A cohort study reporting normal oximetry values in healthy infants under 4 months of age using Masimo technology

Gas exchange parameters for the prediction of obstructive sleep apnea in infants

STUDY OBJECTIVES

Sleep laboratory polysomnography is the gold standard for obstructive sleep apnea (OSA) diagnosis in infants, but its access remains limited. Oximetry-capnography is another simple and widely used tool that can provide information on the presence of desaturations and alveolar hypoventilation. However, its reliability is debated. This study aimed at examining its use in determining OSA severity in infants.

METHODS

This retrospective study was conducted in a sleep unit in a tertiary hospital in infants < 4 months old with clinical signs of OSA or Pierre Robin sequence who underwent a 1-night polysomnography coupled with oximetry-capnography.

RESULTS

Among the 78 infants included (median [interquartile range] age: 61 [45-89] days at polysomnography), 44 presented with Pierre Robin sequence and 34 presented with isolated airway obstruction. The clinical, sleep, and respiratory characteristics were not significantly different between the 2 subgroups. In the entire cohort, 63.5% had severe OSA. The median obstructive apnea-hypopnea index was 14.5 (7.4-5.9) events/h, peripheral oxygen saturation (SpO2) was 97.4% (96.5-98.1%), and transcutaneous carbon dioxide pressure (PtcCO2) was 41.1 mmHg (38.3-44.9). The optimal threshold to predict an obstructive apnea-hypopnea index > 10 events/h was 6 events/h for an oxygen desaturation index ≥ 3% (sensitivity, 95.7%; specificity, 51.9%) and 2 events/h for an oxygen desaturation index ≥ 4% (sensitivity, 95.7%; specificity, 48.1%).

CONCLUSIONS

Whereas transcutaneous capnography does not appear to be sufficient in predicting severe OSA in infants < 4 months old with Pierre Robin sequence or clinical signs of OSA, oximetry may be a useful alternative for the screening of severe OSA in infants in the absence of polysomnography.

CITATION

Gyapay R, Ioan I, Thieux M, et al. Gas exchange parameters for the prediction of obstructive sleep apnea in infants. J Clin Sleep Med. 2024;20(7):1059-1067.

The Montreal Children's Hospital Experience Managing Robin Sequence: An Analysis of Outcomes and Algorithm for Surgical Technique Selection

BACKGROUND

The development of mandibular distraction osteogenesis (MDO) and tongue-lip adhesion (TLA) has led to significant improvements in respiratory outcomes for the Robin sequence (RS) population. Despite such advances, there continues to be debate regarding management strategies. The authors present their experience managing the RS population with insights on technique selection.

METHODS

A retrospective review of RS patients treated at the senior author's institution from 2003 to 2021 was conducted. Baseline patient demographics and clinical parameters including feeding and respiratory status were recorded. Outcomes included the need for tracheostomy or tracheostomy, decannulation rates, and feeding status. Patients were evaluated through overnight oximetry and drug-induced sleep endoscopy (DISE). Outcomes were stratified according to management technique (MDO, TLA, versus conservative) and compared through statistical analysis.

RESULTS

Fifty-nine RS patients were included. Twenty-eight were managed conservatively, 19 underwent MDO, 10 underwent TLA, one underwent both TLA and MDO, and one underwent tracheostomy primarily. Overall, 1.7% of the cohort required a tracheostomy and 86% achieved oral feeding after the procedure. The MDO cohort had lower Apgar scores and mean birth weight compared with the conservative and TLA cohorts ( P < 0.05). There were no statistical differences in respiratory and feeding outcomes across all three cohorts.

CONCLUSIONS

A therapeutic algorithm was developed with insight into the use of DISE and risk stratification with overnight oximetry to guide procedural selection. Using this approach, safe and satisfactory respiratory outcomes were achieved with a low tracheostomy rate. Risk stratification is possible without polysomnography, and DISE is a promising tool (that requires further validation) for procedural selection in this population.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

An update on diagnosis and management of obstructive sleep apnoea in the first 2 years of life

The aim of this review is to summarise evidence that became available after publication of the 2017 European Respiratory Society statement on the diagnosis and management of obstructive sleep apnoea syndrome (OSAS) in 1- to 23-month-old children. The definition of OSAS in the first 2 years of life should probably differ from that applied in children older than 2 years. An obstructive apnoea-hypopnoea index >5 events·h-1 may be normal in neonates, as obstructive and central sleep apnoeas decline in frequency during infancy in otherwise healthy children and those with symptoms of upper airway obstruction. A combination of dynamic and fixed upper airway obstruction is commonly observed in this age group, and drug-induced sleep endoscopy may be useful in selecting the most appropriate surgical intervention. Adenotonsillectomy can improve nocturnal breathing in infants and young toddlers with OSAS, and isolated adenoidectomy can be efficacious particularly in children under 12 months of age. Laryngomalacia is a common cause of OSAS in young children and supraglottoplasty can provide improvement in children with moderate-to-severe upper airway obstruction. Children who are not candidates for surgery or have persistent OSAS post-operatively can be treated with positive airway pressure (PAP). High-flow nasal cannula may be offered to young children with persistent OSAS following surgery, as a bridge until definitive therapy or if they are PAP intolerant. In conclusion, management of OSAS in the first 2 years of life is unique and requires consideration of comorbidities and clinical presentation along with PSG results for treatment decisions, and a multidisciplinary approach to treatment with medical and otolaryngology teams.

Use of pulse oximetry as an investigative test for paediatric respiratory sleep disorders

The article covers the following elements: practical and technological considerations for optimising data collection and output; reference ranges for oximetry parameters across the ages; things to consider when interpreting a pulse oximetry study (eg, sleep/wake times); the ability of pulse oximetry to predict obstructive sleep apnoea; using oximetry as a screening tool for sleep disordered breathing in children with Down syndrome; things to consider when setting up a home oximetry service; and a case of an infant being weaned from oxygen using pulse oximetry studies.

The infant with bronchopulmonary dysplasia on home oxygen: The oxygen weaning conundrum in the absence of good evidence

Bronchopulmonary dysplasia [BPD] is the most common complication of extremely preterm delivery and its optimal management remains challenging because of a lack of evidence to guide management. There has been improvement in the management of evolving BPD in the neonatal intensive care unit (NICU). The threshold for provision of home oxygen therapy, often occurring because of a preference for earlier discharge from the NICU, creates tensions for clincians and families. Once discharged in supplemental oxygen, the approaches for the weaning of this therapy vary considerably across the world. Regardless of guidelines and multidisciplinary team support, up to a third of families of an infant with BPD elect to withdraw home oxygen therapy independently of medical advice. There is a pressing need to derive evidence to better inform practice, generate international consensus and undertake large, appropriately funded, longitudinal studies of BPD with clinically meaningful outcomes (respiratory, cardiovascular and neurodevelopmental) from infancy to adulthood.

Recent advances in paediatric sleep disordered breathing

This article reviews the latest evidence pertaining to childhood sleep disordered breathing (SDB), which is associated with negative neurobehavioural, cardiovascular and growth outcomes. Polysomnography is the accepted gold standard for diagnosing SDB but is expensive and limited to specialist centres. Simpler tests such as cardiorespiratory polygraphy and pulse oximetry are probably sufficient for diagnosing obstructive sleep apnoea (OSA) in typically developing children, and new data-processing techniques may improve their accuracy. Adenotonsillectomy is the first-line treatment for OSA, with recent evidence showing that intracapsular tonsillectomy results in lower rates of adverse events than traditional techniques. Anti-inflammatory medication and positive airway pressure respiratory support are not always suitable or successful, although weight loss and hypoglossal nerve stimulation may help in select comorbid conditions.

Educational aims

To understand the clinical impact of childhood sleep disordered breathing (SDB).To understand that, while sleep laboratory polysomnography has been the gold standard for diagnosis of SDB, other diagnostic techniques exist with their own benefits and limitations.To recognise that adenotonsillectomy and positive pressure respiratory support are the mainstays of treating childhood SDB, but different approaches may be indicated in certain patient groups.

Does Sleep Position Influence Sleep-Disordered Breathing in Infants With Cleft Palate: A Feasibility Study?

OBJECTIVE

Cleft palate (CP) can affect breathing, leading to sleep-disordered breathing (SDB). Sleep position can affect SDB, but the optimum sleep position for infants with CP is unknown. We aimed to determine the design of a pragmatic study to investigate the effect of the 2 routinely advised sleep positions in infants with CP on oxygen saturations.

DESIGN

A multicentered observational cohort.

SETTING

Four UK-based cleft centers, 2 advising supine- and 2 side-lying sleep positions for infants with CP.

PARTICIPANTS

Infants with isolated CP born July 1, 2015, and December 31, 2016. Of 48 eligible infants, 30 consented (17 side-lying; 13 supine).

INTERVENTIONS

Oxygen saturation (SpO2) and end-tidal carbon dioxide (ETCO2) home monitoring at age 1 and 3 months. Qualitative interviews of parents.

OUTCOME MEASURES

Willingness to participate, recruitment, retention, and acceptability/success (>90 minutes recording) of SpO2 and ETCO2 monitoring.

RESULTS

SpO2 recordings were obtained during 50 sleep sessions on 24 babies (13 side-lying) at 1 month (34 sessions >90 minutes) and 50 sessions on 19 babies (10 side-lying) at 3 months (27 sessions >90 minutes). The ETCO2 monitoring was only achieved in 12 sessions at 1 month and 6 at 3 months; only 1 was >90 minutes long. The ETCO2 monitoring was reported by the majority as unacceptable. Parents consistently reported the topic of sleep position in CP to be of importance.

CONCLUSIONS

This study has demonstrated that it is feasible to perform domiciliary oxygen saturation studies in a research setting and has suggested that there may be a difference in the effects of sleep position that requires further investigation. We propose a study with randomization is indicated, comparing side-lying with supine-lying sleep position, representing an important step toward better understanding of SDB in infants with CP.

Weaning oxygen in infants with bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) is a form of chronic lung disease commonly seen in preterm infants as the sequelae following respiratory distress syndrome. The management of evolving BPD aims to minimise lung injury and prevent the impact of hypoxia and hyperoxia. Proposed morbidities include respiratory instability, pulmonary hypertension, suboptimal growth, altered cerebral oxygenation and long-term neurodevelopmental impairment. The ongoing management and associated morbidity present a significant burden for carers and healthcare systems. Long-term oxygen therapy may be required for variable duration, though there is a lack of consensus and wide variation in practise when weaning supplemental oxygen. Furthermore, a shift in care towards earlier discharge and community care underlines the importance of a structured discharge and weaning process that eliminates the potential risks associated with hypoxia and hyperoxia. This review article describes recent evidence outlining oxygen saturation reference ranges in young infants, on which structured guidance can be based.

Observational study to define reference ranges for the 3% oxygen desaturation index during sleep in healthy children under 12 years using oximetry motion-resistant technology

OBJECTIVE

To define reference ranges for the 3% oxygen desaturation index (DI3) in healthy children under 12 years old during sleep.

DESIGN

Observational.

SETTING

Home.

SUBJECTS

Healthy children aged 6 months to 12 years of age.

INTERVENTION

Nocturnal pulse oximetry at home. Parents documented sleep times. Visi-Download software (Stowood Scientific) analysed data with artefact and wake periods removed.

MAIN OUTCOME MEASURES

The following oximetry parameters used in the assessment of sleep-disordered breathing conditions were measured: 3% (DI3) and 4% (DI4) oxygen desaturation indices-the number of times per hour where the oxygen saturation falls by at least 3% or 4% from baseline, mean saturations (SAT50), minimum saturations (SATmin), delta index 12 s (DI12s), and percentage time with saturations below 92% and 90%.

RESULTS

Seventy-nine children underwent nocturnal home pulse oximetry, from which there were 66 studies suitable for analysis. The median values for DI3 and DI4 were 2.58 (95% CI 1.96 to 3.10) and 0.92 (95% CI 0.73 to 1.15), respectively. The 95th and 97.5th centiles for DI3 were 6.43 and 7.06, respectively, which inform our cut-off value for normality. The mean values for SAT50 and SATmin were 97.57% (95% CI 97.38% to 97.76%) and 91.09% (95% CI 90.32% to 91.86%), respectively.

CONCLUSION

In children aged 6 months to 12 years, we define normality of the 3% oxygen desaturation index as <7 using standalone, motion-resistant pulse oximeters with short averaging times.

Study protocol for randomised clinical trial comparing the effectiveness of side-lying sleep positioning to back-lying at reducing oxygen desaturation resulting from obstructive sleep apnoea in infants with cleft palate (SLUMBRS2)

INTRODUCTION

The craniofacial abnormalities found in infants with cleft palate (CP) decrease their airway patency and increase their risk of obstructive sleep apnoea (OSA). We hypothesise that optimising sleep position in infants with CP may improve airway patency and offer a 'low-cost, high-impact' intervention to prevent the negative impacts of OSA. Because cleft centres give inconsistent advice about sleep position: some recommend back-lying and others side-lying, we will compare these in a randomised controlled trial.

METHODS AND ANALYSIS

The aim is to determine the clinical effectiveness of side-lying as compared with back-lying sleep positioning in terms of reducing oxygen desaturation resulting from OSA in 244 infants aged 3-5 weeks of age, diagnosed with an isolated CP in/by UK cleft centres. Primary outcome is the 4% Oxygen Desaturation Index measured using pulse oximetry during sleep.

RESEARCH PLAN

1. Multicentre randomised controlled trial of side-lying compared with back-lying sleep positioning in reducing oxygen desaturation resulting from OSA in infants with CP at one month of age. 2. Internal pilot questionnaire-based study to support parents and clinicians regarding study participation, seeking to identify and address any barriers to recruitment. Monitoring data from the internal pilot will be used in the final analysis. 3. Co-development of new UK recommendations with Cleft Lip and Palate Association (CLAPA) regarding sleep position for infants with CP.

ETHICS AND DISSEMINATION

The study protocol has received the favourable opinion of the West Midlands-South Birmingham Research Ethics Committee. Study results will be published on affiliated webpages and in peer-reviewed publications and conference contributions.

TRIAL REGISTRATION NUMBER

NCT04478201.

Use of oximetry to screen for paediatric obstructive sleep apnoea: is one night enough and is 6 hours too much?

INTRODUCTION

Nocturnal pulse oximetry can be used to screen for obstructive sleep apnoea (OSA) using the McGill Oximetry Score (MOS). The MOS has a time threshold for a technically adequate study of 6 hours. It has been suggested that one night of oximetry is sufficient to screen for OSA using the MOS.

AIMS

(1) To evaluate night-to-night variation of the MOS. (2) To determine the impact of recording three nights of oximetry on the screening yield for OSA. (3) To explore whether useful MOS data are discarded when a threshold of 6 hours of oximetry recording is used.

METHODS

A retrospective study of nocturnal pulse oximetry done at home over three consecutive nights in paediatric patients with suspected OSA. Studies were scored (MOS) using thresholds of ≥6 and ≥4 hours of recording.

RESULTS

A total of 329 patients were studied. MOS scores over three nights showed only fair to moderate agreement. On the first night 126 patients (38%) screened positive for OSA. When three nights of oximetry were done 195 patients (59%) screened positive on at least one of the nights. There were 48 patients with studies of between 4 and 6 hours duration on one or more nights. If these studies are scored 20 patients (42%) would screen positive for OSA on at least one night based on scoring these studies alone.

CONCLUSION

One night of oximetry screening may not be sufficient to screen for OSA. Lowering the time threshold to ≥4 hours may increase the screening capability of nocturnal oximetry.

Respiratory management of infants with chronic neonatal lung disease beyond the NICU: A position statement from the Thoracic Society of Australia and New Zealand

Chronic neonatal lung disease (CNLD) is defined as continued need for any form of respiratory support (supplemental oxygen and/or assisted ventilation) beyond 36 weeks PMA. Low-flow supplemental oxygen facilitates discharge from hospital of infants with CNLD who are hypoxic in air and is widely used despite lack of evidence on the most appropriate minimum mean target oxygen saturations. Furthermore, there are minimal data to guide the home monitoring, titration or weaning of supplemental oxygen in these infants. The purpose of this position statement is to provide a guide for the respiratory management of infants with CNLD, with special emphasis on role and logistics of supplemental oxygen therapy beyond the NICU stay. Reflecting a variety of clinical practices and infant comorbidities (presence of pulmonary hypertension, retinopathy of prematurity and adequacy of growth), it is recommended that the minimum mean target range for SpO2 during overnight oximetry to be 93-95% with less than 5% of total recording time to be below 90% SpO2 . Safety of short-term disconnection from supplemental oxygen should be assessed before discharge, with majority of infants with CNLD not ready for discharge until supplemental oxygen requirement is ≤0.5 L/min. Sleep-time assessment of oxygenation with continuous overnight oximetry is recommended when weaning supplemental oxygen. Palivizumab is considered safe and effective for the reduction of hospital admissions with RSV infection in this group. This statement would be useful for paediatricians, neonatologists, respiratory and sleep physicians and general practitioners managing children with CNLD.

Can overnight portable pulse oximetry be used to stratify obstructive sleep apnea risk in infants? A correlation analysis

INTRODUCTION

There is limited evidence on the accuracy of oximetry in the evaluation of infant obstructive sleep apnea (OSA). We aimed to determine the utility of overnight oximetry to stratify infants at risk for OSA, to determine urgency for definitive screening with an overnight in-laboratory polysomnogram (PSG).

METHODS

Retrospective single-institution cohort study of infants undergoing PSG and a separate overnight oximetry over an 8-year period. Correlations, using oximetry in both in-hospital (attended) or at-home (unattended) settings, for ODI4₁₀ (decrease in oxygen saturation ≥ 4% from baseline, duration ≥ 10 seconds) and ODI4₀ (duration > 0 second) with the obstructive apnea-hypopnea index (AHIo) were obtained. The area under the curve was calculated, and sensitivity and specificity values have been presented as receiver operating characteristic curves.

RESULTS

Thirty-eight infants were included. The mean (SD) age (months) was 5.7 (3.9) at diagnostic PSG and 5.5 (3.7) at the time of oximetry. The mean AHIo for the entire cohort was 6.7 (6.2). The mean (SD) ODI4₀ was 8.6 (9.0) and the mean (SD) ODI4₁₀ was 5.4 (5.1).The correlation between ODI and AHIo was statistically significant for the cohort (ODI4₀ vs. AHIo [r = .59, P < .001] and ODI4₁₀ vs AHIo [r = .55, P = .0003]). Using an ODI4₀ cutoff of 3, the sensitivity, specificity, negative predictive value and positive predictive value for diagnosing OSA was: 86%, 40%, 50%, and 80% respectively for an AHIo greater than 2, and 100%, 35%, 100%, and 58% respectively for an AHIo greater than or equal to 5.

CONCLUSION

There is a significant positive correlation between the ODI₄ obtained from oximetry and the AHIo obtained from PSG in infants at risk for OSA. An ODI4₀ greater than 3 may be useful to stratify infants at risk for moderate to severe OSA when used in attended (in-hospital) or unattended (in-home) settings.

Observational Study of Pulse Transit Time in Children With Sleep Disordered Breathing

Background: Pulse transit time (PTT) is a non-invasive measure of arousals and respiratory effort for which we aim to identify threshold values that detect sleep disordered breathing (SDB) in children. We also compare the sensitivity and specificity of oximetry with the findings of a multi-channel study. Methods: We performed a cross-sectional observational study of 521 children with SDB admitted for multi-channel sleep studies (pulse oximetry, ECG, video, sound, movement, PTT) in a secondary care centre. PTT data was available in 368 children. Studies were categorised as normal; primary snoring; upper airway resistance syndrome (UARS); obstructive sleep apnoea (OSA), and "abnormal other." Receiver operator characteristic curves were constructed for different PTT (Respiratory swing; Arousal index) thresholds using a random sample of 50% of children studied (training set); calculated thresholds of interest were validated against the other 50% (test set). Study findings were compared with oximetry categories (normal, inconclusive, abnormal) using data (mean and minimum oxygen saturations; oxygen desaturations > 4%) obtained during the study. Results: Respiratory swing of 17.92 ms identified SDB (OSA/UARS) with sensitivity: 0.80 (C.I. 0.62-0.90) and specificity 0.79 (C.I. 0.49-0.87). PTT arousal index of 16.06/ hour identified SDB (OSA/UARS) with sensitivity: 0.85 (95% C.I. 0.67-0.92) and specificity 0.37 (95% C.I. 0.17-0.48). Oximetry identified SDB (OSA) with sensitivity: 0.38 (C.I. 0.31-0.46) and specificity 0.98 (C.I. 0.97-1.00). Conclusions: PTT is more sensitive but less specific than oximetry at detecting SDB in children. The additional use of video and sound enabled detection of SDB in twice as many children as oximetry alone.

Sleep-disordered breathing and comorbidities: role of the upper airway and craniofacial skeleton

Obstructive sleep-disordered breathing (SDB), which includes primary snoring through to obstructive sleep apnea syndrome (OSAS), may cause compromise of respiratory gas exchange during sleep, related to transient upper airway narrowing disrupting ventilation, and causing oxyhemoglobin desaturation and poor sleep quality. SDB is common in chronic disorders and has significant implications for health. With prevalence rates globally increasing, this condition is causing a substantial burden on health care costs. Certain populations, including people with sickle cell disease (SCD), exhibit a greater prevalence of OSAS. A review of the literature provides the available normal polysomnography and oximetry data for reference and documents the structural upper airway differences between those with and without OSAS, as well as between ethnicities and disease states. There may be differences in craniofacial development due to atypical growth trajectories or extramedullary hematopoiesis in anemias such as SCD. Studies involving MRI of the upper airway illustrated that OSAS populations tend to have a greater amount of lymphoid tissue, smaller airways, and smaller lower facial skeletons from measurements of the mandible and linear mental spine to clivus. Understanding the potential relationship between these anatomical landmarks and OSAS could help to stratify treatments, guiding choice towards those which most effectively resolve the obstruction. OSAS is relatively common in SCD populations, with hypoxia as a key manifestation, and sequelae including increased risk of stroke. Combatting any structural defects with appropriate interventions could reduce hypoxic exposure and consequently reduce the risk of comorbidities in those with SDB, warranting early treatment interventions.