Upper airway obstruction in neonates: Does sleep exacerbate symptoms?

Abstract

ObjectiveDescribe the factors that exacerbate upper airway obstructions (UAOs) in neonates.Study DesignRetrospective chart review.SettingPediatric tertiary care hospital.Subjects and MethodsAll neonates hospitalized between 1/1/2010 and 12/31/2014 diagnosed with either: 1) laryngomalacia, 2) Pierre Robin sequence, or 3) vocal cord paralysis were included in this study. Patient charts were reviewed to determine factors that exacerbated symptoms of airway obstruction. The independent variable was patient diagnosis, and the outcome measure was exacerbating factors.ResultsIn patients with laryngomalacia (n = 31), 41.9% worsened with agitation, 38.7% worsened with feeding, 16.1% worsened with positioning, 0.0% worsened during sleep, and 25.8% had no aggravating factors. In Pierre‐Robin patients (n = 31), 48.4% worsened with agitation, 16.1% worsened with feeding, 61.3% worsened with positional changes, 0.0% worsened during sleep, and 12.9% had no aggravating factors. In vocal cord paralysis patients (n = 25), 72.0% worsened with agitation, 8.0% worsened with feeding, 20.0% worsened with positional changes, 4.0% worsened during sleep, and 24.0% had no aggravating factors.ConclusionAirway obstruction was not reliably exacerbated during sleep for any of the diagnoses studied in this review. Our findings show that agitation exacerbates airway obstruction in most patients with vocal cord paralysis, and positioning exacerbates airway obstruction in the majority of patients with PRS. Aggravating factors in laryngomalacia are variable. These findings question the utility of polysomnography as a diagnostic tool for hospitalized neonates with these conditions.Level of Evidence4.

Unplanned Intensive Care Unit Admission Following Cleft Palate Repair by Head and Neck Surgeons

“…Two of the 6 surgeons routinely used tongue stitches postoperatively, and these stiches were removed early in the postoperative course, either before the patient left the operating room or hours later at the time of postoperative check by the resident staff. Preoperative sleep studies were not routinely performed on infants with cleft palate who otherwise lacked symptoms of airway obstruction, as the utility of using polysomnography (PSG) in this specific age group and population is subject to debate 12 . However, when possible, preoperative PSG was performed prior to palate repair for any patient with sleep disorder breathing.…”

“…Preoperative sleep studies were not routinely performed on infants with cleft palate who otherwise lacked symptoms of airway obstruction, as the utility of using polysomnography (PSG) in this specific age group and population is subject to debate. 12 However, when possible, preoperative PSG was performed prior to palate repair for any patient with sleep disorder breathing. To align with the primary objective to assess PICU admission related to palate repair, and because many patients had intentional delays of repair due to comorbidities, all patients under 5 years old who underwent primary cleft palate repair were included in the analysis.…”

Detection of Chronic Hypoventilation Among Infants With Robin Sequence Using Capillary Blood Gas Sampling

“…5,6 Normative values for neonatal PSG are still debated, and PSG, which assesses for airway obstruction during sleep alone, may overlook dynamic airway obstruction which manifests during periods of activity. 7,8 One of the objective parameters measured by PSG is end-tidal carbon dioxide. Obstructive hypoventilation, defined as hypercapnea (PaCO 2 > 50 mmHg) present for more than 25% of total sleep time in association with other clinical sleep disordered breathing findings, is a defining feature of obstructive sleep apnea (OSA) in children.…”

“…However, some of these techniques have been criticized as subjective or nonstandardized; moreover, not every institution has resources available for obtaining accurate PSG data on newborns 5,6 . Normative values for neonatal PSG are still debated, and PSG, which assesses for airway obstruction during sleep alone, may overlook dynamic airway obstruction which manifests during periods of activity 7,8 …”