Original article
Non-invasive ventilation in complex obstructive sleep apnea – A 15-year experience of a pediatric tertiary center
Ventilação não-invasiva em apneia obstrutiva do sono complexa – Uma experiência de 15 anos de um centro pediátrico terciário
I.C. Girbal
, C. Gonçalves, T. Nunes, R. Ferreira, L. Pereira, A. Saianda, T. Bandeira
Corresponding author
Respiratory, Sleep and Ventilation Unit, Department of Pediatrics, Santa Maria Hospital - CHLN, Academic Medical Center of Lisbon, Lisbon, Portugal
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Girbal, C. Gonçalves, T. Nunes, R. Ferreira, L. Pereira, A. Saianda, T. Bandeira" "autores" => array:7 [ 0 => array:4 [ "nombre" => "I.C." "apellidos" => "Girbal" "email" => array:1 [ 0 => "inescarmogirbal@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "C." "apellidos" => "Gonçalves" ] 2 => array:2 [ "nombre" => "T." "apellidos" => "Nunes" ] 3 => array:2 [ "nombre" => "R." "apellidos" => "Ferreira" ] 4 => array:2 [ "nombre" => "L." "apellidos" => "Pereira" ] 5 => array:2 [ "nombre" => "A." "apellidos" => "Saianda" ] 6 => array:2 [ "nombre" => "T." "apellidos" => "Bandeira" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Respiratory, Sleep and Ventilation Unit, Department of Pediatrics, Santa Maria Hospital - CHLN, Academic Medical Center of Lisbon, Lisbon, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Ventilação não-invasiva em apneia obstrutiva do sono complexa – Uma experiência de 15 anos de um centro pediátrico terciário" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 350 "Ancho" => 981 "Tamanyo" => 45637 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Annual distribution at NIV starting point.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Pediatric obstructive sleep respiratory disorder has a broad clinical spectrum, from simple snoring to the most severe obstructive sleep apnea (OSA).</p><p id="par0010" class="elsevierStylePara elsevierViewall">OSA occurs in 1–3% of children,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> and is defined by airway obstruction, either partial and prolonged or complete and intermittent, interfering with sleep patterns and ventilation.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Adenotonsillar hypertrophy (ATH) is the most frequent cause in children, but craniofacial malformations, as well as neuromuscular diseases and obesity have been increasingly considered.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In childhood, OSA has important repercussions on somatic growth, the cardiovascular system and neurocognitive development.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a> Early diagnosis and intervention are essential to prevent complications and improve quality of life.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Identification of clinical criteria (respiratory pauses, hard or noisy breathing or excessive daytime somnolence) and predisposing clinical conditions<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> support the diagnosis of OSA, but polysomnography (PSG) is currently considered the gold standard.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">As the main cause of OSA in childhood is ATH, adenotonsillectomy is the most commonly recommended treatment for uncomplicated cases.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,13,14</span></a> There is, however, growing evidence of surgery failure<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> and there are a significant number of children with craniofacial defects who need alternative therapies. These children represent a group with complex OSA, requiring innovative surgical and medical approaches.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In children with chronic conditions or complex OSA, NIV has been increasingly used since 1984,<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,17</span></a> when surgery is contraindicated or ineffective, or as a supportive treatment until appropriate stage for surgical intervention, allowing for clinical stabilization and growth.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18–20</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">NIV efficacy and tolerance in children have been reported in a few studies<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18,21,22</span></a> and clearly the experience of qualified teams with appropriate support facilities warrants high quality care.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,23,24</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The main objective of this study is to describe our experience in a tertiary Portuguese pediatric center in the management of children with complex OSA, for whom noninvasive positive-pressure ventilation was an effective therapeutic alternative.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methods</span><p id="par0050" class="elsevierStylePara elsevierViewall">A retrospective case series study was performed through chart review of all cases of children submitted to NIV, in which complex OSA was the main indication for ventilation. Eligible cases were identified from internal clinical database in the period of January 1997 to March 2012. Children with other indications for NIV were excluded.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Demographic data were collected, including primary and secondary clinical diagnoses, sleep studies results, modes of ventilation, adherence, complications and efficacy related to NIV. Clinical data concerning sleep disordered breathing including difficult or noisy breathing, respiratory pauses, unsettled sleep, excessive sweating, excessive daytime somnolence, morning headache and failure to thrive were assessed.All patients underwent sleep studies: continuous transcutaneous monitoring of O<span class="elsevierStyleInf">2</span> and CO<span class="elsevierStyleInf">2</span> (Tc CO<span class="elsevierStyleInf">2</span>), complemented with capillary blood gases from the begining through 2004, on an inpatient basis, formal sleep studies at the sleep laboratory (cardio-respiratory studies (CRS) from 2004 and PSG after 2008).</p><p id="par0065" class="elsevierStylePara elsevierViewall">OSA was diagnosed based on clinical signs of sleep disordered breathing as described ahead and, whenever available, by an apnea/hypopnea index (AHI)<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>1.</p><p id="par0070" class="elsevierStylePara elsevierViewall">OSA plus hypoventilation syndrome was considered when there was hypoventilation associated to obstructive events (Tc CO<span class="elsevierStyleInf">2</span>median<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>45<span class="elsevierStyleHsp" style=""></span>mmHg or morning p CO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>45<span class="elsevierStyleHsp" style=""></span>mmHg).</p><p id="par0075" class="elsevierStylePara elsevierViewall">For PSG and CRS, average saturation and AHI were collected. An AHI<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>1/h was considered abnormal.</p><p id="par0080" class="elsevierStylePara elsevierViewall">In this study NIV was defined as any noninvasive ventilatory support delivered by flow generators suitable for ambulatory use, whenever CPAP or bi-level positive airway pressure (BiPAP) was applied. The decision on ventilatory modality relied on the presence of isolated OSA or associated hypoventilation, CPAP was the choice in the former cases and BiPAP in the latter. BiPAP was also used in isolated OSA to increase tolerance when high pressures were needed.</p><p id="par0085" class="elsevierStylePara elsevierViewall">In all patients NIV was started in the pediatric respiratory ward or in the pediatric sleep laboratory, depending on the clinical status of the patient and availability. In the ward, pressures were progressively increased until elimination of snoring and improvement in the respiratory pattern and pulse oximetry. In the laboratory, the pressures were titrated according to international guidelines.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11–13</span></a> In both settings the initial pressure was always above 4<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O and resulted in the elimination of respiratory events and normalization of pulse oximetry, TcCO<span class="elsevierStyleInf">2</span> and morning blood gases.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Families and patients underwent training in mask fitting, equipment management and adverse effects prevention. Their ability to maintain NIV at home was evaluated. A 24-h phone number was available for additional information. A first follow-up appointment was booked for 2–3 weeks after starting following NIV.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Adherence to treatment was evaluated by subjective estimation of daily NIV hours, based upon information provided by caregivers registered in the clinical file. Adherence was classified as insufficient where the NIV time was less than 3<span class="elsevierStyleHsp" style=""></span>hours per night.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The recording and analysis of data were performed on SPSS<span class="elsevierStyleSup">®</span> statistics for Windows<span class="elsevierStyleSup">®</span>, version 19.0<span class="elsevierStyleSup">©</span>. Quantitative absolute and relative data are expressed as mean and standard deviation or median and interquartile range (IQR) for data not normally distributed.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0105" class="elsevierStylePara elsevierViewall">During the study period, 68 children with OSA started NIV, representing 41.2% of all the pediatric patients under NIV program at the Pediatric Respiratory Unit.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Forty (59%) patients were male, median age at starting NIV was 6 years and 7 months (IQR: 15–171 months).</p><p id="par0115" class="elsevierStylePara elsevierViewall">Two main age distribution groups were identified, 22(32%) infants and 25 (37%) adolescents (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">A progressive increase in the number of patients entering the program yearly was found, with 61.7% of them starting NIV in 2005 or later (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">The most frequent diagnoses were congenital malformations and genetic disorders in 34 (50%) patients, cerebral palsy in 9 (13%) and inborn errors of metabolism in 6 (9%). Eight (12%) patients were referred to the center because of OSA after treatments for central nervous system (CNS) tumors. Obesity and ATH were found as a primary diagnosis for 3 patients each (4%). The complete distribution of the pathologies is illustrated in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">Comorbidities were present in 38 (56%), gastro-esophageal reflux (GER) in 17, obesity in 13, rhinitis in 7 and asthma in 5 patients. Some patients had association of comorbidities.</p><p id="par0135" class="elsevierStylePara elsevierViewall">In 52 (76%) patients respiratory sleep disorders were considered exclusively obstructive and CPAP was prescribed.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Sixteen patients (24%) started on bilevel NIV, in four to increase tolerance when high pressures were needed to surpass the airway obstruction and in twelve patients because of mixed ventilatory conditions (OSA plus hypoventilation syndrome): 5 with secondary obesity (2 Prader–Willi, 2 trisomy 21, 1 CNS tumor) and the rest because of significant hypotonic disorder or restrictive respiratory pattern.</p><p id="par0145" class="elsevierStylePara elsevierViewall">In all patients the interface for positive pressure delivering was nasal mask or <span class="elsevierStyleItalic">prongs</span>.</p><p id="par0150" class="elsevierStylePara elsevierViewall">NIV was started electively in 42 (62%) patients and in acute setting in 26 (38%) after respiratory exacerbation or as transition from invasive ventilation, most transferred from Pediatric or Neonatal Intensive Care Units.</p><p id="par0155" class="elsevierStylePara elsevierViewall">NIV was started without previous ear, nose and throat (ENT) or craniofacial surgery in 55 (81%) patients. Nine of them had surgery during follow-up, and after intervention it was possible to stop ventilation in 5. Thirteen children (19%) started NIV after ENT surgery failure.</p><p id="par0160" class="elsevierStylePara elsevierViewall">Prior to the implementation of NIV, 33 (49%) patients performed a formal sleep study (PSG or CRS). These results are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">The median duration on NIV (data from 62/68 patients) was 21.5 (IQR: 7–72) months. Thirty (44%) patients are still on NIV. In 22 (32%) NIV was successfully withdrawn, 17 (77%) of which due to spontaneous resolution of clinical condition and 5 after relevant surgery. Eight patients (12%) died as result of their main diagnosis: CNS tumor,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> mucopolysaccharidosis,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Prader–Willi syndrome,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> cerebral palsy<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and tongue sarcoma.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Eight patients (12%) were lost to follow-up.</p><p id="par0170" class="elsevierStylePara elsevierViewall">According to information provided by the parents, subjective evidence of adherence was considered good in 53 (78%) children. No objective measures of adherence were applied.</p><p id="par0175" class="elsevierStylePara elsevierViewall">Minor complications of NIV were recorded in ten (14.7%) patients: local skin irritation was reported in 3, conjunctivitis in 4 and skin breakdown in 3. In two (3%) slight facial deformation was found.</p><p id="par0180" class="elsevierStylePara elsevierViewall">All patients with sustained NIV had clinical improvement, as reported in clinical files.</p><p id="par0185" class="elsevierStylePara elsevierViewall">Twenty-nine (43%) patients performed PSG or CRS after the implementation of NIV, in order to monitor their response to treatment. The results are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0190" class="elsevierStylePara elsevierViewall">Our study shows, as other series have done,<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24–27</span></a> that OSA is a common indication for NIV in pediatric patients. This therapeutic support has been increasingly used in selected pediatric populations, as our data also confirm, with most of the patients (61.7%) starting NIV in 2005 and thereafter.</p><p id="par0195" class="elsevierStylePara elsevierViewall">There was a wide age range distribution for starting NIV, clearly related to the different timings of ventilation support needed for different disorders. We found a significant number of infants, being about a third of the patients. In this age group airway malacia and Pierre–Robin syndrome were the most frequent diseases found, usually with transient NIV and a good prognosis. This emphasizes the fact that NIV is being increasingly used in small children, with good tolerance and efficacy<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,22,28</span></a> allowing somatic growth to occur and in some cases avoiding tracheostomy.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a>As described in other series, we verified a slight male predominance (58.8%).<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30,31</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Half of patients had congenital malformations or genetic disorders as the main cause of OSA. This multiplicity of diagnosis has been previously described by others,<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9,23,24</span></a> the most relevant features being craniofacial malformations and airway malacia. The reason for opting for NIV in these complex patients is easily understood, as most of these disorders have several simultaneous factors contributing to OSA, as well as isolated adenoid hypertrophy, and hence have suboptimal results or no indication for surgical approach. The accumulated experience with this heterogeneous group of patients depends on the specificity of our institution, a tertiary university hospital, where a multidisciplinary approach is possible and often warrants support for these complex patients with multiple medical needs. CPAP is very helpful in isolated OSA, improving the quality of sleep, daytime functioning and caregiver concern<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> but BiPAP is preferred when there is associated hypoventilation. As described before,<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> the main benefits obtained in these patients could be different from otherwise healthy children and focused on palliation of symptoms and quality of life improvement, for patients and their families.</p><p id="par0205" class="elsevierStylePara elsevierViewall">Three patients had isolated ATH for whom NIV was a transient support used to stabilize the patients while waiting for surgery, as described in the literature.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">Three patients were started on NIV because of primary obesity, which is increasingly associated to childhood OSA<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> and often a cause of persistent OSA after adenotonsillectomy.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Implementation of CPAP effectively controlled OSA in 52 patients. In the rest, BiPAP was started. Both forms are effective in pediatric OSA,<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> and the option is determined by the existence of an OSA plus hypoventilation syndrome or the need for high ventilatory pressures.</p><p id="par0220" class="elsevierStylePara elsevierViewall">Comorbidities, present in more than half of our patients, either alone or in association, are relevant issues. Their identification and treatment are essential because they can interfere with therapeutic choices, adhesion and adverse events of treatment.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> Obesity is the main cause of OSA in adult population, and it also plays a relevant role in childhood OSA, often being responsible for failure to respond to surgical treatment in children without other contributing factors.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> As shown in this series, overweight children and adolescents are a relevant group, including simple and secondary obesity, and in both situations a dietary plan should be part of the therapeutic approach.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">GER or rhinitis must be actively sought and should be medically controlled. Specifically the treatment of allergic rhinitis is an adjuvant measure in controlling AOS,<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> and rhinitis can also interfere with NIV compliance, worsening nasal obstruction and mucosal dryness, frequent side effects associated to NIV.</p><p id="par0230" class="elsevierStylePara elsevierViewall">The gold-standard for OSA diagnosis is the PSG. However, if not readily available, alternative tests like pulse oximetry<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> may be indicated. This was the method used in our setting until 2004. From this date on, the existence of CRS and later, of PSG (from 2008) have allowed for a more accurate monitoring for NIV management.</p><p id="par0235" class="elsevierStylePara elsevierViewall">The reason why less than half of the patients<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> performed a formal sleep study before implementing NIV (23 PSG and 10 CRS), besides availability, is due to a significant number of children starting treatment in a respiratory exacerbation and hence without previous studies.</p><p id="par0240" class="elsevierStylePara elsevierViewall">In fact in our population NIV was started in a non-elective manner in 38% of patients, who needed this support to deal with critical OSA and impending respiratory failure.</p><p id="par0245" class="elsevierStylePara elsevierViewall">After starting treatment, clinical improvement was recorded in every child, and withdrawal was feasible in 22 (32%). Over a third (43%) of our population performed a formal sleep study to monitor their response to treatment.</p><p id="par0250" class="elsevierStylePara elsevierViewall">Unlike other pediatric groups with NIV indication, such as neuromuscular patients, some patients with OSA are expected to improve as the result of somatic growth or surgery (when NIV is used as a temporary bridge to the procedure).<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">In four of the eight deceased patients, with oncologic diseases, NIV was started to control OSA and also as a palliative measure, improving comfort and decreasing hospital stay. Even if it was not initially the main objective, these patients benefited from greater clinical stability, reducing the burden for themselves and their families. In the pediatric setting, we have to consider NIV as part of a palliative care plan, in which the objective is not the cure but the preservation of comfort and decreasing suffering for both the patient and the family.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,23,39</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">Adherence to treatment is an important issue in the assessment of NIV in children being closely related to the acceptance and tolerability of the mask and to early detection of minor skin lesions.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> A careful mask fitting was carried out with the patients, allowing them to choose the most comfortable.</p><p id="par0265" class="elsevierStylePara elsevierViewall">Another very important issue on adherence to treatment is education. Families require appropriate training to be able to provide care for the child at home,<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> so teaching the caregivers (and when possible, the child) about practical issues, main goals and consequences of withdrawal of the treatment are essential for the success of NIV. The adherence was considered good in over two thirds of our population, but objective measurements of adherence were lacking; hence the data cannot be accurately interpreted.</p><p id="par0270" class="elsevierStylePara elsevierViewall">We registered an abandon rate of 12%, which we considered high, but still lower than that described in the literature. Marcus et al.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> demonstrated that both methods (CPAP and BiPAP) are highly effective, but over a third of their patients had abandoned treatment at 6 months follow-up.</p><p id="par0275" class="elsevierStylePara elsevierViewall">The main limitation of our study is its retrospective design, which limited the availability of some data and prevents a uniform approach for each patient.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusion</span><p id="par0280" class="elsevierStylePara elsevierViewall">This study described a complex group of patients, in whom NIV was used as an option to treat OSA. We demonstrated its feasibility with a high success rate, documented few complications, and found this treatment to be well-tolerated and effective in the management of OSA, even in toddlers. As other groups have already shown, the optimal care for these patients can only be given in qualified specialized centers<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23,24</span></a> because the management of these complex patients requires an holistic understanding of the diagnosis, technology involved in diagnosis and therapy, prognosis and long-term care.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Ethical disclosures</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Protection of human and animal subjects</span><p id="par0285" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Confidentiality of data</span><p id="par0290" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Right to privacy and informed consent</span><p id="par0295" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflicts of interest</span><p id="par0300" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres740825" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objectives" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec745011" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres740824" "titulo" => "Resumo" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introdução" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusões" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec745012" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:3 [ "identificador" => "sec0030" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-03-01" "fechaAceptado" => "2013-08-08" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec745011" "palabras" => array:3 [ 0 => "Noninvasive ventilation" 1 => "Obstructive sleep apnea" 2 => "Children" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec745012" "palabras" => array:3 [ 0 => "Ventilação não invasiva" 1 => "Apneia obstrutiva do sono" 2 => "Crianças" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Obstructive sleep apnea (OSA) affects approximately 1–3% of pediatric population and is associated with significant morbidity. As adenotonsillar hypertrophy (ATH) is its primary cause in children, elective adenotonsillectomy is the first treatment of choice. Noninvasive ventilation (NIV) has been increasingly considered as an option, mainly for children with complex diseases, ineligible or waiting for surgeries, or after surgery failure.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objectives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To describe the experience in the management of children with complex OSA, and to evidence the feasibility and advantages of NIV.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">This was a retrospective cohort study of 68 children on NIV, in whom complex OSA was the main indication for ventilation, in a Pediatric Respiratory Unit at a University Hospital between January 1997 and March 2012. Demographic and clinical data were collected on the underlying diagnosis, therapeutic interventions prior to NIV, NIV related issues and outcome.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Forty (59%) children were male, median age at starting NIV was 6 years and 7 months, with interquartile range (IQR) of 15–171 months. Twenty-two (32%) were infants and 25 (37%) adolescents.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The most common diagnosis was congenital malformations and genetic disorders in 34 (50%) patients. Nine patients had cerebral palsy, 8 were post treatment for central nervous system tumors and 6 had inborn errors of metabolism. Three children had ATH and three obesity. The majority of patients (76%) had exclusively obstructive OSA and started CPAP. Ten patients had minor complications. Twenty-two patients stopped NIV due to clinical improvement, 8 were non-compliant and 8 patients died. NIV median duration was 21.5 months (IQR: 7–72).</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">NIV is feasible and well tolerated by children with OSA associated with complex disorders, and has been shown to have few complications even in infants and toddlers.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objectives" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introdução</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A apneia obstrutiva do sono (OSA) afeta aproximadamente 1–3% da população pediátrica e está associada com uma morbidade significativa. Como a hipertrofia adenotonsiliana (ATH) é a sua principal causa, a adenocele eletiva é a primeira opção terapêutica. A ventilação não invasiva (VNI) tem sido cada vez mais considerada como uma opção, principalmente para as crianças com doenças complexas, inelegíveis, à espera de cirurgias ou após falência do tratamento cirúrgico.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Descrever a experiência no tratamento de crianças com OSA complexo e avaliação da viabilidade e das vantagens do NIV.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Métodos</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Estudo de coorte retrospetivo de 68 crianças em NIV, onde o complexo OSA foi a principal indicação para ventilação, numa Unidade Respiratória Pediátrica de um Hospital Universitário entre janeiro de 1997 e março de 2012. Os dados demográficos e clínicos recolhidos englobaram o diagnóstico subjacente, as intervenções terapêuticas prévias à NIV, as intercorrências relacionadas com a NIV e a evolução clínica.</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Quarenta (59%) crianças eram do sexo masculino, idade média no início da NIV foi de 6 anos e 7 meses, com intervalo interquartil (IQR) de 15–171 meses. Vinte e duas (32%) eram crianças e 25 (37%) adolescentes.</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">O diagnóstico mais comum foram as malformações congénitas e as doenças genéticas em 34 (50%) pacientes. Nove pacientes tiveram paralisia cerebral, 8 sequelas de pós-tratamento para tumores do sistema nervoso central e seis sofriam de erros inatos do metabolismo. Três crianças sofriam de ATH e três de obesidade. A maioria dos pacientes (76%) sofria exclusivamente de OSA obstrutiva e iniciou CPAP. Dois doentes sofriam complicações menores. Vinte e dois doentes pararam o NIV, devido a melhoria clínica, 8 eram não-conformes e 8 morreram. A duração média do NIV foi 21,5 meses (IQR: 7–72).</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusões</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">A NIV é uma terapia viável e bem tolerada em crianças com OSA e doenças complexas, com poucas complicações, incluíndo em bebés e crianças pequenas.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introdução" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusões" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 493 "Ancho" => 966 "Tamanyo" => 42850 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Age distribution at NIV start.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 350 "Ancho" => 981 "Tamanyo" => 45637 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Annual distribution at NIV starting point.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col">Nosologic group \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Patients (<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>68) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">OSA plus hypoventilation syndrome \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Age at NIV start in months \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span> (%)<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span> (%)<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Median (IQR) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Congenital malformations/genetic disorders \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34 (50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (10) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42.5 (5–144) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Prader–Willi syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">176 (158–187) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Pierre–Robin syndrome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0–2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Trisomy 21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">120 (46–180) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Craniofacial malformation<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 (7–45) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Airway malacia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (2–15) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Other \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 (40–96) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Cerebral palsy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">168 (89–173) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Central nervous system tumor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (12) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">171 (94–180) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Inborn errors of metabolism \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59 (20–135) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Mucopolysaccharidosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59 (46–156) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Gaucher disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Adenoid/tonsil hypertrophy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3(4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (12–31) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Obesity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">166 (154–194) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Others \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">106 (85–110) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1224583.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Including choanal atresia, craniosynostosis, pycnodysostosis, achondroplasia, Charge Syndrome.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">All percentages refer to the total number of patients (<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>68).</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Distribution of patients according to primary diagnosis, presence of associated hypoventilation and age at NIV start.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">IQR: interquartile range.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col">Formal sleep study \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Patients \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Apnea/hypopnea index (AHI) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Average peripheral saturation \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span> (%)<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Median (IQR) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Median (IQR) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Before non-invasive ventilation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 (49) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Polysomnography \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (34) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.7 (5.8–18.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">94.5% (87.9–96.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Cardiorespiratory study \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (15) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.6 (3.3–16.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96% (93.8–96.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">After non-invasive ventilation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 (43) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Polysomnography \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 (37) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.3 (0–2.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">97% (95.2–97.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Cardiorespiratory study \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.6 (0.3–2.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">97.5% (97.8–98.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1224582.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">The percentages refer to the total number of patients in the study (<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>68).</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Formal sleep studies before and after NIV.</p>" ] ] ] 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| Year/Month | Html | Total | |
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| 2024 November | 8 | 8 | 16 |
| 2024 October | 41 | 30 | 71 |
| 2024 September | 41 | 31 | 72 |
| 2024 August | 49 | 36 | 85 |
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| 2023 August | 13 | 13 | 26 |
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