Title: The Open Respiratory Medicine Journal

Abbreviated Title: Open Respir. Med. J.

Publisher: Bentham Science Publishers

ISSN (Electronic): 1874-3064

Publication date (Electronic): 15 May 2023

Publication date Collection: 2023

Volume: 17

Electronic Location Identifier: e187430642303080

Affiliations

[1 ] deptSleep Disorders Center , University of Maryland Medical Center , Baltimore, , Maryland, , MD 21201, USA

[2 ] deptDepartment of Pediatrics, Division of Pediatric Pulmonology , University of Maryland School of Medicine , Baltimore, , Maryland, , MD 21201, USA

[3 ] deptDepartment of Otorhinolaryngology-Head and Neck Surgery , University of Maryland School of Medicine , Baltimore, , Maryland, , MD 21201, USA

[4 ] deptDepartment of Diagnostic Radiology and Nuclear Medicine , University of Maryland School of Medicine , Baltimore, , Maryland, , MD 21201, USA

[5 ] deptDepartment of Medicine, Division of Pulmonary and Critical Care Medicine , University of Maryland School of Medicine , Baltimore, , Maryland, , MD 21201, USA

Author notes

[* ]Address correspondence to this author at the deptDepartment of Medicine, Division of Pulmonary and Critical Care Medicine , University of Maryland School of Medicine , Baltimore, , Maryland, , MD 21201, USA; Tel: 410-706-4771;Fax: 410-706-0345; E-mail: mdiaz@ 123456som.umaryland.edu

Article

Publisher ID: e187430642303080

DOI: 10.2174/18743064-v17-e230418-2022-18

PMC ID: 10351336

PubMed ID: 37916139

SO-VID: 784560db-0bf1-4d1f-a4cc-e96b2856837e

License:

This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 7 September 2022

Date revision received : 20 January 2023

Date accepted : 2 February 2023

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Average Volume-assured Pressure Support as Rescue Therapy after CPAP Failure in Pediatric Obstructive Sleep Apnea: A Retrospective Case Series Study

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Abstract

Background

Objectives

Methods

Results

Conclusion

Related collections

Bentham Science - Open Access

Most cited references 27

Diagnosis and management of childhood obstructive sleep apnea syndrome.

A randomized trial of adenotonsillectomy for childhood sleep apnea.

Sleep disordered breathing in children in a general population sample: prevalence and risk factors.

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