Median Obstructive Apnea-hypopnea Index Research Articles

Pharyngeal Airway Changes Following Mandibular Distraction Osteogenesis as Evaluated with Laryngoscopy.

Mandibular distraction osteogenesis (MDO) may improve airway grade in patients with Robin Sequence (RS), but little is known about the response of the oropharyngeal airway to the distraction process in cases of tongue base obstruction (TBAO). This study used drug-induced sleep endoscopy (DISE) to evaluate the impact of MDO on the oropharynx. RS patients with severe obstructive sleep apnea (OSA) were prospectively enrolled, and underwent DISE prior to MDO, and at the time of distractor removal. Laryngoscopy views, glossoptosis degree, polysomnography (PSG) results, oxygen saturations and airway measurements were compared pre- and post-MDO. Twenty patients met inclusion criteria. At the time of distractor placement, a grade II laryngoscopic view was most frequently observed (63%), and one patient (5%) had a grade I view. Median obstructive apnea hypopnea index (OAHI) improved after MDO (49.1 [30.2-74.0] to 9.1, [3.9-18.0], p ≤ .001). Median oxygen saturation nadir also improved (preoperative 69% [60-76] to 85% [82-91], p ≤ .001). At distractor removal, mean laryngoscopic view improved (p ≤ .002) with no views that were grade 3 or higher. Median intraoperative oropharyngeal width improved, (3.1 mm [2.8-4.4] to 6.0 mm [4.4-6.8], p ≤ .021), as did median cephalometric anteroposterior oropharyngeal width (3.5 mm [2.7-4.1] to 6.3 mm [5.6-8.2], p ≤ .002). Following MDO, RS patients with TBAO have an approximate doubling of oropharyngeal width and an improvement in laryngoscopic grade. These findings likely contribute to improved oxygenation, OAHI and ease of intubation.

Prevalence of Sleep-Disordered Breathing in Prader-Willi Syndrome.

Sleep-disordered breathing (SDB) is common in patients with Prader-Willi Syndrome (PWS). However, the prevalence of SDB varies widely between studies. Early identification of SDB and factors contributing to its incidence is essential, particularly when considering growth hormone (GH) therapy. The aims of the study were to describe the prevalence and phenotypes of sleep-disordered breathing (SDB) in patients with Prader-Willi syndrome (PWS) and to determine the effects of age, gender, symptoms, GH therapy and body mass index on SDB severity. This study was a retrospective chart review of all patients with genetically confirmed Prader-Willi syndrome who underwent diagnostic overnight polysomnography (PSG) in the sleep laboratory at Sidra Medicine. Clinical and PSG data of enrolled patients were collected. We identified 20 patients (nine males, eleven females) with PWS who had overnight sleep polysomnography (PSG) at a median age (IQR) of 5.83 (2.7-12) years. The median apnea-hypopnea index (AHI) was 8.55 (IQR 5.8-16.9) events/hour. The median REM-AHI was 27.8 (IQR 15-50.6) events/hour. The median obstructive apnea-hypopnea index (OAHI) was 7.29 (IQR 1.8-13.5) events/hour. The median central apnea-hypopnea index (CAHI) was 1.77 (IQR 0.6-4.1) events/hour. Nineteen patients (95%) demonstrated SDB by polysomnography (PSG) based on AHI ≥1.5 events/hour. Nine patients (45%) were diagnosed with obstructive sleep apnea (OSA). Three patients (15%) were diagnosed with central sleep apnea (CSA). Seven patients (35%) were diagnosed with mixed sleep apnea. No correlations were observed between AHI and age, gender, BMI, symptoms, or GH therapy. However, REM-AHI was significantly correlated with BMI (P=0.031). This study shows a high prevalence of SDB among our patients with PWS. Obstructive sleep apnea was the predominant phenotype. BMI was the only predictor for high REM-AHI. Further studies of large cohorts are warranted to define SDB in PWS and design the appropriate treatment.

Comparing the Driving Skills of Adolescents with Obstructive Sleep Apnea to Healthy Controls: The Results of a Case-Controlled Observational Study.

Auto crashes are a leading cause of death and injury among adolescents. Untreated obstructive sleep apnea (OSA) can cause sleepiness and inattention, which could negatively impact novice drivers, but OSA-related studies have focused on older drivers. This study used a driving simulator to examine whether licensed 16-19-year-old adolescents with OSA have diminished driving skills. Twenty-one adolescents with OSA and twenty-eight without OSA (both confirmed using polysomnography) completed two randomly ordered driving trials in a simulator (with induced distractions versus without). A mixed ANOVA examined the between-subjects effect of the OSA group, the within-subjects effect of the distraction condition, and the group-by-condition interaction effect on the ability to maintain lane position and the frequency of extended eye glances away from the roadway. T-tests were also used to examine group differences in reported sleepiness and inattention during daily life. The distraction task increased extended off-road glances and difficulties maintaining lane position (p < 0.001). However, adolescents with OSA did not display worse eye glance or lane position than controls and there were no significant group-by-condition interactions. Although the groups differed on polysomonographic features, there were also no significant differences in reported sleepiness or inattention. The distraction task negatively impacted both groups of adolescent drivers, but those with OSA did not fare differentially worse. Most adolescents in our study had mild OSA (median obstructive apnea-hypopnea index = 4.4), the most common form in the community. It remains possible that youth with more severe OSA would show increased driving impairment.

Prevalence, associated risk factors, and respiratory event distribution of obstructive sleep apnea in children with Down syndrome.

Children with Down Syndrome (DS) have a high prevalence of obstructive sleep apnea (OSA). We aimed to assess OSA prevalence in a single center cohort of children with DS, identify associated risk factors of obstructive respiratory events, and examine the influence of different sleep stages and body positions on respiratory events distribution. Single center retrospective study that included children with DS who underwent overnight polysomnogram (PSG). OSA severity was categorized by obstructive apnea-hypopnea index (OAHI) as mild (1.5-4.9 events/h), moderate (5-9.9 events/h), and severe (≥ 10 events/h). A logistic regression analysis was used to examine the association between OSA-related risk factors in normal and abnormal OAHI category and in REM and Non-REM predominant AHI groups. PSG data were available for 192 children with a median age of 5years (IQR 7). OSA prevalence was 82.3% (27.1% mild, 19.8% moderate, and 35.4% severe). A logistic regression model identified BMI and being an African American as significant predictors for OAHI severity. In children with OSA, the median OAHI was 7.6 and obstructive respiratory events were more common in REM sleep and in thesupine position. The median REM OAHI was 20 events/h (IQR: 24.4), whereas the median Non-REM OAHI was 5.2 events/h (IQR: 12.6 p < 0.0001). Similarly, supine OAHI was 11.6 (IQR: 19.3) and off supine OAHI was 6.6 (IQR: 11.6, p = 0.0004). Age was a significant predictor (p = 0.012) for Non-REM predominant OSA which was present in 15.2% of children with OSA. Children with DS have a high prevalence of OSA. Higher BMI and being an African American were significant associated risk factors for higher OAHI. Obstructive respiratory events in children with DS occur predominantly in REM sleep and in thesupine position. Non-REM predominant distribution of respiratory events was noted in older children with DS.

0525 Effect of Body Position and Sleep State on Obstructive Respiratory Events Distribution in Children with Down syndrome

Abstract Introduction The influence of body position and sleep state on obstructive respiratory events distribution in children with Down syndrome (DS) need further studies. Methods This was a single center, retrospective study that included children younger than 18 years old with DS who were evaluated for suspected sleep disordered breathing and underwent a full overnight polysomnography in an academic sleep disorders center over a period of 10 years. DS children with Obstructive apnea hypopnea index (OAHI) ≥ 1.5 were included in this study. Total OAHI, apnea hypopnea index (AHI) in different body positions and in different sleep stages including rapid eye movement (REM) and Non-REM (NREM) sleep were collected. Results A total of 158 children with DS met the inclusion criteria. The median age was 5 years (IQR 8.0---), 53.2% were male with a median BMI z-score of 1.2. Median times (%) spent in REM and NREM sleep were 17 % and 83% respectively. Median times (minutes) spent in different body positions were supine 194.1, left side 53.5, right side 39 and prone 32. The overall median OAHI was 7.6, respiratory obstructive events were more common in REM sleep and in supine position. The median REM obstructive AHI was 20 events per hour (IQR: 10.1-34.5), whereas the median NREM AHI was 5.2 events per hour (IQR: 2.4-15 p &amp;lt; 0.0001). Similarly, supine obstructive AHI was 9.4 (IQR-4.15 – 24.1) and off supine AHI was 2.4 (IQR 0-8.9 p &amp;lt; 0.0001). Only 24 out of 158 subjects had NREM predominant OSA. Age was a significant predictor of NREM predominant OSA (P= 0.012) compared to other factors such as gender, race, BMI, tonsillar grade, hypothyroidism and congenital heart disease. For every one year increase in age, the odds of having NREM predominant OSA was 14% higher than having REM predominant OSA. Conclusion Obstructive respiratory events in children with DS occur predominantly in REM sleep and in supine position. Non-REM predominant distribution of respiratory events was seen in older children with DS. Support (if any)

Obstructive sleep apnea is position dependent in young infants

BackgroundObstructive sleep apnea in infants with Pierre Robin sequence is sleep-position dependent. The influence of sleep position on obstructive events is not established in other infants.MethodsWe re-evaluated ten-year pediatric sleep center data in infants aged less than six months, with polysomnography performed in different sleep positions. We excluded infants with syndromes, genetic defects, or structural anomalies.ResultsComparison of breathing between supine and side sleeping positions was performed for 72 infants at the median corrected age of 4 weeks (interquartile range (IQR) 2-8 weeks). Of the infants, 74% were male, 35% were born prematurely, and 35% underwent study because of a life-threatening event or for being a SIDS sibling. Upper airway obstruction was more frequent (obstructive apnea-hypopnea index (OAHI), p < 0.001), 95th-percentile end-tidal carbon dioxide levels were higher (p = 0.004), and the work of breathing was heavier (p = 0.002) in the supine than in the side position. Median OAHI in the supine position was 8 h−1 (IQR 4–20 h−1), and in the side position was 4 h−1 (IQR 0-10 h−1).ConclusionsObstructive upper airway events in young infants are more frequent when supine than when sleeping on the side.ImpactThe effect of sleep position on obstructive sleep apnea is not well established in infants other than in those with Pierre Robin sequence.A tendency for upper airway obstruction is position dependent in most infants aged less than 6 months. Upper airway obstruction is more common, end-tidal carbon dioxide 95th-percentile values higher, and breathing more laborious in the supine than in the side-sleeping position.Upper airway obstruction and obstructive events have high REM sleep predominance.As part of obstructive sleep apnea treatment in young infants, side-sleeping positioning may prove useful.

Polysomnography-guided mandibular distraction osteogenesis in Pierre Robin sequence patients.

Craniofacial malformations with micrognathia cause high grades of obstructive sleep apnea (OSA) measured by polysomnography (PSG). Mandibular distraction osteogenesis is a novel procedure for upper airway obstruction relief. Our primary objective was to describe the utilization of PSGs to improve obstruction in patients undergoing mandibular distraction. This is a retrospective study. Patients with micrognathia and severe upper airway obstruction, presenting with severe OSA diagnosed by PSG, were included from a single tertiary care center between 2015 and 2019. PSGs were done (1) prior to surgery, (2) once the cosmetic goal was achieved (Post-Op 1), and (3) if residual moderate-to-severe OSA was seen, every 2 nights until mild or no OSA was achieved (Post-Op 2). Thirteen patients were included. The median age at surgery was 1.1 months (10 days-3 months). All 13 patients had baseline severe OSA, with a median obstructive apnea-hypopnea index of 33 events/h and a median O2 nadir of 73%. Post-Op 1 PSG was done at a median of 6 days after surgery. Median first postoperative obstructive apnea-hypopnea index in all 13 patients was 6.8 events/h, with a median O2 nadir of 87%. A median additional distraction of 3 mm was needed beyond the traditionally recommended advancement. Long-term follow-up studies at or after 1 year were done in 5 patients, all showing persistent nonsevere OSA. This is the first case series utilizing PSGs as a guide for mandibular distraction osteogenesis in patients with micrognathia showing the need for jaw overcorrection to achieve resolution of OSA. Kochhar R, Modi V, de Silva N, etal. Polysomnography-guided mandibular distraction osteogenesis in Pierre Robin sequence patients. J Clin Sleep Med. 2022;18(7):1749-1755.

Neurobehavioral morbidity of pediatric mild sleep-disordered breathing and obstructive sleep apnea.

Obstructive sleep apnea is associated with neurobehavioral dysfunction, but the relationship between disease severity as measured by the apnea-hypopnea index and neurobehavioral morbidity is unclear. The objective of our study is to compare the neurobehavioral morbidity of mild sleep-disordered breathing versus obstructive sleep apnea. Children 3-12 years old recruited for mild sleep-disordered breathing (snoring with obstructive apnea-hypopnea index < 3) into the Pediatric Adenotonsillectomy Trial for Snoring were compared to children 5-9 years old recruited for obstructive sleep apnea (obstructive apnea-hypopnea 2-30) into the Childhood Adenotonsillectomy Trial. Baseline demographic, polysomnographic, and neurobehavioral outcomes were compared using univariable and multivariable analysis. The sample included 453 participants with obstructive sleep apnea (median obstructive apnea-hypopnea index 5.7) and 459 participants with mild sleep-disordered breathing (median obstructive apnea-hypopnea index 0.5). By polysomnography, participants with obstructive sleep apnea had poorer sleep efficiency and more arousals. Children with mild sleep-disordered breathing had more abnormal executive function scores (adjusted odds ratio 1.96, 95% CI 1.30-2.94) compared to children with obstructive sleep apnea. There were also elevated Conners scores for inattention (adjusted odds ratio 3.16, CI 1.98-5.02) and hyperactivity (adjusted odds ratio 2.82, CI 1.83-4.34) in children recruited for mild sleep-disordered breathing. Abnormal executive function, inattention, and hyperactivity were more common in symptomatic children recruited into a trial for mild sleep-disordered breathing compared to children recruited into a trial for obstructive sleep apnea. Young, snoring children with only minimally elevated apnea-hypopnea levels may still be at risk for deficits in executive function and attention. Pediatric Adenotonsillectomy for Snoring (PATS), NCT02562040; Childhood Adenotonsillectomy Trial (CHAT), NCT00560859.

The Use of Auto-Titrating Continuous Positive Airway Pressure (AutoCPAP) for Obstructive Sleep Apnea Syndrome in Children with Obesity.

Background: Positive airway pressure can be an effective and safe therapy for children with obstructive sleep apnea syndrome (OSAS). Few studies have assessed the safety and efficacy of autoCPAP in pediatric patients with obesity. Methods: This was a retrospective chart review of children with obesity (Body Mass Index (BMI) > 99th percentile), ages 2–18, diagnosed with OSAS (Obstructive Apnea-Hypopnea Index (OAHI) > 1/h) and used autoCPAP with 30-day adherence. Exclusion criteria included patients with complex comorbidities. Adherence was defined as autoCPAP use ≥4 h/night for at least 21/30 days. Baseline PSG OAHI was compared to the AHI from the 30-day autoCPAP compliance report. We also compared autoCPAP 30-day 95th percentile pressures with the pressures from PAP titration. Results: The study included 19 children, ranging 5–15 years old. The median BMI was 99.6th percentile and average adherence was 25/30 nights with mean of 7.3 h/night. The median OAHI was 12.3/h on baseline PSG and the 30-day autoCPAP download AHI decreased to 1.7/h. No adverse outcomes were identified. The average difference between 95th percentile autoCPAP pressure and PAP titration pressure was 0.89 cmH20. Conclusion: Our study suggests autoCPAP is effective and safe for the treatment of OSAS in pediatric patients with obesity. Using autoCPAP may reduce delays in treatment. Additional research is needed to verify the long-term effectiveness of autoCPAP in this population.

Clinical application of home sleep apnea testing in children: a prospective pilot study.

(1) To determine the sensitivity and specificity of the home sleep apnea test (HSAT) performed in typically developing children who were diagnosed with moderate to severe obstructive sleep apnea during overnight attended laboratory polysomnography (LPSG). (2) To determine the utility of a screening questionnaire to identify children at increased risk for obstructive sleep apnea. Participants completed 2 consecutive study nights, the first night with the HSAT followed by LPSG on the second night. The SHOOTS questionnaire, composed of 6 questions (snoring, hyperactivity, obesity, observed apnea, tonsillar hypertrophy, and sleepiness) concerning sleep-disordered breathing, was administered by the clinician before the first study night. Thirty-eight participants completed both studies. The mean age was 13.8 ± 3.0 years. Twenty (53%) were male. Most participants were obese. The mean LPSG total sleep time was 7.34 ± 1.19 hours; the mean HSAT total recording time was 8.86 ± 1.73 hours (P < .001). The median obstructive apnea-hypopnea index for LPSG and HSAT was 6.6 and 0.8 events/h, respectively. For an obstructive apnea-hypopnea index ≥ 3.1 events/h by HSAT, the sensitivity was 71.43% (95% confidence interval, 41.9-91.6) and the specificity was 95.83% (95% confidence interval, 78.9-99.9) for identifying those with an LPSG obstructive apnea-hypopnea index of ≥ 10 events/h. For a SHOOTS score with ≥ 4 "yes" responses, the sensitivity and specificity were 85.7% (95% confidence interval, 57.2-98.2) and 54.2% (95% confidence interval, 32.8-74.4), respectively, for identifying those with an LPSG obstructive apnea-hypopnea index ≥ 10 events/h. Using HSAT, we clinically applied cutoff values to identify moderate to severe obstructive sleep apnea in typically developing children. The SHOOTS questionnaire may aid in identifying children at risk for obstructive sleep apnea and who are candidates for HSAT. Revana A, Vecchio J, Guffey D, Minard CG, Glaze DG. Clinical application of home sleep apnea testing in children: a prospective pilot study. J Clin Sleep Med. 2022;18(2):533-540.

Accuracy of the sleep clinical record for the diagnosis of pediatric moderate-to-severe obstructive sleep apnea syndrome.

The sleep clinical record (SCR) has been used to diagnose obstructive sleep apnea syndrome (OSAS) in children when access to polysomnography (PSG) is limited. Our aim was to determine the best SCR score that could facilitate diagnosis of moderate-to-severe OSAS in children with snoring. Healthy children with history of snoring, who were referred for PSG, were prospectively recruited. The SCR score was calculated. Receiver operating characteristic curves (ROCs) were plotted to determine the area under curve (AUC), and the optimum SCR cutoff value was determined using the Youden index (J). Two hundred and seventy-three children were recruited (mean age 6.3 ± 2.5years; median obstructive apnea-hypopnea index 1.5 episodes/h; range 0-61.1). The mean SCR score was 6.9 ± 3.6. Forty-six children had moderate-to-severe OSAS. Subjects with moderate-to-severe OSAS had a significantly higher mean SCR score (10.2 ± 2.9) than those with mild OSAS (6.2 ± 3.3; P < 0.001). Based on the plotted ROC, the AUC was 0.811 (95% confidence interval: 0.747-0.876; P < 0.001). Calculation of J, based on its ROC coordinates, indicated that the optimum cutoff SCR score to predict moderate-to-severe OSAS was 8.25, corresponding to a sensitivity of 83% and a specificity of 70%. Among children with history of snoring, an SCR score above 8.25 can identify those with moderate-to-severe OSAS.

Mandibular Distraction Osteogenesis for Tongue-Based Airway Obstruction Without Micrognathia.

Mandibular distraction osteogenesis (MDO) effectively treats tongue-based airway obstruction (TBAO) in micrognathic patients with Robin Sequence. Mandibular distraction osteogenesis may also address TBAO in certain nonmicrognathic patients who have severe obstructive apnea, although there is no current literature to guide MDO use in these atypical patients. This study describes outcomes of MDO in a series of patients with TBAO without micrognathia. Patients who underwent MDO for TBAO from 2013-20 were reviewed, and patients with micrognathia were excluded. Study subjects received baseline/follow up polysomnography. Polysomnography variables, including Obstructive Apnea Hypopnea Index, oxyhemoglobin saturation nadir (SpO2 nadir), percent sleep time end tidal CO2 greater than 50 mm Hg (%ETCO2 > 50), and respiratory-related arousals were compared before and after MDO. Demographics, syndromic/cleft palate status, airway anomalies, respiratory support, and feeding outcomes were collected. One hundred and twenty-four patients underwent MDO during this study period; 5 were nonmicrognathic and included in analysis. Sixty percent (n = 3) of the cohort was syndromic: 1 patient each had Trisomy 9, Beckwith Wiedemann syndrome, and duplicated pituitary gland plus syndrome. Forty percent (n = 2) of patients had a cleft palate, 60% (n = 3) had laryngomalacia, and 40% had tracheomalacia. Median (range) age at MDO was 53 days (47-167 days), and median length of distraction was 16 mm (14-20 mm). After MDO, median Obstructive Apnea Hypopnea Index decreased from x̃ = 60.7/h (11.6-109.4) to x̃ = 5.3/h (3.5-19.3) (P = 0.034). SpO2 nadir increased (69% [58-74] to 85% [80-88], P = 0.011), and median %ETCO2 > 50 mm Hg decreased (5.8% [5.2-30.1] to 0.0% [0.0-1.3], P ≤ 0.043). Continuous positive airway pressure was used by all patients immediately after MDO, and at 6 months postoperatively, 1 patient remained on continuous positive airway pressure and 1 patient required supplemental oxygen. At last follow up, no patients had significant residual airway obstruction or required a tracheostomy. Mandibular distraction osteogenesis can effectively treat severe TBAO in some patients without micrognathia that would otherwise be candidates for tracheostomy. When used in select patients, MDO significantly improves obstructive sleep apnea and reduces need for ventilatory support, although feeding support is still needed in most patients at 6 months. Further study in a larger cohort will help identify appropriate candidates for MDO and characterize outcomes of unique patient populations.

Polysomnography parameters as predictors of respiratory adverse events following adenotonsillectomy in children

The first-line treatment of obstructive sleep apnea syndrome in children is adenotonsillectomy, but this may result in perioperative respiratory adverse events (PRAEs). The primary aim of this study is to examine whether the McGill oximetry score (MOS) and other polysomnography parameters can predict major PRAEs following adenotonsillectomy. We secondarily evaluated the MOS interrater reliability and correlation with other polysomnography parameters. This retrospective study included all children aged 0-18 years who underwent preoperative polysomnography between June 2010 and January 2016 prior to adenotonsillectomy at a tertiary pediatric institution. Oximetries from polysomnograms were assigned an MOS. Univariable and multivariable models for prediction of major PRAEs were constructed. MOS was correlated with polysomnography parameters and interrater reliability was evaluated. This study included 106 children; 15 had a major PRAE. A multivariable prediction model that combined MOS and age showed evidence for the ability to predict major PRAEs with an area under the receiver operating characteristic curve of 0.68 (95% confidence interval: 0.52, 0.84), whereby increased MOS and younger age were associated with PRAEs, but apnea-hypopnea index was not. MOS had excellent interrater reliability (κ = 0.95) and was highly correlated with oxygen saturation nadir and cumulative time percentage with oxygen saturation less than 90%. A prediction model including MOS and age may predict PRAEs following adenotonsillectomy. This suggests that nocturnal oximetry provides the most essential information of polysomnography measures to direct postoperative monitoring following adenotonsillectomy. Xiao L, Barrowman N, Momoli F, etal. Polysomnography parameters as predictors of respiratory adverse events following adenotonsillectomy in children. J Clin Sleep Med. 2021;17(11):2215-2223.

Retrospective analysis of inpatient polysomnogram characteristics and discharge outcomes in infants with bronchopulmonary dysplasia requiring home oxygen therapy.

Little is known about the polysomnogram (PSG) characteristics in infants with bronchopulmonary dysplasia (BPD), especially severe BPD, who do not need home ventilatory support but are at increased risk for chronic hypoxia and are vulnerable to its effects. This study aims to assess PSG characteristics and change in discharge outcomes in premature infants with BPD who required oxygen therapy at discharge. This is a retrospective chart review of premature infants with BPD who were admitted to a quaternary newborn and infant intensive care unit from January 1, 2012 to December 31, 2015 and who underwent polysomnography before discharge. Data from 127 patients were analyzed. The median gestational age of our patients was 26 weeks and 1 day (interquartile range [IQR]: 24.71, 28.86). The majority of the patients had moderate-to-severe BPD. The median obstructive apnea-hypopnea index was 5.3 events/h (IQR: 2.2, 10.1). The median oxygen desaturation index was 15.7 events/h (IQR: 4.7, 35). Nadir oxygen saturation measured by pulse oximeter was 81% (IQR: 76-86) and the arousal/awakening indexwas 21.9 (IQR: 13.3-30.9). No statistically significant difference was noted between severe and nonsevere BPD groups for PSG characteristics. However, average end-tidal CO2 was significantly higher in the severe BPD group (p = .0438). Infants in the severe BPD group were intubated longer than infants with nonsevere BPD (p = .0082).The corrected gestational age (CGA) at the time of discharge (CGA-PSG) and PSG (CGA-DC) was higher in severe BPD patients but not statistically different. The majority of premature infants who underwent a PSG were discharged home with oxygen, and 69% required a titration of their level of support based on results from the PSG. Our results highlight the presence of abnormal PSG characteristics in BPD patients, as early as 43 weeks CGA. These findings have not been previously described in this patient population prior to initial discharge from the hospital. A severe BPD phenotype tends to be associated with higher respiratory morbidity compared with a nonsevere BPD phenotype for the comparable CGA. PSG, when available, may be helpful for individualizing and streamlining treatment in preparation for discharge home and mitigating the effects of intermittent hypoxic episodes.

Laryngoscopy Grade Improvement and Difficult Airway Resolution in Infants With Robin Sequence Undergoing Mandibular Distraction Osteogenesis: A Multi-Institutional Study.

Mandibular distraction osteogenesis (MDO) aims to relieve tongue-based airway obstruction in Robin Sequence (RS). We investigated direct laryngoscopy grade (DLG) improvement and difficult airway (DA) resolution following MDO. Retrospective cohort analysis. Three tertiary care institutions. Sixty-four infants with RS who underwent a single MDO procedure in their first year of life were identified from January 2010 to January 2019. The primary outcome was DLG pre- and post-MDO. Secondary outcomes included DA designation, pre- and post-MDO polysomnographic assessment for obstructive sleep apnea (OSA), length of stay, need for gastrostomy, and major/minor adverse events. Median DLG improved from II pre-MDO to I at the time of distractor removal (n = 43, P < .001). No significant change was seen in patients with a third recorded time point (eg, palatoplasty; n = 78, P = .52). Twenty-six (47%) of 55 patients were designated as DA pre-MDO, and 10 (18%) of 55 patients retained the label post-MDO (P < .01). Five (50%) of these 10 patients appeared to be inappropriately retained. Median obstructive apnea-hypopnea index improved from 38.6 (range 31.2-62.8) pre-MDO to 2.9 (range 1-3.9) post-MDO (n = 12; P = .002). Mandibular distraction osteogenesis allowed for DLG improvement that was stably maintained as well as functional improvement in OSA, with minimal morbidity. Difficult airway designation persisted in the electronic record of some infants despite clinical resolution.

Positive Airway Pressure for the Treatment of OSA in Infants

Positive airway pressure (PAP) is a standard therapy for the treatment of OSA in children, but objective data on the effectiveness of PAP in infants are sparse. The aim of this study was to compare the effectiveness of PAP in infants younger than 6months of age with that in school-aged children. Compared with PAP in school-aged children, can PAP be titrated as successfully in infants, and is adherence to PAP similar in both age groups? Single-center retrospective study. For consecutive infants younger than 6months of age and school-aged children 5 to 10 years of age with OSA treated with PAP, baseline and titration polysomnography data, PAP adherence data, and parent-reported barriers to adherence were compared between groups. Forty-one infants and 109 school-aged children were included. Median obstructive apnea hypopnea index (OAHI) in infants was 25.7/h (interquartile range [IQR], 17.8-35.9/h) and was greater than that in school-aged children (12.1/hr; IQR, 7.6-21.5/h; P< .0001). After PAP titration, OAHI was reduced by a median of 92.1%in infants, similar to the median 93.4%reduction in school-aged children (P= .67). PAP was used in infants on 94.7%of nights, which was more than the 83%in school-aged children (P= .003). No differences were found in barriers to adherence between infants and school-aged children, with behavioral barriers being most common in both groups. Objective data demonstrate that PAP is both highly effective at treating OSA and well-tolerated in infants. Like older patients, PAP should be considered along with other therapies for the treatment of OSA in even the youngest children.

Use of heated humidified high flow nasal cannula for obstructive sleep apnea in infants

ObjectiveHeated humidified high flow nasal cannula (HHHFNC) has gained popularity in the treatment of children with respiratory distress and bronchiolitis in the past decade. Its efficacy as a mode of non-invasive respiratory support has been demonstrated in both adults and children. However, reports on its use in the treatment of obstructive sleep apnea (OSA) in infants are limited. We aimed to evaluate the efficacy of HHHFNC therapy as treatment in infants with OSA. MethodsA retrospective analysis of OSA infants who had undergone polysomnographic titration between 2015 and 2017 was undertaken. Data about the age, gender, AHI, co-morbid conditions and flow used for each patient were retrieved. ResultsTen infants were included in this study (median age 34 weeks; IQR 27–38 weeks). The median optimal HHHFNC flow rate was 8.0 L/min (IQR 6.7–8.0 L/min). HHHFNC significantly reduced median obstructive apnea–hypopnea index (OAHI) from 9.1 (IQR 5.1–19.3) to 0.9 (IQR 0–1.6; P = 0.005) events/h; median obstructive apnea index (OAI) from 5.8 (IQR 1.1–13.4) to 0 (IQR 0–0.9; P = 0.021) events/h; median obstructive hypopnea index (OHI) from 4.1 (IQR 0.9–6.8) to 0.1 (0–0.9; P = 0.017) events/h; and median oxygen saturation (SpO2) nadir increased from 88% (IQR 83–94%) to 94% (IQR 93–96%; P = 0.040). ConclusionHHHFNC significantly reduced respiratory events and improved oxygenation in infants with OSA.

Children with Down syndrome and mild OSA: treatment with medication versus observation.

Children with Down syndrome (DS) have a high prevalence of obstructive sleep apnea (OSA). Anti-inflammatory medications have been shown to be an effective treatment for mild OSA in otherwise healthy children. However, the efficacy in children with DS and mild OSA has not been investigated. Our aim was to examine the polysomnographic changes of children with DS and mild OSA treated with medication. A retrospective chart review was performed in children with DS (< 18 years) and mild OSA (obstructive apnea-hypopnea index ≤ 5 events/h) diagnosed by polysomnography (PSG) between 2006 and 2018. Patients were included if they were treated with medications (intranasal corticosteroids and/or montelukast) or by observation with a duration of at least 3 months and had baseline and follow-up PSGs. Demographic data, comorbid diagnoses, and PSG data were collected and analyzed. Forty-five children met inclusion criteria. In the medication group, 29 children were identified. The median age was 7.4 years (interquartile range [IQR] 4.9-9.3). In the observation group, 16 children were identified. The median age was 4.0 years (IQR 3.2-5.3). The median time from baseline to follow-up PSG was 14.0 months (IQR 10.0-22.9) for the medication group and 10.5 months (IQR 6.5-33.5) for the observation group. There were no significant changes in the median obstructive apnea-hypopnea index from the baseline to follow-up PSG in either the medication group (2.8 [IQR 2.2-3.6) versus 3.5 [IQR 1.4-4.8) events/h; P = .25) or the observation group (2.3 [IQR 1.3-3.1] versus 2.9 [IQR 1.9-6.8] events/h; P = .12). Similarly, there were no significant differences in apnea-hypopnea index, oxygen nadir or end-tidal carbon dioxide between the groups (P = .07-1). In our cohort, medication therapy did not significantly improve polysomnographic measures in children with DS and mild OSA. Several factors such as hypotonia and relative macroglossia may explain the ineffectiveness of medical therapy for OSA in this population. Further prospective studies are necessary to confirm these results and to evaluate if a subgroup of DS children may benefit from medical therapy.

Obstructive Sleep Apnea in School-Aged Children Presented with Nocturnal Enuresis.

We aimed to detect obstructive sleep apnea (OSA) among school-age children presented with nocturnal enuresis (NE) and to identify the possible risk factors for OSA in them. Sixty-six children aged > 5-16years presented with NE were enrolled in the study. Children with urinary tract anatomical abnormalities or infection, intellectual disabilities, genetic syndromes, psychological issues, and diabetes mellitus were excluded. They were clinically examined, scored using sleep clinical record score (SCR), and subjected for full-night polysomnogram (PSG). Children with obstructive apnea/hypopnea index (AHI) ≥ 2 episodes/hour (h) were considered as OSA. Fifty-four children (81.8% of the recruited children) aged 8.3 ± 2.8years agreed to undergo PSG as 68.5% had OSA with median obstructive AHI of 6.1 (3.7-13.2) episodes/h, median oxygen saturation of 97% and nadir of 88%. Thirty-three percent were obese with significantly higher AHI [7.0 (3.7-12.4) vs. 2.4 (1.3-6.1) episodes/h; p = 0.023]. SCR score correlated significantly with AHI (r2 = 0.462, p = 0.001) with 91% sensitivity in detecting OSA ≥ 5 episodes/h. Nasal obstruction, adenoid/adult facial phenotype, and arched palate were associated with OSA (p < 0.05). NE is commonly associated with OSA especially in obese children. Nasal obstruction, abnormal facial phenotype, and high-arched palate were common risk factors.

Secondhand Smoke exposure and risk of Obstructive Sleep Apnea in Children

ObjectivesObstructive sleep apnea (OSA) has a prevalence of 4% in children. Few studies have explored the role of secondhand smoke (SHS) on OSA severity and have shown contradicting results. Most studies have focused on the effect of SHS on snoring. This study explored the association of SHS exposure and OSA severity in children aged 3–18 years. MethodsThis is a retrospective single center IRB-approved study. Electronic Medical Records (EMR) were queried between 1/24/2015 and 1/24/2018 to obtain data on SHS exposure with standard questionnaires from perioperative database. SHS was analyzed as a binary variable and OSA was measured using obstructive apnea hypopnea index (OAHI) from polysomnography (PSG) as a continuous variable. Analyses were done on all children and in those with severe OSA (OAHI≥10/h) as a subgroup. ResultsEMR query yielded 101,884 children of whom 3776 had PSG. Limiting baseline PSG in 3–18-year-old and reliable information on SHS yielded 167 analyzable children of whom 70 had severe OSA. Children exposed to SHS had significantly more public insurance than non-exposed (p < 0.0001). Among children with severe OSA, median OAHI was significantly higher in SHS exposed compared to non-exposed (29.0vs.19.5,p = 0.04), but not across all children. In multivariable analysis SHS exposure increased OAHI by 48% in severe OSA subgroup (95%CI: 8%–102%; p = 0.01) when adjusted for race, body mass index, and adjusted household income. ConclusionChildren aged 3–18 years with severe OSA who were exposed to SHS were found to have 1.48 increase in odds of OAHI than those without SHS exposure. Results could be limited by retrospective nature of study and EMR tools.