Pediatric Year in Review

PEDIATRIC YEAR IN REVIEW 9 ous RCT of CPAP versus HFNC in the home is needed to address these questions. 4. HFNC devices have no in-built mechanism to measure adherence 5. Limitation of the study are that the time between baseline (diag- nostic PSG) and HFNC titration with PSG was approximately 9 months and that several patients received oxygen limiting accu- rate scoring of respiratory events. NOVEL PHARMACOLOGICAL THERAPEUTICS FOR OSA Taranto-Montemurro L, Messineo L, Sands SA, Azarbarzin A, Marques M, Edwards BA, et al. The Combination of Atomoxetine and Oxybutynin Greatly Reduces Obstructive Sleep Apnea Severity: A Randomized, Placebo-Controlled, Double-Blind Crossover Trial. Am J Respir Crit Care Med. 2018. Summary Recently, there is evidence to suggest that sleep-related hypotonia of the pharyngeal muscles is related to the central reduction of norepinephrine from wakefulness to sleep and REM related hypotonia is due to an inhibitory effect of acetylcholine through muscarinic receptors. To date, there are no pharmacological treatments for OSA. This study was a randomized, placebo controlled double blind cross- over trial to evaluate the effectiveness of Atomoxetine (norepinephrine reuptake inhibitor) and Oxybutynin (an anti-muscarinic) on OSA severity and genioglossus activity in subjects with OSA. Subjects were randomized to either placebo or a combination of Atomoxetine and Oxybutynin 30 minutes before lights out with simultaneous PSG. Subjects had placement of esophageal catheter and intramuscular electrodes in the genioglossus muscle. Patients were asked to sleep in supine position. Majority of the subjects were male (16/20), with a mean age of 53 years and BMI of 34.8kg/m2. The mean AHI in the placebo group and Ato-oxy group was 28.5 and 7.5 events per hour respectively (p<0.001). There were significant improvements in the ODI and nadir SaO2 in the treatment group vs placebo. There was a significant increase in genioglossus muscle responsiveness in the Ato-oxy group compared to placebo. Comments 1. This study provides exciting, novel data of the potential for phar- macological interventions for the management of OSA in adults. 2. The combination of the Atomoxetine and Oxybutynin are believed to have synergistic effects on upper airway dilator muscles. Atomoxetine and Oxybutynin alone did not result in a significant reduction in AHI. 3. There were no significant changes in sleep architecture and arousal index between the groups. 4. Data has to be interpreted with caution given that this is a proof of concept physiological trial. Prolonged use of these pharmacologi- cal agents on the impact of OSA and symptoms are unknown. Future studies will also have to address the long-term risks and adverse effects of pharmacological agents. 5. While these data are unlikely to be extrapolated to children in the very near future, pharmacological approaches for OSA is an excit- ing area of future research. PERSONALIZED SURGICAL MANAGEMENT OF OSA USING DISE Collu MA, Esteller E, Lipari F, Haspert R, Mulas D, Diaz MA, et al. A case-control study of Drug-Induced Sleep Endoscopy (DISE) in pediatric population: A proposal for indications. Int J Pediatr Otorhinolaryngol. 2018;108:113-9. Summary DISE is a 3-dimensional assessment of the upper airway (UA) under unconscious sedation and is used to characterize the location and pattern of the UA obstruction. DISE has mostly been used to evaluate UA obstruction following an adeno-tonsillectomy. This study evaluated the role of DISE in mostly healthy children diagnosed with OSA regardless of whether adenotonsillectomy had previously been performed. In the study, 150 children presenting to ENT clinic with suspected OSA had 1) PSG 2) Chervin PSQ 3) ENT exam (grading of tonsils) and 4) DISE. DISE was performed by the same endoscopist with a baseline plan to undertake an adenotonsillectomy (AT). The population was divided into 3 categories; 1) Conventional OSA – no previous surgery with AHI >0 and AHI <10 with variable tonsil size, 2) Disproportional OSA – AHI >10 and no previous surgery or AHI >3 with tonsils < size 3 and no surgery for OSA and 3) Persistent OSA – AHI >3 and previous AT surgery for OSA. All patients in conventional group (n=88) underwent tonsillectomy and 80/88 underwent adenoidectomy. Of these 4/88 had a change in management due to DISE – 3 had tongue base reduction and one had pharyngoplasty. For the disproportional OSA group (n=40), all had tonsillectomy and adenoidectomy and 7/40 had a change in the surgical management plan. For the persistent OSA (n=22), 16/22 had additional surgery, including tongue base reduction, inferior turbinate surgery and pharyngoplasty. Overall 37% of otherwise healthy children patients had a change in final surgical plan following DISE. Comments 1. DISE is a safe procedure but could not be completed in 17 cases due to tonsillar obstruction, secretions and inability to reproduce apnea during sedation. 2. Tonsillectomy and/or adenoidectomy should be considered first line surgery in traditional OSA cases. 3. No PSG data post-surgery to evaluate effectiveness and rel- evance of DISE and surgery. 4. In this cohort of mostly healthy children, advanced surgery occurred mostly in patients with persistent OSA. UPDATE IN THE MANAGEMENT OF SLEEP DISORDERED BREATHING IN CHILDREN