Predictors of NIV-related adverse events in children using long-term noninvasive ventilation.

BACKGROUND AND OBJECTIVES: An increasing number of children with diverse medical conditions are using long-term noninvasive ventilation (NIV). This study examined the impact of demographic, clinical, and technology-related factors on long-term NIV adverse events in a large cohort of children using long-term NIV. METHODS: This was a multicenter retrospective review of all children who initiated long-term NIV in the province of Alberta, Canada, from January 2005 to September 2014, and followed until December 2015. Inclusion criteria were children who had used NIV for 3 months or more and had at least one follow-up visit with the NIV programs. RESULTS: We identified 507 children who initiated NIV at a median age of 7.5 (interquartile range: 8.6) years and 93% of them reported at least one NIV-related adverse event during the initial follow-up visit. Skin injury (20%) and unintentional air leaks (19%) were reported more frequently at the initial visit. Gastrointestinal symptoms, midface hypoplasia, increased drooling, aspiration and pneumothorax were rarely reported (<5%). Younger age and underlying conditions such as Down syndrome, achondroplasia, and Duchenne muscular dystrophy were early predictors of unintentional air leak. Younger age also predicted child sleep disruption in the short term and ongoing parental sleep disruption. Obesity was a risk factor for persistent nasal symptoms. Mask type was not a significant predictor for NIV-related short- or long-term complications. CONCLUSIONS: This study demonstrates that NIV-related complications are frequent. Appropriate mask-fitting and headgear adaptation, and a proactive approach to early detection may help to reduce adverse events.

Predictors of longitudinal outcomes for children using long-term noninvasive ventilation.

BACKGROUND: Noninvasive ventilation (NIV) is a first-line therapy for sleep-related breathing disorders and chronic respiratory insufficiency. Evidence about predictors that may impact long-term NIV outcomes, however, is scarce. The aim of this study is to determine demographic, clinical, and technology-related predictors of long-term NIV outcomes. METHODS: A 10-year multicentred retrospective review of children started on long-term continuous or bilevel positive airway pressure (CPAP or BPAP) in Alberta. Demographic, technology-related, and longitudinal clinical data were collected. Long-term outcomes examined included ongoing NIV use, discontinuation due to improvement in underlying conditions, switch to invasive mechanical ventilation (IMV) or death, patient/family therapy declination, transfer of services, and hospital admissions. RESULTS: A total of 622 children were included. Both younger age and CPAP use predicted higher likelihood for NIV discontinuation due to improvement in underlying conditions (p < .05 and p < .01). Children with upper airway disorders or bronchopulmonary dysplasia were less likely to continue NIV (p < .05), while presence of central nervous system disorders had a higher likelihood of hospitalizations (p < .01). The presence of obesity/metabolic syndrome and early NIV-associated complications predicted higher risk for NIV declination (p < .05). Children with more comorbidities or use of additional therapies required more hospitalizations (p < .05 and p < .01) and the latter also predicted higher risk for being switched to IMV or death (p < .001). CONCLUSIONS: Demographic, clinical data, and NIV type impact long-term NIV outcomes and need to be considered during initial discussions about therapy expectations with families. Knowledge of factors that may impact long-term NIV outcomes might help to better monitor at-risk patients and minimize adverse outcomes.

The scope of sleep problems in Canadian children and adolescents with obesity.

OBJECTIVE: To determine the scope of sleep concerns, clinical features, and polysomnography (PSG) results and to identify factors that predict obstructive sleep apnea (OSA) in a cohort of children with obesity. METHODS: The study was a multicenter retrospective chart review. Data were collected from three pediatric sleep laboratories over a two year period for all children of age 8-16 years with a body mass index [BMI] ≥95th centile who were undergoing PSG. Data sources included clinical charts and PSG results. Clinical and PSG factors were examined as predictors of OSA. RESULTS: A total of 210 children met inclusion criteria, and 205 had sufficient data for analysis. The mean age was 12.5 ± 2.7 years; and 65% were male. Multiple sleep concerns and comorbidities were reported in most children (90% and 91%, respectively). OSA was identified by PSG in 44% of children; and 28% of children demonstrated moderate/severe OSA. Mouth breathing/nasal congestion (odds ratio [OR] = 0.33, 95% confidence interval [CI] = 0.18-0.61), syndrome/multiple anomalies (OR = 2.4, 95% CI = 1.22-4.93), and family history of OSA (OR = 2.7, 95% CI = 1.2-5.8) or sleep problems (OR = 12.4, 95% CI = 1.5, 99.6) were the only factors predictive of OSA. Oxygen desaturation index <6 events/h measured by PSG showed an OR of 4.96 (95% CI = 2.27-10.86) for the absence of OSA. CONCLUSIONS: Children with obesity who undergo PSG are medically complex with multiple sleep concerns including a high burden of daytime symptoms; slightly less than half of children demonstrate polysomnographic features of OSA. Earlier identification of OSA, recognition of non-OSA sleep concerns, and treatment strategies to improve sleep may contribute to overall health outcomes for children with obesity.

Longitudinal changes in clinical characteristics and outcomes for children using long-term non-invasive ventilation.

OBJECTIVES: To describe longitudinal trends in long-term non-invasive ventilation (NIV) use in children including changes in clinical characteristics, NIV technology, and outcomes. METHODS: This was a multicenter retrospective cohort of all children started on long-term NIV from 2005 to 2014. All children 0 to 18 years who used NIV continuously for at least 3 months were included. Measures and main outcomes were: 1) Number of children starting NIV; 2) primary medical condition; 3) medical complexity defined by number of comorbidities, surgeries and additional technologies; 4) severity of sleep disordered breathing measured by diagnostic polysomnography; 5) NIV technology and use; 6) reasons for NIV discontinuation including mortality. Data were divided into equal time periods for analysis. RESULTS: A total of 622 children were included in the study. Median age at NIV initiation was 7.8 years (range 0-18 years). NIV incidence and prevalence increased five and three-fold over the 10-year period. More children with neurological and cardio-respiratory conditions started NIV over time, from 13% (95%CI, 8%-20%) and 6% (95%CI, 3%-10%) respectively in 2005-2008 to 23% (95%CI, 18%-28%) and 9% (95%CI, 6%-14%, p = 0.008) in 2011-2014. Medical complexity and severity of the sleep-disordered breathing did not change over time. Overall, survival was 95%; mortality rates, however, rose from 3.4 cases (95% CI, 0.5-24.3) to 142.1 (95% CI 80.7-250.3, p<0.001) per 1000 children-years between 2005-2008 and 2011-2014. Mortality rates differed by diagnostic category, with higher rates in children with neurological and cardio-respiratory conditions. CONCLUSIONS: As demonstrated in other centers, there was a significant increase in NIV prevalence and incidence rate. There was no increase in medical complexity or severity of the breathing abnormalities of children receiving long-term NIV over time. The mortality rate increased over time, maybe attributable to increased use of NIV for children with neurological and cardio-respiratory conditions.

Long-term non-invasive ventilation therapies in children: A scoping review.

Long-term non-invasive ventilation (NIV) is a common modality of breathing support used for a range of sleep and respiratory disorders. The aim of this scoping review was to provide a summary of the literature relevant to long-term NIV use in children. We used systematic methodology to identify 11,581 studies with final inclusion of 289. We identified 76 terms referring to NIV; the most common term was NIV (22%). Study design characteristics were most often single center (84%), observational (63%), and retrospective (54%). NIV use was reported for 73 medical conditions with obstructive sleep apnea and spinal muscular atrophy as the most common conditions. Descriptive data, including NIV incidence (61%) and patient characteristics (51%), were most commonly reported. Outcomes from sleep studies were reported in 27% of studies followed by outcomes on reduction in respiratory morbidity in 19%. Adverse events and adherence were reported in 20% and 26% of articles respectively. Authors reported positive conclusions for 73% of articles. Long-term use of NIV has been documented in a large variety of pediatric patient groups with studies of lower methodological quality. While there are considerable data for the most common conditions, there are fewer data to support NIV use for many additional conditions.

Polysomnography for the diagnosis of sleep disordered breathing in children under 2 years of age.

OBJECTIVES: To describe clinical polysomnography (PSG) results, sleep physicians' diagnosis, and treatment of sleep disorder breathing in children less than 2 years of age. STUDY DESIGN: Retrospective clinical chart review at a pediatric tertiary care center, pediatric sleep laboratory. SUBJECT SELECTION: Children less than 2 years of age who underwent clinical PSG over a 3-year period. METHODOLOGY: PSG results and physician interpretations were identified for inclusions. Children were excluded if either PSG results or physician interpretations were unavailable for review. Infants were classified in three age groups for comparison: <6 months, 6-12 months, and >12 months. RESULTS: Matched records were available for 233 PSGs undertaken at a mean age 11.1 ± 7.0 months; 31% were <6 months, 23% were 6-12 months, and 46% were 12-24 months of age. Infants <6 months showed significant differences on sleep parameters and respiratory indicators compared to other groups. Compared to physician sleep disordered breathing (SDB) classification, current pediatric apnea-hypopnea index (AHI)-based SDB severity classification overestimated SDB severity. Age and obstructive-mixed AHI (OMAHI) were most closely associated with physician identification of SDB. CONCLUSION: Children <6 months of age appear to represent a distinct group with respect to PSG. Experienced sleep physicians appear to incorporate age and respiratory event frequently when determining the presence of SDB. Further information about clinical significance of apnea in infancy is required, assisted by identification of factors that sleep physicians use to identify SDB in children <6 months of age.