Respiratory outcomes after cleft palate closure in Robin sequence: a retrospective study

OBJECTIVES

There is a paucity of information about the possible risk factors that could identify patients with Robin sequence (RS) who are more prone to developing obstructive airway complications after palate closure. This study aimed to compare the respiratory complication rates in patients with RS and isolated cleft palate (ICP).

MATERIALS AND METHODS

In this retrospective study, we reviewed the medical records of 243 consecutive patients with RS and ICP who were treated at Amsterdam University Medical Centers over the past 25 years. We collected preoperative data on previous treatment, diagnostic findings, surgical technique, weight, and presence of congenital anomalies.

RESULTS

During cleft palate closure, patients with RS were older (11.9 versus 10.1 months; p = 0.001) and had a lower gestational age than those with ICP (37.7 versus 38.5 weeks; p = 0.002). Patients with RS had more respiratory complications (17 versus 5%; p = 0.005), were more often non-electively admitted to the pediatric intensive care unit (PICU) (13 versus 4.1%; p = 0.022), and had a longer hospital stay duration (3.7 versus 2.7 days; p = 0.011) than those with ICP. The identified risk factors for respiratory problems were a history of tongue-lip-adhesion (TLA) (p = 0.007) and a preoperative weight of < 8 kg (p = 0.015). Similar risk factors were identified for PICU admission (p = 0.015 and 0.004, respectively).

CONCLUSIONS

The possible risk factors for these outcomes were a low preoperative weight and history of TLA. Closer postoperative surveillance should be considered for patients with these risk factors.

CLINICAL RELEVANCE

Identifying risk factors for respiratory complications could provide clinicians better insight into their patients and allows them to provide optimal care for their patients.

Evaluating International Diagnostic, Screening, and Monitoring Practices for Craniofacial Microsomia and Microtia: A Survey Study

To (1) appraise current international classification and clinical management strategies for craniofacial microsomia (CFM) and microtia, and (2) to assess agreement with the European Reference Network "European Guideline Craniofacial Microsomia" recommendations on screening and monitoring.

This was a cross-sectional online survey study. The survey consisted of 44 questions on demographics, diagnostics and classification, obstructive sleep apnea, feeding difficulties, speech and language development, hearing, ocular abnormalities, visual development, orthodontic screening, genetic counselling, psychological wellbeing, and extracraniofacial anomalies.

Respondents were participants of 3 international cleft and craniofacial conferences, members of the American Cleft Palate and Craniofacial Association and members of the International Society for Auricular Reconstruction. Respondents were requested to complete 1 questionnaire per multidisciplinary team.

Fifty-seven responses were received from 30 countries (response rate ∼3%).The International Consortium for Health Outcomes Measurement diagnostic criteria were used by 86% of respondents, though 65% considered isolated microtia a mild form of CFM. The Orbit, Mandible, Ear, Facial Nerve and Soft Tissue classification system was used by 74% of respondents. Agreement with standardized screening and monitoring recommendations was between 61% and 97%. A majority of respondents agreed with screening for extracraniofacial anomalies (63%-68%) and with genetic counselling (81%).

This survey did not reveal consistent agreement on the diagnostic criteria for CFM. Respondents mostly supported management recommendations, but frequently disagreed with the standardization of care. Future studies could focus on working towards international consensus on diagnostic criteria, and exploring internationally feasible management strategies.

Differences in analysis and treatment of upper airway obstruction in Robin sequence across different countries in Europe

The goal of this study was to explore the availability of diagnostic and treatment options for managing upper airway obstruction (UAO) in infants with Robin Sequence (RS) in Europe. Countries were divided in lower- (LHECs, i.e., PPP per capita < $4000) and higher-health expenditure countries (HHECs, i.e., PPP per capita ≥ $4000). An online survey was sent to European healthcare professionals who treat RS. The survey was designed to determine the availability of diagnostic tools such as arterial blood gas analysis (ABG), pulse oximetry, CO2 analysis, polysomnography (PSG), and sleep questionnaires, as well as to identify the used treatment options in a specific center. Responses were received from professionals of 85 centers, originating from 31 different countries. It was equally challenging to provide care for infants with RS in both LHECs and HHECs (3.67/10 versus 2.65/10, p = 0.45). Furthermore, in the LHECs, there was less access to ABG (85% versus 98%, p = 0.03), CO2 analysis (45% versus 70%, p = 0.03), and PSG (54% versus 93%, p < 0.01). There were no significant differences in the accessibility concerning pulse oximetry, sleep questionnaires, home saturation monitoring, nasopharyngeal tubes, Tuebingen plates, and mandibular distraction.    Conclusion: This study demonstrates a large difference in available care for infants with RS throughout Europe. LHECs have less access to diagnostic tools in RS when compared to HHECs. There is, however, no difference in the availability of treatment modalities between LHECs and HHECs. What is Known: • Patients with Robin sequence (RS) require complex and multidisciplinary care. They can present with moderate to severe upper airway obstruction (UAO). There exists a large variety in the use of diagnostics for both UAO treatment indications and evaluations. In most cases, conservative management of UAO in RS is sufficient. Patients with UAO that persist despite conservative management ultimately need surgical intervention. To determine which intervention is best suitable for the individual RS patient, the level of UAO needs to be determined through diagnostic testing. • There is a substantial variation among institutions across Europe for both diagnostics and treatment options in UAO. A standardized, internationally accepted protocol for the assessment and management of UAO in RS could guide healthcare professionals in the timing of assessment and indications to prevent escalation of UAO. Creating such a protocol might be a challenge, as there are large financial differences between countries in Europe (e.g., health expenditure per capita in purchasing power parity in international dollars ranges from $600 to over $8500). What is New: • There is a substantial variation in the availability of objective diagnostic tools between European countries. Arterial blood gas analysis, CO2 analysis and polysomnography are not equally accessible for lower-healthcare expenditure countries (LHECs) compared to higher-healthcare expenditure countries (HHECs). These differences are not only limited to availability; there is also a difference in quality of these diagnostic tools. Surprisingly, there is no difference in access to treatment tools between LHECs and HHECs. • There is national heterogeneity in access to tools for diagnosis and treatment of RS, which suggests centralization of health care, showing that specialized care is only available in tertiary centers. By centralization of care for RS infants, diagnostics and treatment can be optimized in the best possible way to create a uniform European protocol and ultimately equal care across Europe. Learning what is necessary for adequate monitoring could lead to better allocation of resources, which is especially important in a low-resource setting.

Objective measurements for upper airway obstruction in infants with Robin sequence: what are we measuring? A systematic review

STUDY OBJECTIVES

Identifying optimal treatment for infants with Robin sequence (RS) is challenging due to substantial variability in the presentation of upper airway obstruction (UAO) in this population. Objective assessments of UAO and treatments are not standardized. A systematic review of objective measures of UAO was conducted as step towards evidence based clinical decision making for RS.

METHODS

A literature search was performed in Pubmed and Embase databases (1990-2020) following PRISMA-guidelines. Articles reporting on RS and UAO-treatment were included if the following objective measures were studied: oximetry, polysomnography and blood gas. Quality was appraised by methodological index for non-randomized studies (MINORS, range:0-24).

RESULTS

A total of 91 articles met inclusion criteria. Mean MINORS-score was 7.1 (range:3-14). Polysomnography was most frequently used (76%) followed by oximetry (20%) and blood gas (11%). Sleep position of the infant was reported in 35% of studies, with supine position most frequently, and monitoring time in 42%, including overnight recordings in more than half. Of 71 studies that evaluated UAO-interventions, the majority used polysomnography (90%), of which 61% did not specify the polysomnography technique. Reported polysomnography metrics included oxygen saturation (61%), apnea-hypopnea index (52%), carbon dioxide levels (31%), obstructive-apnea-hypopnea index (27%), and oxygen-desaturation-index (16%). Only 42 studies reported indications for UAO-intervention, with oximetry and polysomnography thresholds used equally (both 40%). In total, 34 distinct indications for treatment were identified.

CONCLUSIONS

This systematic review demonstrates a lack of standardization, interpretation and reporting of assessment and treatment indications for UAO in RS. An international, multidisciplinary consensus protocol is needed to guide clinicians on optimal UAO assessment in RS.

A neonate with marked prolonged mixed apneas and CHARGE syndrome: a case report

Background

Upper airway abnormalities in the newborn are associated with obstructive breathing but not with mixed apneas. A tracheostomy is necessary to treat severe obstructive apneas but will not have an effect on the central part of the mixed apneas. As far as we know, this is the first case report describing disappearance of severe mixed apneas after tracheostomy in a 7-week-old infant.

Case presentation

We report a case of a white female neonate with anatomical upper airway abnormalities and severe mixed apneas with desaturations needing respiratory support. Polysomnography revealed striking mixed apneas, starting as a prolonged central apnea and merging into an obstructive apnea, and were not appropriate for her age. Additional examination revealed no explanation for the central component of the mixed apneas. Because of persistent, severe desaturations, she needed respiratory support with failure to wean. Finally, a tracheostomy was performed to treat the obstructive apneas, but unexpectedly the central apneas also resolved. Recently, additional genetic testing revealed that she has CHARGE syndrome (coloboma of the eye, heart defects, atresia of the choanae, retardation of growth and development, genital and/or urinary abnormalities, and ear abnormalities and deafness).

Conclusions

Mixed apneas are not a common feature in the newborn or infant with upper airway abnormalities. However, treatment with tracheostomy in our patient (day 46 postpartum) with anatomical upper airway abnormalities resolved not only obstructive apneas but also, unexpectedly, severe mixed apneas. Surprisingly, a posttracheostomy polygraph showed only short central apneas appropriate for age.

Evaluation of a rapid antigen detection point-of-care test for respiratory syncytial virus and influenza in a pediatric hospitalized population in the Netherlands

This pilot study evaluates the diagnostic performance of Sofia RSV Fluorescent Immunoassay Analyzer (FIA) and Sofia Influenza A + B FIA for rapid detection of respiratory syncytial virus and influenza A and B. Sofia had a lower-than-expected sensitivity for all viruses and a high rate of false-positive results for influenza B virus.

Analysis of the question-answer service of the Emma Children's Hospital information centre

The information centre of the Emma Children's Hospital AMC (EKZ AMC) is a specialised information centre where paediatric patients and persons involved with the patient can ask questions about all aspects of disease and its social implications. The aim of the study was to evaluate the question-answer service of this information centre in order to determine the role of a specialised information centre in an academic children's hospital, identify the appropriate resources for the service and potential positive effects. For this purpose, a case management system was developed in MS ACCESS. The characteristics of the requester and the question, the time it took to answer questions, the information sources used and the extent to which we were able to answer the questions were registered. The costs of the service were determined. We analysed all questions that were asked in the year 2007. Fourteen hundred thirty-four questions were asked. Most questions were asked by parents (23.3%), healthcare workers (other than nurses; 16.5%) and nurses (15.3%). The scope of the most frequently asked questions include disease (20.2%) and treatment (13.0%). Information on paper was the main information source used. Most questions could be solved within 15 min. Twelve percent to 28% of total working hours are used for the question-answer service. Total costs including staff salary are rather large. In conclusions, taking over the task of providing additional medical information and by providing readily available, good quality information that healthcare professionals can use to inform their patients will lead to less time investment of these more expensive staff members. A specialised information service can anticipate on the information need of parents and persons involved with the paediatric patient. It improves information by providing with relatively simple resources that has the potential to improve patient and parent satisfaction, coping and medical results. A specialised information centre is therefore a valuable and affordable asset to an academic children's hospital.

The prolonged use of the laryngeal mask airway in a neonate with airway obstruction and Treacher Collins syndrome

Upper airway obstruction and difficult tracheal intubation are often encountered in patients with Treacher Collins syndrome (mandibulofacial dysostosis). In this case report, the use of a laryngeal mask airway (LMATM) in a 10-day-old newborn with severe Treacher Collins syndrome and acute airway obstruction is described. It successfully relieved the airway obstruction and was left in situ for an exceptionally long period of 4 days. The difficult decisions with respect to the management of the airway and specifically the role of the laryngeal mask are described. In our opinion, in some newborns with severe mandibulofacial disorders and upper airway obstruction, where conservative airway management procedures have failed, the laryngeal mask can be considered not only to relieve the obstruction but also to buy time until there is full insight into the medical condition and its consequences.

Availability and usability of data for medical practice assessment

OBJECTIVE

We analyzed availability and usability of the electronic patient data required for assessment of medical practice for a specific patient group.

DESIGN

Case study in which physicians defined performance indicators and additional exploratory information. Data availability in the hospital information system was determined. Data usability was evaluated based on reason for recording, administrative procedures, and comparison with paper data.

SETTING

A 155 bed pediatric department in a public academic medical center.

STUDY PARTICIPANTS

Pediatricians and children with suspected meningitis.

MAIN OUTCOME MEASURES

Availability and usability of electronic patient data. Usability criteria were standardization, completeness, and accuracy.

RESULTS

A total of 14 performance indicators were defined. Of 39 data items required for indicator quantification, 29 were available, and 19 were usable without manual handling. Completeness and accuracy of the registration of reason for admission and discharge diagnoses were insufficient, leading to problematic patient selection and complication detection. Time-points of patient events were inaccurate or not available. Data regarding outpatient diagnosis, signs and symptoms, indications for test ordering, and medication administration were missing. Test result reports were not adequately standardized. Based on electronic patient data, five out of 14 performance indicators could be quantified reliably, but only after patient selection problems were overcome. For exploratory information, 16 out of 25 required data items were available and 13 were usable.

CONCLUSIONS

Availability and usability of electronic patient data are insufficient for physician-led and detailed assessment of medical practice for specific patient groups. Extended registration of the reason for admission will improve patient selection and assessment of diagnostic process.

Availability and accuracy of electronic patient data for medical practice assessment

We analyzed availability and accuracy of electronic patient data needed to assess medical practice. A case study was performed in which pediatricians formulated 14 performance indicators that cover aspects of care for children with suspected meningitis. Data items needed to quantify these indicators were listed. Required patient data were gathered from hospital information system and paper medical records. Accuracy of electronically available data was based on comparison with paper data and, when paper data were not available, on how data were recorded at the source, administrative procedures and original goal for which data were recorded.

CONCLUSION

Registration of reason for admission and diagnoses gives no reliable basis to select patients with 'suspicion on a disease' as selection criterion. Besides, many performance indicators cannot be reliably quantified because data are not recorded electronically (indication, medication, outpatient diagnosis), are not recorded specific enough (intervention time), are not standardized (radiology report), or cannot be obtained from other hospitals.