The management of pediatric obstructive sleep apnea in the COVID-19 era: to PAP or not to PAP?

Abstract

Free AccessLetters to the EditorThe management of pediatric obstructive sleep apnea in the COVID-19 era: to PAP or not to PAP? Zarmina Ehsan, MD Zarmina Ehsan, MD Address correspondence to: Zarmina Ehsan, MD, Division of Pulmonary and Sleep Medicine, Children’s Mercy-Kansas City, 2401 Gillham Road, Kansas City, MO 64108, phone: 816-983-6644, Fax: 816-802-4022, Email: E-mail Address: [email protected] Search for more papers by this author Published Online:June 1, 2021https://doi.org/10.5664/jcsm.9146SectionsAbstractPDF ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutABSTRACTCitation:Ehsan Z. The management of pediatric obstructive sleep apnea in the COVID-19 era: to PAP or not to PAP? J Clin Sleep Med. 2021;17(6):1323–1324.INTRODUCTIONAlthough sleep medicine specialists have transitioned well in the COVID-19 era, unique challenges have arisen highlighting the paucity of evidence (or lack thereof) that has traditionally guided decision-making for pediatric obstructive sleep apnea (OSA). At the onset of the pandemic, adenotonsillectomy (the “first-line” management for most children with moderate to severe OSA) was labeled an elective surgical procedure and one that confers a high risk for COVID-19 transmission. Therefore, unless the OSA was severe enough to warrant an urgent adenotonsillectomy, otolaryngologists were deferring surgery. This led to a slew of phone calls to sleep medicine clinics requesting nonsurgical management for OSA. However, simultaneously, continuous positive pressure therapy (CPAP) was added to the World Health Organization list of aerosol-generating procedures, leading to significant angst over in-laboratory titrations during the pandemic and worry about aerosolization of viral particles in the sleep laboratory and patients’ homes.1 In addition, concern that untreated OSA can increase morbidity related to COVID-19 infection has further complicated the issue.2,3 This begs the question, what is the best way to manage a child with moderate to severe OSA in the COVID-19 era?CPAP is an effective therapy for pediatric OSA when used consistently. Positive pressure is delivered through use of a mask that in children often requires real-time fitting by an experienced respiratory therapist (mask fitting). Because this therapy poses a risk of aerosolizing viral particles, sleep facilities have been cautious with liberal scheduling of in-laboratory positive airway pressure titration polysomnograms. Although these studies have resumed (with strict policies in place, such as pre-procedure COVID-19 testing, 1-to-1 respiratory therapist-to-patient ratio, and the use of personal protective equipment), business remains slow and worry prevails over false-negative tests. While most adults with OSA are managed with CPAP initiated in the unattended setting (auto-titrating CPAP) and can choose a mask interface of their liking, there is no such guidance on empiric CPAP use in children and in-laboratory titration studies and in-person mask-fitting appointments have traditionally been required. While it is encouraging that a handful of studies in children have demonstrated efficacy of auto-titrating CPAP,4,5 these studies focused on older children, whereas those at highest risk of OSA from adenotonsillar hypertrophy are typically younger. Moreover, it is less clear whether these auto-titrating devices have algorithms that can safely treat younger children with OSA.This brings up the second critical issue, one that relates to the use of CPAP and risk of COVID-19 transmission in the household. The Centers for Disease Control and Prevention’s guidance regarding risk mitigation is difficult to apply in children who cannot be effectively isolated, often share rooms with siblings, and need adult supervision and assistance to wear the mask interface and use the CPAP device. Frequent checks during the night may also be needed, theoretically increasing the risk of exposure to the caregiver. How, then, must we empower our patients (and their parents) to ensure their disease is adequately treated and their family remains safe? Perhaps it is time to think outside the box (or CPAP in this case).DISCLOSURE STATEMENTThe author reports no conflicts of interest.REFERENCES1. Miller MA, Cappuccio FP. A systematic review of COVID-19 and obstructive sleep apnoea. Sleep Med. Rev. 2021;55:101382. https://doi.org/10.1016/j.smrv.2020.101382 CrossrefGoogle Scholar2. Maas MB, Kim M, Malkani RG, Abbott SM, Zee PC. Obstructive sleep apnea and risk of COVID-19 infection, hospitalization and respiratory failure [published online ahead of print, 2020 Sep 29]. Sleep Breath. https://doi.org/10.1007/s11325-020-02203-0 Google Scholar3. Voulgaris A, Ferini-Strambi L, Steiropoulos P. Sleep medicine and COVID-19: has a new era begun? Sleep Med. 2020;73:170–176. https://doi.org/10.1016/j.sleep.2020.07.010 CrossrefGoogle Scholar4. Mihai R, Vandeleur M, Pecoraro S, Davey MJ, Nixon GM. Autotitrating CPAP as a tool for CPAP initiation for children. J Clin Sleep Med. 2017;13(5):713–719. https://doi.org/10.5664/jcsm.6590 LinkGoogle Scholar5. Khaytin I, Tapia IE, Xanthopoulos MS, et al.. Auto-titrating CPAP for the treatment of obstructive sleep apnea in children. J Clin Sleep Med. 2020;16(6):871–878. https://doi.org/10.5664/jcsm.8348 LinkGoogle Scholar Previous article Next article FiguresReferencesRelatedDetails Volume 17 • Issue 6 • June 1, 2021ISSN (print): 1550-9389ISSN (online): 1550-9397Frequency: Monthly Metrics History Submitted for publicationJanuary 4, 2021Submitted in final revised formJanuary 11, 2021Accepted for publicationJanuary 11, 2021Published onlineJune 1, 2021 Information© 2021 American Academy of Sleep MedicinePDF download