OBJECTIVES. Positive airway pressure therapy (PAP) is frequently used to treat children who have obstructive sleep apnea syndrome and do not respond to adenotonsillectomy. However, no studies have evaluated objectively adherence to PAP in children, and few studies have evaluated objectively the effectiveness of PAP. The objective of this study was to determine adherence and effectiveness of PAP (both continuous [CPAP] and bilevel [BPAP] pressure) in children with obstructive apnea.METHODS. A prospective, multicenter study was performed of children who were randomly assigned in a double-blind manner to 6 months of CPAP versus BPAP. Adherence was measured objectively using the equipment's computerized output. Effectiveness was evaluated using polysomnography.RESULTS. Twenty-nine children were studied. Approximately one third of children dropped out before 6 months. Of the 21 children for whom 6-month adherence data could be downloaded, the mean nightly use was 5.3 Ϯ 2.5 (SD) hours. Parental assessment of PAP use considerably overestimated actual use. PAP was highly effective, with a reduction in the apnea hypopnea index from 27 Ϯ 32 to 3 Ϯ 5/hour, and an improvement in arterial oxygen saturation nadir from 77 Ϯ 17% to 89 Ϯ 6%. Results were similar for children who received CPAP versus BPAP. Children also had a subjective improvement in daytime sleepiness.CONCLUSIONS. Both CPAP and BPAP are highly efficacious in pediatric obstructive apnea. However, treatment with PAP is associated with a high dropout rate, and even in the adherent children, nightly use is suboptimal considering the long sleep hours in children. T HE OBSTRUCTIVE SLEEP apnea syndrome (OSAS) affects ϳ2% of children. 1 The pathogenesis of childhood OSAS is multifactorial. Contributing factors include anatomic narrowing (as a result of both soft tissue and craniofacial structure) and abnormal upper airway neuromotor control. 2 In most children with OSAS, the primary factor that leads to the upper airway obstruction is adenotonsillar hypertrophy, and OSAS can be treated effectively with tonsillectomy and adenoidectomy. 3 However, in a small number of children in whom additional anatomic factors (including obesity) or abnormal upper airway neuromotor tone is the predominant cause for OSAS, OSAS persists postoperatively. 4 In these children, continuous positive airway pressure (CPAP) is usually used as the second line of treatment. 5 Although home CPAP use has been reported in Ͼ300 children of all ages, 5-7 it is not yet approved by the Food and Drug Administration (FDA) for use in children who weigh Ͻ30 kg. Furthermore, few studies have evaluated the effectiveness of positive airway pressure (PAP) therapy in children, and no prospective studies have evaluated objective measures of adherence in the pediatric age group. We therefore conducted a multicenter, prospective study of PAP therapy in children with OSAS. The objectives of this study were to assess objectively adherence to and effectiveness of PAP in children. In addition, we sought in a r...

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Obstructive sleep apnea syndrome (OSA) affects 1%-3% of children. Children with OSA can present for all types of surgical and diagnostic procedures requiring anesthesia, with adenotonsillectomy being the most common surgical treatment for OSA in the pediatric age group. Thus, it is imperative that the anesthesiologist be familiar with the potential anesthetic complications and immediate postoperative problems associated with OSA. The significant implications that the presence of OSA imposes on perioperative care have been recognized by national medical professional societies. The American Academy of Pediatrics published a clinical practice guideline for pediatric OSA in 2002, and cited an increased risk of anesthetic complications, though specific anesthetic issues were not addressed. In 2006, the American Society of Anesthesiologists published a practice guideline for perioperative management of patients with OSA that noted the pediatric-related risk factor of obesity, and the increased perioperative risk associated with adenotonsillectomy in children younger than 3 yr. However, management of OSA in children younger than 1 yr-of-age was excluded from the guideline, as were other issues related specifically to the pediatric patient. Hence, many questions remain regarding the perioperative care of the child with OSA. In this review, we examine the literature on pediatric OSA, discuss its pathophysiology, current treatment options, and recognized approaches to perioperative management of these young and potentially high-risk patients.

Regulation of arterial oxygen levels is critically important in mammals, particularly during early life. Peri-and postnatal hypoxia may lead to impaired cognitive development, abnormalities in cardiovascular function, breathing control maturation and lung function, and death (Okubo & Mortola, 1988;Nyakas et al. 1996;Hudlicka & Brown, 1996). The main sensors of arterial Oµ tension are the carotid body chemoreceptors, which are located bilaterally at the bifurcations of the common carotid arteries. Carotid chemoreceptor sensory afferents, via the carotid sinus nerves (CSN), project to the nucleus tractus solitarii and other brainstem nuclei, providing the major source of Oµ-mediated ventilatory drive. Neural signals from the carotid chemoreceptors to brainstem cardiorespiratory control nuclei also mediate critically important respiratory reflexes such as arousal from sleep during hypoxia and cardiovascular reflexes that modulate heart rate and blood pressure (Marshall, 1987). The primary site of oxygen sensing in the carotid body is thought to be the type I cell (Gonzalez et al. 1994). Type I cells are specialized sensory neurons which depolarize in response to low Oµ, resulting in Ca¥ entry via voltage-gated calcium channels, and exocytosis of neurotransmitters and modulators onto apposed CSN terminals (Gonzalez et al. 1994). Although further study is needed to define their precise role, there is little question that type I cells play a crucial role in carotid chemoreceptor oxygen sensing. Carotid denervation, which is well tolerated by adults, in neonates leads to profound abnormalities of respiratory control and high mortality rates. In piglets and in lambs the

PITA cures otherwise healthy children with obstructive sleep apnea of moderate severity, at least in the short-term, as documented by postoperative polysomnography. Improvements in quality of life measures, as documented by changes in OSA-18, were seen in all children as well.

The site of postnatal maturation of carotid body chemoreception is unclear. To test the hypothesis that maturation occurs synchronously in type I cells and the whole carotid body, the development of changes in the intracellular Ca2+ concentration responses to hypoxia, CO2, and combined challenges was studied with fluorescence microscopy in type I cells and compared with the development of carotid sinus nerve (CSN) responses recorded in vitro from term fetal to 3-wk animals. Type I cell responses to all challenges increased between 1 and 8 days and then remained constant, with no multiplicative O2-CO2interaction at any age. The CSN response to hypoxia also matured by 8 days, but CSN responses to CO2 did not change significantly with age. Multiplicative O2-CO2interaction occurred in the CSN response at 2–3 wk but not in younger groups. We conclude that type I cell maturation underlies maturation of the CSN response to hypoxia. However, because development of responses to CO2 and combined hypoxia-CO2 challenges differed between type I cells and the CSN, responses to these stimuli must mature at other, unidentified sites within the developing carotid body.

Summary Objective To determine the utility of overnight polysomnography (PSG) in assessing pulmonary reserve in stable preterm children with chronic lung disease (CLD). Study design: A retrospective review and descriptive study of overnight PSGs and clinic visits of preterm infants/children less than 3 years of age who were diagnosed with bronchopulmonary dysplasia at discharge from the hospital and enrolled in the Johns Hopkins CLD patient registry between 2008 and 2010. Results Sixty-two clinically stable patients underwent at least one overnight polysomnogram for clinical indications. The majority of patients were referred for oxygen titration (71%). PSGs from first studies revealed a mean respiratory disturbance index (RDI) of 8.2 ± 10.1 events/hr and a mean O2 saturation (SaO2) nadir of 86.2 ± 5.7%. In patients who underwent more than one PSG (n = 23), a significant decrease in RDI (P < 0.001) was found between the first study (mean age: 8.0 ± 3.3 months) and second study (mean age: 13.4 ± 5.2 months). Outpatient clinical measures of mean room air SaO2 and respiratory rate were not predictive of PSG measures of RDI and SaO2 nadir. Conclusion Mean RDI was higher in stable preterm infants/children with CLD compared to previously published controls. RDI decreased with age in stable preterm infants/children with CLD suggesting improved pulmonary reserve with age. Outpatient clinical measures (respiratory rate and room air SaO2) did not correlate with RDI and SaO2 nadir indicating that overnight PSG is more sensitive in assessing pulmonary reserve than outpatient clinical measures.