Respiratory Events In Children Research Articles

Altered Cortical Information Interaction During Respiratory Events in Children with Obstructive Sleep Apnea-Hypopnea Syndrome.

Obstructive sleep apnea-hypopnea syndrome (OSAHS) significantly impairs children's growth and cognition. This study aims to elucidate the pathophysiological mechanisms underlying OSAHS in children, with a particular focus on the alterations in cortical information interaction during respiratory events. We analyzed sleep electroencephalography before, during, and after events, utilizing Symbolic Transfer Entropy (STE) for brain network construction and information flow assessment. The results showed a significant increase in STE after events in specific frequency bands during N2 and rapid eye movement (REM) stages, along with increased STE during N3 stage events. Moreover, a noteworthy rise in the information flow imbalance within and between hemispheres was found after events, displaying unique patterns in central sleep apnea and hypopnea. Importantly, some of these alterations were correlated with symptom severity. These findings highlight significant changes in brain region coordination and communication during respiratory events, offering novel insights into OSAHS pathophysiology in children.

O018 Improvement in Obstructive Sleep Apnoea Improves Heart Rate response to Obstructive Respiratory events in Children with Down syndrome.

Abstract Background Children with Down syndrome (DS) have a much higher predisposition to obstructive sleep apnoea (OSA) compared to typically developing (TD) children. Children with DS have a lower heart rate (HR) response to respiratory event termination compared with TD children matched for age, sex and OSA severity, but the effect of improvement in OSA severity over time or with treatment is unknown. We compared the HR surge at event termination in children with DS with improved OSA to those with unimproved OSA 2 y following baseline study. Methods 24 children (3-19 y at baseline) were included. Children were grouped into Improved (decrease in obstructive apnoea hypopnoea index (OAHI) to ≤ 50% of baseline OAHI; n=12; 7 treated between studies) and Unimproved (n=12; 2 treated between studies). Beat-to-beat HR was averaged 10s before (pre), during and the peak after (post) each obstructive event during sleep, and expressed as percentage change. Results 583 obstructive events at baseline and 435 at follow up were identified. % change in HR from during the event to post event was greater at follow up (mean±sem, 22.4%±0.9%) than baseline (19.0%±0.8%; p<0.01) in the improved group, but reduced at follow up (16.8%±1.1%) compared with baseline (21.1%±0.7%; p<0.001) in the unimproved group and was greater at follow up in the improved group than in the unimproved group (p<0.001). Conclusion These results suggest that the dampened HR response to events seen in DS is reversible, adding weight to the need for diagnosis and management of OSA in this population.

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)

Literature Review for Office-Based Anesthesia

Literature Review for Office-Based Anesthesia

P140 Non-invasive Ventilation prior to Adenotonsillectomy

Abstract Introduction Prolonged wait times to ENT surgery, combined with the risk for post-operative respiratory events in children with severe OSA led to a clinical pathway of implementing CPAP therapy in children with severe OSA whilst on waiting lists for adenotonsillectomy. This study evaluated the impact of this pathway on the clinical care of these patients. Methods A retrospective review of medical records of patients under 18yrs of age diagnosed with OSA and initiated on CPAP whilst awaiting review by ENT / Adenotonsillectomy, between January 2019 and December 2020. Results 36 patients were identified, age 4.3 ± 3.2 years, 86% male, and 80.6% had comorbidities. 16 (44.4%) were overweight or obese, and for 8 (22.2%) obesity was the primary comorbidity. Mean delays: Sleep study to Referral = 4.5 ± 10.5 weeks, Referral to NIV initiation 5.6 ± 8.7 weeks, and NIV to ENT surgery 13.6 ± 13.6 weeks. Total delay from referral to the surgery was 19.6 ± 19.4 weeks. 31 (86%) children were initiated on therapy in hospital, and five (13.9%) patients were non-compliant with the therapy. Discussion Current delays to ENT surgery for children identified with OSA on sleep study average 5 months. Where OSA is sufficient to recommend ENT surgery, the majority (80%) of children tolerated CPAP therapy while they await surgery. We suggest that the benefits obtained are that therapy can be instituted more rapidly than surgery, and where children are able to use CPAP therapy it reduced the requirement for high-dependency or intensive care admission post-operatively.

Risk Factors for Post-Tonsillectomy Respiratory Events in Children With Severe Obstructive Sleep Apnea.

To identify risk factors for postoperative respiratory events in pediatric patients with severe obstructive sleep apnea (OSA). Retrospective single-institution retrospective cohort study of pediatric patients with severe OSA who were admitted postoperatively after tonsillectomy. Patients who experienced respiratory events after surgery were identified and differences between the respiratory event and no event groups were compared. There were 887 patients included in this study. 14.8% (n= 131) experienced a documented respiratory event. The following risk factors were found to be most significant: %sleep time with O2 < 90% (tb90) (95% CI=1.07-1.14, OR=1.10, p< 0.001), Black race (95% CI=1.53-3.58, OR=2.34, p< 0.001), primary neurologic co-morbidity (1.67-6.32, OR=3.27, p< 0.001), Down syndrome (1.25-5.94, OR=2.72, p =0.01), and age (0.84-0.94, OR=0.88, p< 0.001). Regression modeling demonstrated that the rate of respiratory events increased with tb90. Our results demonstrate that there are other potential risk factors outside of AHI and O2 nadir that are associated with respiratory events after tonsillectomy. Black race and prolonged desaturations during polysomnography (PSG) are independent risk factors. Measures of abnormal gas exchange on PSG may be better at identifying at risk patients. 4 Laryngoscope, 133:1251-1256, 2023.

Nasal cannula use during polysomnography in children aged under three with suspected sleep apnea

ObjectiveEarly diagnosis of obstructive sleep apnea (OSA) in children is important. The use of a nasal cannula as an airflow sensor during polysomnography has not been evaluated in younger children. The study aims to evaluate the use of nasal cannula in detecting respiratory events in children under three with suspected OSA during daytime nap studies. MethodsA total of 185 patients were prospectively included. Respiratory events were scored using nasal cannula alone, thermistor alone, and both methods simultaneously as the airflow sensor. Agreement and diagnostic accuracy were assessed. ResultsOne hundred and seventy-two children were finally analyzed and 110 (64.0%) presented OSA. Total sleep time with an uninterpretable signal was longer with the nasal cannula than with the thermistor (17.8% vs 1.9%; p < 0.001), and was associated with poor sensor tolerance and adenotonsillar hypertrophy. In the estimation of the apnea-hypopnea index, the nasal cannula showed lower agreement than the thermistor with the joint use of the two sensors (intraclass correlation coefficient: 0.79 vs 0.996 with thermistor). Compared with the thermistor, the nasal cannula presented lower sensitivity for detecting OSA (82.7% vs 95.5%) and a lower negative predictive value (76.5% vs 92.4%). Overall, fewer children were diagnosed with severe OSA with the nasal cannula (19.8% vs 30.8% with the thermistor, and 32.6% with both). ConclusionsIn children under the age of three, the ability of the nasal cannula to detect obstructive events was relatively low. Therefore, other non-invasive measurements for identifying respiratory events during sleep may be of additional value.

Comparative analysis of respiratory symptom scores to detect acute respiratory events in children with cystic fibrosis

BackgroundPatient-reported outcomes (PROs) are important outcome measures in research and clinical practice. This study describes the longitudinal variability the Cystic Fibrosis Questionnaire-Revised (CFQ-R) Respiratory score and the Chronic Respiratory Infection Symptom Score (CRISS), as well as their ability to identify acute respiratory events in children with CF. MethodsIn this prospective observational study, the parent-proxy (6 -13 years) and self-reported (6–18 years) CFQ-R Respiratory score and CRISS (6–18 years) were measured every 3 months over 2 years. The lung clearance index (LCI) and FEV1 were also measured. We compared the diagnostic accuracy of the PROs in distinguishing acute respiratory events and clinically stable visits, using the minimal important difference of each PRO as the threshold. ResultsA total of 98 children with CF were included. On average, the symptom scores did not change between clinically stable visits. The positive predictive value (PPV) and negative predictive value (NPV) of a ≥8.5-point worsening in the parent-proxy CFQ-R score to identify acute respiratory events (n=119) (PPV 70.2% and NPV 87.0%) were higher than for the self-reported CFQ-R score (PPV 58.9% and NPV 72.2%). The PPV and NPV of an ≥11-point change in the CRISS for acute respiratory events (n=137) was 56.5% and 79.6%, respectively. The PPV and NPV of all PROs were increased when combined with the LCI and/or FEV1pp. ConclusionSymptoms scores differ in their ability to identify acute respiratory events in children with CF; PPV and NPV of all PROs were improved when combined with lung function outcomes.

Perioperative Adverse Respiratory Events in Children with Obstructive Sleep Apnoea

Background: Obstructive sleep apnoea (OSA) in children is associated with the development of perioperative adverse respiratory events. The aim of our study was to find out the incidence of perioperative adverse respiratory events, to identify the risk predictors and to determine the appropriate anaesthetic agents in children with OSA. Methods After obtaining approval from the the Institutional Review Board, 189 children with OSA who had undergone adenotonsillectomy between 2004 and 2009 were selected from a retrospective review of case files. Variables recorded included demographic data, coexistent medical illnesses, anaesthetic techniques (including induction agents and muscle relaxants) and perioperative analgesia. The severity of OSA was determined based on polysomnographic criteria. Adverse events including difficult airway, desaturation due to bronchospasm or laryngospasm, postoperative desaturation and unplanned intensive care unit (ICU) admission occurring up to 24 h postoperatively were recorded. Results The incidence of perioperative respiratory adverse events was 19.6%. Severe OSA (odds ratio [OR] 5.8; 95% confidence interval [CI] 1.8–18.53; P = 0.003) and moderate OSA (OR 3.9; 95% CI 1.1–13.1; P = 0.029) were independent risk factors associated with complications. There was no correlation between the intraoperative anaesthetic techniques or use of perioperative opioid analgesics and the perioperative adverse respiratory events. Conclusions Preoperative diagnosis of OSA using polysomnography has been shown to identify children who are at increased risk of perioperative adverse respiratory events in children. In our review, 19.6% of children with OSA were at risk. The use of a severity index may better identify children at higher risk.

O014 Heart rate response to obstructive respiratory events in children born preterm with OSA

Abstract Background Preterm-born (PT) children have an increased risk for obstructive sleep apnoea (OSA) and adverse cardiovascular outcomes. Respiratory events elicit acute changes in heart rate (HR) in term-born (T) children. Whether this response is augmented in PT children with OSA remains unclear. We aimed to analyse the HR response during obstructive respiratory events in PT children with OSA. Methods Nine PT children (3–12 y), were matched for obstructive apnoea hypopnoea index (OAHI), age and gender with T children. Beat-to-beat HR was averaged 10s before, during and the peak after (post) each obstructive event, and peak HR was expressed as percentage change. Results 323 obstructive events in PT and 376 in T children were identified, consisting of 681 hypopnoeas (PT 320; T 361) and 18 apnoeas (PT 3; T 15). There were insufficient apnoeas in the PT group for analysis. For hypopnoeas during total sleep, the PT group had significantly lower HR compared to the T group before median 81bpm (IQR 74–87) vs 88 bpm (79–99); p&amp;lt;0.001), during (76 bpm (69–83) vs 82 bpm (74–92; p&amp;lt;0.001) and post (97 bpm (89–103) vs 105 bpm (95–115; p&amp;lt;0.001) events. The post event increase in HR was significantly higher in the PT (26%, (16–39)) compared with the T (23%, (14–36)) group, p=0.008. Conclusion Although HR was lower during obstructive hypopnoeas in preterm compared with term-born children, the post event surge was significantly higher. This heightened HR response to respiratory events in children born preterm may underlie the worse cardiovascular outcomes in these children.

Independent risk factors for adverse events associated with propofol-based pediatric sedation performed by anesthesiologists in the radiology suite: a prospective observational study.

This study aimed to identify the types and frequencies of adverse events, as well as the risk factors for respiratory complications related to pediatric sedation. This single-center, prospective, observational study was conducted in a radiology suite at a tertiary university hospital for 2 years. Patients aged under 18 years, who underwent sedation solely by anesthesiologists for computed tomography or magnetic resonance imaging scans, were eligible for inclusion. Univariate and multivariate logistic regression analyses were carried out to identify the risk factors of adverse events, including respiratory complications, related to the propofol-based sedation. We further performed a sensitivity test with 1-to-5 propensity score matching analysis to assess the robustness of our findings. Among 2569 children, 3.9% experienced respiratory problems related to the sedation. After 1-to-5 propensity matching analysis, cardiac and neurologic comorbidities, crying before sedation, a history of snoring or upper respiratory infection, and prolonged duration of sedation were independently associated with the occurrence of adverse respiratory events.Conclusions: Our protocol for pediatric sedation demonstrates a high success rate and low likelihood of fatal complications, but proactive management prior to propofol-based sedation is critical to prevent adverse respiratory events in children. What is Known: • Propofol-based pediatric sedation is associated with adverse events necessarily even though performed by professional anesthesiologists solely. What is New: • Cardiac and neurologic comorbidities, crying before sedation, a history of snoring or upper respiratory infection, and prolonged duration of sedation were independently associated with the occurrence of respiratory adverse events. • Proactive management prior to sedation is critical to preventing adverse respiratory events for pediatrics.

Associations between polysomnography measurements and postoperative adverse respiratory events in children with neuromuscular disease.

To determine if polysomnographic cardiorespiratory outcomes are associated with and could have the potential to predict the presence of postoperative adverse respiratory events in children with neuromuscular disease undergoing any surgical procedure. A retrospective cohort study was conducted at a tertiary pediatric institution. The study population included individuals with neuromuscular disease admitted for a surgical intervention under general anesthetic who had undergone a polysomnogram within 1 year before surgical intervention. Polysomnographic indices and postoperative adverse respiratory events were collected through chart review. Multivariable logistic regression was used to model postoperative adverse respiratory events, where PSG results were considered primary predictors. Postoperative adverse respiratory events occurred in 25/61 (41%) of individuals and consisted mainly of desaturations requiring intervention 33 (73%), airway obstruction 15 (33%), and atelectasis (22%). Results from the unadjusted and adjusted logistic regression models indicated that saturation nadir and bulbar dysfunction individually were independent risk factors for postoperative adverse respiratory events with the highest areas under the receiver operating characteristic curve. A multivariable prediction model using these 2 risk factors provided an area under the receiver operating characteristic curve of 0.74 (95% confidence interval, 0.65-0.83). Knowing that nocturnal oxygen saturation nadir and the presence of bulbar dysfunction are potential predictors of postoperative adverse respiratory events is useful for future counseling of families and surgical planning, in an effort to improve perioperative management and reduce adverse events.

Salbutamol administered preoperatively to children undergoing tonsillectomy resulted in a significant reduction in rates of respiratory adverse events

Review of Von Ungern-Sternberg BS, Sommerfield D, Slevin L, Drake-Brockman TFE, Zhang G, Hall GL. Effect of albuterol premedication vs placebo on the occurrence of respiratory adverse events in children...

Tracheal sounds for the scoring of sleep respiratory events in children.

Oronasal thermistor and nasal cannula are recommended for the scoring of respiratory events (RE) but these sensors are poorly tolerated in children. The aim of the study was to evaluate tracheal sounds (TS) and suprasternal pressure (SSP) for the scoring of RE during sleep in children. We compared the detection and characterization of RE by AASM-recommended sensors ("AASM" scoring), with the detection and characterization of RE by the combination of TS and SSP with respiratory inductance plethysmography-sum (TS-RIP scoring), and TS and SSP only (TS scoring). The recordings of 17 patients were analyzed. The TS, SSP, and RIP flow signals were present during 95%, 95%, and 99% of the validated recording time, respectively, as compared to 79% and 86% for nasal cannula and oronasal thermistor. A total of 1,456 RE were scored with the "AASM" scoring, 1,335 with the TS-RIP scoring, and 1,311 with the TS scoring. Sensitivity for apnea and hypopnea detection was 88% and 84% for the TS-RIP scoring, and 86% and 77% for the TS scoring. For apnea characterization, the TS-RIP scoring sensitivities and specificities were 97% and 100%, 76% and 98%, and 95% and 97%, for obstructive, mixed, and central apnea, respectively. For the TS scoring, they were 95% and 100%, 95% and 97%, and 91% and 97%, respectively. TS and SSP + RIP-sum has a good sensitivity and specificity for the detection and characterization of apnea and hypopnea in children. TS and SSP alone have good sensitivity and specificity for apnea detection and characterization but lower sensitivity for hypopnea detection.

Cerebral Oxygenation During Respiratory Events in Children with Sleep-Disordered Breathing and Associated Disorders

To evaluate changes in cerebral oxygenation by means of near-infrared spectroscopy during respiratory events in children with sleep-disordered breathing (SDB) and associated disorders. Sixty-five children suspected of having SDB underwent a respiratory polygraphy with simultaneous recording of cerebral oxygenation indices. Respiratory events were analyzed by type of event, duration, variations of pulse oximetry (oxygen saturation [SpO2]), cerebral tissue oxygenation index (TOI), and heart rate. Data were categorized according to the severity of SDB and age. There were 540 obstructive and mixed apneas, 172 central apneas, and 393 obstructive hypopneas analyzed. The mean decreases in SpO2 and TOI were 4.1±3.1% and 3.4±2.8%, respectively. The mean TOI decrease was significantly smaller for obstructive hypopnea compared with apneas. The TOI decrease was significantly less in children with mild SDB as compared with those with moderate-to-severe SDB and in children >7years as compared with those <7years old. TOI decreases correlated significantly with SpO2 decreases, duration of event, and age, regardless of the type of event. In a multivariable regression model, predictive factors of TOI decreases were the type of respiratory event, SpO2 decrease, apnea-hypopnea index, and age. In children with SDB and associated disorders, cerebral oxygenation variations depend on the type of respiratory event, severity of SDB, and age.

Respiratory polygraphy in children: Feasibility in everyday practice in an ENT department and value of automatic detection of respiratory events

ObjectivesUsing respiratory polygraphy (RP) in children for diagnosis of obstructive sleep apnea/hypopnea syndrome (OSAHS) can be challenging in terms of device acceptance and sensor displacement. Automatic analysis of respiratory events has never been evaluated in a pediatric population. The primary objective of this study was to determine the feasibility of pediatric RP in routine ENT department practice. The secondary objective was to evaluate the reliability of the automatic detection of obstructive and central respiratory events in children. MethodsA single-center retrospective study included 50 children (32 boys, 18 girls; mean age 5.5±2.3years) undergoing overnight RP in an ENT department between January and August 2016 for suspected OSAHS. Manual detection of respiratory events was performed by one ENT specialist experienced in RP interpretation, and compared to automatic analysis. ResultsThe device was well accepted in 98% of cases. Overall signal quality was>50% in 76% of cases, with average signal quality of 70.8% (86% in patients>3 yrs, 25% in patients<3 yrs, P=0.0013). There was no significant correlation between manual and automatic analyses, except for central apnea (Spearman coefficient 0.43; P=0.0015). One hundred percent of patients presented OSAHS according to automatic detection, compared to 32% according to manual detection (P<0.005). ConclusionsPediatric RP is feasible in routine practice in an ENT department, with good acceptance and satisfactory signal quality in children older than 3years. Automatic analysis of respiratory events in children is unreliable, except for central apnea.

Optimal inspiratory pressure for face mask ventilation in paralyzed and unparalyzed children to prevent gastric insufflation: a prospective, randomized, non-blinded study.

Gastric insufflation is common during face mask ventilation and results in unfavourable respiratory events in children. The purpose of this study was to evaluate the effect of a muscle relaxant on gastric insufflation and determine the optimal inspiratory pressure during face mask ventilation in children. Children aged one month to five years were randomly assigned to neuromuscular blocker (NM) or non-neuromuscular blocker (non-NM) groups. After administering intravenous anesthetics, face mask ventilation commenced via pressure-controlled mechanical ventilator. Initial inspiratory pressure was 10 cmH2O and was increased by 2 cmH2O until gastric insufflation was detected via gastric ultrasonography or epigastric auscultation. The primary outcome was the difference in the inspiratory pressure that causes gastric insufflation between the two groups. Diagnostic methods that detect gastric insufflation first were also evaluated. There was no significant difference in the median [interquartile range] inspiratory pressure inducing gastric insufflation between the non-NM (n = 52) and NM groups (n = 60) (18 [16-18] cmH2O vs 18.0 [16-20] cmH2O; median difference, 0 cmH2O; 95% confidence interval [CI], 0 to 2; P = 0.57). The incidence of gastric insufflation increased with increasing inspiratory pressure. Gastric insufflation was detected first by ultrasonography in 44% and by epigastric auscultation in 19% of the non-NM group (difference in percentage, 25%; 95% CI, 6 to 42; P = 0.006) and by ultrasonography in 73% and by epigastric auscultation in 7% of the NM group (difference in percentage, 66%; 95% CI, 50 to 78; P < 0.001). A neuromuscular blocking agent has minimal effect on the inspiratory pressure that causes gastric insufflation during face mask ventilation in children. www.clinicaltrials.gov (NCT02471521); registered 15 June 2015.

Airway management in paediatric anaesthesia in Europe—insights from APRICOT (Anaesthesia Practice In Children Observational Trial): a prospective multicentre observational study in 261 hospitals in Europe

BackgroundCritical respiratory events are common in children in the peri-anaesthetic period and are caused by airway and ventilation management difficulties. We aimed to analyse current European paediatric airway management practices and identify the incidence and potential consequences of difficult airway management. MethodsWe performed a secondary analysis of airway and ventilation management details of the European multicentre observational trial (Anaesthesia PRactice in Children Observational Trial, APRICOT) of children from birth to 15 yr of age. The primary endpoint was the incidence of difficult airway management. Secondary endpoints were the associations between difficult airway management, known pre-existing respiratory risk factors, and the occurrence of critical respiratory events. ResultsDetails for 31 024 anaesthetic procedures were available for analysis. Three or more tracheal intubation attempts were necessary in 120 children (0.9%) and in 40 children (0.4%) for supraglottic airways insertions. The incidence (95% confidence interval) for failed tracheal intubation and failed supraglottic airway insertions was 8/10 000 (0.08%; 0.03–0.13%) and 8.2/10 000 (0.08%; 0.03–0.14%) children, respectively. Difficulties in securing the airway increased the risk for a critical respiratory event for tracheal tube (2.1; 1.3–3.4) and supraglottic airway (4.3; 1.9–9.9) placement. History of pre-existing respiratory risk factors was significantly associated with critical respiratory events independently of the airway device used. ConclusionsAirway management practices vary widely across Europe. Multiple airway device insertion attempts and pre-existing respiratory risk factors increase the likelihood of critical respiratory events in children and require further stratification during preoperative assessment and planning. This study highlights areas where education, research, and training may improve perioperative care. Clinical trial registrationNCT01878760.

Randomized phase 2 trial of monthly vitamin D to prevent respiratory complications in children with sickle cell disease

AbstractIn sickle cell disease, respiratory infection and asthma may lead to respiratory complications that are a leading cause of morbidity and mortality. Vitamin D has anti-infective and immunomodulatory effects that may decrease the risk for respiratory infections, asthma, and acute chest syndrome. We conducted a randomized double-blind active-controlled clinical trial to determine whether monthly oral vitamin D3 can reduce the rate of respiratory events in children with sickle cell disease. Seventy sickle cell subjects, ages 3-20 years, with baseline records of respiratory events over 1 year before randomization, underwent screening. Sixty-two subjects with 25-hydroxyvitamin D levels of 5-60 ng/mL were randomly assigned to oral vitamin D3 (100 000 IU or 12 000 IU, n = 31 each) under observed administration once monthly for 2 years. The primary outcome was the annual rate of respiratory events (respiratory infection, asthma exacerbation, or acute chest syndrome) ascertained by the use of a validated questionnaire administered biweekly. Analysis included 62 children (mean age of 9.9 years, 52% female, and predominantly with homozygous HbS disease [87%]) with mean baseline 25-hydroxyvitamin D of 14.3 ng/mL. The annual rates of respiratory events at baseline and intervention years 1 and 2 were 4.34 ± 0.35, 4.28 ± 0.36, and 1.49 ± 0.37 (high dose) and 3.91 ± 0.35, 3.34 ± 0.37, and 1.54 ± 0.37 (standard dose), respectively. In pediatric patients with sickle cell disease, 2-year monthly oral vitamin D3 was associated with a >50% reduction in the rate of respiratory illness during the second year (P = .0005), with similar decreases associated with high- and standard-dose treatment. This trial was registered at www.clinicaltrials.gov as #NCT01443728.