Study: Not Sticking to Schedule Shouldn’t Block PAP Machines for Kids With OSA

CHARLOTTE, N.C. — Positive airway pressure (PAP) machines were helpful enough that pediatric patients could have symptoms improve even without being compliant, according to researchers advocating for greater access to this therapy for this population.

At one center’s sleep clinic, 172 out of 221 children with obstructive sleep apnea (OSA) reported improved symptoms approximately 3 months after PAP initiation, and 81 out of 90 had better symptoms at the 1.5- to 2-year mark, reported Supriya Jambhekar, MD, of Arkansas Children’s Hospital in Little Rock, and colleagues, at SLEEP 2022, a joint meeting of the American Academy of Sleep Medicine and the Sleep Research Society.

Notably, improvements did not hinge on children meeting a standard insurer’s threshold of PAP adherence (at least 4 hours a night for 70% of nights for payment). Among those who reported improvement in symptoms after 3 months of PAP use and had sufficient adherence data, about 56% had been nonadherent; similarly, about 49% of those with improvements out to 2 years were deemed non-adherent, according to Jambhekar’s group reported in a separate presentation.

Symptoms particularly relevant to children with OSA included decreased concentration, hyperactivity, memory impairment, learning disorders, nocturnal enuresis, and growth impairment. These “improved with PAP and are important indicators in this population of improved clinical outcomes,” according to the authors.

“Due to the clinically significant outcomes to growth and development that PAP provides to pediatric patients with OSA, we suggest that they should not be held to the same insurance requirements as adults and further studies should be conducted to validate these findings,” they urged.

The favorable findings for PAP in children come during a time when sleep research is being criticized for inconsistencies and a reliance on surrogate measures instead of more clinically meaningful outcomes (e.g. all-cause mortality, stroke, myocardial infarction). Prompted by the Centers for Medicare & Medicaid Services (CMS), the Agency for Healthcare Research and Quality (AHRQ) performed a review and released a draft report in 2021 stating that the available evidence does not support continuous PAP (CPAP) having an effect on clinical outcomes in the long term, though more studies are needed.

Jambhekar’s group noted that there were no pediatric studies included in the AHRQ report. Additionally, when the report came out, sleep experts maintained to MedPage Today that CPAP remains an effective treatment for sleep-related outcomes even if adherence is an issue.

Currently, CMS and other insurance providers can deny payment for PAP therapy if there is no proof of adequate usage.

For their two posters, the authors reviewed the charts of 235 kids with OSA (64% boys; mean age 12 years at PAP initiation). This was a group that was largely white (51.5%) or African American (38.3%). Over half of the kids had obesity, and their apnea-hypopnea index averaged 24.7/hour.

A limitation of the retrospective studies was the amount of missing data: Just 138 children had adherence data available at 3 months, dropping down to 74 children at 18 months-2 years.