Prevalence of Sleep Disorders in Thai Children

New noninvasive modalities in long-term pediatric ventilation: a scoping review

Long-term noninvasive ventilation modalities for the pediatric population have undergone a continuous evolution. Hybrid noninvasive ventilation modalities have been recently introduced in clinical practice. Combining the advantages of conventional ventilation, hybrid modes use algorithms that automatically adjust the ventilator's settings to achieve a predefined ventilation target. Most of the recommendations on the use and settings of hybrid noninvasive ventilation modalities in children are derived from adult experience. Therefore, there is a lack of evidence on its implementation in pediatric chronic respiratory diseases. This scoping review aims to map the existing information regarding the use of hybrid ventilation modalities in the pediatric population and identify knowledge or research gaps. We performed a literature search using MEDLINE and Pubmed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. We included 13 studies (ten studies on average volume-assured pressure-support ventilation; two studies on intelligent volume-assured pressure-support ventilation; and one study on adaptive servoventilation). The use of new noninvasive ventilation modes in the pediatric population has been applied for the treatment of neuromuscular and hypoventilation syndromes as an alternative therapeutic option in the case of the failure of conventional noninvasive ventilation. Their widespread use has been hampered by the limited evidence available. Longitudinal studies on a larger number of patients are needed to confirm their effectiveness and evaluate their long-term clinical and functional outcomes.

Worldwide prevalence and associated risk factors of obstructive sleep apnea: a meta-analysis and meta-regression

PURPOSE

This study aimed to identify the prevalence of obstructive sleep apnea (OSA) and associated risk factors globally.

METHODS

Six databases and registrations and three grey databases were explored for observational field research. Independently and impartially paired reviewers selected research, gathered data, and evaluated the methodological quality. Heterogeneity was investigated using subgroup analysis and meta-regression following the moderating variable in a meta-analysis of proportions with a random-effects model. The critical appraisal instrument developed by the Joanna Briggs Institute was used to evaluate the listed studies' methodology. The certainty of the evidence was evaluated using the GRADE tool.

RESULTS

A total of 8236 articles were collected during the database search, resulting in 99 articles included for qualitative synthesis, and 98 articles were included for the meta-analysis. The estimated combined prevalence of OSA was 54% [CI 95% = 46-62%; I2 = 100%]. Mean age, percentage of moderate-severe cases, and the sample's body mass index (BMI) did not affect the heterogeneity that was already present when meta-regressed (p > 0.05). Ninety-one studies were deemed to have a low risk of bias, while eight were deemed to have a moderate risk. For OSA prevalence outcomes, the GRADE criteria were considered very low.

CONCLUSION

Approximately half of the people worldwide have OSA. High BMI, increasing age, and male gender are described as risk factors in the literature, but these covariates do not affect pre-existing heterogeneity.

Prevalence and Risk Factors for Rapid Eye Movement-Related Obstructive Sleep Apnea in Children

OBJECTIVES

Different pathophysiological mechanisms and the distribution of respiratory events among rapid eye movement (REM) and non-rapid eye movement (NREM) sleep modulate the effect of obstructive sleep apnea (OSA). We aimed to study the prevalence and risk factors for REM-related OSA in children.

STUDY DESIGN

Retrospective, cross-sectional study.

METHODS

We recruited 366 children with OSA confirmed by polysomnography (PSG) over a 5-year period. REM-related OSA is defined by an obstructive apnea-hypopnea index (OAHI) in the REM sleep ≥2× than during NREM sleep.

RESULTS

The prevalence of REM-related OSA in children was 50.3%. Children with REM-related OSA were more likely to be female (P = 0.042), and had lower prevalence of adenotonsillar hypertrophy (P = 0.043) compared with children with other OSA subtypes. Children with REM-related OSA slept longer in the supine position (P = 0.003), had shorter duration of NREM1 sleep (P = 0.018), lower nadir SpO₂ (P = 0.005), and a higher oxygen desaturation index 3% (ODI3%) (P = 0.014), and lower arousal index (P = 0.034) compared with other OSA subtypes. Female gender and supine sleep was the independent risk factors for REM-related OSA.

CONCLUSION

The prevalence of REM-related OSA was 50.3%. OAHI_REM should be considered as an important parameter in future clinical research studies done in children with OSA.

Incidence / predictors of pediatric obstructive sleep apnea with normal oximetry

BACKGROUND

The polysomnogram (PSG) is the "gold standard" for diagnosing obstructive sleep apnea (OSA). However, nocturnal oximetry is a practical screening tool for children with adenotonsillar hypertrophy (ATH). This study aimed to investigate the incidence of, and predictive factors for, OSA in children with ATH and normal / inconclusive overnight oximetry.

METHODS

The prospective study enrolled children aged 3-15 years with ATH and normal / inconclusive overnight oximetry. All participants underwent full-night PSG. To evaluate the predictors of OSA, we used logistic regression analysis, including sex, history of allergic rhinitis, body mass index z-score, neck circumference-height ratio, and polysomnographic parameters (obstructive apnea-hypopnea index (OAHI), nadir oxygen saturation (SpO2), peak end-tidal CO₂ , and arousal index).

RESULTS

The participants were 189 children; 167 (88%) were diagnosed with OSA by PSG. A history of allergic rhinitis (P = 0.033), and the PSG findings for nadir SpO₂ (P = 0.027) and arousal index (P = <0.001) predicted the diagnosis of OSA. We divided patients with OSA into two groups (mild versus moderate to severe OSA). Patients with OAHI ≥5/h were defined as having moderate-to-severe OSA. No clinical factors significantly predicted OAHI ≥5. Of the 189 participants, 58 children (31%) were diagnosed with severe OSA (OAHI ≥10). The only PSG factor that predicted severe OSA was the arousal index (P < 0.001).

CONCLUSIONS

The observed incidence of OSA in children aged 3-15 years with ATH and normal/inconclusive overnight oximetry was very high. A history of allergic rhinitis may help to triage the patients. The arousal index was a predictor of pediatric OSA.

Restless sleep in children: A systematic review

This systematic review assessed the prevalence of restless sleep in children, documented the association of restless sleep with other conditions, and summarized the existing evidence regarding whether restless sleep should be considered a distinct sleep disorder. A comprehensive search of electronic databases was performed using the broad search term "restless sleep" in all fields. Of the 266 articles retrieved, 107 were retained for inclusion in this review. The majority (n = 93) were observational studies. The studies were grouped under several pathologic/condition categories: sleep-disordered breathing (n = 19); adenotonsillectomy (n = 7); respiratory disorders, otitis media, and smoke exposure (n = 12); sleep-related movement disorders and restless sleep disorder (n = 11); neurologic or psychiatric disorders (n = 7); Down syndrome/other neurodevelopmental disorders (n = 10); sleep-related bruxism and other sleep disorders (n = 7); and restless sleep in the general population/mixed clinical samples (n = 18). A high prevalence of restless sleep was found in children with many of these underlying conditions, likely related to associated inherent sleep disruption and frequent awakenings (e.g., apnea and periodic limb movements), pain, sleep instability, and caregiver perception. The majority of studies identified restless sleep as reported by the caregiver, only 34 studies attempted to define restless sleep further. Four studies provided supportive evidence for designating restless sleep as an independent sleep disorder, restless sleep disorder (RSD). This review highlights the fact that the prevalence, etiology and sequelae (including daytime impairments) of restless sleep in children are important topics deserving of further research and that clinical definitions based on empirical evidence need to be developed. The designation of "primary" versus "secondary" restless sleep may be a useful construct, especially with regard to developing clinical trials and treatment algorithms.

Ventilators and Ventilatory Modalities

Non-invasive ventilation is increasingly used in children for acute and chronic respiratory failure. Ventilators available for clinical use have different levels of complexity, and clinicians need to know in detail their characteristics, setting variables, and performances. A wide range of ventilators are currently used in non-invasive ventilation including bi-level ventilators, intermediate ventilators, and critical care ventilators. Simple or advanced continuous positive airway pressure devices are also available. Differences between ventilators may have implications on the development of asynchronies and air leaks and may be associated with discomfort and poor patient tolerance. Although pressure-targeted (controlled) mode is preferable in children because of barotrauma concerns, volume-targeted (controlled) ventilators are also available. Pressure support ventilation represents the most used non-invasive ventilation mode, as it is more physiological. The newest ventilators allow the clinicians to use the hybrid modes that combine the advantages of volume- and pressure-targeted (controlled) ventilation while limiting their drawbacks. The use of in-built software may help clinicians to optimize the ventilator setting as well as to objectively monitor patient adherence to the treatment. The present review aims to help the clinician with the choice of the ventilator and its ventilation modalities to ensure a successful non-invasive ventilation program.