Continuous positive airway pressure and noninvasive ventilation adherence in children

doi:10.1016/j.sleep.2013.06.020

Sleep Medicine

Volume 14, Issue 12, December 2013, Pages 1290-1294

https://doi.org/10.1016/j.sleep.2013.06.020 Get rights and content

Highlights

•
Adherence to continuous positive airway pressure and noninvasive ventilation (CPAP/NIV) therapy is crucial for the success of the treatment.
•
Long-term CPAP/NIV adherence was extremely high in our group of 62 children.
•
Adherence did not correlate with age, underlying disease, or nocturnal gas exchange.
•
Adherence did not correlate with the type of interface or duration of CPAP/NIV.

Abstract

Background

Adherence to continuous positive airway pressure (CPAP) and noninvasive ventilation (NIV) is crucial for the successful treatment of sleep-disordered breathing. The aim of our study was to analyze the adherence of children to long-term home CPAP/NIV treatment.

Methods

We analyzed data from all consecutive patients older than the age of 2 years, in whom CPAP/NIV treatment was initiated in a specialized pediatric NIV and in those who were receiving CPAP/NIV treatment at home for at least 1 month. Data of the memory cards of the ventilators and nocturnal gas exchange were analyzed during a routine CPAP/NIV overnight control in the hospital. CPAP/NIV adherence during the previous month was analyzed according to patient’s age, ventilatory mode, type of interface, nocturnal gas exchange, and duration of treatment.

Results

The data of 62 children (mean age, 10 ± 5 years) with obstructive sleep apnea (n = 51) treated with CPAP and neuromuscular disease (n = 6) or lung diseases (n = 5) treated with NIV were analyzed. Mean adherence was 8:17 ± 2:30 h:min per night, and the results did not significantly differ between CPAP and NIV adherence. Seventy-two percent of the patients used their device >8 h per night. The mean number of nights of CPAP/NIV use during the last month was 26 ± 5 nights per month. Treatment adherence was not correlated to age, the type of underlying disease, the type of interface (nasal, facial mask, or nasal cannula), nocturnal gas exchange, and duration of CPAP/NIV treatment.

Conclusion

Long-term CPAP/NIV adherence at home was extremely high in this group of children followed in a pediatric NIV unit. This finding may explain the lack of effect of the interface, nocturnal gas exchange, and duration of CPAP/NIV treatment.

Introduction

Noninvasive continuous positive airway pressure (CPAP) and noninvasive ventilation (NIV) are effective treatments for obstructive sleep apnea (OSA) and nocturnal hypoventilation, respectively. By maintaining a constant positive pressure in the airways during the whole breathing cycle, CPAP is able to correct the complete (apnea) or partial (hypopnea) closure of the upper airways during sleep. By delivering a positive pressure or a volume during the patient’s inspiration, NIV is able to reverse nocturnal alveolar hypoventilation in patients who experience hypoventilation during sleep, such as patients with restrictive or neuromuscular disease or patients with lung disease. Adherence to these treatments is essential for their efficacy. Indeed, a study performed in 52 children with OSA showed a correlation between CPAP use and the improvement in daytime sleepiness assessed by the change in the Epworth Sleepiness Scale [1]. Moreover, regular overnight use of NIV treatment has been shown to correct nocturnal and daytime gas exchange in children with neuromuscular disease [2], [3]. However, the minimal hours of CPAP or NIV use for an optimal effectiveness in children is not known and may vary by the age of the patient and by the type and the severity of the underlying disease.

Adherence has to be assessed on objective data. Indeed, initial studies reported adherence to be high when using self-reported or parent-reported measures of CPAP use [4], [5]. However, adherence proved to be lower when objective adherence was gathered from the ventilators [6]. Nowadays, objective adherence is accessible from most of the ventilators not only as an hour meter recording (i.e., when the ventilator is switched on), but also from built-in software that delivers a detailed report of all the parameters of the ventilator, such as airway pressure, leaks, and several respiratory parameters, thus allowing a more comprehensive approach of observing the patient’s sleep with CPAP or NIV treatment [7], [8].

Numerous factors, such as age [9], [10], type of interface [9], and the association of an educational program may influence treatment adherence [11]. With the rapid increase of children needing CPAP or NIV treatment [12], together with continuous improvements in ventilators and interfaces, adherence may change in children. The primary objective of our study was to assess the objective compliance in children treated with long-term CPAP or NIV treatment at home with a standardized medical follow-up in a tertiary pediatric NIV unit. The secondary objective was to determine the variables significantly associated with CPAP/NIV adherence.

Section snippets

Subjects

Between June 2012 and January 2013, data from all consecutive patients older than the age of 2 years, who were receiving CPAP or NIV treatment at home for at least 1 month and who were hospitalized for a routine CPAP/NIV overnight control in the hospital, were analyzed. Nocturnal gas exchange with CPAP/NIV was recorded in all the patients. Demographic data and ventilator and interface equipment were obtained. Patients were classified in three groups according to the underlying disease: OSA,

Results

The data of 62 patients (ages, 2–18 years) were analyzed (Table 1). The majority of the patients had OSA (82%). Most patients (61%) were ventilated with a nasal mask; these patients were significantly younger than the patients ventilated with a facial mask or nasal cannula (P < .001).

Mean objective adherence was extremely high with a mean use of 8:17 ± 2:30 h:min per night and 72% of the patients using their CPAP or NIV >8 h:min per night (Table 1). The mean number of nights of CPAP or NIV use during

Discussion

Our study shows that objective adherence to home CPAP and NIV use was extremely high in children in whom CPAP or NIV treatment was initiated in a pediatric NIV unit. Treatment adherence was not affected by the underlying disease, the age of the patient, the type of ventilation (CPAP or NIV), the type of interface, the duration of CPAP or NIV, or the efficacy of treatment assessed by nocturnal gas exchange. This finding may be explained by the high level of adherence, which is close to the

Conclusion

Our observational study revealed a high level of adherence in a large group of children older than the age of 2 years who were treated at home with long-term CPAP or NIV, with a mean nighttime use close to that of the normal sleep duration. These adequate results underline the importance of a dedicated pediatric NIV unit for the initiation and follow-up of these patients. This availability provides strong, positive, and continuous support of the patient and his or her family by the expert team

Conflict of interest

The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: http://dx.doi.org/10.1016/j.sleep.2013.06.020.

. ICMJE Form for Disclosure of Potential Conflicts of Interest form.

Acknowledgments

The research of Brigitte Fauroux is supported by the Association Française contre les Myopathies (AFM), Vaincre la Mucoviscidose (VLM), Assistance Publique-Hôpitaux de Paris, Inserm, Université Pierre et Marie Curie-Paris6, ADEP Assistance, S2A Santé, and IP Santé Domicile.

References (22)

C.L. Marcus et al.
Use of nasal continuous positive airway pressure as treatment of childhood obstructive sleep apnea
J Pediatr
(1995)
O. Contal et al.
Monitoring of noninvasive ventilation by built-in software of home bilevel ventilators. A bench study
Chest
(2012)
J.H. Storre et al.
Average volume-assured pressure support in obesity hypoventilation: a randomized crossover trial
Chest
(2006)
J.P. Janssens et al.
Impact of volume targeting on efficacy of bi-level non-invasive ventilation and sleep in obesity-hypoventilation
Respir Med
(2009)
B.C. Galland et al.
Normal sleep patterns in infants and children: a systematic review of observational studies
Sleep Med Rev
(2012)
E. Chailleux et al.
Predictors of survival in patients receiving domiciliary oxygen therapy or mechanical ventilation. A ten-year analysis of ANTADIR observatory
Chest
(1996)
C.L. Marcus et al.
Effects of positive airway pressure therapy on neurobehavioral outcomes in children with obstructive sleep apnea
Am J Respir Crit Care Med
(2012)
A.K. Simonds et al.
Outcome of paediatric domiciliary mask ventilation in neuromuscular and skeletal disease
Eur Respir J
(2000)
U. Mellies et al.
Long-term noninvasive ventilation in children and adolescents with neuromuscular disorders
Eur Respir J
(2003)
F. Massa et al.
The use of nasal continuous positive airway pressure to treat obstructive sleep apnoea
Arch Dis Child
(2002)

C.L. Marcus et al.

Adherence to and effectiveness of positive airway pressure therapy in children with obstructive sleep apnea

Pediatrics

(2006)

Cited by (76)

Positive end-expiratory pressure in chronic care of children with obstructive sleep apnoea
2024, Paediatric Respiratory Reviews
Positive end-expiratory pressure (PEEP) consists of the delivery of a constant positive pressure in the airways by means of a noninvasive interface aiming to maintain airway patency throughout the entire respiratory cycle. PEEP is increasingly used in the chronic care of children with anatomical or functional abnormalities of the upper airways to correct severe persistent obstructive sleep apnea despite optimal management which commonly includes adenotonsillectomy in young children. PEEP may be used at any age, due to improvements in equipment and interfaces. Criteria for CPAP/NIV initiation, optimal setting, follow-up and monitoring, as well as weaning criteria have been established by international experts, but validated criteria are lacking. As chronic PEEP is a highly specialised treatment, patients should be managed by an expert pediatric multidisciplinary team.
Persistent obstructive sleep apnoea in children: treatment options and management considerations
2023, The Lancet Respiratory Medicine
Unresolved obstructive sleep apnoea (OSA) after an adenotonsillectomy, henceforth referred to as persistent OSA, is increasingly recognised in children (2–18 years). Although associated with obesity, underlying medical complexity, and craniofacial disorders, persistent OSA also occurs in otherwise healthy children. Inadequate treatment of persistent OSA can lead to long-term adverse health outcomes beyond childhood. Positive airway pressure, used as a one-size-fits-all primary management strategy for persistent childhood OSA, is highly efficacious but has unacceptably low adherence rates. A pressing need exists for a broader, more effective management approach for persistent OSA in children. In this Personal View, we discuss the use and the need for evaluation of current and novel therapeutics, the role of shared decision-making models that consider patient preferences, and the importance of considering the social determinants of health in research and clinical practice. A multipronged, comprehensive approach to persistent OSA might achieve better clinical outcomes in childhood and promote health equity for all children.
Long term noninvasive ventilation and continuous positive airway pressure in children with neuromuscular diseases in France
2022, Neuromuscular Disorders
Citation Excerpt :
NIV/CPAP was initiated on “other criteria” in 20% of the patients, comprising: abnormal blood gases, clinical criteria, the relay of invasive ventilation and/or the impossibility to wean the patient from NIV/CPAP initiated during a respiratory exacerbation, prior to elective surgery [22], restrictive lung disease on lung function tests, or thoracic deformity. The mean objective adherence was good as reported by other French studies [23–25]. This may be explained by the therapeutic education of the patients and caregivers and the expertise of the centres, associated with a well organised national home care provider network.
The aim of the study was to describe the characteristics of children with neuromuscular diseases treated with long term noninvasive ventilation or continuous positive airway pressure in France. On June 1st 2019, 387 patients (63% boys, mean age 11.2 ± 5.5 years) were treated with long term noninvasive ventilation/continuous positive airway pressure. Thirty three percent of patients had spinal muscular atrophy, 30% congenital myopathy/dystrophy, 20% Duchenne muscular dystrophy, 7% Steinert myotonic dystrophy, and 9% other neuromuscular diseases. Ninety-four percent of patients were treated with long term noninvasive ventilation and 6% with continuous positive airway pressure. Treatment was initiated electively for 85% of patients, mainly on an abnormal overnight gas exchange recording (38% of patients). Noninvasive ventilation/continuous positive airway pressure was initiated during a respiratory exacerbation in 15% of patients. Mean duration of noninvasive ventilation/continuous positive airway pressure was 3.3 ± 3.1 years. Mean objective long term noninvasive ventilation/continuous positive airway pressure use was 8.0 ± 3.1 h/24. Spinal muscular atrophy, congenital myopathy/dystrophy, and Duchenne muscular dystrophy represented 83% of children with neuromuscular diseases treated with long term noninvasive ventilation in France. Screening for nocturnal hypoventilation was satisfactory as noninvasive ventilation /continuous positive airway pressure was predominantly initiated electively.
Paradigm shift in the era of disease-modifying therapies for Spinal Muscular Atrophy type 1: respiratory challenges and opportunities
2021, Sleep Medicine
Adherence to Sleep Therapies in Children and Adolescents
2021, Sleep Medicine Clinics
Long Term Ventilation in Children
2021, Encyclopedia of Respiratory Medicine, Second Edition
Long term ventilation (LTV) refers to various types of respiratory support provided for a period of at least 3 months. Respiratory support is delivered via a tracheostomy (invasive) or via an interface (non-invasive). Advances in ventilator technology, increased medical knowledge and familiarity in delivery of home care have contributed to the exponential rise in the number of children on LTV worldwide. The indications for LTV fall broadly into three etiological categories: failure of central drive, neuromuscular weakness or obstruction/restriction of respiratory system. The LTV population consists of a great heterogeneity of disorders, age ranges, prognosis and outcomes, requiring highly skilled multidisciplinary teams. This chapter covers epidemiology, different ventilation modes, devices and accessories, indications, contraindications, suggested settings, troubleshooting, practical pointers, complications and outcomes of LTV.

View all citing articles on Scopus

View full text

Original ArticleContinuous positive airway pressure and noninvasive ventilation adherence in children

Highlights

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Subjects

Results

Discussion

Conclusion

Conflict of interest

Acknowledgments

J Pediatr

Chest

Chest

Respir Med

Sleep Med Rev

Chest

Effects of positive airway pressure therapy on neurobehavioral outcomes in children with obstructive sleep apnea

Am J Respir Crit Care Med

Outcome of paediatric domiciliary mask ventilation in neuromuscular and skeletal disease

Eur Respir J

Long-term noninvasive ventilation in children and adolescents with neuromuscular disorders

Eur Respir J

The use of nasal continuous positive airway pressure to treat obstructive sleep apnoea

Arch Dis Child

Adherence to and effectiveness of positive airway pressure therapy in children with obstructive sleep apnea

Pediatrics

Original Article
Continuous positive airway pressure and noninvasive ventilation adherence in children