The impact of obstructive sleep apnea in children with sickle cell disease and asthma

INTRODUCTION

Asthma and obstructive sleep apnea (OSA) are chronic diseases that disproportionately affect children with sickle cell disease (SCD). The literature describes the negative impact that both conditions have on children with SCD separately; however, the effect of OSA on asthmatic children with OSA is less specific. We hypothesized that the presence of OSA in children with SCD and asthma is associated with specific hematologic markers, worse clinical outcomes, and greater healthcare utilization.

METHODS

We retrospectively evaluated children with both SCD and asthma who underwent polysomnography (PSG). We assessed their demographic information, PSG data, hematologic indices, and healthcare utilization based on the concurrent presence of OSA.

RESULTS

Fifty-nine percent of the cohort had OSA with a lower oxygen saturation (SpO2 ) nadir (87% vs. 93%, p < 0.001) and a lower median daytime SpO2 (96.5% vs. 98.5%, p < 0.05); those with OSA were more likely to have the hemoglobin SS genotype (86% vs. 46.5%, p = 0.03). Additionally, those with OSA had a higher mean corpuscular volume (87 vs. 77.2 fL, p = 0.03) and reticulocyte count (10.1% vs. 5.5%, p < 0.01). There was no difference in asthma severity or healthcare utilization between those with OSA and those without OSA.

DISCUSSION

Overall, children with SCD and asthma might be at increased risk for developing OSA, and screening for sleep-disordered breathing should be incorporated as part of their routine care.

Continuous positive airway pressure care for pediatric obstructive sleep apnea: A long-term quality improvement initiative

Successful treatment of pediatric obstructive sleep apnea syndrome (OSAS) with continuous positive airway pressure (CPAP) is challenging due to behavioral, technical, medical, and systems factors. We undertook a quality improvement (QI) initiative involving physicians, nurses, psychologists, and respiratory therapists to improve CPAP outpatient care and processes. We aimed to: (1) increase the proportion of patients with a follow-up visit within 4 months of initiation of CPAP, (2) reduce the median time to first follow-up visit to under 4 months, and (3) increase the proportion of patients obtaining a post-initiation polysomnogram within 1 year to &gt;50%. We also explored healthcare utilization (HCU) in a subsample of patients. Interventions focused on developing a tracking system and standardizing interdisciplinary clinical care. The proportion of patients returning to clinic within 4 months improved from 38.2% to 65.5% and median time to first follow-up visit improved from 133 to 56 days. The percentage of patients who returned for a post-initiation polysomnogram within 1 year was 71.1%. Subsample analyses showed significant reductions in the length of stay for emergency department visits from pre-CPAP initiation (Mdn = 3.00 h; interquartile range [IQR] = 7.00) to post-initiation (Mdn = 2.00 h, IQR = 5.00). The length of hospitalizations was also significantly shorter from pre (Mdn = 48.00 h, IQR = 243.00) to post-CPAP initiation (Mdn = 0.00 h, IQR = 73.00). A standardized, tracked approach to interdisciplinary outpatient CPAP care can improve follow-up care and potentially HCU.

Pediatric pulmonary year in review 2021: Sleep medicine

Pediatric pulmonology publishes original research, review articles, and case reports on a wide variety of pediatric respiratory disorders. In this article, we summarized the past year's publications in sleep medicine and reviewed selected literature from other journals in this field. We focused on original research articles exploring aspects of sleep-disordered breathing in patients with underlying conditions such as cystic fibrosis, asthma, and sickle cell disease. We also explored sleep-disordered breathing risk factors, monitoring, diagnosis, and treatment; and included recent recommendations for drug-induced sleep endoscopy and ways to monitor and improve PAP adherence remotely.

A social media intervention for the families of young Black men with obstructive sleep apnoea

OBJECTIVE

To address positive airway pressure (PAP) adherence in adolescents diagnosed with obstructive sleep apnoea (OSA) by pilot testing a novel, online, facilitated, peer-support and health education programme for families.

DESIGN SETTING AND METHODS

Families participated in separate Facebook peer-groups (adolescent [n=6] and parent [n=6]) for four weeks, followed by face-to-face interviews. Participants received OSA and PAP educational videos and posts, engaged with questions and polls, and viewed de-identified postings of peer PAP use data.

RESULTS

Adolescent participants were young Black males aged 13-17 years (n=6) with obesity (n=5), severe sleep apnoea (100%) and 4-15 months of prior PAP use. Parent participants were mothers (n=4) and fathers (n=2). Four of six young males increased their mean PAP use during the intervention period. Overall, parents were more engaged with the Facebook group page than adolescents, but interviews revealed the online group/peer-support and education provided was highly regarded and appreciated by families. Parents were particularly appreciative of being involved in care and diagnosis in this way.

CONCLUSION

Results of this pilot trial provide important data regarding intervention design, content, and delivery approaches to be considered in the development of future interventions aiming to engage families and improve adolescent PAP adherence.

Sleep Deficiency in Adolescents: The School Start Time Debate

Adolescence is commonly accepted as a challenging time for sleep, with multiple factors contributing to sleep deficiency in adolescents. These include physiologic changes with shifts in their circadian rhythm; medical sleep disorders; and social, cultural, and environmental factors. Early school start times negatively affect sleep in adolescents as well, with poorer outcomes in their overall health, wellbeing, and performance. This article highlights the different contributing factors for sleep deficiency in adolescents and the consequences of sleep deficiency. In addition, the authors discuss the impact of delayed school start times in improving adolescents' sleep and overall function.

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.

0357 Interdisciplinary Training in Pediatric Sleep

Introduction

Sleep is a critical domain of child functioning. However, clinical psychology programs lack formal sleep education while behavioral sleep instruction is deficient in sleep and pulmonary fellowships. Cross-disciplinary training in pediatric sleep is ideal. This study examined medical and psychology trainee satisfaction with two interdisciplinary experiences: a 1-2 semester clinical rotation for medical fellows and psychology doctoral students and a concentrated annual elective for medical students. The rotation includes 1-2 half-day clinics per week wherein medical sleep fellows and behavioral sleep medicine trainees conduct a sleep interview together and ask specific questions within their discipline. With an attending psychologist and physician, they discuss case conceptualization, differential diagnoses, and possible interventions. The team reviews pertinent findings and collaboratively provides recommendations to the patient. Trainees also participate in weekly didactics presented by psychologists and physicians.The second interdisciplinary training experience, Frontiers, is designed to impact physician learners earlier in their careers. Sleep physicians and psychologists teach an annual week-long sleep elective for medical students.

Methods

Evaluations from fellows, psychology trainees, and medical students from the most recent 3 years were analyzed to determine trainee satisfaction with the interdisciplinary rotation and the medical student course.

Results

Results of sleep fellow evaluations rated the program as having effective teachers`X=4.67 (0.62) and high educational value `X=4.6 (0.83) on a 5-point Likert scale with 5 being the highest. Similarly, psychology trainees rated the overall rotation experience over the past 3 years on a 4-point Likert scale with 4 being the highest as`X=3.74 (0.43).Medical students who took the Frontiers course also rated the training highly on a 4-point Likert scale with 4 being the highest:`X=3.79 (0.43) in 2021,`X=3.76 (0.75) in 2019, and,`X= 3.73 (0.47) in 2018. The course was not offered in 2020 due to the pandemic.

Conclusion

Comprehensive pediatric sleep education and training (both clinical and didactic) is feasible within a single interdisciplinary rotation provided simultaneously to both psychology and medical trainees with high trainee satisfaction. Sleep-related in vivo training and didactics are relevant to physician and psychology training programs and prepare trainees for future work in interdisciplinary care.

Support (If Any)

 

Benefit of pulmonary subspecialty care for children with sickle cell disease and asthma

OBJECTIVE

Asthma is a recognized comorbidity in children with sickle cell disease (SCD). It increases the risk of acute chest syndrome (ACS), vaso-occlusive episodes, and early mortality. We aim to determine whether evaluation and management of children with SCD and asthma by a pulmonologist reduce rate of asthma exacerbation and ACS.

METHODS

The study included 192 patients with SCD (0-21 years) followed at Children's Hospital of Philadelphia Hematology between January 1, 2015, and December 31, 2018, with a diagnosis of asthma, wheeze, or cough. Patients were placed in two groups: those evaluated by a pulmonologist (SCD-A-P) and those not (SCD-A). Rates of emergency department (ED) visits and hospitalizations for asthma exacerbation and ACS were compared between groups and over time.

RESULTS

SCD-A-P patients (n = 70) were predominantly SCD type SS with lower hemoglobin and hematocrit compared to SCD-A patients (n = 122). SCD-A-P started with a higher average rate of hospital visits for asthma exacerbation and ACS per year (2.69 [1.02-4.37]) compared to SCD-A (0.43 [0.24-0.63]), (p < 0.001). For SCD-A-P patients with at least one hospital visit (n = 48), the average rate decreased from 3.93 (1.57-6.29) to 0.85 (0.48-1.23) following pulmonary consultation (p = 0.014) and was comparable to the SCD-A rate by study end.

CONCLUSION

SCD-A-P was mainly SCD type SS and had higher ED/hospitalization rates for asthma exacerbation and ACS compared to SCD-A, but the rates significantly decreased following pulmonology consultation. These findings support the pulmonologist's role in the multidisciplinary care of SCD patients and highlight the need for evidence-based asthma guidelines for children with SCD.

Pediatric pulmonology year in review 2019: Sleep medicine

Pediatric Pulmonology publishes original research, review articles as well as case reports on a wide variety of pediatric respiratory disorders. In this article, we summarize the past year's publications in sleep medicine and we review selected literature from other journals within this field. Articles highlighted are topics on risk factors of sleep-disordered breathing, diagnosis, and treatment of obstructive sleep apnea as well as the utility of polysomnography in various complex conditions.

1251 Management Considerations in an Adolescent with Kleine-Levin Syndrome

Introduction

Kleine-Levin syndrome (KLS) is a central disorder of hypersomnolence characterized by recurrent episodes of excessive sleepiness and sleep duration, along with varying degrees of cognitive dysfunction, altered perception, disinhibited behaviors, and eating disorders. Individuals with KLS are reported to be asymptomatic between episodes. KLS has a male preponderance with symptom onset typically during adolescence. A genetic basis has been suggested due to clustering of cases in certain ethnic populations and families. Purported triggers include viral infections, physical exertion, head trauma, and sleep deprivation.

Report of Case

A 15-year old male developed sudden-onset hypersomnolence with sleep duration of 20-23 hours per day. While awake, he had altered mentation and personality changes; parents reported aggression, hypersexual behaviors, hyperphagia, and derealization. During this 2-week episode, he underwent an extensive, yet unrevealing work-up and eventually experienced symptom resolution. Over 16 months, he has had 5 discrete episodes of hypersomnolence with abnormal wake behaviors, all preceded by viral illnesses and/or significant physical exertion and felt to be consistent with KLS. He has reported ongoing, albeit less severe, excessive daytime sleepiness between episodes. Polysomnography and multiple sleep latency testing, both performed while asymptomatic, were largely unremarkable. As episodes have decreased in duration and intensity over time, trials of lithium and stimulant therapy have been deferred per family preference, though the patient was started on a short course of azithromycin during his last episode for anti-inflammatory properties. Notably, the patient has developed significant anxiety due to fear of recurrence and is now engaged in therapy.

Conclusion

KLS is a rare disorder that tends to have shorter and less severe manifestations over time. To date, very few systematic studies have been done to evaluate potential treatments, such as lithium and macrolide therapy. Avoidance of triggers and adequate sleep are encouraged, and mental health support should also be considered.

0888 A Peer-Based Social Media Intervention to Promote Continuous Positive Airway Pressure Adherence in Adolescents With Obstructive Sleep Apnea

Introduction

Continuous positive airway pressure (CPAP) adherence in adolescents with obstructive sleep apnea (OSA) is suboptimal. This study evaluated an innovative CPAP adherence intervention for adolescents and their caregivers delivered via private Facebook groups. Study aims: (1) determine feasibility and acceptability of the intervention and (2) assess CPAP use pre- and post-intervention.

Methods

A pilot cohort study design was employed (N=6 dyads). Intervention included psychoeducation, CPAP use downloads/feedback, promoting peer-engagement through posts, videos, and polls. Adolescent and caregiver groups ran separately and simultaneously over 4-weeks. Measures: demographics, engagement/participation data, CPAP use, semi-structured interviews. Analysis: descriptive statistics and thematic content analysis.

Results

Adolescents were Black/African American (100%), males (100%) with a median age of 16 years (range 13-17). Caregivers (n=6) were mothers (67%) and fathers (33%) with a median age of 47 years (range 38-55). Caregivers were more engaged with the intervention than adolescents, viewing content 65%, 75%, 85%, 90%, and 100% (n=2) of days versus adolescents who viewed content 0%, 20% (n=2), 40%, 75% and 100%. Semi-structured interviews revealed the intervention was perceived positively; learning/expanded knowledge, gaining a sense of community, and enjoyment in the opportunity to help others were commonly identified. Interview feedback revealed utilizing a different social media platform may be more beneficial for adolescent engagement. Participants noted the intervention promoted conversations between the adolescent and caregiver, and 4/6 teens cited increased motivation to use CPAP. Average CPAP use increased in 50% of participants (n=3); 33% (n=2) sustained their use, and one decreased use.

Conclusion

Participants consistently noted appreciation for knowledge gained and sense of community derived from the intervention. This study supports the potential utilization of social media platforms to not only provide reliable OSA/CPAP education but to also promote peer-engagement. Given the acceptability and increased CPAP use in this small sample, a larger trial is indicated.

Support

Lead author receives support from NIH/NHLBI Award T32 HL07953. Videos included in intervention supported by The Children’s Hospital of Philadelphia Metabolism, Nutrition and Development Research Affinity Group Pilot and Feasibility Grant.

Pediatric polysomnography-A review of indications, technical aspects, and interpretation

Polysomnography is an elaborate diagnostic test composed of numerous data-collecting sensors working concomitantly to aid in the evaluation of varied sleep disorders in all age groups. Polysomnography is the study of choice for the assessment of pediatric sleep-disordered breathing, including obstructive sleep apnea syndrome, central apnea, and hypoventilation disorders, and is used to help determine treatment efficacy. Beyond the purview of snoring and breathing pauses, polysomnography can elucidate the etiology of hypersomnolence, when associated with a multiple sleep latency test, and abnormal movements or events, whether nocturnal seizure or complex parasomnia, when a thorough patient history cannot provide clear answers. This review will highlight the multitudinous indications for pediatric polysomnography and detail its technical aspects by describing the multiple neurophysiologic and respiratory parametric sources. Knowledge of these technical aspects will provide the practitioner with a thoughtful means to understand the limitations and interpretation of polysomnography.

Positive airway pressure adherence in pediatric obstructive sleep apnea: A systematic scoping review

Positive airway pressure (PAP) therapy is a commonly prescribed treatment for pediatric obstructive sleep apnea (OSA). Negative health consequences associated with untreated OSA make understanding the utilization of PAP therapy imperative. The aim of this review was to describe PAP use in children and adolescents with OSA, explore factors that influence use, and describe published scientific or clinical approaches to improve use. Among 20 studies, average PAP adherence was 56.9% (range, 24-87%). PAP use averaged 4.0 h (SD = 3.1) to 5.2 h (SD = 3.4) per night. Cautious consideration of summary estimates of PAP use is necessary as studies were heterogeneous and adherence definitions widely varied across studies. Age, sex, and developmental delay were the only factors associated with PAP use in more than one study. The majority of approaches to improve use were program evaluations rather than scientifically tested interventions. This review identified critical gaps in the existing literature and sets forth a research agenda for the future.

The role of polysomnography in tracheostomy decannulation of children with bronchopulmonary dysplasia

BACKGROUND

Patients with bronchopulmonary dysplasia (BPD) may require tracheostomy for long-term mechanical ventilation. Polysomnography (PSG) may predict successful decannulation in children, however it is unclear how this success compares with children without a PSG. To better evaluate this role, we compared decannulation outcomes between tracheostomy-dependent children with BPD who underwent PSG before decannulation to those who did not.

METHODS

This is a retrospective cohort study between 1 January 2007 and 1 June 2017 of tracheostomy-dependent children with BPD who were clinically considered for decannulation. Patient demographics, PSG results, and medical comorbidities were abstracted from medical records and compared between groups. Decannulation outcomes were compared between children with BPD who underwent PSG before decannulation and those who did not.

RESULTS

One hundred twenty-five patients with BPD were considered for tracheostomy decannulation. Forty-six (37%) had a pre-decannulation PSG while 79 (63%) did not. Nineteen (41%) patients did not undergo decannulation within 6 months of the PSG. One (3%) patient with pre-decannulation PSG failed decannulation. Four (5%) patients without pre-decannulation PSG failed decannulation. Nineteen patients with PSG and no decannulation had significantly higher obstructive apnea-hypopnea index (OAHI) (13.62 vs 2.68 events per hour, P = 0.004), higher end-tidal CO ₂ max (52.84 vs 48.03 mm Hg, P = 0.035), and were older at PSG (median age, 6.04 vs 4.04 years, P = 0.008).

CONCLUSIONS

While successful decannulation can be achieved without a PSG in some patients, PSG is a valuable tool to identify BPD patients undergoing clinical evaluation for decannulation who would benefit from treatment of OSA before decannulation.

Kleine-Levin Syndrome

Kleine-Levin syndrome (KLS) is a rare disorder characterized by discrete episodes of hypersomnia associated with cognitive and behavioural abnormalities, as well as normal alertness and function between episodes. The prevalence of KLS may be underestimated as it is often misdiagnosed and managed as another sleep disorder, neurological disorder or psychiatric condition. KLS is more typically seen in adolescence than at other ages, and is more common in males than in females. There are currently neither standard biomarkers nor specific imaging study findings, making the diagnosis of KLS a challenge. Furthermore, there are no consistently effective therapies. The prognosis, however, is felt to be overall favorable, as episodes become progressively milder and less frequent before resolving entirely in most patients.