Morning Blood Pressure is Associated with Sleep Quality in Obese Adolescents

Objective To examine relationships between blood pressure (BP), adiposity, and sleep quality using overnight polysomnography (PSG) in obese adolescents. Study design Overnight PSG and morning BP measurements were performed in obese (BMI >97th %ile) non-diabetic adolescents (eligible age range 12-18 years, n=49). Subjects were stratified into two groups, one with normal BP, and one with elevated BP, and demographic and clinical characteristics compared between the groups. Multiple linear regression analysis was used to assess the BP effects of sleep quality measures. Results Participants (n=27) had normal morning BP, and 22 (44.9%) had elevated morning BP. There were no differences in age (p=0.53), sex (p=0.44), race (p=0.58) or BMI (p=0.56) between the two BP groups. The group with elevated BP spent shorter percentages of time in rapid eye movement (REM; p=0.006) and slow-wave sleep (SWS; p=0.024). Multiple linear regression analysis showed a lower percent of both REM and SWS were associated with increased morning BP, after adjusting for pubertal stage, sex, race, and BMI. Conclusion Lack of deeper stages of sleep, REM sleep and SWS, is associated with higher morning BP in obese adolescents, independent of BMI. Poor sleep quality should be considered in the work-up of obese youth with hypertension. Intervention studies are needed to evaluate whether improving the quality of sleep will reduce blood pressure elevation

Effect of CPAP on airway reactivity and airway inflammation in children with moderate-severe asthma

BACKGROUND AND OBJECTIVE: Asthma is characterized by airway hyperreactivity and airway inflammation. We previously demonstrated that adults with mild well-controlled asthma exhibited a marked decrease in airway reactivity (PC20 increased >2-fold) after using nocturnal continuous positive airway pressure (CPAP) for 1 week. If CPAP produces a similar suppression of airway reactivity in children with moderate-severe asthma, who require chronic use of corticosteroids, then this non-pharmacological therapy might provide a beneficial alternative or supplemental therapy in these subjects. METHODS: Children aged 8-17 years with moderate-severe asthma were treated with 4 weeks of nocturnal CPAP (8-10 cm H2 O) or sham CPAP (<2 cm H2 O). Adherence was monitored with a modem installed in the equipment or by memory cards. Airway reactivity, assessed by methacholine bronchial challenge, was measured prior to and following treatment. RESULTS: The percentage of subjects adherent to treatment was similar in both groups (19/27 CPAP vs 19/28 sham, ~70%). There was a tendency for PC20 to increase with treatment in both groups (3.0-5.3 mg/mL CPAP vs 3.2 to 4.3 mg/mL sham, P = 0.083); however, the change did not differ significantly between groups (P = 0.569). CONCLUSION: We found that the 4-week treatment with nocturnal CPAP did not produce a twofold suppression of airway reactivity in children with moderate-severe asthma

Clinical identification of feeding and swallowing disorders in 0-6 month old infants with Down syndrome

Feeding and swallowing disorders have been described in children with a variety of neurodevelopmental disabilities, including Down syndrome (DS). Abnormal feeding and swallowing can be associated with serious sequelae such as failure to thrive and respiratory complications, including aspiration pneumonia. Incidence of dysphagia in young infants with DS has not previously been reported. To assess the identification and incidence of feeding and swallowing problems in young infants with DS, a retrospective chart review of 174 infants, ages 0-6 months was conducted at a single specialty clinic. Fifty-seven percent (100/174) of infants had clinical concerns for feeding and swallowing disorders that warranted referral for Videofluroscopic Swallow Study (VFSS); 96/174 (55%) had some degree of oral and/or pharyngeal phase dysphagia and 69/174 (39%) had dysphagia severe enough to warrant recommendation for alteration of breast milk/formula consistency or nonoral feeds. Infants with certain comorbidities had significant risk for significant dysphagia, including those with functional airway/respiratory abnormalities (OR = 7.2). Infants with desaturation with feeds were at dramatically increased risk (OR = 15.8). All young infants with DS should be screened clinically for feeding and swallowing concerns. If concerns are identified, consideration should be given to further evaluation with VFSS for identification of dysphagia and additional feeding modifications

Polysomnography Reference Values in Healthy Newborns

Study objectives: Polysomnography (PSG) is increasingly used in the assessment of infants. Newborn PSG reference values based on recent standardization are not available. This study provides reference values for PSG variables in healthy newborn infants. Methods: Cross-sectional study of normal term newborn infants using standardized PSG collection and American Academy of Sleep Medicine interpretation criteria. Results: Thirty infants born between 37 and 42 weeks gestation underwent PSG testing before 30 days of age (mean 19.6 days). The infants had a mean sleep efficiency of 71% with average proportions of transitional, NREM and REM sleep estimated at 16.1%, 43.3% and 40.6% respectively. Mean arousal index was 14.7 events/h with respiratory arousal index of 1.2 events/h. Mean apnea-hypopnea index (AHI) was 14.9 events/h. Central, obstructive, and mixed apnea indices were 5.4, 2.3, and 1.2 events/h respectively. Mean oxygen saturation in sleep was 97.9% with a nadir of 84.4%. Mean end tidal CO2 was 35.4 mmHg with an average of 6.2% of sleep time spent above end-tidal CO2 45 mmHg and 0.6% above 50 mmHg. Conclusions: The sleep efficiency was significantly lower and the AHI was significantly higher compared to healthy children older than 1 year. The AHI was also higher than reported in healthy infants older than 1 month. These findings suggest current severity classifications of sleep apnea may not apply to newborn infants

Retrospective Analysis of Factors Leading to Pediatric Tracheostomy Decannulation Failure. A Single-Institution Experience

RATIONALE: There is a lack of evidence regarding factors associated with failure of tracheostomy decannulation. OBJECTIVES: We aimed to identify characteristics of pediatric patients who fail a tracheostomy decannulation challenge Methods: A retrospective review was performed on all patients who had a decannulation challenge at a tertiary care center from June 2006 to October 2013. Tracheostomy decannulation failure was defined as reinsertion of the tracheostomy tube within 6 months of the challenge. Data on demographics, indications for tracheostomy, home mechanical ventilation, and comorbidities were collected. Data were also collected on specific airway endoscopic findings during the predecannulation bronchoscopy and airway surgical procedures before decannulation. We attempted to predict the decannulation outcome by analyzing associations. MEASUREMENTS AND MAIN RESULTS: 147 of 189 (77.8%) patients were successfully decannulated on the first attempt. Tracheostomy performed due to chronic respiratory failure decreased odds for decannulation failure (odds ratio = 0.34, 95% confidence interval = 0.15-0.77). Genetic abnormalities (45%) and feeding dysfunction (93%) were increased in the population of patients failing their first attempt. The presence of one comorbidity increased the odds of failure by 68% (odds ratio = 1.68, 95% confidence interval = 1.23-2.29). Decannulation pursuit based on parental expectation of success, rather than medically determined readiness, was associated with a higher chance of failure (P = 0.01). CONCLUSIONS: Our study highlights the role of genetic abnormalities, feeding dysfunction, and multiple comorbidities in patients who fail decannulation. Our findings also demonstrate that the outcome of decannulation may be predicted by the indication for tracheostomy. Patients who had tracheostomy placed for chronic respiratory support had a higher likelihood of success. Absence of a surgically treatable airway obstruction abnormality on the predecannulation bronchoscopy increased the chances of success

Characteristics of Obstructive Sleep Apnea Across the Spectrum of Glucose Tolerance in Obese Adolescents

BackgroundIt is not known if dysglycemia and sleep-disordered breathing are linked in adolescents, as in adults.ObjectiveTo perform a pilot study evaluating measures of sleep-disordered breathing across the spectrum of glucose tolerance in obese adolescents. We hypothesized that dysglycemia would be associated with sleep-disordered breathing.Participants/methodsThis was a prospective, cross-sectional clinical pilot study that included 57 adolescents [body mass index (BMI) 38.9 ± 8.4 kg/m2] aged 12–18 years (14.5 ± 1.6) with normal glucose tolerance (NGT), or dysglycemia [impaired glucose tolerance (IGT) or type 2 diabetes (T2D)].MeasuresAnthropometrics, overnight polysomnogram, and oral glucose tolerance tests were performed. Participant characteristics and outcome measures were compared by glucose tolerance status. Correlational analyses were conducted to assess the associations between variables of interest.ResultsParticipants with dysglycemia (n = 21) were not different from those with NGT (n = 36) for BMI, waist circumference, body fat, or sleep characteristics. Nocturnal oxygen desaturation was associated with higher BMI (r = −0.334, p = 0.012). The apnea–hypopnea index (AHI) was not associated with physical and metabolic parameters. Although participants with dysglycemia tended to have higher AHIs (median 3.2, 2.2, and 1.6 events/h for T2D, IGT, and NGT, respectively), there was not a linear relationship between measures of glycemia and AHI.ConclusionFurther study with a larger proportion of youth with prediabetes and T2D is necessary to determine whether evaluation for sleep-disordered breathing is uniformly warranted

Use of Polysomnography to Assess Safe Decannulation in Children

Background Tracheostomy is a lifesaving procedure to secure the airway and provide respiratory support. The decision to decannulate has classically been an individual physician decision without consensus among experts. The objective of this retrospective study was to assess the safety and efficacy of a standard institutional protocol that utilizes the sleep laboratory to assist in the decannulation process. Methods Between 2006 and 2013, patients were identified using a clinical database of decannulation studies. A protocol, finalized in 2005, was implemented for each decannulation attempt. In brief, all patients eligible for decannulation based on physician's assessment undergoes bronchoscopy. Once bronchoscopy findings reveal that the patient's airway is free of significant obstruction, decannulation is conducted in the sleep laboratory. The stoma is covered by an occlusive dressing and respiratory parameters are measured awake and asleep during the day and overnight by polysomnogram (PSG). The patient undergoes re-cannulation if the study shows significant obstruction, hypoventilation, or prolonged desaturation. Results A total of 210 decannulation attempts were performed on 189 patients (16 patients had multiple attempts). One hundred sixty-seven (79.5%) decannulation attempts were successful. Of those successfully decannulated, four (2.4%) were recannulated within 6 months. PSG parameters, specifically the apnea-hypopnea index, percent of total sleep time with oxygen saturation levels less than 90%, and lowest oxygen saturation levels were significantly associated with successful decannulation. No deaths occurred. Conclusions We present a safe and successful decannulation protocol that includes bronchoscopy coupled with PSG evaluation of the patient with the stoma decannulated and covered by an occlusive dressing