I applaud the AASM for putting together clinical guidelines for positive airway pressure (PAP) titration. I understand that this was a very challenging task and, as with many areas of sleep medicine, there was a paucity of hard data upon which to base practical recommendations. However, I do have concerns regarding some of the pediatric recommendations.
Recommendation 4.2.1.3.: The recommended maximum CPAP should be 15 cm H2O for patients < 12 years and 20 cm H2O for patients ≥ 12 years (Consensus).
To the best of my knowledge, there are no data justifying lower nasal CPAP pressure ranges for children compared to adults. The level of pressure needed relates to the collapsibility of the upper airway rather than to age per se. In a previous study of 94 children, we reported that there was no significant correlation between CPAP level and age (the correlation coefficient was only 0.09).1 Although we agree that bilevel pressure is likely to be more comfortable for most patients requiring pressures greater than 15 cm H2O, we have reported the successful use of higher CPAP pressures in children.1
4.2.2.2: CPAP should be increased (according to the criterion in Recommendation 4.2.2.1) if at least 1 obstructive apnea is observed for patients < 12 years or if at least 2 obstructive apneas are observed for patients ≥ 12 years (Consensus).
The wording in this recommendation is unclear. Do the task force members mean 1 apnea per hour or one apnea per night (if the same pressure level is maintained all night)? Clearly, one obstructive apnea per night is in the normal range. Furthermore, one obstructive apnea per hour is at the upper limit of normal for children.2–4 Whereas increasing the pressure for an obstructive apnea index of 1/h is appropriate for a child on low pressure levels, it may not be the best option for a child requiring higher pressure levels who is having a hard time tolerating CPAP in the laboratory.
The same concern exists in relation to the guideline regarding hypopneas.
4.3.1.4.: The recommended maximum IPAP should be 20 cm H2O for patients < 12 years or 30 cm H2O for patients ≥ 12 years (Consensus).
The same concerns apply as for Recommendation 4.2.1.3. Children requiring high PAP pressures often have additional risk factors for obstructive sleep apnea, such as craniofacial anomalies. Although a number of surgical and other options may be available for these patients, in many of them, the only option other than PAP is tracheostomy. There is no evidence that an IPAP > 20 cm H2O is more dangerous in a child than in an adult, and recommending this limit may inhibit practitioners as well as funding agencies from prescribing and paying for higher pressures, even when the only alternative may be a tracheostomy.
I again want to thank the Task Force for undertaking this difficult task. However, I recommend that recommendations not be made in situations where evidence is not available.
DISCLOSURE STATEMENT
Dr. Marcus has received research support from Respironics.
REFERENCES
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