Management Of Apnea Research Articles

Standardized framework to report on the role of sleeping position in sleep apnea patients.

Sleep apnea is a multifactorial illness which can be differentiated in various physiological phenotypes as a result of both anatomical and non-anatomical contributors (e.g., low respiratory arousal threshold, high loop gain). In addition, the frequency and duration of apneas, in the majority of patients with OSA, are influenced by sleeping position. Differences in characteristics between non-positional patients (NPP) and positional patients (PP) suggest another crucial phenotype distinction, a clinical phenotype focusing on the role of sleeping position on sleep apnea. Since this clinical phenotype distinction has therapeutic implications, further research is necessary to better understand the pathophysiology behind this phenotypic trait and to improve management of PP. Therefore, we suggest a standardized framework that emphasizes the role of sleeping position when reporting clinical and research data on sleep apnea. We identified 5 key topics whereby a standardized framework to report on the role of sleeping position would be of added value: (1) sleep study data, (2) anatomical, morphological and physiological factors, (3) drug-induced sleep endoscopy (DISE) findings, (4) sleep apnea management, and (5) effectiveness versus efficacy of positional therapy in sleep apnea management. We performed a literature search to identify evidence to describe and support the rationale behind these5 main recommendations. In this paper, we present the rationale behind this constructand present specific recommendations such as reporting sleep study indices (disease severity) and sleep time spent in various sleeping positions. The same is suggested for DISE findings and effect of treatment. Sleep study indices (disease severity), anatomical, morphological, and physiological factors in sleep apnea patientsshould be reported separately for PP and NPP. Applying these suggestions in future research will improve patient care, assist in better understanding of this dominant phenotype, and will enhance accurate comparisons across studies and future investigations.

Effects of Cannabinoids on Sleep and their Therapeutic Potential for Sleep Disorders.

The recent trend for legalization of medicinal cannabis and cannabinoid-containing products, together with their soporific effects, has led to a surge of interest of their potential therapeutic role in the management of some common sleep disorders, such as insomnia, sleep disordered breathing, and restless legs syndrome, and less common disorders such as narcolepsy and parasomnias. Although much of the pre-clinical and clinical data were derived from studies with relatively small sample sizes and limited by biases in assessment, and in clinical trials lack of allocation concealment, as a whole, the results indicate a potential therapeutic role for cannabinoids in the management of some sleep disorders. Clinical trials are underway for insomnia and obstructive sleep apnea management, but there remains a substantial need for rigorous large multi-center studies to assess the dose, efficacy, and safety of the various types of cannabinoids on sleep disorders. This review aims to summarize the modulatory effects of cannabinoids on sleep physiology and provide a critical evaluation of the research on their potential therapeutic benefit in various sleep disorders.

The orthodontist and obstructive Sleep Apnea - an orthodontic perspective

Obstructive sleep apnea (OSA) is a recurrent respiratory condition related to sleep, characterised by sporadic narrowing and pharyngeal airway obstruction, with adverse effects on sleep efficiency and gaseous exchange. OSA is a poorly identified medical disorder where the diagnosis of undiagnosed patients involves a thorough history and concentrated physical assessment. The combination of anatomical and neuromuscular risk factors in the pathogenesis of OSA has resulted in a varied approach to its management. Individuals with OSA often feel unrested, fatigued, and sleepy during the daytime. These declines in daytime function can translate into higher rates of job-related and motor vehicle accidents. Screening to identify unrecognized OSA followed by appropriate treatment might improve sleep quality and normalize the AHI and oxygen saturation levels to prevent adverse health outcomes. The role of orthodontist in screening and cure is treasured in the multidisciplinary administration of OSA. The aim of this assessment is to summarize the recent information’s on the unique contributors to OSA with a centre of attention on diagnostic strategies and various orthodontic appliances which may also be considered for the cure of OSA and designed to offer guidance to practising orthodontists on the suggested role of the speciality of orthodontics in the management of obstructive sleep apnea.

Barriers and facilitators to the implementation of a novel web-based sleep apnea management platform.

Obstructive sleep apnea (OSA) is a highly prevalent yet underdiagnosed disorder affecting US military Veterans. The Remote Veterans Apnea Management Platform (REVAMP) is a web-based OSA management program created to improve access to care. REVAMP was launched within the Veterans Health Administration (VHA) in July 2017, with variable patient recruitment rates (from 0 to 573 patients per site) at the first 10 Veterans Affairs (VA) medical centers (Wave-1 sites). This study aimed to examine the contextual circumstances surrounding the implementation of REVAMP from the provider perspective to inform strategies to increase its uptake at future rollout sites. A purposive sample of REVAMP site leaders from the Wave-1 sites was recruited with additional staff members being solicited as well. Semi-structured interviews were conducted. Two independent coders reviewed individual transcripts using content analysis to identify emerging themes. Fifteen individuals from Wave-1 sites were interviewed. Implementation of REVAMP was facilitated by the presence of leadership support, staff, and time dedicated to REVAMP, and perceived usefulness of REVAMP by staff as well as positive feedback from the Veterans using REVAMP. The difficulty of supporting Veteran creation of login credentials to the program and integrating REVAMP into the existing workflow were major barriers to its implementation. Improving leadership engagement, simplifying the enrollment process, and enhancing the medical staff experience through shared best practice alerts were identified as actions needed to improve the penetration of REVAMP at future rollout sites.

The effect of apnea management on novel coronavirus infection: A study on patients with obstructive sleep apnea

ObjectiveTo assess the frequency of coronavirus disease-2019 (COVID-19) and the effect of obstructive sleep apnea (OSA) management on COVID-19 among patients with confirmed OSA. DesignCross-sectional telephone interview survey. SettingAcademic sleep labs. ParticipantsIranian adults ≥ 18 years old with confirmed OSA. ResultsAmong 275 participants with OSA, 20% (n = 55) were suspected to have history of COVID-19 but had no positive test, and 18% (n = 51) were in the definite COVID-19 group according to their reported symptoms or confirmed positive test. Having severe OSA (apnea hypopnea index ≥ 30) was associated with an increased risk of definite COVID-19, with an odds ratio (OR) with 95% confidence interval (95% CI) of 2.31 (0.87-5.55) compared to having mild OSA in definite COVID-19 group. Those not undergoing treatment for OSA had an OR (95% CI) of 2.43 (1.26-4.67) for definite COVID-19 compared to those accepting treatment in definite COVID-19 group. Total sleep times (TSTs) were 354, 340, and 320 minutes in healthy, suspected, and COVID-19 groups, respectively; TST was associated with COVID-19 (P-value = .04). Similarly, sleep efficiency (SE) scores were 75.7, 74.2, and 67.9% for the healthy, suspected, and COVID-19 groups, respectively (P-value = .005); Beck Depression scores were 13.8, 13.0, and 17.7, respectively (P-value = .056). ConclusionsOSA as a proinflammatory condition with multiple comorbidities may be a contributing factor to developing COVID-19. Greater OSA severity, no treatment for OSA, and lower TST and SE were associated with increased COVID-19 prevalence among patients with OSA.

Clinical audit on management of apnea of prematurity in neonatal intensive care unit

Introduction Apnea of prematurity (AOP) is one of the most common diagnoses in the neonatal intensive care unit (NICU). An apneic spell is usually defined as a cessation of breathing for 20 s or longer or a shorter pause accompanied by bradycardia, cyanosis, or pallor. The incidence of AOP increased with decreasing gestational age. Essentially, all infants born at less than or equal to 28 weeks of gestation were diagnosed with apnea. Apnea may be obstructive, central, or mixed. Idiopathic AOP is mostly of mixed etiology (50–75). The physiopathological mechanism underlying AOP is not fully clear, but is certainly linked to the immaturity of the central nervous system of the preterm neonate. Apnea is a diagnosis of exclusion. It usually resolves by 36–37 weeks' corrected age without long-term sequelae. Patients and methods The study includes all preterms at NICU in Assiut University Children Hospital with idiopathic apnea of prematurity in a period of 1 year (March 2018–March 2019). The study included 50 preterm neonates admitted to the NICU with idiopathic AOP. Their ages ranged from 27 to 34 weeks, 27 male and 23 female. The study is a clinical audit to detect the adherence of physicians to the Protocol for Management of AOP at NICU in Assiut University Children Hospital. Results A total of 54% were males whereas 46% were females. Gestational age of the studied cases range from 27 to 34 weeks with a mean age of 30.4 ± 1.99 weeks. Caffeine citrate treatment was given in 100% of the studied cases; 68% of them showed good response to caffeine citrate therapy. A total of 86% of the studied cases improved and discharged without further attacks of apnea; 14% of the studied cases died during the study due to complications and sequela of the disease. Conclusion Stark's 2016 Guidelines have been followed in the management of idiopathic pnea of prematurity in the studied cases but there were some defects that can affect the outcome of management of idiopathic apnea of prematurity. The study recommends avoiding these defects.

Utilization of surgical treatment for sleep apnea: A study of health disparities.

Barriers to surgical treatment for sleep apnea remain understudied. In this study, we sought to evaluate whether specific demographic and socioeconomic characteristics are associated with whether or not patients receive surgery for sleep apnea management. The National Inpatient Sample (NIS) database was analyzed for 2007-2014. Patients aged 18 or older with primary or secondary diagnoses of sleep apnea were selected. Patients were sub-categorized by whether they received related soft-tissue removal or skeletal modifying procedures. Age, race, gender, region, insurance, comorbidities, procedure type, and procedure setting were analyzed between surgical and nonsurgical groups. A total of 449,705 patients with a primary or secondary diagnosis of sleep apnea were identified, with 27,841 (5.8%) receiving surgical intervention. Compared with the non-surgical group, patients in the surgical cohort were more likely to be younger, male (74.4% vs. 59.0%), Hispanic (10.2% vs. 6.2%), Asian (3.6% vs. 1.0%) (p<0.001), and have less clinical comorbidities. Those receiving surgery were more likely to be in the highest income bracket (36.1% versus 25.1%) and utilize private insurance (76.3% vs. 50.8%). Soft-tissue surgeries comprised 88.5% of total procedures while skeletal modifying procedures constituted 11.5% (p<0.001). This study identified multiple demographic, socioeconomic, and clinical discrepancies in the utilization of surgical versus nonsurgical management of sleep apnea in the United States. Future studies should examine the causes for these health disparities in the ultimate effort to provide more equitable healthcare in the United States.

Obstructive Sleep Apnea: Diagnosis and Management

As part 2 of three chapters on sleep disordered breathing, this chapter reviews obstructive sleep apnea (OSA) diagnosis and management. OSA should be considered in all patients who have loud habitual snoring, excessive daytime sleepiness, and witnessed apneas. On physical examination, craniofacial abnormalities that can lead to sleep apnea include retrognathia, micrognathia, a narrow hard palate, nasal obstruction, an overjet, and an overbite. Enlargement of the upper airway soft tissue structures (the tongue, soft palate, lateral walls, and parapharyngeal fat pads) also increases the risk of OSA. The gold standard for making the diagnosis of OSA is overnight polysomnography, but home sleep apnea tests (HSAT) are rapidly gaining acceptance, especially in patients with a high probability of OSA. The first line of therapy for OSA remains positive airway pressure (PAP), with the second line of therapy being oral appliances. Another alternative to PAP therapy is hypoglossal nerve stimulation, which has been shown to decrease the Apnea-Hypopnea index by 67.4%. This review contains 6 figures, 3 tables, and 52 references. Key Words: craniofacial abnormalities, Epworth Sleepiness Scale, home sleep apnea test, hypoglossal nerve stimulation, obstructive sleep apnea, oral appliances, oral pharyngeal crowding, polysomnography, positive airway pressure, STOP-BANG

Caffeine for the Treatment of Apnea in the Neonatal Intensive Care Unit: A Systematic Overview of Meta-Analyses.

BackgroundCaffeine is a common treatment for neonatal intensive care management of the developmental complication of apnea of prematurity in preterm infants. There are several systematic reviews (SRs) on the performance of caffeine in the treatment of apnea. The evidence provided by those, however, is depressed by an information overload due to high heterogeneity in the characteristics as well as the quality of these SRs.ObjectiveThe aim was to provide a systematic overview of SRs on the use of caffeine for the management of neonatal apnea. Such overviews are a recent method used to assess and filter top evidence among SRs, enabling enhanced access to targeted information of interest.MethodsA comprehensive literature search was conducted via EMBASE, Cochrane Database of Systematic Reviews (CDSR), and PubMed since inception to January 2020. Two reviewers independently conducted study selection and data extraction, and assessed the quality of methods and the risk of bias in included SRs based on A Measurement Tool to Assess Systematic Reviews (AMSTAR-2) and Risk of Bias in Systematic Reviews (ROBIS) tools. Extracted data related to study type, characteristics, patients, intervention, comparator, regimen, and outcome measures.ResultsSeven SRs with meta-analyses (SRMAs) were included in the current overview, involving a total of 63,315 neonates. SRMAs included randomized clinical and observational studies, with various types of patients, comparators, and outcomes. The quality of SRMAs ranged from critically low (n = 1), low (n = 1), moderate (n = 2), to high (n = 3), and the risk of bias was unclear (n = 2), low (n = 4), and high (n = 1). The effectiveness of caffeine with regard to treatment success and the rate of apnea was not significantly different from that of theophylline or doxapram in two SRMAs. Against control, in one SRMA, while caffeine reduced the rate of failure as well as the need for pressure ventilation, it did not significantly reduce mortality. This comparative effectiveness of caffeine was based on high-quality SRMAs with a low risk of bias. The effectiveness against apnea seems to be enhanced via the administration of early (0–2 days) or high doses of caffeine in one and three SRMAs, respectively. This, nevertheless, was based on lower-quality SRMAs with a higher risk of bias. Safety outcomes were mostly based on comparative SRMAs of different drug regimens, whereby, less tachycardia and lower risk for complications were reported with lower and earlier caffeine administrations, respectively. The evidence behind this, however, was limited in quantity and quality.ConclusionWhile limited in quantity, there is evidence of non-inferior effectiveness of caffeine against other methylxanthines or doxapram for the management of apnea in neonates. Owing to the limited quality, however, limited evidence exists in support of an optimal administration regimen for caffeine. Further controlled studies are, therefore, needed to confirm the comparative usefulness of caffeine as well as to assess its different potential regimens, including in relation to safety.Electronic supplementary materialThe online version of this article (10.1007/s40272-020-00404-4) contains supplementary material, which is available to authorized users.

0662 Hybrid Therapies to Improve Sleep Apnea Management

Abstract Introduction A one-size fits all approach to sleep apnea management, as is promoted by insurance requirements, pervades the field of sleep medicine but does not address individual differences in disease phenotype or treatment tolerance or attempt to achieve meaningful targets for adherence or disease optimization. Continuous positive airway pressure (CPAP) is considered to be the gold standard treatment for sleep apnea, yet CPAP nonadherence rates remain high (estimates at &amp;gt; 30%) while usage goals (at least 4 hours/night) and therapeutic success targets (machine detected AHI &amp;lt; 5) allow for substantial residual disease to persist. Hybrid therapy, combining mandibular advancement device (MAD) and positive airway pressure (PAP), has demonstrated additive effects on lowering the AHI, ODI, and therapeutic PAP pressure in severe OSA patients with pressure intolerance. This analysis explores the impact of hybrid therapy on treatment adherence and optimization, and identifies patient and data characteristics suggestive of benefit from combined therapies. Methods In a retrospective analysis, we reviewed the demographic data, medical histories, home sleep test, diagnostic and therapeutic attended polysomnography results, and PAP device settings and data (including usage, leak, residual event index, and waveforms) pre-and post-hybrid approach, in patients treated with hybrid therapy in our multidisciplinary academic sleep disorders clinic from 2014-2019. Results Hybrid therapies utilized include simultaneous (MAD worn together with PAP), alternating (MAD and PAP separately over parts of or on alternating nights), and anchoring (MAD to maintain mouth closure and jaw stability to minimize leak). Preliminary analysis (N=30) shows that hybrid therapy compared to PAP alone improves PAP adherence, lowers residual AHI, minimizes periodic breathing, reduces aerophagia, and lowers therapeutic PAP pressure in these patients. Patient and data characteristics suggestive of benefit include high loop gain sleep apnea, complex apnea, mouth breathing, and position dominance. Conclusion Individualizing treatment by combining therapies can result in improved PAP tolerance, usage, and disease control. Support

1240 Obstructive Sleep Apnea Management in Weill-Marchesani Syndrome: A Case Report

Abstract Introduction Weill-Marchesani Syndrome (WMS) is a rare systemic genetic connective tissue disorder which usually presents with symptoms of short stature, limited joint movement, and eye problems such as glaucoma and microspherophakia. This genetic condition is associated with fibrous tissue hyperplasia. WMS is inherited as autosomal dominant or autosomal recessive patterns in families leading to a variability in presenting phenotype. Few papers have been written on airway management during anesthesia but as far as we know, this is the first case report on obstructive sleep apnea management in a patient with WMS. Report of Case A 9 year old boy with a past medical history of Methylene THF Reductase deficiency, von Willebrand’s Disease, seizure disorder, premature birth, developmental delays and Weill-Marchesani syndrome was referred to Sleep Medicine due to tonsillar hypertrophy (3+), snoring and witnessed apneas. Upon physical examination, patient had mid-facial hypoplasia, retropositioning of the mandible, high arched palate, Mallampti class IV, maxillary hypoplasia and mandibular hypoplasia. He had been evaluated by ENT which determined the patient to be too high risk due to his medical conditions for T&amp;A. The patient had a polysomnogram in 2018 indicating OSA with an apnea-hypopnea index of 4.2 and a minimum oxygen saturation of 91%. After a CPAP titration study, the patient was started on Auto CPAP of 5-15 cmH2O and has shown improvement in symptoms based on subjective and objective compliance report. Patient has been able to tolerate PAP therapy well with 100% compliance greater than 4 hours per night. Conclusion This case is the first illustrating OSA in a patient with Weill-Marchesani Syndrome. In WMS, the causes of OSA are not only due to tonsillar hypertrophy, but multifactorial, including craniofacial abnormalities. Given the high risk of surgical complications in WMS patients, PAP therapy appears to be a reasonable option for OSA management.

1162 Financial Savings and Improved Outcomes from an Innovative, Integrated Sleep Apnea Management Program for a Safety Net Population: 5-Year Results

Abstract Introduction Sleep disorders are extremely common in the general population and are associated with an increased risk for fatal accidents, heart disease, stroke, neurocognitive decline, and diabetes. Sleep problems disproportionately affect socioeconomically disadvantaged and under resourced communities. We present here a 5-year analysis of a private-public partnership between a private sleep medicine practice (Redwood Pulmonary Medical Associates, RPMA) and county medical system (the Health Plan of San Mateo) to provide a coordinated, value-based sleep apnea program to adult residents of San Mateo County, CA. Methods Referring providers send referrals to a single location (RPMA), and sleep consultations, testing, follow-up care, and CPAP management occur out of the same location by a dedicated staff. Limited channel cardiopulmonary (CP) sleep testing initiated in the office and completed at home was done for most patients. Patients with AHI&amp;gt;5 plus daytime sleepiness were offered nasal CPAP, unlimited mask fittings, and compliance checks. Results 2101 CP tests were successfully completed (93.5%). There were 49.6% females and 50.4% males, with an average age of 51.6 years. 31% had severe obstructive sleep apnea (OSA) and 59% were moderate or severe. 1471 (65%) of patients were given prescriptions for CPAP and 471 (32%) were still using CPAP at 5 years, 68.7% of whom were initiated within 3 years of the analysis. Of the patients returning satisfaction surveys, 97% would recommend the program to a relative or friend, and all respondents (99 to date) who were using CPAP felt it had benefitted their health overall. Comparing actual costs of the program to projected fee-for-service costs for the same services, the program saved the Health Plan of San Mateo $1,132,510, or 51.4%. Conclusion This program demonstrates the potential clinical and financial benefit of private-public partnerships in administering clinical programs to high risk populations, as private businesses can quickly adapt to new technologies, financial metrics, and standards of care. Support No outside financial support was provided

ApneBoot: A Novel Device for Apnea Management in Premature Infants

In India, each year 3.5 million babies are born premature ranking it first among the top 10 countries with the greatest number...

Caffeine Citrate for Apnea of Prematurity: A Prospective, Open-Label, Single-Arm Study in Chinese Neonates.

Background: Caffeine citrate has been approved in China for the management of apnea of prematurity. This clinical trial was conducted as a condition of regulatory approval. The aim was to confirm the efficacy of caffeine citrate in the treatment of recurrent intermittent hypoxia and bradycardia in preterm newborns with primary apnea.Objectives: The primary outcome was the change from baseline in the number of apnea events after loading dose administration of caffeine citrate. Secondary efficacy outcomes included the change from baseline in apnea events after 2 and 4 weeks of maintenance doses.Methods: This was a multicenter, prospective longitudinal open-label, single-arm study. Neonates who had experienced at least four apnea events during a 24 h period received a loading dose of caffeine citrate 20 mg/kg; those who required additional maintenance doses received 5 mg/kg/day (titrated up to 10 mg/kg/day in case of insufficient response). The number of apnea events was recorded for 6–12 h prior to the loading dose (baseline), and for 12 h post-dose, following the loading dose and at Weeks 2 and 4 (during maintenance).Results: A total of 247 neonates received the loading dose, who had a significant reduction from baseline of 3.9 events (p < 0.001) in the mean number of apnea events. The subset of neonates who required maintenance doses also had significant reductions in the number of events at all visits (p < 0.001 for all). A total of 79.4% of participants had at least one adverse event, but only one non-serious and no serious events were considered related to treatment.Conclusions: In this large, prospective, open-label study, premature infants with a history of apnea who received caffeine citrate were significantly less likely to experience further apnea events.

Reducing Variation in the Management of Apnea of Prematurity in the Intensive Care Nursery

Premature infants have bradycardia and/or desaturation events due to apnea of prematurity that resolve as the infants mature. Despite American Academy of Pediatrics guidelines recommending a standard "event-free" period before discharge, length of observation in our Intensive Care Nursery was variable. By June 2018, for infants born <36 weeks' gestation in the Intensive Care Nursery, we aimed to standardize time to discharge after the last documented event at 5 days, when the baseline mean was 3.6 days (range 0-6 days). A quality-improvement team used the Model for Improvement. Plan-do-study-act cycles improved nursing documentation of events and standardized discharge criteria after consensus on operational definitions. The outcome measure was days to discharge after last documented event. Process measures included percentage of events documented completely and correctly in the electronic medical record. Balancing measure was length of stay after 36 weeks' corrected gestational age. We used statistical process control. The baseline event watch ranged from 0 to 6 days. After defining significant events, documentation expectations, and consensus on a 5-day "watch" before discharge, the event watch range narrowed with a mean that shifted from 3.6 to 4.8 days on X-bar S statistical process control chart. Completeness of documentation increased from 38% to 63%, and documentation of significant events increased from 38% to 88%. Length of stay after 36 weeks' corrected gestational age was unchanged, and nursing satisfaction improved. We found decreasing variation in the management of apnea of prematurity while simultaneously improving staff satisfaction. Next steps include revising electronic medical record flowsheets and spread to network NICUs.

Feasibility of Online Haemodiafiltration in Sleep Apnoea: A Randomized Crossover Study

Background: Sleep apnoea is prevalent in dialysis patients. Previous studies identified excessive inflammation in ­patients with sleep apnoea. Online haemodiafiltration ­(OL-HDF) may reduce systematic inflammation through better clearance of middle molecules. We aimed to determine the feasibility of OL-HDF in sleep apnoea management. Methods: Eligible dialysis patients were screened for risk of sleep apnoea by nocturnal oximetry followed by a diagnostic sleep study to assess apnoea-hypopnea index (AHI). Patients with AHI ≥15/h were invited to a randomized crossover trial. The intervention was 2-month high-flux haemodialysis (HF-HD) followed by 2-month OL-HDF or vice versa with 1-month washout via HF-HD. Feasibility was assessed by patient recruitment and the primary outcome, severity of sleep apnoea (AHI). Secondary outcomes were pro-inflammatory cytokines, patient-reported daytime sleepiness, quality of sleep and health-related quality of life. Results: Of 65 participants at risk of sleep apnoea, only 15 were consented and randomized (mean age 70 years, 80% male, mean AHI 42.2/h). AHI was not statistically different between OL-HDF versus HF-HD (55.6/h vs. 48.3/h, p = 0.134); however, when sleep apnoea was stratified into obstructive and central apnoea, patients had less obstructive episodes after treated by OL-HDF (23.2/h vs. 18.6/h, p = 0.178); a sensitivity analysis was performed excluding outliers, and the treatment effect for obstructive episodes was found to be statistically significant (11.1 vs. 18.2/h, p = 0.019). Pro-inflammatory biomarkers and patient-reported outcomes were similar between OL-HDF and HF-HD. Conclusion: Patient recruitment was a major challenge in this feasibility study. OL-HDF may reduce obstructive sleep apnoea; however, the result needs to be confirmed by larger studies.

Agreement of sleep specialists with registered nurses' sleep study orders in supervised clinical practice.

Incorporating registered nurses (RN-level) into obstructive sleep apnea (OSA) management decisions has the potential to augment the workforce and improve patient access, but the appropriateness of such task-shifting in typical practice is unclear. Our medical center piloted a nurse triage program for sleep medicine referrals. Using a sleep specialist-designed decision-making tool, nurses triaged patients referred for initial sleep studies to either home sleep apnea test (HSAT) or in-laboratory polysomnography (PSG). During the first 5 months of the program, specialists reviewed all nurse triages. We compared agreement between specialists and nurses. Of 280 consultations triaged by nurses, nurses deferred management decisions to sleep specialists in 6.1% (n = 17) of cases. Of the remaining 263 cases, there was 88% agreement between nurses and specialists (kappa 0.80, 95% confidence interval 0.74-0.87). In the 8.8% (n = 23) of cases where supervising specialists changed sleep study type, specialists changed from HSAT to PSG in 16 cases and from PSG to HSAT in 7. The most common indication for change in sleep study type was disagreement regarding OSA pretest probability (n = 14 of 23). Specialists changed test instructions in 3.0% (n = 8) of cases, with changes either related to the use of transcutaneous carbon dioxide monitoring (n = 4) or adaptive servo-ventilation (n = 4). More than 80% of sleep study triages by registered nurses in a supervised setting required no sleep specialist intervention. Future research should focus on how to integrate nurses into the sleep medicine workforce in a manner that maximizes efficiency while preserving or improving patient outcomes.

Confounding biases in studies on early- versus late-caffeine in preterm infants: a systematic review.

Caffeine is indicated for the management of apnoea of prematurity and extubation in preterm infants. Early initiation of caffeine administration has increased in the past decades with the purpose of reducing respiratory morbidity. However, there might be harms associated with this approach. This systematic review aims to assess whether early administration of caffeine reduces morbidity and mortality in preterm infants. The methods were published in a preregistered protocol. The literature search was performed in February 2019 with no restrictions for language or publication date. Randomised controlled trials (RCTs) and cohort studies comparing early versus late caffeine administration to infants born before week 34 were included. Two RCTs and 14 cohort studies were included. All studies but one had a serious/critical overall risk of bias. Few studies reported on long-term or patient-relevant outcomes. No meta-analysis could be performed. Based on the available evidence, no conclusions about the optimal timing of caffeine administration can be drawn. There are inherent methodological problems in the cohort studies. RCTs are needed to answer the question of optimal timing for caffeine administration in neonatal care. Future trials should focus on outcomes relevant to patients and their families and include long-term outcomes.

Assessing the Impact of Obstructive Sleep Apnea (OSA) Management on Quality of Life (QoL) in Pediatric Patients: A Cross-Sectional Study

Assessing the Impact of Obstructive Sleep Apnea (OSA) Management on Quality of Life (QoL) in Pediatric Patients: A Cross-Sectional Study

Management of apnea in infants with trisomy 18.

This case series aimed to characterize the clinical features, management, and outcomes of apnea in infants with trisomy 18. Participants in this study were infants with trisomy 18 who were born alive and admitted to the neonatal intensive care unit in Kyushu University Hospital from 2000 to 2018. Retrospective analysis was performed on clinical data recorded in our department. Twenty-seven infants with trisomy 18 were admitted to our hospital during the study period, of which 25 (nine males, 16 females) were enrolled as eligible participants in this study. Among them, 14 started presenting with apnea from median 3.5days of age (range 0-47d). In these infants with apnea, eight received respiratory support of positive pressure ventilation (PPV). The 1-year survival rate of infants in the PPV group was higher than that of non-PPV-supported infants (5 out of 8 vs 0 out of 6 infants). Five PPV-supported infants received a diagnosis of epilepsy, which was controlled by antiepileptic drugs. Postnatal respiratory intervention provides better prognosis in infants with trisomy 18. Improved survival leads to accurate diagnosis and treatment of apneic events in association with epilepsy. WHAT THIS PAPER ADDS: Respiratory support is effective against apnea in infants with trisomy 18. Intervention with ventilation provides a higher chance of prolonged survival. Improved survival leads to the accurate diagnosis and treatment of epilepsy-associated apnea.