Quality measures for the care of pediatric patients with obstructive sleep apnea

Screening for obstructive sleep apnea (OSA) in children and adolescents with obesity: A scoping review of national and international pediatric obesity and pediatric OSA management guidelines

Obstructive sleep apnea (OSA) is a prevalent complication that affects up to 60% of children and adolescents with obesity. It is associated with poorer cardiometabolic outcomes and neurocognitive deficits. Appropriate screening and intervention for OSA are crucial in the management of children with obesity. We performed a scoping review of international and national pediatric obesity (n = 30) and pediatric OSA (n = 10) management guidelines to evaluate the recommendations on OSA screening in pediatric obesity. Sixteen (53%) of the pediatric obesity guidelines had incorporated OSA screening to varying extents, with no consistent recommendations on when and how to screen for OSA, and subsequent management of OSA in children with obesity. We provide our recommendations that are based on the strength and certainty of evidence presented. These include a clinical-based screening for OSA in all children with body mass index (BMI) ≥ 85th percentile or those with rapid BMI gain (upward crossing of 2 BMI percentiles) and the use of overnight polysomnography to confirm the diagnosis of OSA in those with high clinical suspicion. We discuss further management of OSA unique to children with obesity. An appropriate screening strategy for OSA would facilitate timely intervention that has been shown to improve cardiometabolic and neurocognitive outcomes.

Quality measures for the care of pediatric patients with obstructive sleep apnea: 2023 update after measure maintenance

Obstructive sleep apnea (OSA) is the most common respiratory sleep disorder in the United States in preschool and school-aged children. In an effort to continue addressing gaps and variations in care in this patient population, the American Academy of Sleep Medicine (AASM) Quality Measures Task Force performed quality measure maintenance on the Quality Measures for the Care of Pediatric Patients with Obstructive Sleep Apnea (originally developed in 2015). The Quality Measures Task Force reviewed the current medical literature, including updated clinical practice guidelines and systematic literature reviews, existing pediatric OSA quality measures, and performance data highlighting remaining gaps or variations in care since implementation of the original quality measure set to inform any potential revisions to the quality measures. These revised quality measures have been implemented in the AASM Sleep Clinical Data Registry (Sleep CDR) to capture performance data and encourage continuous quality improvement, specifically in outcomes associated with diagnosing and managing OSA in the pediatric population.

CITATION

Lloyd RM, Crawford T, Donald R, et al. Quality measures for the care of pediatric patients with obstructive sleep apnea: 2023 update after measure maintenance. J Clin Sleep Med. 2024;20(1):127-134.

Pediatric sleep: current knowledge, gaps, and opportunities for the future

This White Paper addresses the current gaps in knowledge, as well as opportunities for future studies in pediatric sleep. The Sleep Research Society's Pipeline Development Committee assembled a panel of experts tasked to provide information to those interested in learning more about the field of pediatric sleep, including trainees. We cover the scope of pediatric sleep, including epidemiological studies and the development of sleep and circadian rhythms in early childhood and adolescence. Additionally, we discuss current knowledge of insufficient sleep and circadian disruption, addressing the neuropsychological impact (affective functioning) and cardiometabolic consequences. A significant portion of this White Paper explores pediatric sleep disorders (including circadian rhythm disorders, insomnia, restless leg and periodic limb movement disorder, narcolepsy, and sleep apnea), as well as sleep and neurodevelopment disorders (e.g. autism and attention deficit hyperactivity disorder). Finally, we end with a discussion on sleep and public health policy. Although we have made strides in our knowledge of pediatric sleep, it is imperative that we address the gaps to the best of our knowledge and the pitfalls of our methodologies. For example, more work needs to be done to assess pediatric sleep using objective methodologies (i.e. actigraphy and polysomnography), to explore sleep disparities, to improve accessibility to evidence-based treatments, and to identify potential risks and protective markers of disorders in children. Expanding trainee exposure to pediatric sleep and elucidating future directions for study will significantly improve the future of the field.

Lost to follow-up: Post-operative polysomnography in at-risk, pediatric obstructive sleep apnea

OBJECTIVE

Analyze adherence to AASM recommendations for post-operative polysomnography in eligible pediatric patients.

STUDY DESIGN

Retrospective Cohort.

SETTING

Tertiary, Outpatient Sleep Lab.

METHODS

We conducted a retrospective analysis of pediatric patients, ages 1-17, previously diagnosed with moderate-severe obstructive sleep apnea that completed a surgical intervention. Chart review included demographic data, a co-morbidity of interest, the presence of an otolaryngology, primary care, or sleep medicine encounter, time to follow-up, the presence of a post-operative polysomnography, time to post-operative polysomnography, and the presence of an annual follow-up with any provider.

RESULTS

Of the 373 patients, 67 patients met inclusion criteria. Fifty-nine followed-up with any provider, with 21 completing post-operative polysomnography. Patients with residual or recurrent symptoms (p < 0.01) and all patients with severe obstructive sleep apnea (p = 0.04) were more likely to complete post-operative polysomnography (PSG). Sub-analysis across at-risk categories (isolated moderate, isolated severe, moderate & a co-morbidity, and severe & a co-morbidity) revealed patients with severe obstructive sleep apnea & a co-morbidity completed a follow-up PSG more often than isolated moderate obstructive sleep apnea (p = 0.01). There was a difference in follow-up with sleep medicine across at-risk categories (p < 0.01).

CONCLUSION

Recurrent symptoms and increasing disease severity were associated with obtaining post-operative polysomnography. However, variability existed for which patients completed post-operative polysomnography. We speculate an inconsistent standard across disciplines, inadequate post-operative obstructive sleep apnea management education, and uncoordinated systemic processes contribute to this discrepancy. Our findings support a standardized, multi-disciplinary care pathway for the management of at-risk, pediatric obstructive sleep apnea.

Age and weight considerations for the use of continuous positive airway pressure therapy in pediatric populations: an American Academy of Sleep Medicine position statement

This position statement provides guidance for age and weight considerations for using continuous positive airway pressure (CPAP) therapy in pediatric populations. The American Academy of Sleep Medicine (AASM) commissioned a task force of experts in pediatric sleep medicine to review the medical literature and develop a position statement based on a thorough review of these studies and their clinical expertise. The AASM Board of Directors approved the final position statement. It is the position of the AASM that CPAP can be safe and effective for the treatment of obstructive sleep apnea (OSA) for pediatric patients, even in children of younger ages and lower weights, when managed by a clinician with expertise in evaluating and treating pediatric OSA. The clinician must make the ultimate judgment regarding any specific care in light of the individual circumstances presented by the patient, accessible treatment options, patient/parental preference, and resources.

Respiratory concerns in children with medical complexity

Children with medical complexity (CMC) are a diverse group of children affected by a spectrum of chronic disorders and physiologic abnormalities. Due to their underlying disorders, they disproportionately experience respiratory comorbidities and complications. Respiratory-related complications that arise in this population often begin subtly and progress over time and can result in lung injury, respiratory insufficiency, and eventual chronic respiratory failure. CMC make up a substantial proportion of pediatric hospitalizations and healthcare expenditures, with respiratory-related illness being one of the leading causes of admission. It is, therefore, important for the practitioner caring for these children to have knowledge of the common respiratory concerns in this population as well as prevention and management strategies. This review will describe the most common respiratory concerns in CMC and will provide an overview of diagnosis and management.

Multidisciplinary clinic for care of children with complex obstructive sleep apnea

OBJECTIVE

While adenotonsillectomy (AT) remains first line therapy for pediatric obstructive sleep apnea (OSA), management of children who are not candidates for AT or who have residual OSA post AT varies and spans across multiple specialties. We aim to report our experience in managing this population through a multidisciplinary sleep clinic composed of specialists in pediatric dentistry, otolaryngology, plastic surgery, and pulmonary/sleep medicine.

STUDY DESIGN

Retrospective chart review.

METHOD

The medical records of children attending our complex sleep apnea clinic were reviewed. Data pertaining to demographics, underlying diagnoses, prior evaluation and treatment, recommendations, and initial therapy were collected.

RESULT

Two-hundred and thirty patients (mean age 10.7 ± 5.1 years, 62.2% male) were assessed. Underlying conditions included Trisomy 21 (n = 65, 28.2%), other genetic syndromes (n = 37, 16.1%), obesity in an otherwise typically developing child (n = 36, 15.2%), cerebral palsy (n = 27, 11.7%), and craniofacial syndromes (n = 7, 3.0%). Mean obstructive apnea hypopnea index (OAHI) was 14.2 events/hour at first clinic visit, and the majority of children had previously undergone at least one upper airway surgery (n = 168, 73.0%), primarily adenotonsillectomy. Recommended initial treatment plans included positive airway pressure (PAP) therapy (n = 108, 47.0%), surgery (n = 75, 32.6%), allergy management (n = 52, 22.6%), and/or weight loss (n = 34, 14.8%). Patients prescribed PAP therapy with follow up data were found to be adherent 43.9% of the time. Surgical patients with post-operative polysomnography had pre-operative OAHI 15.6 ± SD13.4 decrease to 10.7 ± 14.2 events/hour (p = 0.61).

CONCLUSION

Genetic conditions and obesity were the most common underlying diagnoses cared for in the complex sleep apnea clinic. Patients presented with severe OSA, most having already had upper airway surgery. Management plans were frequently adjusted, and we observed improvement in SDB in a sub-segment of patients, suggesting benefit to a coordinated, multi-disciplinary approach.

Prevalence of Pulmonary Hypertension in Pediatric Patients With Obstructive Sleep Apnea and a Cardiology Evaluation: A Retrospective Analysis

STUDY OBJECTIVES

Pulmonary hypertension (PH) has been reported as a serious complication of obstructive sleep apnea (OSA) in children; however, estimated prevalence rates vary widely (zero to 85%). The purpose of this study is to determine the prevalence of PH in children with OSA and identify factors that may predict an increased PH risk in children with OSA.

METHODS

A retrospective review of all pediatric beneficiaries (88,058) in the San Antonio Military Health System with a diagnosis of OSA and a clinical evaluation by a pediatric cardiologist. OSA severity and nadir oxygen saturation were recorded from overnight polysomnography. Reason for referral, comorbid disorders, echocardiogram results, and cardiac diagnoses were obtained from cardiology records.

RESULTS

OSA was identified in 2,020 pediatric patients (2.3%). A pediatric cardiology consultation was reported for 296 patients with OSA. After excluding 95 patients for incorrect OSA diagnoses, incomplete data, or OSA treatment before cardiology evaluation, 163 patients were included in the final analysis. A diagnosis of PH was found in 3 patients with OSA (1.8%). Two of these patients had obesity, and all three had comorbid cardiac disorders.

CONCLUSIONS

Prevalence of PH in pediatric patients with OSA is low and none of the patients with PH had severe OSA. Current guidelines recommend PH screening in patients with severe OSA, yet OSA severity may not accurately predict risk. Factors evaluated in this study did not demonstrate an increased PH risk; additional research is necessary to improve screening in pediatric patients with OSA.

CITATION

Burns AT, Hansen SL, Turner ZS, Aden JK, Black AB, Hsu DP. Prevalence of pulmonary hypertension in pediatric patients with obstructive sleep apnea and a cardiology evaluation: a retrospective analysis. J Clin Sleep Med. 2019;15(8):1081-1087.

Validation and confirmatory factor analysis of the pediatric Adherence Barriers to Continuous Positive Airway Pressure Questionnaire

OBJECTIVE

To evaluate and refine a newly proposed factor structure for the Adherence Barriers to Continuous Positive Airway Pressure Questionnaire (ABCQ) and to present psychometric data from a large, geographically diverse sample of children and young adults with sleep disordered breathing (SDB) treated with positive airway pressure (PAP).

METHODS

A sample of 181 patients prescribed PAP for treatment of SDB, ages 8-21 years, and caregivers (n = 234) of patients ages 2-21 years, completed the ABCQ during routine sleep medicine clinic visits. Adherence data from participants' PAP machines were obtained via electronic download, providing objective data on PAP adherence immediately preceding the clinic visit during which the ABCQ was completed.

RESULTS

A three-factor structure (1. Behavior, Beliefs, Environment, 2. Emotional Barriers, & 3. Physical Barriers) exhibited good model fit in confirmatory factor analysis. Results indicate that the ABCQ has strong psychometric properties, including good internal consistency among subscales and strong convergent validity with objectively measured PAP adherence. Analysis of the Receiver Operator Characteristic Curve (ROC) yielded an ABCQ total cut-off score of 46.5 for patient report and 53.5 for caregiver report. Scores above the cutpoint predicted nonadherence to PAP, defined as failure to use PAP for ≥4 h on 70% of nights.

CONCLUSIONS

The three-factor ABCQ appears to be a useful patient- and caregiver-report instrument to measure barriers to PAP treatment in children and young adults with sleep disordered breathing.

Regulatory, Legal, and Ethical Considerations of Telemedicine

Sleep telemedicine practitioners must ensure their practice complies with all applicable institutional, state, and federal regulations. Providers must be licensed in any state in which they provide care, have undergone credentialing and privileging procedures at outside facilities, and avoid real or perceived conflicts of interest while providing that care. Internet-based prescribing remains limited to certain circumstances. Whether or not a malpractice insurance policy covers telemedicine depends on the insurer, especially if interstate care is provided. All telemedicine programs must protect patient health information. Similarly, bioethical principles of autonomy, beneficence, nonmaleficence, and justice apply to both in-person and telemedicine-based care.

Does obstructive sleep apnoea contribute to obesity, hypertension and kidney dysfunction in children? A systematic review protocol

INTRODUCTION

Childhood obstructive sleep apnoea (OSA) is a highly prevalent disorder that may directly contribute to the development of obesity, hypertension and renal injury. Although those associations seem to be clearer in adults, studies in children have revealed conflicting results and updated synthesis of the evidence is lacking. The aim of this systematic review is to summarise the available evidence on the effect of OSA on obesity, systemic blood pressure and kidney function, to help to elucidate whether respiratory interventions to correct OSA would have the potential to improve those outcomes.

METHODS AND ANALYSIS

A systematic literature review search was created by a medical librarian and peer-reviewed by a second librarian prior to running. Ovid Medline, Ovid Embase, CINAHL via EbscoHOST, Wiley Cochrane Library and ProQuest Dissertations and Theses Global were searched on 25 February 2020. Titles and abstracts will be screened by two independent reviewers for inclusion, followed by full-text screening of relevant articles. Studies in children will be included if they report data on OSA and weight, systemic blood pressure or kidney parameters. The extracted data will be combined for analysis and the information subcategorised in groups based on outcome. Risk of bias will be determined using tools specific to study methodology and certainty of the evidence using the Grading of Recommendations, Assessment, Development and Evaluations approach.

ETHICS AND DISSEMINATION

This study will provide essential information for healthcare professionals to better understand the relationship between childhood OSA and changes in body mass index, systemic blood pressure and kidney function indicators. Our findings will be disseminated through conferences and publications. The results of this review may guide the initiation of new strategies and the development of future research studies. This research did not involve human subjects and therefore did not undergo research ethical review.

PROSPERO REGISTRATION NUMBER

CRD42020171186.

Sleep-disordered breathing in paediatric setting: existing and upcoming of the genetic disorders

Childhood obstructive sleep apnea syndrome (OSAS) is characterized by anatomical and functional upper airway abnormalities as pathophysiological determinants, and clinical symptoms are frequently clear. OSAS is widely described in rare genetic disorders, such as achondroplasia, Down syndrome, Prader-Willi syndrome, Pierre Robin sequence, and mucopolysaccharidosis. Craniofacial and upper airway involvement is frequently morbid conditions. In children with genetic diseases, the clinical symptoms of OSAS are often slight or absent, and related morbidities are usually more severe and can be observed at any age. The present review is aimed to updating the discoveries regarding OSAS on Achondroplasia, Down syndrome, Prader-Willi syndrome, Pierre Robin sequence, Sickle cell disease, or encountered in our clinical practice (Ehlers-Danlos syndrome, Ellis-van Creveld syndrome, Noonan syndrome). Two additional groups of genetic disorders will be focused (mucopolysaccharidoses and osteogenesis imperfecta). The flowing items are covered for each disease: (I) what is the pathophysiology of OSAS? (II) What is the incidence/prevalence of OSAS? (III) What result from the management and prognosis? (IV) What are the recommendations? Considering the worries of OSAS, such as inattention and behavioural problems, daytime sleepiness, failure to thrive, cardiological and metabolic complications, the benefit of a widespread screening and the treatment in children with genetic diseases is undoubtful. The goals of the further efforts can be the inclusion of various genetic diseases into guidelines for the screening of OSAS, updating the shreds of evidence based on the research progression.

The Evolution of the AASM Clinical Practice Guidelines: Another Step Forward

ABSTRACT

One of the goals of the American Academy of Sleep Medicine (AASM) is to provide clear, evidence-based recommendations in our clinical practice guidelines. Periodically, the AASM will assess and update the process by which these guidelines are developed so that it is in line with the standards currently being used for guideline development. The AASM is now taking the next step forward by fully adopting GRADE (Grading of Recommendation Assessment, Development and Evaluation) as the methodology used for evaluating evidence and forming clinical practice guidelines recommendations. Starting this year, AASM recommendations will be based on the following four interdependent domains: 1. quality of evidence; 2. balance of desirable and undesirable consequences; 3. patients' values and preferences; and 4. resource use (when known). AASM strengths of recommendations will be dichotomized into two categories: "Strong" and "Weak," either for or against a patient-care strategy. In an effort to provide clarity and transparency, all AASM recommendations will be actionable statements that include the specific patient population for which the patient-care strategy is recommended, and clearly define the comparator against which the patient-care strategy was evaluated. In some recommendations, the comparator will be an alternative patient-care strategy (e.g., a "gold standard" or previously available alternative), while in other recommendations the comparator will be a placebo or no treatment; this is determined by the availability of evidence, and analyses decisions made by the AASM task force. Implementation of the complete GRADE criteria by the AASM allows us the best path forward towards continuing to provide high quality clinical practice guidelines.

Treatment options for obstructive sleep apnea

Purpose of review

Obstructive sleep apnea (OSA) is a global problem with implications for general health and quality of life, and is often encountered in patients with neurologic disease. This review outlines treatment modalities to consider for management of OSA in patients with neurologic disease.

Recent findings

New advances in positive airway pressure (PAP) devices, oral appliances, and surgical interventions offer a wide range of treatment options for patients with OSA.

Summary

PAP therapy remains the gold standard treatment for OSA. Other treatment modalities may be considered for OSA patients who decline or cannot tolerate PAP therapy. Some OSA patients may benefit from multimodal treatment.

Measurement of quality to improve care in sleep medicine

ABSTRACT

The Board of Directors of the American Academy of Sleep Medicine (AASM) commissioned a Task Force to develop quality measures as part of its strategic plan to promote high quality patient-centered care. Among many potential dimensions of quality, the AASM requested Workgroups to develop outcome and process measures to aid in evaluating the quality of care of five common sleep disorders: restless legs syndrome, insomnia, narcolepsy, obstructive sleep apnea in adults, and obstructive sleep apnea in children. This paper describes the rationale, background, general methods development, and considerations in implementation for these sleep disorder quality measures. The Workgroup papers are published in this issue under the following titles: Quality Measures for the Care of Adult Patients with Restless Legs Syndrome, Quality Measures for the Care of Patients with Insomnia, Quality Measures for the Care of Patients with Narcolepsy, Quality Measures for the Care of Adult Patients with Obstructive Sleep Apnea, and Quality Measures for the Care of Pediatric Patients with Obstructive Sleep Apnea.