Study objectives

Sleep-disordered breathing (SDB) may significantly impact the course of medical illness in hospitalized children. Polysomnography (PSG) is the gold standard for establishing diagnosis of SDB, but its availability is limited. The aim of this study was to explore the feasibility and utility of level III portable sleep studies in hospitalized children with SDB.

Methods

A retrospective study was conducted at a tertiary hospital over the preceding 2 years in hospitalized children < 18 years who had undergone a level III sleep study using the Nox T3 system. The information obtained included demographic data, comorbidities, indication for admission and sleep study, time interval between the study ordered and done, adequacy of technical data from sleep study, study diagnosis, and subsequent management interventions for SDB.

Results

A total of 51 hospitalized children had these studies; 32 were female and mean age was 4.3 years. Approximately 90% of children had significant comorbidities, including neurological and craniofacial abnormalities. The majority (80%) of studies were conducted within 24 hours of the time requested and 92.1% studies had technically adequate data for analysis. Thirty-nine (76.5%) children were identified with SDB; all but one patient underwent therapy for SDB during that same hospitalization, including supplemental oxygen (48.7%), positive airway pressure therapy (23%), surgical intervention (38.2%) or caffeine (10.2%). Twelve percent of children had more than one intervention done.

Conclusions

The level III portable sleep study is readily available, sufficient to diagnose SDB, and help to provide appropriate medical and/or surgical therapies in hospitalized children with complex medical conditions.

We present a case of successful long-term use of nasal trumpet for severe obstructive sleep apnea syndrome in a child with cerebral palsy and complex medical issues. Obstructive sleep apnea syndrome is frequently seen in pediatric patients with cerebral palsy due to their abnormal airway tone and pulmonary vulnerability. Identifying children with cerebral palsy who are at risk for obstructive sleep apnea syndrome is important because its treatment can improve quality of life and seizure control. Although first-line treatment for obstructive sleep apnea syndrome is adenotonsillectomy, children with cerebral palsy are more likely to have residual obstructive sleep apnea syndrome postoperatively. Other options such as positive airway pressure therapy and other upper airway surgeries may pose significant challenges and tolerance issues, as in our patient. As demonstrated in our report, the low rate of complications and ease of use make nasal trumpets a potential long-term treatment option for children with obstructive sleep apnea syndrome who fail or cannot comply with the traditional treatment options.

Background

Patients receiving therapeutic paralysis may experience inadequate sedation due to intrinsic limitations of behavioral sedation assessment. Bispectral index (BIS™) provides an objective measure of sedation; however, the role of BIS™ is not well defined in intensive care unit (ICU) patients on neuromuscular blocking agents (NMBA).

Objective

The aim of this study was to delineate the relationship between BIS™ and level of sedation for critically ill patients during therapeutic paralysis.

Methods

This was a retrospective observational study conducted in ICU patients receiving continuous infusion NMBA and BIS™ monitoring. The primary endpoint was the correlation of BIS™ <60 during therapeutic paralysis with a Richmond Agitation Sedation Score (RASS) of -4 to -5 (i.e., deep or unarousable sedation) at the time of emergence from therapeutic paralysis.

Results

Thirty-one patients were included in the analysis. Three of these patients (9.6 %) were inadequately sedated upon emergence from paralysis; that is, restless or agitated (RASS +1 to +2). We did not observe a correlation between BIS™ and RASS upon emergence from paralysis (r = 0.27, p = 0.14). The sensitivity of BIS™ <60 in predicting deep sedation (RASS -5 to -4) was 100 % (95 % confidence interval [CI] 0-100) with a positive predictive value of 35.7 %. The sensitivity and positive predictive value of BIS™ <60 in predicting light sedation or deeper (RASS -5 to -2) was 92.9 % (95 %CI 83.3-100) and 92.9 %, respectively.

Conclusion

These results suggest that 1 in 10 critically ill patients receiving therapeutic paralysis may be inadequately sedated. BIS™ monitoring may serve as a useful adjunctive measure of sedation in critically ill patients receiving therapeutic paralysis.

Purpose

Postictal pulmonary edema (PPE) is almost invariably present in human and animal cases of sudden unexpected death in epilepsy (SUDEP) coming to autopsy. PPE may be a contributing factor in SUDEP. The incidence of postictal PPE is unknown. We retrospectively investigated PPE following generalized tonic clonic seizures (GTCS) in the epilepsy monitoring unit.

Methods

Chest X-Rays (CXR) following each GTCS were obtained in 24 consecutive patients. Relationship of CXR abnormality to seizure duration, ictal/postictal oxygen desaturation (SpO2), apnea and presence of postictal generalized EEG suppression (PGES) was investigated using logistic regression.

Results

Eleven of 24 patients had CXR abnormalities following a GTCS. In these 11 patients, 22 CXR were obtained and abnormalities were present in 15 CXR. Abnormalities included PPE in 7 patients, of which 2 also had focal infiltrates. In 4 patients focal infiltrates were present without PPE. There was no significant difference in mean time to CXR (225 min) following GTCS in the abnormal CXR group versus the normal group of patients (196 min). Mean preceding seizure duration was longer (p=0.002) in GTCS with abnormal CXR (259.7 sec) versus GTCS with normal CXR (101.2 sec). Odds-ratio for CXR abnormality was 20.46 (p=0.006) with seizure duration greater than 100 sec versus less than 100 sec. On multivariable analysis, only the seizure duration was a significant predictor of CXR abnormality (p=0.015).

Conclusions

Radiographic abnormalities are not uncommon following GTCS. The presence of CXR abnormality is significantly associated with the duration of the preceding GTCS. Severe, untreated PPE may be relevant to the pathophysiology of SUDEP.