A TECH S TOOLKIT FOR THE PEDIATRIC SLEEP LAB

Transcription

1 A TECH S TOOLKIT FOR THE PEDIATRIC SLEEP LAB Craig Canapari, MD craig.canapari@gmail.com drcraigcanapari.com: Updated syllabus will be here along with link to visual presentation. Twitter: DrCanapari INTRODUCTION Working with kids in the Pediatric Sleep Lab is analogous to working in other parts of health care. It's not for everybody. However, for the people who are interested, there are great dividends: 1. The kids are often really cute 2. You are more likely to see weird or unusual diseases as their is a high proportion of children with complex and interesting medical conditions who will pass through the pediatric sleep laboratory. 1. By diagnosing a sleep disorder (or ruling one out), you can really make a difference in a child's life which will yield dividends for years to come. There are several domains I m going to discuss which you need for success. 1. Technical skills 2. Pattern recognition 3. Curiosity. TECHNICAL SKILLS SET-UP A good set up is critically important in any sleep study; this is especially true in children. The consequences of a bad set-up can include poor quality information and, on occasion, needing to repeat the test. If you have children, you know that this is a really big deal. Critical leads include oximetry, NAF, end tidal CO2s, and belts if the study was ordered to answer a respiratory question. Understand Capnography THE ART OF DISTRACTION Certain leads absolutely need to go on during wakefulness, such as head leads, EKG, chest bands. Others, specifically leads on the face, can be really challenging to put on certain children-- I highly recommend putting NAF, thermistor, EtCO2 on after SWS. CPAP Prepare patients in advance Ideally, provide mask in advance for practice, desensitization, etc. This will greatly expedite your evening. Don t be afraid to push up CPAP levels on titrations A common rookie move is increasing pressures too slowly in little kids. If there are events or residual snoring, turn it up

2 Avoid Splits like the plague In a small child or a child with developmental issues you will frequently end up with a limited diagnostic portion and an inadequate titration. I generally do not allow referring doctors to send splits in patients who lack prior CPAP experience, and will only order them myself if I have time to review in detail what will occur. PROVIDE ENOUGH STAFF Appropriate staffing levels are critical. Our laboratory is a two bed lab. We have different staffing based on the complexity of patients. I won t pretend that this is the right way to do this in your laboratory but it is worth thinking about. We run 2 beds x 7 nights/week. 1.5 :1-- second tech goes home at midnight Most children 2+ yrs of age (that do not meet age/no special need criteria for the 2:1 nights) Trach/feeding tube (without additional comorbidities) Muscular dystrophy (without sensory issues) Developmental delays not accompanied by severe sensory issues Down Syndrome not accompanied by severe sensory issues PDD/Autism (including Aspergers)not accompanied by severe sensory issues It is common for autistic and Down kids almost by definitions to have sensory issues, please continue to have schedulers address this question to the parents, if the parents suggest that there are sensory issues, that will define the child as 1:1 regardless of age. 1:1 all night all children <2 yrs of age regardless of special needs Cerebral Palsy Any disorder accompanied with severe sensory issues regardless of age ALL titrations on children <5 yrs of age tracheostomy capping trials <5 yrs of age 2:1 ratio for all other kids DOCUMENTATION IS CRITICAL CPAP settings (why did you select a final value) and mask of choice CLIP VIDEOS of any concerning event DETAILED NOTES of parental interaction, behavior, causes of artifact (e.g. patting back, pacifier, etc) are tremendously useful Flag epochs where things happen and include in the tech notes for the studies. PATTERN RECOGNITION CAPNOGRAPHY OXIMETRY RESPIRATORY CHANNELS UNDERSTAND ADULT VS. PEDIATRIC SCORING The main difference is event duration.

3 You can apply adult criteria between ages 13-18; there is not much clarity on the best way to do this. Arbitrarily, I use age 16. Adult Pediatric Obstructive or mixed apnea duration 10 seconds duration 2 breaths duration Central apnea 10 seconds 20 seconds OR 2 missed breaths followed by arousal or 3% Hypopneas 10 seconds duration and associated with arousal and/or 3% or 4% 2 breaths duration and associated with arousal and/or 3% or 4% Hypoventilation rule Usually not measured Score the presence of sleep-related hypoventilation when >25 % of the total sleep time as measured by either the transcutaneous PCO2 and/or end-tidal CO2 sensor(s) is spent with a CO2 > 50 mm Hg. Periodic breathing rule Cheyne-Stokes rule applies Score periodic breathing if there are > 3 episodes of central apnea lasting > 3 seconds separated by no more than 20 seconds of normal breathing. EEG There is a lot of noise in little children with thin skulls EEG changes over time; adult patterns usually by 6 months of age Hypersynchronous theta is normal INFANT SLEEP SLEEP VS. WAKE DETERMINED BY EYES OPEN OR CLOSED Spindles start around age 2 months Slow waves 3 months of age K complexes 6 months of age OK to use normal sleep staging after 6 months

4 Prior to this, you score Active sleep (REM analogue): Predominant at birth and characterized by REM, twitches, and irregular breathing Quiet sleep (SWS analogue): Predominant by 3 months of age and characterized by regular breathing, minimal movement, and high voltage slow wave and/or trace alternant pattern Indeterminate sleep: Does not meet criteria for either CURIOSITY COMMON CONDITIONS SEEN IN THE SLEEP LAB DOWN SYNDROME/TRISOMY 21 These children have an array of features predisposing them to sleep disordered breathing including flattened midface, low tone, enlarged tongue, and increased risk of aspiration OSA, central sleep apnea, hypoventilation, and nocturnal seizures are all common PRADER-WILLI SYNDROME These children have low tone and failure to thrive in infancy but develop uncontrollable appetite and severe obesity later Sleep disorders include OSA, central sleep apnea, and narcolepsy DUCHENNE MUSCULAR DYSTROPHY (OR OTHER NEUROMUSCULAR DISORDERS) DMD is X-linked and thus occurs only in boys. It is characterized by progressive muscle weakness with eventual recurrent pneumonia and hypoventilation; the majority of these boys will require nocturnal respiratory support by the end of their teens, and around the clock respiratory support in their 20s We frequently titrate bilevel with the goal of maximizing ventilation by using large spans (~10 cm H20 or greater) Keep EPAP low Titrate IPAP to normalize gas exchange in REM Pediatric patients may require a back up rate O2 should be avoided in hypoventilators! LOOK STUFF UP I cannot overstate the importance of looking up unusual problems which you encounter in the lab. Some places to start: Page Dr. Google google.com; Google Scholar for more technical info For full text articles: SPEND TIME WITH THE SCORING TECH It s really critical to understand scoring. You already know more than many MDs about issues like scoring. You certainly know more about EKG than me. SPEND TIME WITH THE MD

5 This can be difficult to arrange but is worth your while, and my while too. I look at things differently that techs do as we have different skill sets, but there is no reason we can t learn from each other. I rely on our techs to pick up arrhythmias as they are better at detecting it than I am. One recently picked up a 3rd degree AV block which I had not seen since med school. ASK FOR FEEDBACK "If you can not measure it, you can not improve it." -- Lord Kelvin