1
|
Chidambaram AG, Jhawar S, McDonald CM, Nandalike K. Sleep Disordered Breathing in Children with Neuromuscular Disease. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1675. [PMID: 37892338 PMCID: PMC10605855 DOI: 10.3390/children10101675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/06/2023] [Accepted: 10/07/2023] [Indexed: 10/29/2023]
Abstract
Sleep disordered breathing (SDB) in children with neuromuscular disease (NMD) is more prevalent compared to the general population, and often manifests as sleep-related hypoventilation, sleep-related hypoxemia, obstructive sleep apnea, central sleep apnea, and/or disordered control of breathing. Other sleep problems include, sleep fragmentation, abnormal sleep architecture, and nocturnal seizures in certain neuromuscular diseases. The manifestation of sleep disordered breathing in children depends on the extent, type, and progression of neuromuscular weakness, and in some instances, may be the first sign of a neuromuscular weakness leading to diagnosis of an NMD. In-lab diagnostic polysomnography (PSG) remains the gold standard for the diagnosis of sleep disordered breathing in children, but poses several challenges, including access to many children with neuromuscular disease who are non-ambulatory. If SDB is untreated, it can result in significant morbidity and mortality. Hence, we aimed to perform a comprehensive review of the literature of SDB in children with NMD. This review includes pathophysiological changes during sleep, clinical evaluation, diagnosis, challenges in interpreting PSG data using American Academy of Sleep (AASM) diagnostic criteria, management of SDB, and suggests areas for future research.
Collapse
Affiliation(s)
- Ambika G. Chidambaram
- Division of Pediatric Pulmonary and Sleep Medicine, Department of Pediatrics, University of California, Davis, CA 95817, USA
| | - Sanjay Jhawar
- Division of Pediatric Pulmonary and Sleep Medicine, Department of Pediatrics, University of California, Davis, CA 95817, USA
| | - Craig M. McDonald
- Department of Physical Medicine and Rehabilitation, University of California, Davis, CA 95817, USA
| | - Kiran Nandalike
- Division of Pediatric Pulmonary and Sleep Medicine, Department of Pediatrics, University of California, Davis, CA 95817, USA
| |
Collapse
|
2
|
Teplitzky TB, Zauher AJ, Isaiah A. Alternatives to Polysomnography for the Diagnosis of Pediatric Obstructive Sleep Apnea. Diagnostics (Basel) 2023; 13:diagnostics13111956. [PMID: 37296808 DOI: 10.3390/diagnostics13111956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/16/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023] Open
Abstract
Diagnosis of obstructive sleep apnea (OSA) in children with sleep-disordered breathing (SDB) requires hospital-based, overnight level I polysomnography (PSG). Obtaining a level I PSG can be challenging for children and their caregivers due to the costs, barriers to access, and associated discomfort. Less burdensome methods that approximate pediatric PSG data are needed. The goal of this review is to evaluate and discuss alternatives for evaluating pediatric SDB. To date, wearable devices, single-channel recordings, and home-based PSG have not been validated as suitable replacements for PSG. However, they may play a role in risk stratification or as screening tools for pediatric OSA. Further studies are needed to determine if the combined use of these metrics could predict OSA.
Collapse
Affiliation(s)
- Taylor B Teplitzky
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Audrey J Zauher
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Amal Isaiah
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD 21201, USA
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| |
Collapse
|
3
|
Graustein A, Carmona H, Benditt JO. Noninvasive respiratory assistance as aid for respiratory care in neuromuscular disorders. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:1152043. [PMID: 37275400 PMCID: PMC10233137 DOI: 10.3389/fresc.2023.1152043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/02/2023] [Indexed: 06/07/2023]
Abstract
Chronic respiratory failure is a common complication of neuromuscular disease. The use of noninvasive ventilation and mechanically assisted cough can reduce symptoms of hypoventilation, slow lung function decline, improve sleep quality, and in some cases prolong survival in patients with neuromuscular disease. In this article, we review indications for the initiation of noninvasive ventilation and mechanically assisted cough as well as provide recommendations for settings and titration. We discuss the evidence supporting the use of noninvasive ventilation as an adjunct to rehabilitation in patients with neuromuscular disease. Lastly, we review the ethical considerations that are relevant to decisions regarding initiation and cessation of noninvasive ventilation. While noninvasive ventilation and mechanically assisted cough have become standards of care in many forms of neuromuscular disease, most current recommendations are based on expert opinion rather than much-needed data from prospective clinical trials and we emphasize topics requiring future research.
Collapse
Affiliation(s)
- Andrew Graustein
- Division of Pulmonary, Critical Care and Sleep Medicine, United States Department of Veterans Affairs, VA Puget Sound Health Care System, Veterans Health Administration, Seattle, WA, United States
| | - Hugo Carmona
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, School of Medicine, University of Washington, Seattle, WA, United States
| | - Joshua O. Benditt
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, School of Medicine, University of Washington, Seattle, WA, United States
| |
Collapse
|
4
|
Abstract
Pediatric leukodystrophies are rare neurodegenerative diseases involving multiple systems. Each form has unique neurologic features but are characterized by encephalopathy with accompanying impairments evidenced in reflexes, muscle tone and movement control. Weakness of expiratory, inspiratory, and upper airway muscles may lead to impaired airway secretion clearance resulting in recurrent respiratory infections, dysphagia, sleep-disordered breathing, restrictive lung disease, and ultimately chronic respiratory insufficiency.
Collapse
|
5
|
Frohlich M, Widger J, Thambipillay G, Teng A, Farrar M, Chuang S. Daytime predictors of nocturnal hypercapnic hypoventilation in children with neuromuscular disorders. Pediatr Pulmonol 2022; 57:1497-1504. [PMID: 35278044 DOI: 10.1002/ppul.25890] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 02/03/2022] [Accepted: 02/03/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To examine objective daytime predictors of nocturnal hypercapnic hypoventilation (NHH) and identify a forced vital capacity (FVC) z-score cut off that predicts NHH using the 2012 Global Lung Function Initiative (GLI) reference equations in pediatric neuromuscular patients. DESIGN Single-centre retrospective medical record review. SETTING Tertiary pediatric hospital in Australia. PATIENTS Children (<18 years old) with a neuromuscular disorder (NMD) who had a diagnostic sleep study over a 5-year period. RESULTS Fifty children were included, median age 11.9 years (interquartile range [IQR]: 4.5-14.3). The majority of children had a diagnosis of Duchenne Muscular Dystrophy (32%). NHH was diagnosed in 18 children (36%). Multivariate logistic regression analysis performed for the entire cohort confirmed a statistically significant association between NHH and scoliosis (odds ratio [OR]: 3.3, p = 0.03), but not age (OR: 1.01, p = 0.26), body mass index z-score (OR: 0.86, p = 0.26) or use of a wheelchair for mobility (OR: 1.25, p = 0.72). For the subset of 29 children who had spirometry testing (median age 12.9 years [IQR: 10.2-14.3]), FVC z-score was the only statistically significant predictor of NHH (OR: 0.45, p = 0.02). NHH was predicted by an FVC z-score <-3.24 (sensitivity 78%, specificity 73%), or FVC <60% predicted (sensitivity 78%, specificity 73%). There was a strong positive correlation between FVC and forced expiratory volume in 1 s z-scores (rp = 0.98, p = 0.00) and FVC and peak expiratory flow z-scores (rp = 0.72, p = 0.00). CONCLUSION Children with a NMD and scoliosis or a lower FVC z-score have increased odds of having NHH.
Collapse
Affiliation(s)
- Megan Frohlich
- Department of Respiratory Medicine, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - John Widger
- Department of Respiratory Medicine, Sydney Children's Hospital, Randwick, New South Wales, Australia.,School of Women's and Children's Health, UNSW Sydney, Randwick, New South Wales, Australia
| | - Ganesh Thambipillay
- Department of Sleep Medicine, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Arthur Teng
- School of Women's and Children's Health, UNSW Sydney, Randwick, New South Wales, Australia.,Department of Sleep Medicine, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Michelle Farrar
- School of Women's and Children's Health, UNSW Sydney, Randwick, New South Wales, Australia.,Department of Neurology, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Sandra Chuang
- Department of Respiratory Medicine, Sydney Children's Hospital, Randwick, New South Wales, Australia.,School of Women's and Children's Health, UNSW Sydney, Randwick, New South Wales, Australia
| |
Collapse
|
6
|
Ayhan Y, Yuksel Karatoprak E, Onay ZR, Can Oksay S, Girit S. Assessment of Nocturnal Hypoventilation by Different Methods and Definitions in Children with Neuromuscular Disease: Oxycapnography and Blood Gas Analysis. Medeni Med J 2021; 36:106-116. [PMID: 34239762 PMCID: PMC8226400 DOI: 10.5222/mmj.2021.42385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/24/2021] [Indexed: 11/06/2022] Open
Abstract
Objective To investigate whether partial arterial carbon dioxide pressure (PaCO2) level in arterial blood gas analysis that was used to predict nocturnal hypoventilation (NH) is concordant with nocturnal end-tidal CO2 (PetCO2) measurement obtained by a noninvasive method of oxycapnography in children with neuromuscular disease (NMD). Methods Twenty-one patients aged 6-18 years with a confirmed diagnosis of NMD were enrolled. Each patient underwent a nocturnal oxycapnography study using an orinasal probe and a pulse oximetry finger probe to record PetCO2, oxygen saturation (SpO2), pulse rate, and respiratory rate. Arterial blood gas analysis was performed to record PaCO2 levels on three occasions at night (23:00 pm, 03:00 am, 07:00 am). Results The mean overnight PaCO2 level of the three blood gas analyses (mean PaCO2noct) was 41.78±4.69 mmHg. A significant change was observed between mean PaCO2 23:00 and PaCO2 07:00 levels (p=0.032). There was no significant difference between PaCO2, PetCO2, and SpO2 levels in the NMD group. The interclass correlation coefficient between PaCO2 07:00 and PetCO2 levels was 0.791 (95% CI: 0.533-0.923); the interclass correlation coefficient between overnight mean PaCO2 and PetCO2 levels was 0.811 (95% CI:0.533-0.923). Conclusion Our study indicates that nocturnal PetCO2 and PaCO2 levels were statistically comparable but the use of PaCO2 alone is not adequate to make an early diagnosis of NH in NMD. There is a need for making more restrictive definitions for NH, and conducting studies with larger study populations to reach an agreement on the best definition of hypoventilation, and updating consensus guidelines.
Collapse
Affiliation(s)
- Yetkin Ayhan
- Istanbul Medeniyet University Faculty of Medicine, Department of Pediatric Pulmonology, Istanbul, Turkey
| | - Elif Yuksel Karatoprak
- Istanbul Medeniyet University, Faculty of Medicine, Depatment of Pediatric Neurology, Istanbul, Turkey
| | - Zeynep Reyhan Onay
- Istanbul Medeniyet University Faculty of Medicine, Department of Pediatric Pulmonology, Istanbul, Turkey
| | - Sinem Can Oksay
- Istanbul Medeniyet University Faculty of Medicine, Department of Pediatric Pulmonology, Istanbul, Turkey
| | - Saniye Girit
- Istanbul Medeniyet University Faculty of Medicine, Department of Pediatric Pulmonology, Istanbul, Turkey
| |
Collapse
|
7
|
Rodrigues Filho JC, Neves DD, Moreira GA, Viana ADC, Araújo-Melo MH. Nocturnal oximetry in the diagnosis of obstructive sleep apnea syndrome in potentially hypoxic patients due to neuromuscular diseases. Sleep Med 2021; 84:127-133. [PMID: 34147027 DOI: 10.1016/j.sleep.2021.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 03/16/2021] [Accepted: 05/09/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Polysomnography is the recommended method for the diagnosis of obstructive sleep apnea (OSA); however, it is expensive, uncomfortable, and inaccessible. Alternative diagnostic methods are necessary, and Nocturnal Oximetry (NO) has proven to be reliable. Nevertheless, there have been doubts about its accuracy in patients with a history of hypoxia. Hence, the objective of this study was to evaluate the performance of NO in patients with neuromuscular diseases (NMD). METHOD This was a cross-sectional study in patients with NMD suspected of having OSA. We performed a statistical analysis using Spearman's correlation coefficients (SCCs). We used the value of the area under the ROC curve (AUCROC), just as we calculated the sensitivities (Sens) and specificities (Spec) for the chosen variables. RESULTS The sample comprised 41 patients; 51.2% with muscular dystrophies and 48.8% with motor neuron diseases, with a predominance of men (63.4%). Median age was 42 (19.7-55) years, body mass index (BMI) was 27.9 (23.8-32) kg/m2, forced vital capacity was 67% (54%-76.5%), and maximum inspiratory pressure was-60 cmH2O (-87.5 to -50). The prevalence of OSA was 75.7%. We analyzed and selected the best four oximetric variables with the following performance in identifying the apnea/hypopnea index >5/h, ODI3/2, cutoff>5/h, AUCROC 0.919, Sens 82.3%, Spec 91.7%; ODI3/5, cutoff>11.2/h, AUCROC 0.904, Sens 82.3%, Spec 87.5%; ODI4/5, cutoff>6.02, AUCROC 0.839, Sens 70.6%, Spec 91.6%, and ODI5/5, cutoff>0.87/h, AUCROC 0.870, Sens 94.1%, and Spec 70.8%. CONCLUSION NO can be used as a diagnostic tool for OSA, even in patients with neuromuscular diseases and potentially hypoxic diseases.
Collapse
Affiliation(s)
- Júlio Cezar Rodrigues Filho
- PPGNEURO/UNIRIO, Rio de Janeiro, Brazil; LabSono - Sleep Laboratory of Gafrée and Guinle Hospital / UNIRIO, Mariz e Barros Street, 775, Tijuca, Rio de Janeiro, RJ, Brazil; TDN/Afip, Paulo Barreto Street, 91, Botafogo, Rio de Janeiro, RJ, Brazil.
| | - Denise Duprat Neves
- Department of Specialized Medicine - Discipline of Pulmonology, School of Medicine and Surgery, Federal University of Rio de Janeiro State, Sleep Laboratory of Gaffrée e Guinle University Hospital / UNIRIO, Brazil; LabSono - Sleep Laboratory of Gafrée and Guinle Hospital / UNIRIO, Mariz e Barros Street, 775, Tijuca, Rio de Janeiro, RJ, Brazil.
| | - Gustavo Antonio Moreira
- Discipline of Medicine and Sleep Biology, Department of Psychobiology, Pneumopediatrics Sector, UNIFESP, Brazil.
| | - Alonço da C Viana
- Department of Otorhinolaryngology of Marcílio Dias Naval Hospital, Rio de Janeiro, Brazil.
| | - Maria Helena Araújo-Melo
- Department of Specialized Medicine - Discipline of Otorhinolaryngology, School of Medicine and Surgery, Federal University of Rio de Janeiro State, Sleep Laboratory at Gafrée e Guinle University Hospital / UNIRIO, Brazil; LabSono - Sleep Laboratory of Gafrée and Guinle Hospital / UNIRIO, Mariz e Barros Street, 775, Tijuca, Rio de Janeiro, RJ, Brazil.
| |
Collapse
|
8
|
Gurbani N, Pascoe JE, Katz S, Sawnani H. Sleep disordered breathing: Assessment and therapy in the age of emerging neuromuscular therapies. Pediatr Pulmonol 2021; 56:700-709. [PMID: 32720756 DOI: 10.1002/ppul.24988] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 07/24/2020] [Indexed: 11/10/2022]
Abstract
The term neuromuscular disease (NMD) encompasses a large variety of disorders that result in abnormal muscle function. Although it may be conventional to relate the use of this term to the most common muscular diseases (Duchenne muscular dystrophy [DMD], spinal muscular atrophy [SMA], and amyotrophic lateral sclerosis, etc), it is important to extend the term to pathologies manifested by severe neurologic (brain and spinal cord) malformations and injuries. In many of these scenarios, there are common mechanisms that contribute to sleep disordered breathing (SDB) and respiratory insufficiency although comorbidities may be somewhat different. Advances in the understanding of these diseases and their natural history, and increasing availability of mechanical ventilation to these patients have improved survival. The development of novel genetic and molecular therapies (as in the cases of DMD, SMA, and X-linked myotubular myopathy) provides an opportunity to use SDB as a reasonable outcome measure while also allowing the use of polysomnography as a validation tool in the assessments of effectiveness of therapies. We seek to provide an understanding of SDB in NMDs, and in the same light, would like to begin the conversation of thinking about weaning respiratory support when possible.
Collapse
Affiliation(s)
- Neepa Gurbani
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - John E Pascoe
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Sherri Katz
- Division of Respiratory Medicine, Children's Hospital of Eastern Ontario/University of Ottawa, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario/University of Ottawa, Ottawa, Ontario, Canada
| | - Hemant Sawnani
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
9
|
Rao F, Garuti G, Vitacca M, Banfi P, Racca F, Cutrera R, Pavone M, Pedemonte M, Schisano M, Pedroni S, Casiraghi J, Vianello A, Sansone VA. Management of respiratory complications and rehabilitation in individuals with muscular dystrophies: 1st Consensus Conference report from UILDM - Italian Muscular Dystrophy Association (Milan, January 25-26, 2019). ACTA MYOLOGICA : MYOPATHIES AND CARDIOMYOPATHIES : OFFICIAL JOURNAL OF THE MEDITERRANEAN SOCIETY OF MYOLOGY 2021; 40:8-42. [PMID: 33870094 PMCID: PMC8033426 DOI: 10.36185/2532-1900-045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 03/16/2021] [Indexed: 12/03/2022]
Abstract
Respiratory complications are common in the patient with muscular dystrophy. The periodic clinical and instrumental respiratory evaluation is extremely important. Despite the presence in the literature of updated guidelines, patient associations often report lack of knowledge of these pathologies, particularly in peripheral hospitals. The purpose of this work, inspired by the Italian Muscular Dystrophy Association (UILDM) is to improve management of respiratory problems necessary for the management of these patients complex. To this end, the main items that the specialist can meet in the follow-up of these pathologies have been analyzed and discussed, among which the respiratory basal evaluation, the criteria of adaptation to non-invasive ventilation, management of bronchial secretions, situations of respiratory emergency, indications for tracheostomy and the subject of advance directives of treatment (DAT).
Collapse
Affiliation(s)
- Fabrizio Rao
- Respiratory Unit, NEuroMuscular OmniCentre (NeMO), Serena Onlus Foundation, Niguarda Hospital, Milan, Italy
| | - Giancarlo Garuti
- Pneumology Unit, Santa Maria Bianca Hospital, AUSL Modena, Italy
| | | | - Paolo Banfi
- IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy
| | - Fabrizio Racca
- Department of Anaesthesia and Intensive Care, Division of Paediatric Intensive Care Unit, Alessandria General Hospital, Alessandria, Italy
| | - Renato Cutrera
- Pulmonology Unit, Academic Paediatric Department, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Martino Pavone
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long Term Ventilation Unit, Department of Pediatrics, Bambino Gesù Children's Research Hospital, Rome, Italy
| | - Marina Pedemonte
- Pediatric Neurology and Muscle Diseases Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Matteo Schisano
- Respiratory Medicine Unit, AOU "Policlinico-San Marco", Catania, Italy
| | - Stefania Pedroni
- Neurorehabilitation Unit, the NEMO Clinical Center in Milan, University of Milan, Italy
| | - Jacopo Casiraghi
- Neurorehabilitation Unit, the NEMO Clinical Center in Milan, University of Milan, Italy
| | - Andrea Vianello
- Respiratory Pathophysiology Division, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy
| | - Valeria A Sansone
- Neurorehabilitation Unit, the NEMO Clinical Center in Milan, University of Milan, Italy
| | | |
Collapse
|
10
|
Jewitt N, Orkin J, Cohen E, Narang I, Al-Saleh S, Amin R. The impact of polysomnograms and family-centred decision making in children with medical complexity. Paediatr Child Health 2021; 26:114-119. [DOI: 10.1093/pch/pxaa021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 11/03/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
To determine whether a change in clinical management (e.g., new tracheostomy or adenotonsillectomy) occurred following a polysomnogram (PSG) in children with medical complexity (CMC) and to explore whether families’ goals of care (regarding results and treatment implications) were discussed prior to the completion of a PSG.
Methods
All CMC enrolled in a complex care program at the Hospital for Sick Children, Canada, who underwent a baseline PSG from 2009 to 2015 were identified. Exclusion criteria included (1) PSGs for ventilation titration and (2) PSGs outside the study time frame. Health records were retrospectively reviewed to determine demographics, medical histories, families’ wishes, PSG results, and their impact on clinical care. Descriptive statistics were used to summarize results.
Results
Of 145 patients identified, 96 patients met inclusion criteria. Fifty (52%) were male. Median age was 3 years. Forty-eight (50%) were diagnosed with clinically significant (i.e., moderate to severe obstructive sleep apnea, central sleep apnea, and/or hypoventilation) sleep-related breathing disorders. Of those diagnosed, 9 (19%) had surgery, 25 (52%) underwent respiratory technology initiation, and 3 (6%) underwent both. In the remaining 11 (23%) patients, treatment was either considered too risky or did not align with the families’ wishes. Only 3 of 96 patients had clear documentation of their families’ wishes prior to PSG completion.
Conclusion
Recognizing the burden of medical tests for both the child and the health care system, a process of shared-decision making that includes clarifying a family’s wishes may be prudent prior to conducting a PSG.
Collapse
Affiliation(s)
- Natalie Jewitt
- Department of Paediatrics, University of Toronto, Toronto, Ontario
| | - Julia Orkin
- Department of Paediatrics, University of Toronto, Toronto, Ontario
- Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario
| | - Eyal Cohen
- Department of Paediatrics, University of Toronto, Toronto, Ontario
- Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Ontario
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario
| | - Indra Narang
- Department of Paediatrics, University of Toronto, Toronto, Ontario
- Division of Respiratory and Sleep Medicine, Hospital for Sick Children, Toronto, Ontario
| | - Suhail Al-Saleh
- Department of Paediatrics, University of Toronto, Toronto, Ontario
- Division of Respiratory and Sleep Medicine, Hospital for Sick Children, Toronto, Ontario
| | - Reshma Amin
- Department of Paediatrics, University of Toronto, Toronto, Ontario
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario
- Division of Respiratory and Sleep Medicine, Hospital for Sick Children, Toronto, Ontario
| |
Collapse
|
11
|
Abstract
Respiration is an event of oxygen consumption and carbon dioxide production. Respiratory failure is common in pediatric neuromuscular diseases and the main cause of morbidity and mortality. It is a consequence of lung failure, ventilatory pump failure, or their combination. Lung failure often is due to chronic aspiration either from above or from below. It may lead to end-stage lung disease. Ventilatory pump failure is caused by increased respiratory load and progressive respiratory muscles weakness. This article reviews the normal function of the respiratory pump, general pathophysiology issues, abnormalities in the more common neuromuscular conditions and noninvasive interventions.
Collapse
|
12
|
Sunkonkit K, Al-Saleh S, Chiang J, Hamilton A, Medin D, Syed F, Mocanu C, Qazi A, Ambreen M, Amin R. Volume-assured pressure support mode for noninvasive ventilation: can it improve overnight adherence in children with neuromuscular disease? Sleep Breath 2021; 25:1843-1850. [PMID: 33469734 PMCID: PMC7815273 DOI: 10.1007/s11325-021-02288-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 12/10/2020] [Accepted: 01/05/2021] [Indexed: 12/29/2022]
Abstract
Purpose Volume-assured pressure support in noninvasive ventilation (VAPS-NIV) is a newer mode providing automatic pressure support adjustment to ensure a constant alveolar ventilation. Previous studies have shown that NIV effectiveness depends on patient adherence and tolerance. The aim of this study was to determine the adherence and efficacy of VAPS-NIV compared to spontaneous-time (S/T) mode in pediatric patients with neuromuscular disease (NMD). Methods This was a prospective observational study. Children with NMD who utilized NIV at home for ≥ 3 months were recruited from the Long-term ventilation clinic at The Hospital for Sick Children, Toronto, Canada, from July 1, 2015, to July 1, 2019. Baseline characteristics, date of initiation of NIV, and pulmonary function tests were recorded. Polysomnogram (PSG) data and adherence were recorded and analyzed comparing VAPS and S/T modes. Results Twenty children with NMD (17 male, 85%) were enrolled. The mean (SD) age at initiation of NIV was 11.6 ± 4.6 years. The median (IQR) duration of ventilation was 1.36 (0.80–2.98) years. The mean average daily usage and the median daily usage for VAPS mode and S/T mode were 8.4 ± 1.6 versus 7.2 ± 2.5 h (p = 0.012) and 8.6 ± 1.4 versus 7.8 ± 2.1 h (p = 0.022), respectively. There was no difference in sleep architecture, gas exchange, or parent proxy report of NIV tolerance between S/T and VAPS modes. Conclusion VAPS was associated with an improvement in adherence to therapy in children with NMD compared to S/T mode. Longitudinal studies are required to evaluate long-term clinical outcomes using VAPS mode in children with NMD. Supplementary Information The online version contains supplementary material available at 10.1007/s11325-021-02288-1.
Collapse
Affiliation(s)
- Kanokkarn Sunkonkit
- Division of Respiratory Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada.
- Division of Pulmonary and Critical Care, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
| | - Suhail Al-Saleh
- Division of Respiratory Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Jackie Chiang
- Division of Respiratory Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Complex Continuing Care, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
| | - Ashley Hamilton
- Division of Respiratory Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
| | - Debra Medin
- Division of Respiratory Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
| | - Faiza Syed
- Division of Respiratory Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
| | - Cora Mocanu
- Division of Respiratory Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
| | - Adam Qazi
- Division of Respiratory Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
| | - Munazzah Ambreen
- Division of Respiratory Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
| | - Reshma Amin
- Division of Respiratory Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
13
|
Trucco F, Carruthers E, Davies JC, Simonds AK, Bush A, Tan HL. Inflammation in children with neuromuscular disorders and sleep disordered breathing. Sleep Med 2020; 72:118-121. [DOI: 10.1016/j.sleep.2020.03.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/29/2020] [Accepted: 03/30/2020] [Indexed: 10/24/2022]
|
14
|
MacLean JE. Assessment and treatment of pediatric obstructive sleep apnea in Canada: history and current state of affairs. Sleep Med 2019; 56:23-28. [PMID: 30745075 DOI: 10.1016/j.sleep.2019.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 01/04/2019] [Accepted: 01/06/2019] [Indexed: 02/07/2023]
Abstract
AIM To highlight Canada's contributions to the assessment and treatment of pediatric obstructive sleep apnea as well as outline the current state of pediatric obstructive sleep apnea in Canada. METHODS A search was conducted in MEDLINE (Ovid) using Medical Subject Headings (MeSH) and free-text terms for 'child' and 'obstructive sleep apnea' with subsequent 'human' limit. The results were reviewed to identify publications where any author's listed a Canadian institution. RESULTS Canadian contributions to the field of pediatric obstructive sleep apnea have grown over the last 30 years with an increase in number of contributors and centres. Much of the early work stemmed from McGill University with important contributions in examining alternatives to polysomnography and post-adenotonsillectomy respiratory compromise. Today, contributors from centres across the country are engaged in the field and come from a greater diversity of disciplines. With continued challenges and opportunities, Canada will continue to help advance the field of pediatric OSA. CONCLUSION Canada has a strong community of people invested in continuing to work to improve the lives of Canadian children with pediatric OSA.
Collapse
Affiliation(s)
- Joanna E MacLean
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; Women & Children's Health Research Institute, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada; Stollery Children's Hospital, Edmonton, Alberta, Canada.
| |
Collapse
|
15
|
Fishman H, Massicotte C, Li R, Zabih W, McAdam LC, Al-Saleh S, Amin R. The Accuracy of an Ambulatory Level III Sleep Study Compared to a Level I Sleep Study for the Diagnosis of Sleep-Disordered Breathing in Children With Neuromuscular Disease. J Clin Sleep Med 2018; 14:2013-2020. [PMID: 30518444 DOI: 10.5664/jcsm.7526] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 08/10/2018] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Polysomnography (PSG) surveillance recommendations are not being met for children with neuromuscular disease (NMD) because of limited diagnostic facilities. We evaluated the diagnostic accuracy of an ambulatory level III device as compared to a level I PSG. METHODS A cross-sectional study was conducted at a tertiary pediatric institution. Eligibility criteria included: (1) children with NMD; (2) age 6 to 18 years; (3) booked for a clinically indicated overnight level I PSG. Participants were randomized to an overnight level I PSG followed by an ambulatory level III study with end tidal carbon dioxide (etCO2) or vice versa. Sensitivity and specificity of the ambulatory level III device to diagnose sleep-disordered breathing (SDB) at an apnea-hypopnea index (AHI) cutoff of > 1.0 events/h was the primary outcome. RESULTS Moderate to severe SDB was found in 46% of participants (13/28). The device's sensitivity and specificity to detect SDB was 61.5% and 86.7%, respectively. The positive predictive value of the level III study was 80.0% and the negative predictive value was 72.0%. Fifty percent of the cohort were either missing or had incomplete or falsely low ambulatory etCO2 data. CONCLUSIONS A level III device with etCO2 is not yet able to be implemented in clinical practice as a diagnostic tool for SDB in pediatric patients with NMD. COMMENTARY A commentary on this article appears in this issue on page 1973.
Collapse
Affiliation(s)
- Haley Fishman
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Colin Massicotte
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rhonda Li
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Weeda Zabih
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Laura C McAdam
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Division of Developmental Pediatrics, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
| | - Suhail Al-Saleh
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Reshma Amin
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
16
|
Nakamura Y, Saito Y, Kubota N, Matsumura W, Hosoda C, Tamasaki-Kondo A, Nishimura Y, Sunada Y, Fukada M, Ohno T, Maegaki Y, Matsuo M, Tokita Y. Identification of sleep hypoventilation in young individuals with Becker muscular dystrophy: A pilot study. Brain Dev 2018. [PMID: 29526517 DOI: 10.1016/j.braindev.2018.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIM To report on sleep hypercapnia in Becker muscular dystrophy (BMD) at earlier stages than ever recognized. SUBJECTS AND METHODS This retrospective study examined nocturnal hypercapnia in six young Becker muscular dystrophy (BMD) patients with deletions of one or more exons of DMD gene. Clinical information, consecutive data on forced vital capacity (FVC%), forced expiratory volume in one second (FEV1%), peak expiratory flow (PEF%), peak cough flow (PCF), average PCO2 in all-night monitoring, and left ventricular ejection fraction (LVEF) were reviewed. RESULTS In five BMD patients, including three who were still ambulant, nocturnal average PCO2 was elevated to >45 mmHg at 12-31 years of age. Noninvasive positive pressure ventilation was initiated in four patients. Gradual declines in FVC% and PEF% were evident in one BMD patient with exon 3-7 deletion, whereas these functions did not change in the remaining BMD patients. PCF, FEV1%, and LVEF were less informative for the assessment of respiratory function in this patient series. CONCLUSION Sleep hypercapnia was present in certain BMD patients, which was unexpected from the routine pulmonary function tests. Individualized assessment of nocturnal PCO2, partly based on the deletion types, should be further explored in the clinical practice of BMD patients.
Collapse
Affiliation(s)
- Yuko Nakamura
- Department of Pediatrics, Matsue Medical Center, 5-8-31 Agenogi, Matsue 690-8556, Japan; Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, 36-1 Nishi-cho, Yonago 683-8504, Japan
| | - Yoshiaki Saito
- Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, 36-1 Nishi-cho, Yonago 683-8504, Japan.
| | - Norika Kubota
- Department of Pediatrics, Matsue Medical Center, 5-8-31 Agenogi, Matsue 690-8556, Japan
| | - Wataru Matsumura
- Department of Pediatrics, Matsue Medical Center, 5-8-31 Agenogi, Matsue 690-8556, Japan; Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, 36-1 Nishi-cho, Yonago 683-8504, Japan
| | - Chika Hosoda
- Department of Pediatrics, Matsue Medical Center, 5-8-31 Agenogi, Matsue 690-8556, Japan; Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, 36-1 Nishi-cho, Yonago 683-8504, Japan; Department of Pediatrics, Tottori Rehabilitation Center for Children with Disabilities, 7-13-3 Kamifukubara, Yonago 683-0004, Japan
| | - Akiko Tamasaki-Kondo
- Department of Pediatrics, Matsue Medical Center, 5-8-31 Agenogi, Matsue 690-8556, Japan; Department of Pediatrics, Shimane Prefectural Central Hospital, 4-1-1 Himebara, Izumo 693-8555, Japan
| | - Yoko Nishimura
- Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, 36-1 Nishi-cho, Yonago 683-8504, Japan
| | - Yoshihide Sunada
- Department of Neurology, Kawasaki Medical School, 577 Matsushima, Kurashiki 701-0192, Japan
| | | | - Takako Ohno
- Western Shimane Medical and Welfare Center for the Disabled, 1926 Watazu, Gotsu 695-0001, Japan
| | - Yoshihiro Maegaki
- Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, 36-1 Nishi-cho, Yonago 683-8504, Japan
| | - Masafumi Matsuo
- Department of Medical Rehabilitation, Faculty of Rehabilitation, Kobe Gakuin University, 518 Arise, Ikawadani-cho, Nishi-ku, Kobe 651-2180, Japan
| | - Yasuko Tokita
- Department of Pediatrics, Matsue Medical Center, 5-8-31 Agenogi, Matsue 690-8556, Japan
| |
Collapse
|
17
|
Trucco F, Pedemonte M, Fiorillo C, Tan HL, Carlucci A, Brisca G, Tacchetti P, Bruno C, Minetti C. Detection of early nocturnal hypoventilation in neuromuscular disorders. J Int Med Res 2018; 46:1153-1161. [PMID: 29210305 PMCID: PMC5972237 DOI: 10.1177/0300060517728857] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 08/02/2017] [Indexed: 11/30/2022] Open
Abstract
Objective Nocturnal hypoventilation (NH) is a complication of respiratory involvement in neuromuscular disorders (NMD) that can evolve into symptomatic daytime hypercapnia if not treated proactively with non-invasive ventilation. This study aimed to assess whether NH can be detected in the absence of other signs of nocturnal altered gas exchange. Methods We performed nocturnal transcutaneous coupled (tc) pCO2/SpO2 monitoring in 46 consecutive cases of paediatric-onset NMD with a restrictive respiratory defect (forced vital capacity < 60%). Nocturnal hypoventilation was defined as tcPCO2 > 50 mmHg for > 25% of recorded time, and hypoxemia as tcSpO2 < 88% for > 5 minutes. Daytime symptoms and bicarbonate were recorded after overnight monitoring. Results Twenty-nine of 46 consecutive patients showed NH. Twenty-three patients did not have nocturnal hypoxemia and 18 were clinically asymptomatic. In 20 patients, PaCO2 in daytime blood samples was normal. Finally, 13/29 patients with NH had isolated nocturnal hypercapnia without nocturnal hypoxia, clinical NH symptoms, or daytime hypercapnia. Conclusions Paediatric patients with NMD can develop NH in the absence of clinical symptoms or significant nocturnal desaturation. Therefore, monitoring of NH should be included among nocturnal respiratory assessments of these patients as an additional tool to determine when to commence non-invasive ventilation.
Collapse
MESH Headings
- Adolescent
- Blood Gas Monitoring, Transcutaneous
- Carbon Dioxide/blood
- Child
- Female
- Humans
- Hypercapnia/blood
- Hypercapnia/diagnosis
- Hypercapnia/physiopathology
- Hypoventilation/blood
- Hypoventilation/diagnosis
- Hypoventilation/physiopathology
- Male
- Muscular Dystrophies/blood
- Muscular Dystrophies/diagnosis
- Muscular Dystrophies/physiopathology
- Muscular Dystrophy, Duchenne/blood
- Muscular Dystrophy, Duchenne/diagnosis
- Muscular Dystrophy, Duchenne/physiopathology
- Myopathies, Structural, Congenital/blood
- Myopathies, Structural, Congenital/diagnosis
- Myopathies, Structural, Congenital/physiopathology
- Oximetry/methods
- Oxygen/blood
- Retrospective Studies
- Sclerosis/blood
- Sclerosis/diagnosis
- Sclerosis/physiopathology
- Spinal Muscular Atrophies of Childhood/blood
- Spinal Muscular Atrophies of Childhood/diagnosis
- Spinal Muscular Atrophies of Childhood/physiopathology
- Vital Capacity/physiology
Collapse
Affiliation(s)
| | - Marina Pedemonte
- Unit of Pediatric Neurology and Muscle Disease, Istituto Giannina Gaslini, Genova, Italy
| | - Chiara Fiorillo
- Unit of Pediatric Neurology and Muscle Disease, Istituto Giannina Gaslini, Genova, Italy
| | - Hui-leng Tan
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
| | | | - Giacomo Brisca
- Unit of Pediatric Neurology and Muscle Disease, Istituto Giannina Gaslini, Genova, Italy
| | - Paola Tacchetti
- Unit of Pediatric Neurology and Muscle Disease, Istituto Giannina Gaslini, Genova, Italy
| | - Claudio Bruno
- Center of Myology and Neurodegenerative Disorders, Istituto Giannina Gaslini, Genova, Italy
| | - Carlo Minetti
- Unit of Pediatric Neurology and Muscle Disease, Istituto Giannina Gaslini, Genova, Italy
| |
Collapse
|
18
|
Amin R, Holler T, Narang I, Cushing SL, Propst EJ, Al-Saleh S. Adenotonsillectomy for Obstructive Sleep Apnea in Children with Complex Chronic Conditions. Otolaryngol Head Neck Surg 2017; 158:760-766. [PMID: 29232179 DOI: 10.1177/0194599817746959] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To estimate the prevalence of persistent obstructive sleep apnea postadenotonsillectomy in children with complex chronic conditions. Study Design A retrospective cohort study. Setting The Hospital for Sick Children Sleep laboratory. Subjects Children ≤18 years of age who had moderate to severe obstructive sleep apnea and had polysomnography pre- and postadenotonsillectomy. Methods Medical and polysomnographic data were reviewed. The prevalence of persistent obstructive sleep apnea postadenotonsillectomy was determined for the following groups: no complex chronic conditions, single-system complex chronic conditions, and multisystem complex chronic conditions. Results We reviewed data of 133 (84 male) children. Their mean (standard deviation) age was 5.5 (3.8) years. The persistent obstructive sleep apnea rate postadenotonsillectomy was highest in children with multisystem complex chronic conditions (57%), intermediate in children with single-system complex chronic conditions (29%), and lowest in children without complex chronic conditions (15%), P = .0004. The odds (confidence interval) of having persistent obstructive sleep apnea postadenotonsillectomy was 7.42 (2.16-25.51) times higher in children with multisystem complex chronic conditions vs no complex chronic conditions and 3.35 (1.16-9.64) times higher in children with multisystem complex chronic conditions vs single-system complex chronic conditions. Conclusions Although adenotonsillectomy is considered first-line therapy in healthy children older than 2 years for the treatment of obstructive sleep apnea, there is a significantly greater risk of persistent obstructive sleep apnea postadenotonsillectomy in children with complex chronic conditions. Therefore, other surgical procedures or nonsurgical management may need to be considered as first-line treatment for this cohort.
Collapse
Affiliation(s)
- Reshma Amin
- 1 Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario, Canada.,2 University of Toronto, Toronto, Ontario, Canada
| | - Theresa Holler
- 2 University of Toronto, Toronto, Ontario, Canada.,3 Department of Otolaryngology-Head and Neck Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Indra Narang
- 1 Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario, Canada.,2 University of Toronto, Toronto, Ontario, Canada
| | - Sharon L Cushing
- 2 University of Toronto, Toronto, Ontario, Canada.,3 Department of Otolaryngology-Head and Neck Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Evan J Propst
- 2 University of Toronto, Toronto, Ontario, Canada.,3 Department of Otolaryngology-Head and Neck Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Suhail Al-Saleh
- 1 Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario, Canada.,2 University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
19
|
Chiang J, Amin R. Respiratory Care Considerations for Children with Medical Complexity. CHILDREN-BASEL 2017; 4:children4050041. [PMID: 28534851 PMCID: PMC5447999 DOI: 10.3390/children4050041] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/08/2017] [Accepted: 05/16/2017] [Indexed: 12/13/2022]
Abstract
Children with medical complexity (CMC) are a growing population of diagnostically heterogeneous children characterized by chronic conditions affecting multiple organ systems, the use of medical technology at home as well as intensive healthcare service utilization. Many of these children will experience either a respiratory-related complication and/or they will become established on respiratory technology at home during their care trajectory. Therefore, healthcare providers need to be familiar with the respiratory related complications commonly experienced by CMC as well as the indications, technical and safety considerations and potential complications that may arise when caring for CMC using respiratory technology at home. This review will outline the most common respiratory disease manifestations experienced by CMC, and discuss various respiratory-related treatment options that can be considered, including tracheostomy, invasive and non-invasive ventilation, as well as airway clearance techniques. The caregiver requirements associated with caring for CMC using respiratory technology at home will also be reviewed.
Collapse
Affiliation(s)
- Jackie Chiang
- Holland Bloorview Kids Rehabilitation Hospital, The University of Toronto, Toronto, ON M4G 1R8, Canada.
| | - Reshma Amin
- Division of Respiratory Medicine, The Hospital for Sick Children, The University of Toronto, Toronto, ON M5G 1X8, Canada.
| |
Collapse
|
20
|
Establishing a Role for Polysomnography in Hospitalized Children. Pediatr Neurol 2016; 57:39-45.e1. [PMID: 26774552 DOI: 10.1016/j.pediatrneurol.2015.12.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 12/03/2015] [Accepted: 12/21/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Children with medical complexity have a high prevalence of sleep disorders. However, outpatient polysomnography to evaluate for these conditions may be difficult to perform because of lack of skilled nursing care. The aim of this study was to explore polysomnography indications in hospitalized children and assess its impact on patient care. METHODS Data from 85 inpatient polysomnographies of 70 children hospitalized between March and December 2014 were retrospectively collected. RESULTS Sixty percent of patients were boys with ages 6.5 ± 6 years. Chronic respiratory failure was present in 33.8%, airway obstruction due to defects of the tracheobronchial tree or craniofacial abnormalities in 54.3%, neurological complications of the perinatal period in 22.9%, genetic syndromes and neurodegenerative disorders in 31.4%, congenital myopathies in 5.7%, metabolic diseases in 4.3% and congenital cyanotic heart defects in 4.3%. Indications for polysomnography included assessment of chronic pulmonary disease (60%), ventilator requirements (41.2%), apnea/desaturation (23.5%), and acute life-threatening events (1.2%). Abnormal results were found in 89.4%. The observed diagnosis was obstructive sleep apnea in 64.7%, signs of chronic lung disease in 34.1%, hypoventilation in 9.4%, periodic breathing in 3.5%, and periodic limb movement of sleep in 4.7%. The following interventions were performed: adjustment of ventilator parameters (45.8%), positive airway pressure initiation (24.7%), otorhinolaryngology referral (30.6%), supraglottoplasty (2.4%), tracheostomy decannulation (2.4%), and tracheostomy placement (3.5%). Nine patients had available follow-up polysomnograms, all showing improvement in sleep variables after adherence to recommended interventions. CONCLUSIONS In individuals with complex medical disorders, inpatient polysomnographies give invaluable information to guide immediate medical decision making and should be strongly considered if resources allow this.
Collapse
|
21
|
McDonald FB, Dempsey EM, O'Halloran KD. Early Life Exposure to Chronic Intermittent Hypoxia Primes Increased Susceptibility to Hypoxia-Induced Weakness in Rat Sternohyoid Muscle during Adulthood. Front Physiol 2016; 7:69. [PMID: 26973537 PMCID: PMC4777899 DOI: 10.3389/fphys.2016.00069] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 02/12/2016] [Indexed: 12/30/2022] Open
Abstract
Intermittent hypoxia is a feature of apnea of prematurity (AOP), chronic lung disease, and sleep apnea. Despite the clinical relevance, the long-term effects of hypoxic exposure in early life on respiratory control are not well defined. We recently reported that exposure to chronic intermittent hypoxia (CIH) during postnatal development (pCIH) causes upper airway muscle weakness in both sexes, which persists for several weeks. We sought to examine if there are persistent sex-dependent effects of pCIH on respiratory muscle function into adulthood and/or increased susceptibility to re-exposure to CIH in adulthood in animals previously exposed to CIH during postnatal development. We hypothesized that pCIH would cause long-lasting muscle impairment and increased susceptibility to subsequent hypoxia. Within 24 h of delivery, pups and their respective dams were exposed to CIH: 90 s of hypoxia reaching 5% O2 at nadir; once every 5 min, 8 h per day for 3 weeks. Sham groups were exposed to normoxia in parallel. Three groups were studied: sham; pCIH; and pCIH combined with adult CIH (p+aCIH), where a subset of the pCIH-exposed pups were re-exposed to the same CIH paradigm beginning at 13 weeks. Following gas exposures, sternohyoid and diaphragm muscle isometric contractile and endurance properties were examined ex vivo. There was no apparent lasting effect of pCIH on respiratory muscle function in adults. However, in both males and females, re-exposure to CIH in adulthood in pCIH-exposed animals caused sternohyoid (but not diaphragm) weakness. Exposure to this paradigm of CIH in adulthood alone had no effect on muscle function. Persistent susceptibility in pCIH-exposed airway dilator muscle to subsequent hypoxic insult may have implications for the control of airway patency in adult humans exposed to intermittent hypoxic stress during early life.
Collapse
Affiliation(s)
- Fiona B McDonald
- Health Sciences Centre, School of Medicine and Medical Science, University College Dublin Dublin, Ireland
| | - Eugene M Dempsey
- Department of Paediatrics and Child Health, Cork University Maternity Hospital and the Irish Centre for Fetal and Neonatal Translational Research, University College Cork Cork, Ireland
| | - Ken D O'Halloran
- Department of Physiology, School of Medicine, University College Cork Cork, Ireland
| |
Collapse
|
22
|
Ennis J, Rohde K, Chaput JP, Buchholz A, Katz SL. Facilitators and Barriers to Noninvasive Ventilation Adherence in Youth with Nocturnal Hypoventilation Secondary to Obesity or Neuromuscular Disease. J Clin Sleep Med 2015; 11:1409-16. [PMID: 26235150 DOI: 10.5664/jcsm.5276] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 06/16/2015] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Many youth struggle with adherence to bilevel noninvasive ventilation (NIV), often shortly after initiation of treatment. Anecdotal evidence suggests youths with comorbid obesity struggle with adherence while youths with comorbid neuromuscular disease demonstrate better adherence rates. The objective of this study was to explore factors relating to bilevel NIV adherence, and to compare these between youths with underlying obesity or neuromuscular disease. METHODS An exploratory qualitative approach was used to examine youth and caregivers' experiences with and perceptions of bilevel NIV. Semi-structured interviews (n = 16) of caregivers and youths were conducted. Youths 12 years and older with nocturnal hypoventilation diagnosed on polysomnography and managed with bilevel NIV, with either concurrent obesity or neuromuscular disease were included. Thematic analysis of interview data was conducted using qualitative analysis software. RESULTS Factors associated with positive bilevel NIV adherence included previous encouraging experiences with therapy; subjective symptom improvement; familiarity with medical treatments; understanding of nocturnal hypoventilation and its consequences; family and health-care team support; and early adaptation to treatments. Factors associated with poor bilevel NIV adherence included previous negative experiences with therapy, negative attitude towards therapy; difficulty adapting; perceived lack of support from family or health-care team; fear/embarrassment regarding treatment; caregivers not being health-minded; technical issues; side effects; and a lack of subjective symptom improvement. CONCLUSIONS The dimensions which most affect adherence to bilevel NIV are those which contribute to youths' conception of feeling "well" or "unwell." Adherence to treatment may hinge largely on the way in which NIV is initially experienced and framed. COMMENTARY A commentary on this article appears in this issue on page 1355.
Collapse
Affiliation(s)
- Jonathan Ennis
- The University of British Columbia, Vancouver, British Columbia, Canada
| | - Kristina Rohde
- Clinical Research Unit, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Jean-Philippe Chaput
- Centre for Healthy Active Living, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Annick Buchholz
- Centre for Healthy Active Living, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Sherri Lynne Katz
- Clinical Research Unit, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,Division of Respiratory Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
23
|
Khirani S, Ramirez A, Olmo-Arroyo J, Amaddeo A, Quijano-Roy S, Desguerre I, Fauroux B. [Are respiratory muscle testing helpful to prompt sleep studies in children with neuromuscular disease?]. Med Sci (Paris) 2015; 31 Spec No 3:14-7. [PMID: 26546925 DOI: 10.1051/medsci/201531s304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Sonia Khirani
- Chercheur, ASV Santé, Gennevilliers et Unité de ventilation non invasive et du sommeil de l'enfant, Hôpital Necker-Enfants malades, Paris
| | - Adriana Ramirez
- Ingénieur de recherche, ADEP Assistance, Suresnes, et Unité de ventilation non invasive et du sommeil de l'enfant, Hôpital Necker-Enfants malades, Paris
| | - Jorge Olmo-Arroyo
- Technicien de recherche subventionné AFM, Unité de ventilation non invasive et du sommeil de l'enfant, Hôpital Necker-Enfants malades, Paris
| | - Alessandro Amaddeo
- Chef de clinique, Unité de ventilation non invasive et du sommeil de l'enfant, Hôpital Necker-Enfants malades, Paris
| | - Susana Quijano-Roy
- Neuropédiatre, Centre de Référence Maladies Neuromusculaires (GNMH), Hôpital Raymond Poincaré, Garches, Université Versailles UVSQ, Inserm, UMRS1176, Montigny-le-Bretonneau
| | - Isabelle Desguerre
- Neuropédiatre, Centre de Référence Maladies Neuromusculaires (GNMH), Hôpital Necker-Enfants malades, Paris, Université Paris Descartes
| | - Brigitte Fauroux
- Pneumo-pédiatre, Unité de ventilation non invasive et du sommeil de l'enfant, Hôpital Necker-Enfants malades, Paris, Université Paris Descartes, Inserm U955, Équipe 13, Créteil
| |
Collapse
|
24
|
Katz SL, Witmans M, Barrowman N, Hoey L, Su S, Reddy D, Narang I. Paediatric sleep resources in Canada: The scope of the problem. Paediatr Child Health 2014; 19:367-72. [PMID: 25332676 DOI: 10.1093/pch/19.7.367] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2014] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Sleep-disordered breathing (SDB) is prevalent in children and is associated with significant comorbidity. OBJECTIVES To describe paediatric sleep physician and diagnostic testing resources for SDB in Canadian children. METHODS A 38-item, Internet-based survey was sent to the 32 members of the Canadian Pediatric Sleep Network (CPSN). A shorter telephone survey was administered to all 182 non-CPSN sleep laboratories across Canada. RESULTS Responses were obtained from 29 of 31 (91%) CPSN members and 121 of 182 (66%) non-CPSN sleep facilities. Sixty-seven of 121 (55%) of the responding non-CPSN facilities reported that they see children <18 years of age. Thirty-six of 121 (30%) and 23 of 121 (19%), respectively, see children ≤12 years of age or ≤8 years of age. Marked disparities across provinces/territories were observed, with no practitioners or polysomnography in the Yukon, Northwest Territories, Nunavut, Saskatchewan, New Brunswick, Prince Edward Island, and Newfoundland and Labrador. Alberta has the smallest ratio of children to practitioners (approximately 167,000 to 1) and Ontario has the smallest ratio of children to polysomnograms performed per year (approximately 487,000 to 1). Reported wait times for polysomnography ranged from <1 month, to 1.5 to 2 years. In paediatric tertiary care centres, the number of polysomnograms performed per year ranged from 55 to 700 (median 480) and in other laboratories the range was 400 to 4000 (median 1100). CONCLUSIONS The present study demonstrates a significant lack of resources and services for paediatric SDB care across Canada, with pronounced geographical disparities. Even if only affected children were tested with polysomnography, the authors estimate there are 7.5 times more children with SDB than current testing capacity.
Collapse
Affiliation(s)
- Sherri Lynne Katz
- Division of Respiratory Medicine, Children's Hospital of Eastern Ontario; ; Faculty of Medicine, University of Ottawa, Ottawa, Ontario
| | - Manisha Witmans
- Faculty of Medicine, University of Alberta, Edmonton, Alberta
| | - Nicholas Barrowman
- Clinical Research Unit, Children's Hospital of Eastern Ontario Research Institute, Ottawa
| | - Lynda Hoey
- Clinical Research Unit, Children's Hospital of Eastern Ontario Research Institute, Ottawa
| | - Santana Su
- Division of Respiratory Medicine, Children's Hospital of Eastern Ontario
| | - Deepti Reddy
- Clinical Research Unit, Children's Hospital of Eastern Ontario Research Institute, Ottawa
| | - Indra Narang
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Ontario; ; Faculty of Medicine, University of Toronto, Toronto, Ontario
| |
Collapse
|
25
|
McKim DA, Katz SL, Barrowman N, Ni A, LeBlanc C. Lung Volume Recruitment Slows Pulmonary Function Decline in Duchenne Muscular Dystrophy. Arch Phys Med Rehabil 2012; 93:1117-22. [DOI: 10.1016/j.apmr.2012.02.024] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Revised: 01/21/2012] [Accepted: 02/02/2012] [Indexed: 02/07/2023]
|
26
|
Yang ML, Finkel RS. Overview of paediatric neuromuscular disorders and related pulmonary issues: diagnostic and therapeutic considerations. Paediatr Respir Rev 2010; 11:9-17. [PMID: 20113986 DOI: 10.1016/j.prrv.2009.10.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Pulmonary compromise is common in neuromuscular disease. Respiratory failure may be a presenting feature of neuromuscular disease and remains a major cause of morbidity and mortality. This article will review the current understanding of the more commonly encountered neuromuscular disorders in childhood and emphasize related pulmonary issues.
Collapse
Affiliation(s)
- M L Yang
- Children's Hospital Denver, Aurora, CO 80045-7106, USA
| | | |
Collapse
|