Management Of Apnea Research Articles

Caffeine treatment for bronchiolitis-related apnea in the pediatric intensive care unit

IntroductionApnea is commonly encountered in children with bronchiolitis. Despite the lack of recommendations regarding bronchiolitis-related apnea (BRA) management, some pediatric intensive care unit (PICU) practitioners use caffeine treatment based on extrapolation from the recommendations for prematurity-related apnea management. The objectives of this study were to describe the management of BRA in our PICU, evaluate the caffeine prescription rate for this indication, and explore its potential effects on clinical outcomes. MethodsThis was a retrospective study in a university hospital PICU between January 1st, 2009 and December 31st, 2016. All children under 1 year of age admitted to the PICU with a diagnosis of BRA were included. Patients were allocated to a control group or a caffeine group depending on the administration of caffeine. ResultsIn total, 54 infants were included and caffeine treatment was administered to 49 (91%) of them. Patient characteristics were similar between the two groups. Ventilatory support was initiated for 50 patients (93%). Supportive care and length of PICU stay were similar between the two groups. Caffeine was not associated with adverse events. ConclusionCaffeine treatment in BRA could be considered as a local standard practice. This retrospective study was underpowered to show any benefit of caffeine treatment on clinical outcomes. This treatment was not associated with significant adverse effects. We raised the question of the appropriate caffeine dosing regimen for BRA in this postterm population. Further studies on this topic are warranted.

Caffeine and Clinical Outcomes in Premature Neonates.

Caffeine is the most widely used drug by both adults and children worldwide due to its ability to promote alertness and elevate moods. It is effective in the management of apnea of prematurity in premature infants. Caffeine for apnea of prematurity reduces the incidence of bronchopulmonary dysplasia in very-low-birth-weight infants and improves survival without neurodevelopmental disability at 18–21 months. Follow-up studies of the infants in the Caffeine for Apnea of Prematurity trial highlight the long-term safety of caffeine in these infants, especially relating to motor, behavioral, and intelligence skills. However, in animal models, exposure to caffeine during pregnancy and lactation adversely affects neuronal development and adult behavior of their offspring. Prenatal caffeine predisposes to intrauterine growth restriction and small growth for gestational age at birth. However, in-utero exposure to caffeine is also associated with excess growth, obesity, and cardio-metabolic changes in children. Caffeine therapy is a significant advance in newborn care, conferring immediate benefits in preterm neonates. Studies should help define the appropriate therapeutic window for caffeine treatment along with with the mechanisms relating to its beneficial effects on the brain and the lung. The long-term consequences of caffeine in adults born preterm are being studied and may depend on the ability of caffeine to modulate both the expression and the maturation of adenosine receptors in infants treated with caffeine.

Multidisciplinary Approach to Sleep Apnea Management

Obstructive sleep apnea (OSA) is one of the more common, yet least appreciated of the common chronic conditions in the United States. OSA is a syndrome with multifactorial pathophysiology, and is associated with increased morbidity and mortality, with many patients living with OSA for years before diagnosis. Because of the efficacy of CPAP, it has been considered a first-line therapy and OSA care has been primarily organized around it. However, several factors are converging that provide a sound argument for a multidisciplinary approach to OSA management. Over 35 therapeutic options exist for OSA, but they tend to be underutilized especially for patients with mild-to-moderate OSA. Most OSA care is provided by pulmonary physicians, without reference to the inclusion of other disciplines in the evaluation and therapeutic process. Finally, with increased recognition of both OSA phenotypes and non-anatomical causes of OSA, the field has now commenced in increasing the understanding of subgroups of OSA patients, and the new era of personalized, tailored treatment approach has begun. OSA healthcare services will need to either organize multidisciplinary clinics physically, virtually, or via some combination to care for the large number of OSA patients in the United. States.

NIV in amyotrophic lateral sclerosis: The 'when' and 'how' of the matter.

Non-invasive ventilation (NIV) has become an essential part of the treatment of amyotrophic lateral sclerosis (ALS) since 2006. NIV very significantly improves survival, quality of life and cognitive performances. The initial NIV settings are simple, but progression of the disease, ventilator dependence and upper airway involvement sometimes make long-term adjustment of NIV more difficult, with a major impact on survival. Unique data concerning the long-term adjustment of NIV in ALS show that correction of leaks, management of obstructive apnoea and adaptation to the patient's degree of ventilator dependence improve the prognosis. Non-ventilatory factors also impact the efficacy of NIV and various solutions have been described and must be applied, including cough assist techniques, control of excess salivation and renutrition. NIV in ALS has been considerably improved as a result of application of all of these measures, avoiding the need for tracheostomy in the very great majority of cases. More advanced use of NIV also requires pulmonologists to master the associated end-of-life palliative care, as well as the modalities of discontinuing ventilation when it becomes unreasonable.

TORS for OSA: a practice, pitfalls and literature review

PurposeTrans-oral robotic surgery (TORS) is increasingly employed in obstructive sleep apnoea (OSA) management. Objective outcomes are generally assessed through polysomnography. Pre-operative magnetic resonance imaging (MRI) can be a useful adjunct in objective upper airway assessment, in particular the tongue base, providing useful information for surgical planning and outcome assessment, though care must be taken in patient positioning during surgery. The purpose of this paper is to identify pitfalls in this process and suggest a protocol for pre-operative MRI scanning in OSA.Design/methodology/approachThis study is a four-patient prospective case-series and literature review. Outcome measures include pre- and post-operative volumetric changes in the pharynx as measured on MRI and apnoea–hypopnea indices (AHI), with cure being OSA resolution or a 50 per cent reduction in AHI.FindingsAll patients achieved AHI reduction and/or OSA cure following TORS, despite a decrease in pharyngeal volume measurements at the tongue base level. This study and others lacked standardisation in the MRI scanning protocol, which resulted in an inability to effectively compare pre- and post-operative scans. Pitfalls were related to variation in head/tongue position, soft-tissue marker usage and assessed area boundary limits.Practical implicationsTORS appears to be effective in OSA management. A new protocol for patient positioning and anatomical landmarks is suggested.Originality/valueThe findings could provide directly comparable data between scans and may allow correlation between tongue base volumetric changes and AHI through subsequent and historical study meta-analysis.

What We Know so far about Obstructive Sleep Apnea Management: A Review Article

Obstructive sleep apnea is a common sleep disordered breathing condition. It is well recognized as a major risk factor for multiple medical conditions and poor quality of life. It has a great burden on health care resources and a substantial increase in health care use costs. Unfortunately, despite the prevalence, it is widely recognized that it remains under-diagnosed. 
 Effective treatment needs a comprehensive management plan approach that considers the patient as the centerpiece of management. Regular monitoring and a detailed follow up can have an impact on adherence to therapy. A constant and regular follow up can shed some light on patients who are not compliant with therapy and offer them with alternative therapeutic options that suits them better whenever feasible. 
 In this review, we aim to shed some light on where we are in terms of obstructive sleep apnea management strategies and options available to each individual patient.

Differences in three-dimensional craniofacial anatomy between responders and non-responders to mandibular advancement splint treatment in obstructive sleep apnoea patients.

The primary aim of this study was to assess the differences in the upper airway morphology between responders and non-responders to mandibular advancement splint (MAS) treatment in obstructive sleep apnoea (OSA) management. The secondary aim was to assess the correlation between the minimum cross-sectional area of the upper airway and the anatomical structures (i.e. mandibular external length, maxillary length, soft palate length, area of the tongue, maxillomandibular enclosure size, and anatomical balance ratio) surrounding the upper airway. The third aim was to assess the differences in the overall skeletal configuration between responders and non-responders to MAS treatment. Data from 64 patients (23 females and 41 males) diagnosed with OSA by polysomnography (PSG) at baseline and provided with an adjustable MAS were analysed. All patients had NewTom3G cone beam computed tomography (CBCT) scans, performed in the supine position, at baseline. After acclimatization to MAS, follow-up PSG tests were performed to assess the apnoea-hypopnea index (AHI) with the MAS in situ. Responders were defined by a post-treatment AHI less than 10/hour and at least 50 per cent reduction in AHI, and non-responders by a post-treatment AHI at least 10/hour or less than 50 per cent reduction in AHI. Several upper airway and anatomical variables surrounding the upper airway based on CBCT images were measured to determine the differences between responders and non-responders to MAS. There were 36 responders (AHI = 24.8 ± 11.9 at baseline) and 28 non-responders (AHI = 31.2 ± 20.3 at baseline) to MAS. There were no significant differences in the upper airway morphology between responders and non-responders (P = 0.17-0.93) or in the anatomical structure surrounding the upper airway (P = 0.24-0.58). Within the limitations of this study, it can be concluded that there are no significant differences in upper airway morphology and in anatomical structures surrounding the upper airway between responders and non-responders to MAS treatment. These findings suggest that the craniofacial anatomical structures analyzed in this study cannot explain the response to MAS treatment.

Caffeine use for apnea of prematurity in moderate and late preterm infants: A systematic review

Objective: The objective is to perform a systemic review of the literature on the use of caffeine for the management of apnea of prematurity (AOP) in moderate and late preterm infants. Data Sources: In May 2016, we searched the following databases from the beginning of the year 1980: Medline, Embase, CENTRAL, CINAHL, ProQuest Dissertations and theses Global, and PubMed. Additional citations were searched in the clinical trial registries and from the bibliography of the selected articles. We updated our search in May 2018 to identify any new citations. Methods: Studies were included if they were randomized controlled trials (RCTs) involving preterm infants ≥32 weeks gestation and compared caffeine with placebo, reporting any of the prespecified clinical outcomes. Search strategies combined controlled vocabulary and keywords terms for apnea, caffeine, and preterm infants. No language restriction was applied. Two researchers independently reviewed the retrieved articles for inclusion. Disagreements were resolved by consensus among the review team. Results: The search strategy identified 839 citations after removing duplicates. We did not identify any published RCT that described the use of caffeine for AOP in moderate to late preterm infants. The updated search also did not identify an RCT. Conclusions: There is a lack of good quality evidence for the use of caffeine for the management of AOP in moderate and late preterm infants. An RCT is urgently needed to investigate the clinical benefits of caffeine use in this population and the potential savings in health-care resource utilization.

Primary Care Physicians Can Comprehensively Manage Patients with Sleep Apnea. A Noninferiority Randomized Controlled Trial.

Rationale: General practitioners play a passive role in obstructive sleep apnea (OSA) management. Simplification of the diagnosis and use of a semiautomatic algorithm for treatment can facilitate the integration of general practitioners, which has cost advantages.Objectives: To determine differences in effectiveness between primary health care area (PHA) and in-laboratory specialized management protocols during 6 months of follow-up.Methods: A multicenter, noninferiority, randomized, controlled trial with two open parallel arms and a cost-effectiveness analysis was performed in six tertiary hospitals in Spain. Sequentially screened patients with an intermediate to high OSA probability were randomized to PHA or in-laboratory management. The PHA arm involved a portable monitor with automatic scoring and semiautomatic therapeutic decision-making. The in-laboratory arm included polysomnography and specialized therapeutic decision-making. Patients in both arms received continuous positive airway pressure treatment or sleep hygiene and dietary treatment alone. The primary outcome measure was the Epworth Sleepiness Scale. Secondary outcomes were health-related quality of life, blood pressure, incidence of cardiovascular events, hospital resource utilization, continuous positive airway pressure adherence, and within-trial costs.Measurements and Main Results: In total, 307 patients were randomized and 303 were included in the intention-to-treat analysis. Based on the Epworth Sleepiness Scale, the PHA protocol was noninferior to the in-laboratory protocol. Secondary outcome variables were similar between the protocols. The cost-effectiveness relationship favored the PHA arm, with a cost difference of €537.8 per patient.Conclusions: PHA management may be an alternative to in-laboratory management for patients with an intermediate to high OSA probability. Given the clear economic advantage of outpatient management, this finding could change established clinical practice.Clinical trial registered with www.clinicaltrials.gov (NCT02141165).

Management of Obstructive Sleep Apnoea- A Review Article

Management of Obstructive Sleep Apnoea- A Review Article

0600 Impact of Group-Based Sleep Apnea Management Intervention on Patient Reported Outcomes in Patients on Positive Airway Pressure for Obstructive Sleep Apnea

0600 Impact of Group-Based Sleep Apnea Management Intervention on Patient Reported Outcomes in Patients on Positive Airway Pressure for Obstructive Sleep Apnea

0599 Positive Airway Pressure Barriers Reduction in Response to Group Sleep Apnea Management Clinic

0599 Positive Airway Pressure Barriers Reduction in Response to Group Sleep Apnea Management Clinic

Any sleep is a dream far away: a nominal group study assessing how gout affects sleep

There are no qualitative studies of sleep in gout; the aim of this study was to examine the impact of gout on sleep. Nine nominal groups were conducted, oversampling for African-Americans and women with gout. Patients discussed and rank-ordered their concerns. Nine nominal groups with 46 gout patients were conducted with mean age, 61 years (s.d. 10.6) and gout duration, 14.9 years (s.d. 12); 63% were men, 46% African-American, 52% married, 46% retired and 63% were allopurinol users. The most frequently cited highly ranked concerns could be divided into three categories. The first category, character of sleep interruption, included the concerns: severe and complete sleep interruption by gout flare pain (nine groups); and inability to get rapid eye movement sleep (one group). The second category, causes of sleep interruption, included: inability to get into a comfortable position during sleep (six groups); anxiety and depression associated with severe gout pain (seven groups); sleep interruption by moderate chronic joint pain (three groups); frequent trips to the bathroom interfering with sleep (two groups); gout medication side effects (four groups); frequent trips to the emergency room (one group); joint swelling with physical/functional deficit interfering with sleep (two groups); and flare pain interfering with sleep apnoea management (two groups). The final category, consequences of sleep interruption, included: effect on daily functioning (two groups); worsens other health conditions, which then affect sleep (four groups); and cumulative effect on sleep (one group). Gout has significant impact on sleep quantity, quality and architecture. Sleep disruption due to gout has several pathways and significant consequences.

Hyoid suspension versus laser midline glossectomy in the management of obstructive sleep apnea

Background The base of the tongue and the hypopharynx are the major sites of obstruction in up to 50% of patients with obstructive sleep apnea (OSA) possibly explaining the cause of failure in palatal surgery. Hyoid suspension and laser midline glossectomy can be used as a surgical treatment for tongue base and hypopharyngeal collapse. Objective The aim of this study was to compare hyoid suspension type I and laser midline glossectomy in the management of OSA as regards safety, efficiency, and postoperative morbidity and mortality. Patients and methods In this study, 30 patients were diagnosed as having OSA by means of polysomnography with retrolingual collapse using Muller maneuver. Fifteen patients were operated upon using hyoid suspension type I and the other 15 patients were operated upon using laser midline glossectomy. Results In hyoid suspension type I, the incidence of responder patients [50% or more reduction in their apnea–hypopnea index (AHI) plus reduction in the AHI below 20] was 66.67%, with reduction in the AHI by 77.2%, and the incidence of nonresponder patients was 33.33%, with reduction in the AHI by 36.17%. However, in midline laser glossectomy, the incidence of responder patients was 53.34% with reduction in the AHI by 73.87%, and the incidence of nonresponder patients was 46.67% with reduction in the AHI by 40.79%. Complications were higher in laser midline glossectomy compared with hyoid suspension type I. Conclusion Our data indicate that hyoid suspension type I may be safer and more effective with lesser morbidity compared with laser midline glossectomy.

Caffeine therapy practice in the management of apnea of prematurity: National survey in Saudi Arabia

Background: Caffeine citrate is the drug of choice in management of apnea of prematurity. This study aimed to examine the current management practice of apnea of prematurity, assess the variation in the caffeine therapy use and exploring the physician's management preferences. Methods: An electronic survey was sent to physicians within the Saudi Neonatology Society database, containing questions related to the caffeine use in the management of apnea of prematurity across hospitals in Saudi Arabia. Results: The overall response rate was 53%. Both prevention and treatment of apnea of prematurity are considered the main indication for starting caffeine therapy (87%). If apnea persists while on maintenance caffeine (53%) of the respondent will increase the caffeine dose to a maximum of 10 mg/kg/dose. Discontinuing caffeine therapy is based on the corrected gestational age (78%), mostly at 34 weeks (mean 34.2 weeks [95% confidence interval [CI] 34–34.3]). If caffeine restarted for clinical indication (47%) of the respondent will give loading dose of caffeine followed by the maintenance dose. Once caffeine restarted (49%) of the respondents will continue caffeine till reaching 37 weeks corrected gestational age. Discharging patient after discontinuation of caffeine therapy generally occurs after an observation period of 5 days (82%) (mean 4.5 days [95% CI 4.2–4.9]). Conclusions: There is a considerable variation in the practice regarding caffeine use. Therefore, individual neonatal intensive care unit is encouraged to develop policies and guidelines for apnea of prematurity management, forming the foundation of a national statement to standardize management and maintain high quality of care.

Management of obstructive sleep apnoea in infants

Management of obstructive sleep apnoea in infants

Sleep-disordered breathing in children

Sleep-disordered breathing in children includes disorders of breathing that affect airway patency e.g. obstructive sleep apnoea (OSA), and also conditions that affect respiratory drive (central sleep disorders) or cause hypoventilation, either as a direct central effect or due to peripheral muscle weakness. OSA is an increasingly-recognised clinical entity affecting up to 5.7% young children. OSA, if left untreated, may be associated with adverse effects on growth and development including adverse cognitive and behavioural outcomes. Evidence also exists to suggest that untreated OSA may impact on later cardiovascular risk. Close attention should be paid to assessing and investigating this relatively common condition. This review deals with the presentation, investigation, management, and sequelae of OSA, as well as providing an overview of the presentation, investigation, management of central apnoea in children.

Transoral robotic surgery as an adjunct to obstructive sleep apnoea management

Transoral robotic surgery as an adjunct to obstructive sleep apnoea management

Becoming a team: Findings from a grounded theory study about living with CPAP

Untreated sleep apnoea incurs significant health costs. Continuous positive airway pressure (CPAP) is a recognised, cost-effective treatment that can be challenging for users and about which there is limited evidence from the users’ perspective. Therefore, we aimed to explore experiences of living with this therapy from participants’ perspectives using constructionist grounded theory.Adult participants (n=16) were recruited through a main-centre respiratory service in New Zealand. We used semi-structured interviews, and data were analysed until theoretical saturation was reached.This paper reports the first of three main categories from the grounded theory: bargaining and balancing life with CPAP. The first category, becoming a team for good-sleep, emphasises that partners are not simply bystanders, but integral to using CPAP. Indeed, it was apparent that users and partners formed a team with the mutual goal of achieving a good sleep. Partners experienced and bore witness to consequences of untreated sleep apnoea, prompting the snorer to seek treatment. Joint problem-solving and decision-making facilitated successful therapy management. Conversely, un-collaborative partners hindered this process.Findings provide new insights that illustrate how CPAP may successfully be used at home and strategies for promoting effective sleep apnoea management. Therapy-users’ designated partners should be formally incorporated into the treatment process, including nurse-led and clinician clinic consults, to increase the probability of successful therapy management at home. Further research, including intervention studies, should explore the role of partners in successful positive airway pressure management and other long-term therapies.

Electrophysiology Updates in Adult Congenital Heart Disease.

Electrophysiology Updates in Adult Congenital Heart Disease.