BACKGROUND:Positional obstructive sleep apnea (POSA) is a condition characterized by airway obstruction that is exacerbated during supine sleep. Treatments include adenotonsillectomy and positive airway pressure (PAP) therapy. Positional therapy is an emerging treatment option and refers to a wearable device that physically prevents supine sleep. OBJECTIVE:To explore the experiences and preferences of children and caregivers with POSA treatments, including adenotonsillectomy, PAP therapy, and positional therapy. METHODS:Semi-structured interviews were conducted with the caregivers of children aged 4-18 years old who participated in a trial that evaluated the efficacy of positional therapy in children. Children were invited to participate when possible. Interviews were coded by two reviewers using thematic analysis and themes were generated by the research team. RESULTS:Four children and 16 caregivers participated. Four themes were identified: (1) comfort and convenience, (2) symptom improvement, (3) emotional, psychological, and social aspects of treatment, and (4) shared decision-making. Positional therapy was considered the least burdensome of the three therapies. It was viewed as simple and minimally invasive but was limited by modest symptom improvement. PAP therapy provided symptom relief, but discomfort and poor tolerance were barriers to nightly use. Adenotonsillectomy was the only treatment with curative potential, but was sometimes viewed less favorably due to concerns about surgical risks. CONCLUSION:Families have varied preferences regarding POSA treatments. Identifying priorities prior to treatment may improve treatment satisfaction. To optimize adherence to positional and PAP therapy in children, barriers such as sensory issues and setup and maintenance should be addressed.

Abstract Introduction Obstructive sleep apnea (OSA), characterized by intermittent upper airway blockage during sleep, is a common disorder in children. Continuous positive airway pressure (CPAP) is the standard treatment for OSA, with its effectiveness relying on nightly use during sleep. However, adherence to CPAP among adolescents is often poor, leading to under-treatment and potential chronic health issues. Prior studies suggest that higher dispositional mindfulness correlates with better CPAP adherence in adults. Mindfulness-based interventions (MBI) have been linked to improved health in adolescents with chronic illnesses, but their effectiveness in improving CPAP adherence is unknown. This study aimed to explore adolescents’ experiences and perceptions of their participation in the MBI program. Methods This qualitative study was a part of a two-arm randomized controlled trial evaluating the effectiveness of a 4-week online MBI program versus a peer-support program in 33 adolescents with OSA using CPAP. Semi-structured interviews were conducted post-intervention and four weeks later. Interviews were transcribed and analyzed using Braun and Clarke’s thematic analysis framework. Independent coding was performed by two researchers, with themes developed collaboratively. Results Ten participants in the MBI arm, each with two interviews, were included in this preliminary analysis. Participants reported overall satisfaction with the program, valued social connections with peers, and appreciated learning mindfulness techniques that helped improve mood, stress, and anxiety. However, most did not perceive a direct impact on their CPAP use. Suggestions for improvement included increasing group size and incorporating more discussion about CPAP and OSA. Conclusion These interviews reveal the benefits of MBI on adolescents with OSA using CPAP, including positive psychosocial impacts. They also suggest areas for enhancing the delivery of MBI, particularly regarding logistical challenges and curriculum structure. Support (if any) This work was supported by the Canadian Institutes of Health Research (CIHR) Project Grant (Ref. no.: 452091).

STUDY OBJECTIVES:Positive airway pressure (PAP) therapy is highly efficacious for the treatment of sleep-disordered breathing in children but is limited by poor adherence. We sought to evaluate the relationship between insomnia and chronotype on PAP adherence in children. METHODS:This is a cross-sectional study conducted at the Hospital for Sick Children (Toronto, Canada) of children aged 4-18 years old prescribed PAP for a minimum of six months. Self-reported and/or caregiver-reported questionnaires including the Pediatric Insomnia Severity Index and Children's Chronotype Questionnaire were completed. PAP therapy usage was measured using objective download data. RESULTS:There were 159 participants included (median age = 14.2 years, females = 38%). Median PAP usage was 436.0 min/night (IQR 147.0, 516.0) for the morning group, 417.0 min/night (IQR 189.2, 538.8) for the intermediate group, and 161.5 min/night (IQR 6.0, 405.2) for the evening group. Children with an evening chronotype used PAP therapy for a median of 264.4 min less per night than children with an intermediate chronotype (95% CI 65.8, 397.1; p = 0.0018). Children used PAP therapy for 37.0 min less per night for each 1-point increase in the sleep maintenance problems score (95% CI 10.0, 47.7; p < 0.001) and 33.7 min less per night for each 1-point increase in the sleep onset problems score (95% CI 20.0, 39.5; p < 0.001). Sleep onset and sleep maintenance problems significantly influenced the relationship between chronotype and PAP usage. CONCLUSION:We found that insomnia and evening chronotype were associated with reduced PAP adherence in children. These may be modifiable factors to promote PAP adherence.

RATIONALE: Obstructive sleep apnea (OSA) in children is a common disorder of breathing during sleep that is characterized by upper airway obstruction and is treated using positive airway pressure (PAP) therapy. There is no standardized definition for PAP adherence for paediatric populations. Instead, current adherence criteria is based on the adult definition, defined as >4 hours of PAP use for at least 70% of nights. This relatively low threshold likely under-estimates PAP adherence in children, as children require more sleep than adults do. Thus, we propose defining paediatric PAP adherence as PAP usage for at least 6 hours per night for 100% of nights. The objective of this study is to evaluate PAP adherence in children with OSA using an adherence threshold of a minimum of 6 hours of PAP use per night for 100% of nights. METHODS: The study prospectively recruited children aged 4-18 years old who were prescribed PAP therapy at SickKids. Detailed PAP adherence data was obtained directly from PAP machines. PAP therapy utilization and adherence was analyzed using descriptive statistics. RESULTS: A total of 150 children were included, (median age = 14.0 years, females = 38.7%). Using a criteria of >4 hours of PAP use for at least 70% of nights, 74/150 (49.3%) of children were considered adherent. When applying our proposed >6 hours of PAP use for 100% of nights, only 33/150 (22.0%) met the criteria for PAP adherence. CONCLUSION: Our data reveals that a significant portion of children do not meet the threshold of 6 hours of PAP use for 100% of nights, emphasizing the need for a revised definition that reflects the unique sleep requirements of children. This data also highlights an urgent need for alternative, efficacious therapies for OSA as a significant number of children are not adherent to PAP therapy.

BACKGROUND:Obstructive sleep apnea (OSA) is prevalent in children, but many children remain untreated. Up to one half of children with OSA have positional OSA, a phenotype characterized by the predominance of airway obstruction while supine. Positional devices that prevent sleeping supine may be beneficial for positional OSA. We evaluated the efficacy of positional devices for treating positional OSA in children. STUDY DESIGN AND METHODS:This was a randomized crossover trial of children aged 4-18 years old with positional OSA. There were two treatment periods separated by 1-4 weeks. Each period consisted of a one-night in-laboratory polysomnogram with the experimental intervention (positional device with inflated cushions) or the inactive control (positional device with no cushions). The primary outcome was the difference in the obstructive apnea-hypopnea index (OAHI) between positional therapy and the control. RESULTS:24 participants were randomized (median age = 9.0 years, 63% males). The adjusted relative percentage difference in the OAHI (positional therapy minus control) was -29.9% (95% CI -55.9% to 11.6%; p = 0.13). The adjusted relative percentage differences for the desaturation index, arousal index, and percentage of total sleep time supine were -23.4% (95% CI -45.0% to 6.7%; p = 0.11), -16.7% (95% CI -30.8% to 0.22%; p = 0.053), and -65.9% (95% CI -79.3% to -43.9%; p<0.001), respectively. There were no significant differences in comfort scores or adverse events. INTERPRETATION:Positional therapy reduced supine sleep time, but did not reduce the OAHI in all participants. Future studies with larger sample sizes to evaluate heterogeneity of treatment effects are warranted.

OBJECTIVE/BACKGROUND:Moderate-to-severe obstructive sleep apnea (OSA) is highly prevalent in children with obesity and/or underlying medical complexity. The first line of therapy, adenotonsillectomy (AT), does not cure OSA in more than 50% of these children. Consequently, continuous positive airway pressure (CPAP) is the main therapeutic option but adherence is often poor. A potential alternative which may be associated with greater adherence is heated high-flow nasal cannula (HFNC) therapy; however, its efficacy in children with OSA has not been systematically investigated. The study aimed to compare the efficacy of HFNC with CPAP to treat moderate-to-severe OSA with the primary outcome measuring the change from baseline in the mean obstructive apnea/hypopnea index (OAHI). PARTICIPANTS/METHODS:This was a single-blinded randomized, two period crossover trial conducted from March 2019 to December 2021 at a Canadian pediatric quaternary care hospital. Children aged 2-18 years with obesity and medical complexity diagnosed with moderate-to-severe OSA via overnight polysomnography and recommended CPAP therapy were included in the study. Following diagnostic polysomnography, each participant completed two further sleep studies; a HFNC titration study and a CPAP titration study (9 received HFNC first, and 9 received CPAP first) in a random 1:1 allocation order. RESULTS:Eighteen participants with a mean ± SD age of 11.9 ± 3.8 years and OAHI 23.1 ± 21.7 events/hour completed the study. The mean [95% CI] reductions in OAHI (-19.8[-29.2, -10.5] vs. -18.8 [-28.2, -9.4] events/hour, p = 0.9), nadir oxygen saturation (7.1[2.2, 11.9] vs. 8.4[3.5, 13.2], p = 0.8), oxygen desaturation index (-11.6[-21.0, -2.3] vs. -16.0[-25.3, -6.6], p = 0.5) and sleep efficiency (3.5[-4.8, 11.8] vs. 9.2[0.9, 15.5], p = 0.2) with HFNC and CPAP therapy were comparable between conditions. CONCLUSION:HFNC and CPAP therapy yield similar reductions in polysomnography quantified measures of OSA severity among children with obesity and medical complexities. TRIAL REGISTRATION:NCT05354401 ClinicalTrials.gov.

Purpose: Positive airway pressure (PAP) therapy is an effective treatment prescribed to children with sleep disordered breathing (SDB); however, PAP adherence remains challenging. Given that COVID-19 pandemic continues to impact sleep and daily life, the aim of this study was to evaluate longitudinal trajectory of PAP usage in children during the COVID-19 pandemic. Patients and Methods: This was a retrospective study. Children aged 1-18 years with SDB prescribed PAP at The Hospital for Sick Children (Toronto, Canada) were evaluated for PAP adherence. Demographics, medical history and PAP adherence data during four consecutive 3-month time periods from December 2019 to December 2020 were collected. These four time periods included i) prior to COVID-19 lockdown, ii) during the first three months of lockdown, iii) summer and iv) return to school period. Percentage of days where PAP was used for 4 hours and average nightly usage of PAP were primary outcomes. Results: A total of 149 children (61.7% male, mean (+/- SD) age=12.8 +/- 4.1 years, BMI (+/- SD) z-score=1.45 +/- 1.43) were enrolled. Compared to prior to lockdown, the median (IQR) of percentage of PAP usage >4 hours and average nightly usage of PAP declined significantly during the summer and return to school periods (p<0.001 for all). By the end of the return to school period, only 69/149 (46%) showed sustained PAP usage and 80/149 (54%) had decreased PAP usage. Obesity was a risk factor for a decline in PAP usage after returning to school (beta=-15.36, p=0.03). Conclusion: Compared to COVID-19 pre-pandemic PAP usage, there was a significant decline in PAP usage across COVID-19 pandemic. There is critical under usage of PAP in children diagnosed with SDB, resulting in an urgent need to address barriers to mitigate poor adherence to PAP long-term. Targeted strategies are required to optimize PAP adherence in children with SDB.

BACKGROUND:There is a critical gap in identifying effective interventions for children with obstructive sleep apnea (OSA) who do not tolerate continuous positive airway pressure therapy. Positional OSA (POSA) is a common clinical phenotype whereby OSA occurs predominantly while sleeping in supine position. POSA may be amenable to treatment with a positional device, a belt worn around the chest with cushions on the back to prevent supine positioning, but no data exists in children. The primary aim of this study was to evaluate the efficacy of positional device therapy for the treatment of POSA in children. METHODS:This observational study included children aged 4-18 years with POSA and an obstructive apnea-hypopnea index (OAHI) ≥ 5 events/hour on baseline polysomnogram (PSG) who underwent a second PSG to evaluate the efficacy of a positional device. The primary outcome was the change in OAHI. RESULTS:Ten children were included (8 male, median age 11.2 years, median body mass index z-score 1.6). Compared to the baseline PSG, PSG data obtained while using a positional device showed a reduced median (interquartile range) OAHI (15.2 [8.3-25.6] versus 6.7 [1.0-13.7] events/hour respectively; p = 0.004) and percentage of total sleep time in supine position (54.4 [35.0-80.6]% versus 4.2 [1.1-25.2]% respectively; p = 0.04). Despite observed improvements in the oxygen desaturation index, these results were not statistically significant. SIGNIFICANCE AND CONCLUSIONS:In this novel pilot study, positional device therapy was effective for the treatment of POSA. Positional device therapy may potentially change clinical practice as a cost-efficient and non-invasive treatment option for POSA.

To evaluate the impact of the COVID-19 pandemic on non-invasive positive airway pressure (PAP) usage among children with sleep-disordered breathing (SDB). PAP usage data in children with SDB aged 1 to 18 years old at The Hospital for Sick Children, Canada, were analyzed. The PAP usage data were recorded for 3 months prior to and 3 months following the COVID-19 lockdown in Ontario, Canada. The primary outcomes of interest were (i) percentage of days that PAP was used for ≥ 4 h and (ii) average daily usage of PAP based on days when PAP was used. A total of 151 children were included. The mean (± SD) age and BMI were 12.6 ± 4.1 years and 28.7 ± 12.4 kg/m2, respectively. The median (IQR) percentage of days of PAP usage for ≥ 4 h and average nightly PAP usage was significantly higher during compared with prior to the pandemic (76.7 [19.0–94.0] vs 62.0 [15.5–89.0]%, p = 0.02, and 406.0 [244.0–525.0] vs 367.0 [218.0–496.0] min, p = 0.006, respectively). Within this cohort, 95/151 (63%) children with SDB showed increased PAP usage and 56/151 (37%) either decreased the amount of time they used PAP or stopped PAP use altogether. COVID-19 pandemic has provided opportunities for increased PAP usage in a significant number of children with SDB. A subset of children with prior evidence for suboptimal PAP usage showed further decreases in PAP usage during the pandemic. This information is critical for clinicians to provide anticipatory guidance to encourage PAP usage both during the pandemic and beyond.

There has been a significant increase in the past few decades in the number of children receiving noninvasive positive airway pressure (PAP) therapy at home. At present, PAP therapy can be successfully used in children of all ages, for a variety of indications. Data acquired from PAP devices is clinically useful, providing objective information regarding adherence, leak, and efficacy of PAP therapy. However, guidelines outlining a standardized approach to interpretation of PAP device data in pediatrics is currently lacking. Given the rapidly expanding use of PAP therapy in pediatric practice, we aim to provide an overview of the interpretation of data reports, otherwise called "data downloads," from PAP devices and illustrate how they can be used to guide clinical care.

Correspondence Reshma Amin, MD, Division of Respiratory Medicine, Department of Pediatrics, 4539 Hill Wing, SickKids, 555 University Avenue, Toronto, ON M5G 1X8, Canada. Email: reshma.amin@sickkids.ca Abstract There has been a significant increase in the past few decades in the number of children receiving noninvasive positive airway pressure (PAP) therapy at home. At present, PAP therapy can be successfully used in children of all ages, for a variety of indications. Data acquired from PAP devices is clinically useful, providing objective information regarding adherence, leak, and efficacy of PAP therapy. However, guidelines outlining a standardized approach to interpretation of PAP device data in pediatrics is currently lacking. Given the rapidly expanding use of PAP therapy in pediatric practice, we aim to provide an overview of the interpretation of data reports, otherwise called “data downloads,” from PAP devices and illustrate how they can be used to guide clinical care.

Introduction Positive airway therapy (PAP) adherence rates are suboptimal among adolescents with obstructive sleep apnea (OSA) and strategies to increase PAP adherence is a clinical priority. This study evaluates if caregiver support is associated with PAP adherence rates among adolescents with OSA. Methods We conducted a retrospective study and evaluated PAP adherence rates among adolescents with OSA from 2012 to 2017. Adherence was measured as continuous variables: average PAP usage (minutes per night) and average PAP usage >4 hours/night (% of all nights). We evaluated if adolescents with OSA who were receiving practical caregiver support with PAP had higher adherence than adolescents with OSA without caregiver support. Results One hundred and seven adolescents with OSA (mean age=14.1±2.5 years, 64.5% male, mean BMI percentile=89.0±21.8) seen between January 2012 and August 2017 at our institution were included. In this study, 60.7% (n=65) of adolescents with OSA were receiving practical caregiver support with PAP therapy. Adolescents with OSA receiving practical caregiver support with PAP used therapy for a significantly greater duration each night compared to adolescents who were not receiving practical caregiver support (298.5±206.7 versus 211.9±187.2 minutes; P=0.02). Greater time since the initial PAP prescription was independently associated with PAP adherence. Conclusion Focusing on PAP adherence early may help adolescents with OSA incorporate therapy into their nightly routine, which may improve adherence and lead to improved health outcomes in adolescents with OSA. Practical caregiver support may be an essential component of ensuring optimal PAP adherence among adolescents with OSA.

Obstructive sleep apnea (OSA) is characterized by snoring, recurrent obstruction (apneas) of the upper airway which disrupts normal ventilation during sleep. In the last decade, there has been a increase in children diagnosed with persistent, severe OSA attributed to (1) the obesity epidemic as 25–60% of obese children will have obesity related OSA (2) advances in medical technology that have increased life expectancy of medically complex children (3) improved diagnostics and (4) increased awareness. Positive airway pressure (PAP) is commonly used to treat persistent, severe OSA. PAP devices deliver pressurized air via nasal or oronasal interfaces to distend the upper airway and ameliorate OSA. Although effective in treating OSA, PAP adherence is suboptimal. This review article provides an overview of (1) PAP use in pediatric OSA (2) PAP devices (3) PAP adherence, (4) strategies and interventions to improve adherence and (5) Optimizing PAP delivery during pediatric to adult transition.

Rationale: Low adherence to positive airway pressure (PAP) treatment for adolescents with obstructive sleep apnea (OSA) can have long-term cardiometabolic and developmental impact. Objectives: To explore the facilitators and barriers to PAP use in adolescents with OSA. Methods: Weconducted aqualitative study using a descriptive thematic analysis approach. A total of 21 interviews were conducted in the clinical setting with adolescents prescribed PAP to treat OSA within the previous 12 months. Interview audio recordings were transcribed verbatim for analysis. Transcripts were reviewed, and data were categorized using a coding framework developed by the research team. Codeswere structured into themes related to the barriers and facilitators to using PAP. Results: Participants described numerous challenges with the physical design of the PAP machine, including the restriction of the tubing, the discomfort of the mask, and concerns with its size and weight. A period of adjustment to wearing and preparing the PAP machine was described whereby participants had to develop their own strategies to improve comfort. After initiating the therapy, the challenges experienced by participants were cited more often than the perceived benefits, particularly for those who were less adherent. Finally, the unique needs of adolescents were highlighted, which impacted the amount of family support desired in using PAP. Conclusions: This study identifies factors affecting PAP adherence when prescribed in adolescence and highlights the need for ongoing dialogue between adolescents and their clinical team with respect to challenges encountered, troubleshooting, adherence strategies, and parental engagement.

STUDY OBJECTIVES:Our aim was to identify clinical predictors associated with changes in settings for pediatric invasive and noninvasive positive airway pressure therapy, which could help inform the allocation of limited polysomnogram (PSG) resources. METHODS:A retrospective review was conducted in children who underwent one or more PSGs for technology titration. Children were included if they were using continuous positive airway pressure (CPAP) therapy, bilevel positive airway pressure (BPAP) therapy, or invasive positive pressure ventilation (IPPV) the night of the PSG. The primary outcome measure for the study were predictors of change in settings during IPPV, CPAP, and BPAP titration studies. RESULTS:During the study period, 274 children using CPAP, BPAP, or IPPV underwent one or more titration PSGs. The mean (standard deviation [SD]) age of the children at the time of the first titration PSG was 10.52 (5.11) y. Fifty percent (n = 136) of the study participants were male. Most patients underwent BPAP titration studies (n = 166), followed by CPAP (n = 83) and then IPPV (n = 25). A total of 623 technology titration PSGs were completed. Reason for respiratory technology, type of respiratory technology, and time between ventilation initiation and the PSG were significant predictors of a change in settings in the multivariable regression model. CONCLUSIONS:Children were more likely to have a change in their technology settings during a PSG if there was a shorter period of time from the original technology initiation, if they were using BPAP (as compared to CPAP or IPPV) and/or if they had a primary central nervous system or musculoskeletal diagnosis.