Home Overnight Gas Exchange for Long-Term Noninvasive Ventilation in Children.

BACKGROUND: The aim of CPAP and noninvasive ventilation (NIV) is to correct sleep-disordered breathing and nocturnal gas exchange. The aim of the study was to analyze the results of a systematic home pulse oximetry ([Formula: see text]) and transcutaneous carbon dioxide ([Formula: see text]) monitoring in stable pediatric subjects on long-term CPAP/NIV or screened for CPAP/NIV weaning, and the consequent interventions in the subjects with abnormal gas exchange. METHODS: The home overnight [Formula: see text] and [Formula: see text] recordings of stable pediatric subjects treated with or weaned from CPAP, NIV, or high-flow nasal cannula between January 2017 and March 2018 were analyzed. RESULTS: A total of 110 recordings, performed in 79 subjects, median age 6 (interquartile range [IQR] 1.5-14) y, were analyzed. Fifty-two recordings (47%) were performed during NIV, 43 (39%) during CPAP, 2 (2%) during high-flow nasal cannula, and 13 (12%) during a spontaneous ventilation weaning trial from ventilatory support. The quality of recording was excellent in 81% of recordings, 5 recordings (5%) had <4 h of recording time, 5 (5%) had artifacts on the [Formula: see text] signal, and 16 (15%) had artifacts on the [Formula: see text] signal. Gas exchange abnormalities were observed in 11 subjects with [Formula: see text] > 50 mm Hg during ≥ 2% of recording time (n = 8), mean [Formula: see text] ≥ 50 mm Hg (n = 6), mean [Formula: see text] < 35 mm Hg (n = 3), and [Formula: see text] < 90% during ≥ 2% of recording time (n = 2). Consequent interventions were (multiple interventions possible): change of device settings (n = 6), change of interface (n = 2), switched to high-flow nasal cannula (n = 1), and a control recording (n = 2). CONCLUSIONS: A significant number (∼12%) of systematic home [Formula: see text] and [Formula: see text] recordings in stable pediatric subjects treated with CPAP/NIV were abnormal and may be corrected by adequate therapeutic interventions.

Outpatient initiation of long-term continuous positive airway pressure in children.

INTRODUCTION: Current guidelines recommend initiating continuous positive airway pressure (CPAP) in children during an overnight in-hospital titration study. Due to a shortage of hospital beds and economic constraints, we started a program for outpatient initiation of CPAP in selected children with obstructive sleep apnea (OSA). METHODS: Objective CPAP compliance and efficacy were evaluated in consecutive children enrolled in an outpatient CPAP program when they fulfilled the following criteria: persistent OSA, age >6 months, stable condition, family living in the Parisian area and agreeing with a regular follow-up. RESULTS: Thirty-one children, median (range) age 8.9 years (0.8-17.5), were included in the program. The most common diagnosis were Down syndrome (n = 7), achondroplasia (n = 3), and obesity (n = 3). Median baseline obstructive apnea-hypopnea index (OAHI) was 12.5 events/h (5-100). Median duration of follow-up was 12.3 months (2.2-25.2). Four subjects (three adolescents with Down syndrome) were not compliant at 2-month follow-up with a compliance <4 h/night. In the other 27 subjects, median compliance was 08:21 h:min/night (05:45-12:20), with a median number of night use per month of 25 (18-30). CPAP efficacy at the end of follow-up was excellent in the compliant subjects with a median AHI of two events/h (0-4) and normal gas exchange with CPAP therapy. Three subjects were successfully weaned from CPAP treatment during the study period. CONCLUSION: Initiating CPAP in an outpatient setting in children is feasible and effective in selected subjects. A high rate of compliance can be achieved as well as a correction of OSA.

Weaning from long term continuous positive airway pressure or noninvasive ventilation in children.

OBJECTIVES: A significant number of children are able to discontinue long term continuous positive airway pressure (CPAP) or noninvasive ventilation (NIV) but the underlying disorders, weaning criteria, and outcome of these children have not been studied. STUDY DESIGN: Retrospective cohort follow up. SUBJECT SELECTION: Consecutive children who were weaned from long term CPAP/NIV between October 2013 and January 2016. METHODOLOGY: Underlying disorders, weaning criteria, and clinical outcome were analyzed. RESULTS: Fifty eight (27%) of the 213 patients on long term CPAP/NIV could be weaned from CPAP/NIV with 50 patients being weaned from CPAP and 8 from NIV. Most patients were young children with upper airway anomalies, Prader Willi syndrome or bronchopulmonary dysplasia. CPAP/NIV was discontinued following spontaneous improvement of sleep-disordered breathing in 33 (57%) patients, upper airway surgery (n = 14, 24%), maxillofacial surgery (n = 6, 11%), neurosurgery (n = 1, 2%), upper airway and neurosurgery (n = 2, 3%), or switch to oxygen therapy (n = 2, 3%). CPAP/NIV was discontinued due to normal nocturnal gas exchange during spontaneous breathing in all patients, with an obstructive apnea-hypopnea index ≤6 events/h on a combined poly(somno)graphy in 27 patients. A relapse of obstructive sleep apnea was observed after a median delay of 2 years in six patients who resumed CPAP and in one patient who underwent midface distraction. CONCLUSIONS: Weaning from CPAP/NIV is possible in children treated with long term CPAP/NIV but is highly dependent on the underlying disorder. Spontaneous improvement is possible but most children need specific surgery. Long term follow-up is necessary in children with underlying disorders.

Obstructive sleep apnea in Down syndrome: Benefits of surgery and noninvasive respiratory support.

Children with Down syndrome are at increased risk of obstructive sleep apnea (OSA). The aim of the study was to describe the management of OSA in a large cohort of children with Down syndrome. A retrospective analysis of sleep studies and consequent management was performed for all consecutive Down syndrome patients evaluated between September 2013 and April 2016. The data of 57 patients were analyzed: 51/53 had an interpretable overnight polygraphy and 4 the recording of nocturnal gas exchange. Mean age at baseline sleep study was 6.2 ± 5.9 years. Eighteen patients (32%) had prior upper airway surgery. Mean apnea-hypopnea index (AHI) was 14 ± 16 events/hr with 41 of the 51 (80%) patients having OSA with an AHI >1 event/hr and 20 patients (39%) having an AHI ≥10 events/hr. Consequently, eight patients (14%) had upper airway surgery. OSA improved in all patients except two who needed noninvasive respiratory support. Nineteen (33%) patients required noninvasive respiratory support. Mean age at noninvasive respiratory support initiation was 7 ± 7 years. On 11 patients with objective adherence data available, mean compliance at 2 ± 1 years of treatment was excellent with an average use per night of 8 hr46 ± 3 hr59 and 9 patients using the noninvasive respiratory support >4 hr/night. Noninvasive respiratory support was associated with an improvement of nocturnal gas exchange. The prevalence of OSA is high in Down syndrome. Upper airway surgery is not always able to correct OSA. Noninvasive respiratory support represents then an effective treatment for OSA and good compliance may be achieved in a majority of patients.

Continuous Positive Airway Pressure for Upper Airway Obstruction in Infants with Pierre Robin Sequence.

UNLABELLED: The aim of the study was to evaluate noninvasive continuous positive airway pressure as first-line treatment for upper airway obstruction in neonates with Pierre Robin sequence. Forty-four neonates were enrolled and classified in 4 groups: ventilator-dependent patients (severe upper airway obstruction group), patients with clinical upper airway obstruction, an abnormal (moderate upper airway obstruction group) or normal polygraphy (mild upper airway obstruction group), and those with no clinical upper airway obstruction (no upper airway obstruction group). Five neonates in the severe upper airway obstruction group (n = 9) were successfully managed by noninvasive continuous positive airway pressure and 4 required a tracheotomy. The moderate upper airway obstruction group (n = 4) was successfully managed by noninvasive continuous positive airway pressure and the other patients by prone positioning. Continuous positive airway pressure represents an effective treatment of upper airway obstruction in Pierre Robin sequence and may be recommended in selected patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.