CPAP/bilevel PAP in the home setting

CPAP/bilevel PAP in the home setting

An estimated 1% to 5% of children have sleep-disordered breathing (SDB) related to obstructive sleep apnea (OSA), with a smaller proportion of children having central or mixed sleep apnea.¹ However, pediatric OSA has increased in the past decade and may range as high as 10% to 20%; it is speculated that this increase may be related to increases in the prevalence of obesity or exposure to air pollution.² Undiagnosed or untreated SDB can be associated with behavioral, neurocognitive, endocrine, and metabolic health problems.^3,4

Sleep-disordered breathing

Obstructive apneic events during sleep are rare in healthy children, with findings from studies showing very low rates of occurrence, often fewer than 1 event per hour, and duration of events typically under 10 seconds.⁵ When there is suspicion of SDB, the gold standard test to diagnose OSA and central sleep apnea (CSA) is overnight polysomnography (PSG) supported by clinical findings.^2,5,6

The treatment for OSA may include lifestyle modification, pharmacologic management, surgical correction of the upper airway (eg, tonsillectomy with or without adenoidectomy), and respiratory support for patients who are not candidates for surgery or who have persistent OSA despite surgical intervention. Patients with OSA at risk for an incomplete response to adenotonsillectomy include those who are older, have obesity, and have neuromuscular conditions.^5,6 In this article, we discuss positive airway pressure (PAP) therapies for OSA, including continuous PAP (CPAP) and bilevel PAP, in the home setting.

PAP therapies

CPAP and bilevel PAP are common noninvasive treatments for OSA that provide additional pressure to overcome upper airway obstruction.⁵ The most challenging aspect in the management of OSA with a PAP device is adherence. In most studies, PAP adherence rates in children are generally low, averaging 3 to 4 hours per night. Findings from studies report that only 41% to 75% of children meet adherence criteria for adults (at least 4 hours on 70% of nights); no pediatric-specific criteria exist.⁷ Caregiver involvement plays a critical role in maintaining adherence to PAP therapy.⁷ Higher usage rates (> 8 hours per night) have been reported in a study that emphasized pediatric-specific, noninvasive ventilation machines and caregiver support.^7,8

CPAP modes

Home nasal CPAP has been used successfully in infants and children across various age groups. Its effectiveness was first demonstrated in a prospective study of 5 children aged 3 to 11 years over 10 months in 1986.⁹ Results from subsequent larger retrospective studies, primarily involving children older than 12 months, have confirmed these findings.¹¹ Findings from subsequent studies have shown that infants aged 8 to 18 weeks can also benefit from treatment through their first year of life.¹⁰

Patients with refractory CSA or congenital central hypoventilation syndrome typically require nocturnal PAP therapy, often using a bilevel mode with a backup respiratory rate.⁶ Bilevel PAP devices offer 3 modes besides CPAP, which are selected based on the patient’s breathing patterns and underlying condition. The spontaneous BPAP mode is used for children intolerant of CPAP at high pressures, with no backup rate and higher inspiratory pressure than used with CPAP. The spontaneous-timed BPAP mode is used for children with mixed apnea or persistent hypoventilation after CPAP treatment, incorporating a backup rate to assist when the patient’s respiratory rate falls below a preset threshold. The timed mode, which is rarely used in children, controls the patient’s breathing rate and inspiratory times.¹¹

The primary barrier to good PAP adherence in children is discomfort from device use rather than patient characteristics, device type, or complications.⁷ Minor issues from home CPAP therapy in children are common and similar to those in adults, such as skin redness, eye irritation, and poor mask fit. Clinicians should also monitor facial development in children on CPAP therapy, as prolonged mask use can affect facial growth.¹² Because findings from studies have shown that personalized desensitization and behavioral interventions can improve adherence,^13-15 strategies to enhance adherence may include educating families on PAP benefits, desensitization before therapy, play therapy, cognitive behavioral therapy for older children, positive reinforcement, and parental support through tele-education and telemonitoring.⁸ However, children often require more time to achieve adherence than adults.

PAP mask recommendations

Evidence suggests that oronasal, or full-face, PAP masks may be less effective than nasal PAP masks, as results from a study found that increasing PAP levels failed to open the airway during oronasal PAP.¹⁵ The mechanisms behind this are not fully understood but may involve the neutralization of positive pressure in the airway from the mouth and nose, reducing the splinting effect in the airway. A study comparing upper airway patency found that airway narrowing occurred when switching from nasal to oronasal CPAP, although this was prevented when the mouth was taped shut. Oronasal CPAP may also displace the mandible. These effects likely vary between individuals and depend on the site of obstruction or OSA endotype. A potential advantage of nasal masks is a reduced risk of aspiration.¹⁶ The aspiration risk with an oronasal mask is primarily for patients who are unable to remove the mask quickly, whether through physical or intellectual disability.

Regarding PAP mask adherence, humidification can reduce nasal symptoms such as dryness and congestion, and it is strongly associated with improved adherence, as patients report that it increases comfort.¹⁹ It has been suggested that patients with allergic rhinitis may benefit from an intranasal steroid during CPAP initiation.¹⁷

Regular assessment for facial deformities such as maxillary retrusion, structural changes of the palate anatomy, and flaring of the maxillary incisors should be conducted, particularly in younger patients with skeletal immaturity.¹²

Cleaning recommendations

Several key recommendations regarding the care and cleaning of the equipment should be implemented to improve adherence and reduce potential health risks. First, pediatric sleep clinics should reinforce cleaning guidelines at every visit, emphasizing the importance of daily mask and humidifier chamber cleaning. Educational materials should be provided in multiple formats, including written instructions, verbal explanations, and instructional videos, catering to different learning preferences. Caregivers and adolescent users should be reminded of the risks associated with inadequate cleaning, such as bacterial colonization, respiratory infections, and accumulation of oils on the mask, leading to skin breakdown. Clinics should also assess barriers to adherence with equipment care, such as time restrictions or lack of perceived urgency, and provide practical solutions such as easy-to-follow cleaning checklists.¹⁸

Clinicians should stay informed about emerging technologies and updated manufacturer recommendations to offer the best possible guidance. Standardizing cleaning protocols and replacing disposables according to mask type across health care providers can ensure consistency in patient education. By implementing these strategies, the health care system can bridge the gap between recommended and actual cleaning practices, ultimately improving health outcomes for pediatric PAP users.¹⁸

Titration sleep study and outpatient monitoring

In many sleep clinics, titration sleep studies are considered yearly due to changes in the anatomical structure in children’s faces and the increase in height and weight. Findings from a recent study suggested that repeat PAP titration studies within the first 2 years after PAP initiation do not lead to significant changes in therapeutic settings or apnea severity, suggesting that clinical guidelines for titration studies should be reconsidered to optimize care and resource utilization.¹⁹ Clinicians should also rely on clinical indicators such as worsening symptoms, patient discomfort, or adherence concerns to determine the need for reassessment. Implementing alternative monitoring strategies, such as remote PAP data analysis and patient-reported symptoms, may offer a more efficient and cost-effective approach to tracking treatment efficacy.¹⁹

Additionally, autotitrating PAP devices should be explored further for pediatric use, as they have shown promise in dynamically adjusting pressure without requiring repeat sleep studies. Future prospective studies should identify specific patient subgroups, such as those with comorbidities such as obesity or trisomy 21, who may benefit from more repeat titration studies. Although the algorithms in PAP devices for detecting apneas and hypopneas have not been validated in children, clinicians may use these data along with other clinical information to determine the need for repeating PSG.¹⁹

Lastly, multidisciplinary collaboration between sleep specialists, respiratory therapists, and primary care providers can help refine patient-centered approaches for OSA management, ensuring that resources are directed toward children who truly need further titration.¹⁹

Summary of recommendations

• Key elements of effective PAP therapy include appropriate fit of a nasal interface to avoid air leak and displacement of the mask while sleeping. We also recommend avoiding overtightening to limit skin irritation and alteration of the facial growth.¹²
• Because of the risk of aspiration, we do not recommend using an oronasal mask in general. Humidification is also important, as heated humidification reduced nasal adverse effects in patients with OSA starting CPAP.¹⁶
• Close follow-up is needed to monitor for skin irritation or lesions. Appropriate cleaning is recommended to prevent colonization, risk of opportunistic infections, and accumulation of oils.¹⁸
• Many devices currently in use can store adherence data. Regularly assessing adherence data with caregivers can help determine the best strategies to improve adherence. Provisions should be made to obtain appropriate replacement supplies.
• Once CPAP/bilevel PAP is initiated, the most important recommendation is to consider repeating a PSG to titrate the optimal pressures needed. A repeat study may be needed even after initial resolution of OSA and troubleshooting the PAP device if symptoms such as morning headaches, excessive daytime sleepiness, or frequent nighttime awakenings reappear or if there are anatomical changes such as significant weight gain or facial structure alterations affecting the airway or mask fit.¹⁹

References

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