Objective Retrospective studies have limitations in predicting perioperative risk following adenotonsillectomy in children with obstructive sleep apnea syndrome (OSAS). Few prospective studies exist. We hypothesized that demographic and polysomnographic (PSG) variables would predict respiratory and general perioperative complications. Study Design Prospective, observational cohort study. Setting Pediatric tertiary center. Subjects and Methods Consecutive children undergoing adenotonsillectomy for OSAS within 12 months of PSG were evaluated for complications occurring within 2 weeks of surgery. Results There were 329 subjects, with 27% <3 years old, 24% obese, 16% preterm, and 29% with comorbidities. In this higher risk population, 28% had respiratory complications (major and/or minor), and 33% had nonrespiratory complications. Significant associations were found between PSG parameters and respiratory complications as follows: apnea hypopnea index (rank-biserial correlation coefficient [r] = 0.174, P = .017), SpO2 nadir (r = –0.332, P <.0005), sleep time with SpO2 <90% (r = 0.298, P <.0005), peak end-tidal CO2 (r = 0.354, P <.0005), and sleep time with end-tidal CO2 >50 mm Hg (r = 0.199, P = .006). Associations were also found between respiratory complications and age <3 years (r = –0.174, P = .003) or black race (r = 0.123, P = .039). No significant associations existed between PSG parameters and nonrespiratory complications. A model using age <3 years, SpO2 nadir, and peak CO2 predicted respiratory complications better than the American Academy of Pediatrics or American Academy of Otolaryngology—Head and Neck Surgery Foundation guidelines but was imperfect (area under the curve = 0.72). Conclusion Thus, PSG predicted perioperative respiratory, but not nonrespiratory, complications in children with OSAS. Age <3 years or black race are high-risk factors. Present guidelines have limitations in determining the need for postoperative admission.

Rationale: Positive airway pressure therapy is frequently used to treat obstructive sleep apnea in children. However, it is not known whether positive airway pressure therapy results in improvements in the neurobehavioral abnormalities associated with childhood sleep apnea. Objectives: We hypothesized that positive airway pressure therapy would be associated with improvements in attention, sleepiness, behavior, and quality of life, and that changes would be associated with therapy adherence. Methods: Neurobehavioral assessments were performed at baseline and after 3 months of positive airway pressure therapy in a heterogeneous group of 52 children and adolescents. Measurements and Main Results: Adherence varied widely (mean use, 170 6 145 [SD] minutes per night). Positive airway pressure therapy was associated with significant improvements in attention deficits (P , 0.001); sleepiness on the Epworth Sleepiness Scale (P , 0.001); behavior (P , 0.001); and caregiver-(P ¼ 0.005) and child-(P , 0.001) reported quality of life. There was a significant correlation between the decrease in Epworth Sleepiness Scale at 3 months and adherence (r ¼ 0.411; P ¼ 0.006), but not between other behavioral outcomes and adherence. Behavioral factors also improved in the subset of children with developmental delays. Conclusions: These results indicate that, despite suboptimal adherence use, there was significant improvement in neurobehavioral function in children after 3 months of positive airway pressure therapy, even in developmentally delayed children. The implications for improved family, social, and school function are substantial. Clinical trial registered with www.clinicaltrials.gov (NCT 00458406).Keywords: continuous positive airway pressure; obstructive sleep apnea; sleepinessThe obstructive sleep apnea syndrome (OSAS) affects up to 4% of children (1). In most children, OSAS is associated with adenotonsillar hypertrophy, and improves after adenotonsillectomy (2). However, a significant proportion of children have residual OSAS postoperatively (3). Furthermore, many children with OSAS have other underlying conditions, such as obesity or Down syndrome. In these children, continuous positive airway pressure (CPAP) is usually used as the second line of treatment (2). Although CPAP is now being used commonly in children, only a handful of studies have evaluated its efficacy.If left untreated, OSAS may lead to substantial comorbidities. In particular, childhood OSAS has been shown to be associated with behavioral disturbances and learning deficits (4). The effect of PAP therapy in treating these neurobehavioral deficits in children is unknown. We therefore prospectively evaluated changes in neurobehavioral parameters, including symptoms of attentiondeficit/hyperactivity disorder (ADHD), sleepiness, behavior, and quality of life, at baseline and after 3 months of PAP in children with OSAS. We hypothesized that children treated effectively with PAP, including children with developmental delays, would show improvements in neurobehav...

PAP adherence in children and adolescents is related primarily to family and demographic factors rather than severity of apnea or measures of psychosocial functioning. Further research is needed to determine the relative contributions of maternal education, socioeconomic status and cultural beliefs to PAP adherence in children, in order to develop better adherence programs.

Study Objectives:To determine the effects of bilevel positive airway pressure with pressure release technology (Bi-Flex) on adherence and effi cacy in children and adolescents compared to standard continuous positive airway pressure (CPAP) therapy. We hypothesized that Bi-Flex would result in improved adherence but similar effi cacy to CPAP. Methods: This was a randomized, double-blinded clinical trial. Patients with obstructive sleep apnea were randomized to CPAP or Bi-Flex. Repeat polysomnography was performed on pressure at 3 months. Objective adherence data were obtained at 1 and 3 months. Results: 56 children and adolescents were evaluated. There were no signifi cant differences in the number of nights the device was turned on, or the mean number of minutes used at pressure per night for CPAP vs Bi-Flex (24 ± 6 vs 22 ± 9 nights, and 201 ± 135 vs 185 ± 165 min, respectively, for Month 1). The apnea hypopnea index decreased signifi cantly from 22 ± 21/h to 2 ± 3/h on CPAP (p = 0.005), and 18 ± 15/h to 2 ± 2/h on Bi-Flex (p < 0.0005), but there was no signifi cant difference between groups (p = 0.82 for CPAP vs Bi-Flex). The Epworth Sleepiness Scale decreased from 8 ± 5 to 6 ± 3 on CPAP (p = 0.14), and 10 ± 6 to 5 ± 5 on Bi-Flex (p < 0.0005; p = 0.12 for CPAP vs Bi-Flex). Conclusions: Both CPAP and Bi-Flex are effi cacious in treating children and adolescents with OSAS. However, adherence is suboptimal with both methods. Further research is required to determine ways to improve adherence in the pediatric population. keywords: CPAP, obstructive sleep apnea, Bi-Flex Citation: Marcus CL; Beck SE; Traylor J; Cornaglia MA; Meltzer LJ; DiFeo N; Karamessinis LR; Samuel J; Falvo J; DiMaria M; Gallagher PR; Beris H; Menello MK. Randomized, double-blind clinical trial of two different modes of positive airway pressure therapy on adherence and effi cacy in children.