CPAP for pediatric obstructive sleep apnea
- Ann C Halbower, MD
Ann C Halbower, MD
- Professor, Pediatric Pulmonary Section
- University of Colorado School of Medicine and Children's Hospital Colorado
Continuous positive airway pressure (CPAP) therapy is one of several options for treatment of obstructive sleep apnea (OSA) in children. The goals of CPAP therapy are to ensure unobstructed breathing, good sleep quality, improved daytime function, and in some cases, rest from work of breathing. CPAP can be used temporarily between facial surgeries, while the child grows, or chronically in the presence of a craniofacial malformation or other anatomical predisposition for obstruction . When started early in the course of OSA, CPAP therapy should mitigate the associated cardiovascular risk.
The challenges of CPAP titration in children are illustrated by the following vignette: A six-year-old obese male with OSA undergoes CPAP titration. The sleep technologist increases the pressure progressively from 6 to 15 cm H20 pressure with continued signs of paradoxical breathing, snoring, gasping, and increased leak measured on the polysomnogram (waveform 1). The technologist then switches the mode to bilevel ventilation with no change in the respiratory distress. The child arouses frequently and wakes up crying refusing to complete the study. What was the cause of failure in this CPAP titration?
This topic review will discuss a proactive approach to initiating CPAP therapy in children, including desensitization, equipment selection, promoting adherence to therapy, and troubleshooting problems. Other issues related to OSA in children are discussed in the following topic reviews:To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Lal C, White DR, Joseph JE, et al. Sleep-disordered breathing in Down syndrome. Chest 2015; 147:570.
- Smith PL, Wise RA, Gold AR, et al. Upper airway pressure-flow relationships in obstructive sleep apnea. J Appl Physiol (1985) 1988; 64:789.
- Huang J, Pinto SJ, Yuan H, et al. Upper airway collapsibility and genioglossus activity in adolescents during sleep. Sleep 2012; 35:1345.
- Dedhia RC, Rosen CA, Soose RJ. What is the role of the larynx in adult obstructive sleep apnea? Laryngoscope 2014; 124:1029.
- Limeira AB, Aguiar CM, de Lima Bezerra NS, Câmara AC. Association between breastfeeding and the development of breathing patterns in children. Eur J Pediatr 2013; 172:519.
- Labbok MH, Hendershot GE. Does breast-feeding protect against malocclusion? An analysis of the 1981 Child Health Supplement to the National Health Interview Survey. Am J Prev Med 1987; 3:227.
- Löfstrand-Tideström B, Thilander B, Ahlqvist-Rastad J, et al. Breathing obstruction in relation to craniofacial and dental arch morphology in 4-year-old children. Eur J Orthod 1999; 21:323.
- Zicari AM, Duse M, Occasi F, et al. Cephalometric pattern and nasal patency in children with primary snoring: the evidence of a direct correlation. PLoS One 2014; 9:e111675.
- Huang YS, Guilleminault C. Pediatric obstructive sleep apnea and the critical role of oral-facial growth: evidences. Front Neurol 2012; 3:184.
- Pirilä-Parkkinen K, Löppönen H, Nieminen P, et al. Cephalometric evaluation of children with nocturnal sleep-disordered breathing. Eur J Orthod 2010; 32:662.
- Caprioglio A, Zucconi M, Calori G, Troiani V. Habitual snoring, OSA and craniofacial modification. Orthodontic clinical and diagnostic aspects in a case control study. Minerva Stomatol 1999; 48:125.
- Fitzpatrick MF, McLean H, Urton AM, et al. Effect of nasal or oral breathing route on upper airway resistance during sleep. Eur Respir J 2003; 22:827.
- Goldbart AD, Greenberg-Dotan S, Tal A. Montelukast for children with obstructive sleep apnea: a double-blind, placebo-controlled study. Pediatrics 2012; 130:e575.
- Child performing nasal rinse, available at: https://www.youtube.com/watch?v=LtJypUQV_6c (Accessed on November 10, 2015).
- DiFeo N, Meltzer LJ, Beck SE, et al. Predictors of positive airway pressure therapy adherence in children: a prospective study. J Clin Sleep Med 2012; 8:279.
- Slifer KJ, Kruglak D, Benore E, et al. Behavioral training for increasing preschool children's adherence with positive airway pressure: a preliminary study. Behav Sleep Med 2007; 5:147.
- Paasch V, Hoosier TM, Accardo J, et al. Technical tips: performing EEGs and polysomnograms on children with neurodevelopmental disabilities. Neurodiagn J 2012; 52:333.
- Aurora RN, Zak RS, Karippot A, et al. Practice parameters for the respiratory indications for polysomnography in children. Sleep 2011; 34:379.
- Roberts SD, Kapadia H, Greenlee G, Chen ML. Midfacial and Dental Changes Associated with Nasal Positive Airway Pressure in Children with Obstructive Sleep Apnea and Craniofacial Conditions. J Clin Sleep Med 2016; 12:469.
- Ebben MR, Narizhnaya M, Segal AZ, et al. A randomised controlled trial on the effect of mask choice on residual respiratory events with continuous positive airway pressure treatment. Sleep Med 2014; 15:619.
- Oto J, Li Q, Kimball WR, et al. Continuous positive airway pressure and ventilation are more effective with a nasal mask than a full face mask in unconscious subjects: a randomized controlled trial. Crit Care 2013; 17:R300.
- Nørregaard O. Noninvasive ventilation in children. Eur Respir J 2002; 20:1332.
- To KW, Chan WC, Choo KL, et al. A randomized cross-over study of auto-continuous positive airway pressure versus fixed-continuous positive airway pressure in patients with obstructive sleep apnoea. Respirology 2008; 13:79.
- Masa JF, Jiménez A, Durán J, et al. Alternative methods of titrating continuous positive airway pressure: a large multicenter study. Am J Respir Crit Care Med 2004; 170:1218.
- Vennelle M, White S, Riha RL, et al. Randomized controlled trial of variable-pressure versus fixed-pressure continuous positive airway pressure (CPAP) treatment for patients with obstructive sleep apnea/hypopnea syndrome (OSAHS). Sleep 2010; 33:267.
- Mihai R, Vandeleur M, Pecoraro S, et al. Autotitrating CPAP as a Tool for CPAP Initiation for Children. J Clin Sleep Med 2017; 13:713.
- Mellies U, Ragette R, Dohna Schwake C, et al. Long-term noninvasive ventilation in children and adolescents with neuromuscular disorders. Eur Respir J 2003; 22:631.
- Marcus CL, Rosen G, Ward SL, et al. Adherence to and effectiveness of positive airway pressure therapy in children with obstructive sleep apnea. Pediatrics 2006; 117:e442.
- Marcus CL, Beck SE, Traylor J, et al. Randomized, double-blind clinical trial of two different modes of positive airway pressure therapy on adherence and efficacy in children. J Clin Sleep Med 2012; 8:37.
- Rosen CL, D'Andrea L, Haddad GG. Adult criteria for obstructive sleep apnea do not identify children with serious obstruction. Am Rev Respir Dis 1992; 146:1231.
- Stanchina M, Robinson K, Corrao W, et al. Clinical Use of Loop Gain Measures to Determine Continuous Positive Airway Pressure Efficacy in Patients with Complex Sleep Apnea. A Pilot Study. Ann Am Thorac Soc 2015; 12:1351.
- Chervin RD, Theut S, Bassetti C, Aldrich MS. Compliance with nasal CPAP can be improved by simple interventions. Sleep 1997; 20:284.
- Hawkins SM, Jensen EL, Simon SL, Friedman NR. Correlates of Pediatric CPAP Adherence. J Clin Sleep Med 2016; 12:879.
- Sedaghat AR, Flax-Goldenberg RB, Gayler BW, et al. A case-control comparison of lingual tonsillar size in children with and without Down syndrome. Laryngoscope 2012; 122:1165.
- Guilleminault C, Monteyrol PJ, Huynh NT, et al. Adeno-tonsillectomy and rapid maxillary distraction in pre-pubertal children, a pilot study. Sleep Breath 2011; 15:173.
- TREATMENT DECISIONS
- PREPARING THE ANATOMY FOR SUCCESSFUL AIRFLOW
- FIRST STEPS IN CPAP INTRODUCTION
- Forming a partnership
- The PAP nap
- THE CPAP PRESCRIPTION
- Choosing the right equipment
- - Patient-device interface
- - Humidifiers
- - Auto-CPAP
- - Bilevel PAP
- Titration of CPAP in children
- MEDICAL FOLLOW-UP OF CHILDREN USING CPAP THERAPY
- Follow-up visits and monitoring
- When to repeat a CPAP titration
- Barriers to effective CPAP therapy in children
- CPAP NONRESPONDERS
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS