Practice Parameters for the Respiratory Indications for Polysomnography in Children

Aurora, R. Nisha; R, Zák; Karippot, Anoop; Lamm, Carin; Morgenthaler, Timothy I.; Auerbach, Sanford H.; Bista, Sabin R.; Casey, Kenneth R.; Chowdhuri, Susmita; Kristo, David A.; Ramar, Kannan

doi:10.1093/sleep/34.3.379

Cited by 377 publications

(259 citation statements)

References 148 publications

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“…39,[47][48][49] comprehensive clinical history and physical examination. 50 Symptoms of OSA, which may be subtle or absent in infants, include snoring, noisy respirations, labored breathing, mouth breathing, and profuse sweating. 51 Occasionally, infants with OSA will present with failure to thrive, witnessed apnea, and/ or developmental delay.…”

Section: E Clinicians Should Not Obtain Anmentioning

confidence: 99%

Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants

Tieder¹,

Bonkowsky²,

Etzel³

et al. 2016

Pediatrics

135

154

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This is the fi rst clinical practice guideline from the American Academy of Pediatrics that specifi cally applies to patients who have experienced an apparent life-threatening event (ALTE). This clinical practice guideline has 3 objectives. First, it recommends the replacement of the term ALTE with a new term, brief resolved unexplained event (BRUE). Second, it provides an approach to patient evaluation that is based on the risk that the infant will have a repeat event or has a serious underlying disorder. Finally, it provides management recommendations, or key action statements, for lower-risk infants. The term BRUE is defi ned as an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now resolved episode of ≥1 of the following: (1) cyanosis or pallor; (2) absent, decreased, or irregular breathing; (3) marked change in tone (hyper-or hypotonia); and (4) altered level of responsiveness. A BRUE is diagnosed only when there is no explanation for a qualifying event after conducting an appropriate history and physical examination. By using this defi nition and framework, infants younger than 1 year who present with a BRUE are categorized either as (1) a lower-risk patient on the basis of history and physical examination for whom evidence-based recommendations for evaluation and management are offered or (2) a higher-risk patient whose history and physical examination suggest the need for further investigation and treatment but for whom recommendations are not offered. This clinical practice guideline is intended to foster a patient-and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient outcomes, support implementation, and provide direction for future research. Each key action statement indicates a level of evidence, the benefi t-harm relationship, and the strength of recommendation.

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Section: E Clinicians Should Not Obtain Anmentioning

confidence: 99%

Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants

Tieder¹,

Bonkowsky²,

Etzel³

et al. 2016

Pediatrics

135

154

View full text Add to dashboard Cite

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“…After decannulation, while overnight observation with pulse oximetry is usually recommended, the use of polysomnography is not systematically addressed in the literature; the American Academy of Sleep Medicine recommends clinical assessment for recurrence of sleep related breathing disorders. [8][9][10] However, polysomnography permits robust documentation of oximetry, respiratory distress, airway obstruction, and sleepspecific events after decannulation. In this case, polysomnography allowed demonstration of obstructive sleep apnea due to extrathoracic tracheomalacia and resolution with treatment.…”

Section: Discussionmentioning

confidence: 99%

Obstructive Sleep Apnea Due To Extrathoracic Tracheomalacia

Muzumdar

Nandalike

Bent³

et al. 2013

Journal of Clinical Sleep Medicine

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We report obstructive sleep apnea in a 3-year-old boy with tracheomalacia secondary to tracheotomy that resolved after placement of a metallic stent in the region of tracheomalacia. The tracheal location of obstruction during sleep in this case contrasts with the usual location in the pharynx or, less often, the larynx. This case also demonstrates the utility of polysomnography in managing decannulation of tracheostomies. keywords: Obstructive sleep apnea, polysomnography, stent, tracheomalacia, tracheostomy Citation: Muzumdar H; Nandalike K; Bent J; Arens R. Obstructive sleep apnea due to extrathoracic tracheomalacia. J Clin Sleep Med 2013;9(2):163-164.http://dx.doi.org/10.5664/jcsm.2418 C a S E R E p o R t ST he site of obstruction in obstructive sleep apnea (OSA) is the pharynx or, less often, the larynx. We describe a case of OSA secondary to localized extrathoracic tracheomalacia with resolution of OSA after airway stent placement. REpoRt oF CaSEA 30-month-old boy with mild developmental delay who had undergone tracheotomy for the management of chronic lung disease of prematurity was referred for decannulation of tracheotomy. Previous attempts had resulted in acute airway obstruction. His airway evaluation revealed nasal synechiae, adenotonsillar hypertrophy, mild subglottic narrowing, and signifi cant suprastomal tracheal collapse from the cricoid to the stoma. Adenotonsillectomy was performed at age 36 months.Two months later, stabilization of tracheomalacia by placing suspension sutures between the suprastomal region and the sternum was not adequate, and dyspnea with inspiratory stridor persisted. Thyroid cartilage was therefore grafted in the area of tracheomalacia.Following these procedures, during wakefulness, he had comfortable breathing at rest with oxygen saturations of 98% and had mild intermittent stridor and respiratory distress with excitement. However, during sleep he had hypoxemia, stridor, and notable respiratory distress. Polysomnography on postoperative day 10 demonstrated severe respiratory distress, snoring, and paradoxical breathing with an apnea hypopnea index (AHI) of 6.1/h (mostly obstructive events), fragmented sleep (29 arousals/h), oxygen desaturations to 75%, and a peak end-tidal CO 2 of 63 torr. Most obstructive events occurred in REM sleep. Bronchoscopy demonstrated dynamic suprastomal collapse with 50% narrowing in the area of reconstruction (Figure 1).A 2-cm long, 12-mm diameter, nickel-titanium alloy airway stent was placed in the region of tracheomalacia to manage the residual tracheal obstruction because of the potential to worsen in the setting of exercise and respiratory infections (Figure 1) AHI of 2.5/h, predominantly central apneas, 9.8 arousals/h, and a few desaturations, mostly related to central apneas.Three months later the AHI was 0.1/h, with 4 arousals/h and no desaturations. Bronchoscopy demonstrated a well-epithelialized stent in good position (Figure 1). More than 24 months later, the child has no reported obstructive symptoms. diSCuSSioNTracheomalacia refers...

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“…The most pertinent available literature comprised the Childhood Adenotonsillectomy (CHAT) study, as well as statements and guidelines from the American Academy of Pediatrics (AAP), AASM, and American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). 1,2,[4][5][6][7] The titles and abstracts of all articles were reviewed by two Workgroup members for any relevant literature on childhood OSA. Any disagreements about whether to include a particular reference were resolved by a third Workgroup member.…”

Section: Literature Reviewmentioning

confidence: 99%

“…1,2,4,5,7 Three groups of health care providers (pediatricians, otolaryngologists, and sleep medicine specialists) are closely involved in the evaluation and management of children with OSA. Each group has recently published evidence-based clinical practice guidelines 1,2,5,7-9 that differ somewhat in their recommendations regarding the role of polysomnography (PSG) in the diagnostic evaluation of childhood OSA.…”

Section: Measure Selectionmentioning

confidence: 99%

“…1 The AASM identified certain conditions associated with an elevated prevalence of pediatric OSA in the Practice Parameters for the Respiratory Indications for Polysomnography in Children. 4 These include obesity, Down syndrome, Prader-Willi syndrome, neuromuscular disorders, Chiari malformations and myelomeningocele, and craniofacial anomalies that obstruct the upper airway (including achondroplasia and Pierre Robin sequence), history of prematurity, allergic rhinitis, African American race, and family history of OSA. Furthermore, OSA was identified as an independent risk factor for hypertension.…”

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confidence: 99%

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Quality Measures for the Care of Pediatric Patients with Obstructive Sleep Apnea

Kothare

Rosen

Lloyd

et al. 2015

Journal of Clinical Sleep Medicine

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The Board of Directors of the American Academy of Sleep Medicine (AASM) commissioned a Task Force to develop quality measures as part of its strategic plan to promote high quality patient-centered care. Among many potential dimensions of quality, the AASM requested Workgroups to develop outcome and process measures to aid in evaluating the quality of care of fi ve common sleep disorders: insomnia, obstructive sleep apnea in adults, obstructive sleep apnea in children, restless legs syndrome, and narcolepsy. This paper describes the rationale, background, general methods development, and considerations in implementation of these quality measures in obstructive sleep apnea (OSA) in children. This document describes measurement methods for fi ve desirable process measures: assessment of symptoms and risk factors of OSA, initiation of an evidence-based action plan, objective evaluation of high-risk children with OSA by obtaining a polysomnogram (PSG), reassessment of signs and symptoms of OSA within 12 months, and documentation of objective assessment of positive airway pressure adherence. When these fi ve process measures are met, clinicians should be able to achieve the two defi ned outcomes: improve detection of childhood OSA and reduce signs and symptoms of OSA after initiation of a management plan. The AASM recommends the use of these measures as part of quality improvement programs that will enhance the ability to improve care for patients with childhood OSA. O bstructive sleep apnea (OSA) is a disorder of breathing during sleep in which episodic upper airway collapse disrupts ventilation and leads to oxyhemoglobin desaturation and poor sleep quality. It is a common condition in childhood, with a prevalence rate of 1% to 5%, which can result in a range of adverse health outcomes if left untreated.1,2 Childhood OSA is associated with neurocognitive impairment, behavioral problems, failure to thrive, hypertension, cardiac dysfunction, systemic infl ammation, and increased health care costs. Risk factors include adenotonsillar hypertrophy, obesity, craniofacial anomalies, and neuromuscular disorders. Increases in pediatric obesity rates have markedly increased the risk of OSA in children. Symptoms include habitual snoring (often with intermittent pauses, snorts, or gasps), disturbed sleep, and daytime neurobehavioral problems. In contrast to OSA in adults, daytime sleepiness is not usually obvious in young children. Although there are many similarities, distinctions must be made between adult and pediatric (defi ned as birth to 18 years of age) OSA, especially in terms of key risk factors and treatment. In children, adenotonsillar hypertrophy is the most common cause for OSA and adenotonsillectomy (AT) is recommended as the fi rst-line treatment. 1,2Since the pathophysiology and treatment of pediatric OSA is quite different from adult OSA, the AASM thought it would be important to develop separate quality measures to assess the processes and outcomes unique to children. This Pediatric OSA Quality Measures Workgro...

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Practice Parameters for the Respiratory Indications for Polysomnography in Children

Cited by 377 publications

References 148 publications

Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants

Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants

Obstructive Sleep Apnea Due To Extrathoracic Tracheomalacia

Quality Measures for the Care of Pediatric Patients with Obstructive Sleep Apnea

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