Pediatric Year in Review

PEDIATRIC YEAR IN REVIEW 8 UPDATE IN THE MANAGEMENT OF SLEEP DISORDERED BREATHING IN CHILDREN UPDATE IN THE MANAGEMENT OF SLEEP DISORDERED BREATHING IN CHILDREN Indra Narang, BMed Sci, MBBCH, MD Hospital for Sick Children University of Toronto Division of Respiratory Medicine Toronto, ON, Canada ADVANCES IN MANAGEMENT OF OSA Diercks GR, Wentland C, Keamy D, Kinane TB, Skotko B, de Guzman V, et al. Hypoglossal Nerve Stimulation in Adolescents With Down Syndrome and Obstructive Sleep Apnea. JAMA Otolaryngol Head Neck Surg. 2017. [Epub ahead of print] Summary Hypoglossal nerve stimulation (HGNS) has been shown to successfully treat adults with OSA specifically in those with an apnea- hypopnea index (AHI) between 20-50 events per hour and a BMI of <32 kg/m2 (Strollo PJ Jr, NEJM, 2014). More than 60% of adolescents with Down syndrome (DS) will have significant, persistent OSA despite an adeno- tonsillectomy. This pilot study evaluated HGNS in 6 youth with DS with refractory OSA. Inclusion criteria were BMI <32kg/m2, AHI between 10-50/hour and CAI of <25% and no evidence of circumferential airway collapse as per drug induced endoscopy. Once the device was activated, follow up PSGs were performed at 2, 6, and 12 months. Primary outcome was AHI; secondary outcome was QOL using OSA-18. The device was able to record hours used per week. Six patients (4 male), aged 12-18 years of age were included in the study. At 6-12 months, all 6 patients demonstrated improvement with a 56-85% reduction in AHI with residual AHI in the mild to moderate range. At follow-up, the mean duration of use was 5.6-10 hours per night. All patients demonstrated an improvement in QOL scores. Improved sleep patterns were observed with emergence of REM sleep in 3 patients. Comments 1. HGNS represents an exciting potential therapeutic option for some of the most difficult to treat patients with OSA. 2. Adverse effects included readmission for mild cellulitis of chest requiring antibiotics and one patient was admitted for pain and discomfort requiring narcotics. 3. Data only available for one-year follow-up, long-term efficacy data is required. 4. Highly selected group; there is a need to understand how appli- cable these data would be to an adolescent cohort with other co-morbidities e.g. obesity 5. Expensive, resource intensive therapy and long-term studies will need to address cost-effectiveness. ALTERNATIVES TO CPAP THERAPY FOR CHILDREN WITH PERSISTENT OSA Hawkins S, Huston S, Campbell K, Halbower A. High-Flow, Heated, Humidified Air Via Nasal Cannula Treats CPAP- Intolerant Children With Obstructive Sleep Apnea. J Clin Sleep Med. 2017;13(8):981-9. Summary Continuous positive airway pressure (CPAP) is the mainstay of therapy for persistent OSA. CPAP usage in the pediatric population has increased 3-fold in the past decade. CPAP is an efficacious therapy for OSA but limited by adherence rates of <50% in the pediatric population. This study addresses CPAP alternatives for management of pediatric OSA using high flow nasal cannula therapy (HFNC). Subjects (n=10) intolerant to CPAP (6 males, mean age 10 years and mean BMI percentile 58% were prospectively recruited. Underlying co-morbidities included Down syndrome, craniofacial syndromes and obesity. All subjects had an in sleep-lab HFNC titration study with initial flow of 5 or 15 L/min for pediatric or adult-sized cannula respectively, and titrated until either 1) resolution of OSA or 2) maximum flow rates achieved on HFNC (20 L for pediatric cannula and 50 L for adult cannula). Compared to the diagnostic baseline PSG data, HFNC at optimal flow rates reduced AHI from 11.1 to 2.1 events per hour, reduced the oxygen desaturation index and decreased the maximum tcCO2. However, 4/10 patients required supplemental oxygen despite maximal HFNC flow rates. HFNC may be a promising alternative for CPAP intolerant patients. Comments 1. HFNC is not licensed for the use of OSA treatment in adult or pediatric population. 2. HFNC was well tolerated with no reported adverse events after one night. 3. Unclear whether symptoms of OSA and morbidity associated with OSA disease improves with long-term use of HFNC and a rigor-