Loading

Journal of Sleep Medicine and Disorders

Utilization of Positional Therapy for Management of Severe OSA in a Pediatric Patient

Case Report | Open Access

  • 1. Respiratory Care Services, Arkansas Children’s Hospital, Little Rock, Arkansas, USA
  • 2. Pediatric Sleep Disorders Center, Arkansas Children’s Hospital, Little Rock, Arkansas, USA
  • 3. Pulmonary and Sleep Medicine, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
+ Show More - Show Less
Corresponding Authors
April Scribner, Respiratory Care Services, Arkansas Children’s Hospital, Little Rock, Arkansas, USA
Abstract

We report a longitudinal case of an obese subject presenting at age two (BMI percentile > 99) with symptoms of OSA. Polysomnogram revealed severe OSA (AHI 37.1/hour) with abnormal oxygenation and ventilation. Despite extensive desensitization to PAP, the subject was intolerant to PAP. A tracheostomy was placed due to a failed PAP attempt. Although some children treated with tracheostomy for OSA have medical complexities, this child had no underlying neurologic or craniofacial syndromes. Tracheal de-cannulation occurred following a systematic approach including multiple polysomnograms and PAP desensitization. However, due to inability to resolve OSA with PAP and pressure intolerance, reinsertion of tracheostomy was considered. A second tracheostomy was avoided at age 17 (BMI percentile > 99) by utilizing a commercially available positional device in conjunction with PAP (AHI 3.4/hour, normal oxygenation and ventilation).

Although the utilization of a PAP in conjunction with PAP proved effective in this case, there is limited literature documenting concurrent use, and no current literature describes this practice in children. Further research is needed to determine if the combination of a positional device along with PAP is an effective treatment option in pediatric patients with difficult to treat OSA.

Keywords

CPAP, Positive Airway Pressure, BPAP, Obstructive Sleep Apnea, Positional Therapy, Pediatric

Citation

Scribner A, Pruss K, Jackson R, Jambhekar SK. (2023) Utilization of Positional Therapy for Management of Severe OSA in a Pediatric Patient. J Sleep Med Disord 8(1): 1130.

ABBREVIATIONS

ADP: Adherence Program; AHI: Apnea Hypopnea Index; AI: Arousal Index; BPAP: Bi-Level Positive Airway Pressure; CPAP: Continuous Positive Airway Pressure; EPAP: Expiratory Positive Airway Pressure; ETCO2 : End Tidal Carbon Dioxide; IPAP: Inspiratory Positive Airway Pressure; OSA: Obstructive Sleep Apnea; PAP: Positive Airway Pressure; POSA: Positional Obstructive Sleep Apnea; PSG: Polysomnogram; rAHI: Apnea Hypopnea Index during Rapid Eye Movement Sleep Stage; REM: Rapid Eye Movement; Spo2: Oxygen Saturation Measured by Pulse Oximeter

INTRODUCTION

Obstructive sleep apnea syndrome is defined as complete or partial upper airway obstruction during sleep that is disruptive to normal oxygenation, ventilation, and sleep patterns [1]. Primary snoring can be prevalent in up to 27% of children, with Obstructive Sleep Apnea (OSA) occurring in 1-5% [1,2]. Adenotonsillectomy is many times a curative treatment; however, residual OSA is found in some children [1]. While additional surgery options or an oral appliance are sometimes treatment options for this subset of children, the standard treatment of OSA is Positive Airway Pressure (PAP) therapy [1]. PAP therapy can consist of either Continuous Positive Airway Pressure (CPAP) or Bi-Level Positive Airway Pressure (BPAP). While effective, adherence to PAP therapy is difficult in adults and children alike [1,3,4]. For patients with severe OSA, more invasive treatments, including tracheostomy, are sometimes required to successfully resolve OSA when other treatments have been ineffective [5,6]. We are reporting a case of a pediatric patient intolerant to BPAP, who successfully avoided a second tracheostomy by utilizing a commercially available positional device in conjunction with BPAP at lower pressures.

CASE REPORT

This is a pediatric case report of a now adult black male with morbid obesity (body mass index 52.9 kg/m2 ) and an extensive history of severe OSA. At the age of 2 years and 9 months, obesity (BMI percentile > 99), snoring, snorting, witnessed apneas, and oxygen desaturations were identified during a hospital stay for an asthma exacerbation. CPAP was attempted during sleep, without success, due to pressure intolerance. BPAP was initiated and otolaryngology was consulted. Tonsils were 4+ and adenoids were 80% obstructing. An adeno-tonsillectomy was scheduled, and the subject was discharged home with BPAP settings of Inspiratory Positive Airway Pressure (IPAP) 18 cmH2 O, Expiratory Positive Airway Pressure (EPAP) 6 cmH2 O and a backup respiratory rate 20 breaths per minute. Three months later at 3 years of age, he underwent an adeno-tonsillectomy (removal of 4+ tonsils and 80% obstructing adenoids) which resulted in resolution of symptoms as reported at the surgical follow up visit, and BPAP was discontinued at that time.

At 4 years of age, the patient returned to the otolaryngology clinic, and it was reported that snoring had returned along with struggling to breathe during sleep, respiratory pauses, restless sleep, and the need to sleep in an upright position. Physical exam noted that he was markedly overweight with boggy nasal turbinates, a large tongue, and a long, bulbous uvula. A Polysomnogram (PSG) was performed at 5 years, 11 months of age. The study had been ordered to consider the possibility of the use of CPAP/BPAP, but the child was very anxious and upset during the hookup. Consequently, it was decided to only intervene with supplemental oxygen if needed. After 360 minutes of total sleep time, supplemental oxygen was added during the remaining 117.6 minutes of sleep. During the study, the child had mild to moderate snoring, demonstrated paradoxical breathing, and gasping. Fifty percent of the time, substernal and suprasternal retractions were noted. Without oxygen, this study revealed an overall Apnea- Hypopnea Index (AHI) of 37.2 per hour, AHI during Rapid Eye Movement Sleep (rAHI) 92.4 per hour, an Arousal Index (AI) 60.3 per hour, lowest oxygen saturation (SpO2 ) 57%, and maximum end tidal carbon dioxide (ETCO2 ) 63 mm Hg. With supplemental oxygen, the overall AHI was 65.8 per hour. Almost all events were obstructive with some true apneas recorded. The patient was admitted for inpatient desensitization to BPAP and recommended to follow up in the otolaryngology clinic as quickly as possible to discuss treatment options with continued CPAP/BPAP to be considered as a possibility even with surgical treatment, due to the severity of his OSA. Because of the redundant pharyngeal tissue and flat uvula, an uvulopalatopharyngoplasty with a revision adenoidectomy, tongue-based suspension using a repose bone screw system, and bilateral inferior turbinate trim surgery was performed.

Due to the severity of OSA, continued symptoms, and oxygen desaturations following surgery, he was discharged home on BPAP. Unfortunately, despite being hospitalized to acclimate to PAP in addition to working at home with desensitization to the pressure, his adherence was extremely poor. Eight months following surgery, he attended otolaryngology clinic follow up visit and reported BPAP intolerance, including caregivers needing to replace the mask up to four times per night. Symptoms noted while wearing BPAP included improved but residual snoring, restless sleep, sleeping in an upright position, respiratory pauses, nocturnal enuresis, and frequent arousals. Daytime symptoms included excessive daytime somnolence, poor school performance, behavioral problems, and morning headaches. He was also noted to have acanthosis nigricans, and hypertension. He repeated kindergarten. Discussions were had with the family regarding alternate treatments, specifically tracheostomy since his sleep apnea was severe and he was intolerant to PAP. A plan was made to continue working on desensitization, but also to schedule tracheostomy. If he became tolerant of PAP during the interim, tracheostomy would be deferred.

A split-night PSG was performed. The patient was started on a CPAP pressure of 4cmH2 O, increased up to 10 cmH2 O, and then switched to BPAP up to an IPAP of 16 cmH2 O and EPAP of 12 cmH2 O. Off BPAP, AHI was 124.3 per hour, low SpO2 46%, high ETCO2 62 mm Hg, and AI 202 per hour. On BPAP, AHI was 80.7 per hour, low SpO2 50%, high ETCO2 54 mm Hg, and AI 161.8 per hour. OSA events and oxygenation could not be controlled adequately on any BPAP settings studied. The child was noted to pull on the equipment throughout the night and removed the mask multiple times, especially every time the pressure increased. Due to the severity of OSA and inability to tolerate BPAP, a tracheostomy was performed at 6 years, 2 months of age.

At the one month follow up post tracheostomy, the patient’s caregivers reported no apneas, no bedwetting, and an improvement in diet and exercise. He had lost 15 pounds since the previous clinic visit. Six months following tracheostomy, a PSG with uncapped tracheostomy was performed. During the study, there was only 1 scorable central apnea, obstructive index was zero, a total AHI 0.1 per hour, low SpO2 90%, highest ETCO2 53 mm Hg and AI 4.0 per hour.

The patient continued to do well with issues or signs of OSA. At 10 years and 5 months of age, a PSG with tracheostomy capped to evaluate readiness for tracheal de-cannulation was performed. During this PSG, the first 131 minutes of sleep were recorded with the tracheostomy uncapped, and this portion of the study was normal. After 131 minutes of recording, including the first rapid eye movement sleep cycle, the tracheostomy was capped according to protocol procedure. During this portion of the PSG, the AHI was 41.7 per hour, low SpO2 was 82%, high ETCO2 62 mm Hg and AI was 30.1 per hour. It was determined that OSA remained too severe for tracheal de-cannulation at this time.

At age 12 years and 6 months, tracheal de-cannulation was once again considered, and another PSG with the tracheostomy capped was performed as previously described. On the capped portion of the study, there was significant sleep disruption, oxygenation and ventilation were very abnormal and AHI was elevated at 55.1 per hour. It was again determined that the patient was not ready for tracheal de-cannulation. At this point, the patient and caregiver were interested in attempting PAP again. The plan was for him to enroll in the sleep center’s positive airway pressure Adherence Program (ADP) to acclimate to CPAP with the tracheostomy open, transition to CPAP while capping the trach, and eventually possible de-cannulation, if tolerated.

The ADP is led by respiratory therapists and sleep behavioral psychologists with support from the sleep providers. Children participating in this program receive an individualized desensitization plan and are encouraged to improve PAP adherence while in the program and beyond program completion. This patient trialed both nasal and full-face interfaces and was introduced to CPAP up to 10cm H2 O with tracheostomy both capped, uncapped and with a Passey Muir valve in place. The patient reported feeling more comfortable with CPAP while trach was capped. The family was instructed to practice daytime desensitization with pressure and tracheostomy capped during the daytime and caregivers to check on the patient during the night. During this time, he started wearing the BPAP regularly and achieved good adherence with the tracheostomy open and while capped. Eight months after entering the ADP, the tracheostomy was removed; however, once de-cannulated, he continued struggling with BPAP use, possibly due to a tracheo-cutaneous fistula. Total PAP usage was adequate and in the 90+ percent range, however he was unable to achieve adequate pressure due to a large leak. The patient was scheduled for surgery, and a tracheostomy scar revision was performed.

At 16 years of age, PSG was repeated as a PAP titration. CPAP was started at 6 cmH2 O, quickly titrated up to 20 cmH2 O, and then switched to BPAP with IPAP 20 cmH2 O, EPAP 16 cmH2 O. Due to a large leak, an oronasal mask with chin strap was used. He was titrated for events on BPAP as high as IPAP 30 cmH2 O and EPAP 25 cmH2 O. He spent approximately the last half of the study on BPAP settings of IPAP 30 cmH2 O, EPAP 25 cmH2 O. During this time, he had the lowest AHI exhibited on the positional device which was 31 per hour. This study revealed persistence of OSA on all BPAP pressures attempted, with apnea hypopnea indices as high as 242 per hour on lower PAP settings. It was determined that re-insertion of the tracheostomy seemed to be the only option for management of his OSA. Upon closer analysis of the PSG, OSA events appeared to be managed fairly well on BPAP settings of IPAP 30 cmH2 O, EPAP 25 cmH2 O while in a lateral body position, but no adequate pressure could be identified for control of OSA in the supine body position. It was determined that if he would sleep in a lateral body position while using BPAP, OSA events may be controlled. The patient was provided with a commercially available positional device to keep him on his sides while wearing BPAP with settings of IPAP 30 cmH2 O, EPAP 25 cmH2 O and a full-face PAP interface. This was a commercially available positional device that consisted of a chest belt and an air bladder across the back. The device prevented the patient from lying in the supine body position. A BPAP titration PSG performed with the positional device starting with IPAP 14 cmH2 O, EPAP 14 cmH2 O and titrated to IPAP 22 cmH2 O, EPAP 18 cmH2 O. This study revealed sleep efficiency of 88%. Rapid Eye Movement (REM) sleep was increased at 30% of total sleep time, AI 6.9 per hour, AHI 3.4 per hour, rAHI 3.1 per hour, and the lowest SpO2 was 86%. BPAP was titrated at various pressures. Events were well controlled, and oxygenation was normal on settings of IPAP 20 cmH2O, EPAP 16cmH2 O. The patient was instructed to use these settings and a repeat PSG with BPAP titration would be performed in 6 months using the positional device to determine if BPAP could be titrated to lower pressures. (Table 1).

Table 1: Summary of polysomnograms performed.

Type of Study PSG possible intervention PAP Titration PSG PSG Trach capped protocol PSG Trach capped protocol PAP PAP PAP
trach Titration Titration titration
Age 5y 6y 7Y 10y 12y 16y 17y 17y
BMI Percentile U/A > 99 > 99 > 99 97 99 > 99 > 99
Height (cm)   121 127.8 140.8 151.6 165.5 165.6 165.6
Weight (kg)   42 49 55.9 60.8 108.2 111.7 111.7
                        without positional device
Off O2   Off BPAP On BPAP uncapped uncapped capped uncapped capped Positional device
  On O2                
AHI 37.2 65.8 124.3 80.7 0.1 0.5 41.7 1.2 55.1 56.2 3.4 5.9
rAHI 92.4 119.7 130 NA   NA 74.5 NA 71.2 15 3.1 1.4
Supine AHI Data U/A Data U/A Data U/A Data U/A Data U/A              
0.5 59.9 0 37.3 71.3 4 2.5
Supine rAHI Data Data Data   Data   Data          
U/A U/A U/A NA U/A NA U/A NA 64.9 31.1 2.8 0
Arousal Index 60.3 135.2 202 161.8 4 7.1 30.1 8.8 43.3 51.6 6.9 9.2
Mean Oxygen 87 - 95 - 70 - 80 - 94 - 94 - 93 - 97 - 96 -     96.7 - 100%
Saturation (%) 99% 100% 98% 97% 100% 98% 100% 100% 100% 95 -99% 97.6-100%
Oxygen Nadir 57% 68% 46% 50% 90% 91% 82% 92% 81% 82% 86% 82%
Percentage of Sleep Time Spent                        
with Oxygen ≤  85%                        
                         
  3.90% 2.40% 33.30% 15.30% 0% 0% 0.10% 0% 0.40% 0.20% 0% 0%
Percentage of Sleep Time Spent with Oxygen ≤                        
90%                        
                         
  3.90% 2.40% 33.30% 15.30% 0% 0% 0.10% 0% 2.60% 6.50% 0.20% 0.90%
Maximum End                        
Tidal Carbon Dioxide (mmHg)                        
  63 64 62 54 52 51 62 53 56.3 55.4 52.7 48.9
Mean End Tidal Carbon Dioxide                        
(mmHg) 42-         45-            
  59 42-59 34-52 32-51 44-47 47 48-51 46-50 42.5 35.2-55.4 43.4-52.7 43.5-48.9
Percentage of Time Spent with End                        
Tidal Carbon Dioxide > 50 mmHg                        
                         
  4.40% 23% 4.60% 4% 0.20% 0.30% 45.70% 0.20% 14.60% 0.80% 1.30% 0%

At the follow up PSG, the plan was to start at IPAP 20 cmH2 O, EPAP 16 cmH2 O and decrease pressure until lowest pressure was achieved that resolved obstructive events and normalized oxygenation and ventilation. Sleep was of poor quality with multiple prolonged awakenings during the night of the study, which reduced the sleep efficiency to 68%. There was a total of 364 minutes of sleep. Adequate REM sleep (87 minutes) was studied during the night. He did well on BPAP IPAP 18 cmH2O, EPAP 14 cmH2 O, with good control of OSA (AHI 5.0 per hour), normal oxygenation (mean oximetry 97.2%) and normal ventilation (mean end tidal carbon dioxide 42.3 mm Hg). It was recommended to update to these settings and repeat the PSG with the positional device again in 6 months to one year (Figure 1).

How the positional device was positioned on the patient during  the polysomnogram.

Figure 1: How the positional device was positioned on the patient during the polysomnogram.

At 19 years of age (BMI percentile > 99), the patient transitioned to an adult sleep provider. At the last visit with the adult sleep center, the patient reported he was still using BPAP with the positional device. The most recent results of an in-lab BPAP titration with use of the positional device performed at the adult center included an AHI 134 per hour off BPAP, with pressures titrated to IPAP 17cmH2 O, EPAP13 cmH2O with excellent response during titration. On a pressure of 17/13 cm of water pressure, he had an AHI of 0 per hour. A six-month adherence report was obtained and showed usage > 4 hours per night at 92.4% and total use 97.2%. (Figure 2).

Figure 1: Photograph of the positional device.

Figure 2: Photograph of the positional device

DISCUSSION

Positional Obstructive Sleep Apnea (POSA) is defined as obstructive sleep apnea with a higher number of respiratory events in the supine body position, but specific criteria such as supine to non-supine AHI ratio is debated [7]. In adult patients with difficult to treat POSA where optimal pressures were unable to be achieved during titration, successful management of OSA was obtained by utilizing positional therapy in conjunction with PAP therapy [8]. In children, there is no universally accepted definition of POSA, so prevalence is unclear [7].

Causes of PAP intolerance varies among users, with pressure intolerance being a common complaint. Bhattacharjee, et al. Suggest that children less than 6 years of age and adolescents ages 15 to 18 may need additional interventions and support than other ages to optimize PAP adherence [3]. In our report of this case, the subject was initially very young and the OSA was unable to be controlled on any pressure titrated. Prior to tracheostomy, the reported subject was only followed and managed in the otolaryngology clinic rather than the pediatric sleep clinic. During the treatment of this subject, our organization experienced a change in electronic medical record systems which resulted in some raw data reports being unavailable with only dictated summaries of those reports available after the merge. This is one limitation of the retrospective nature of this case report. However, the authors surmise that positional therapy alone would not have prevented the subject from initial tracheostomy as AHI values noted on the polysomnogram with tracheostomy capped were severely abnormal both in the supine and non-supine body positions. In addition to this, tracheostomy was performed at age six and positional therapy alone may have been difficult in this age. The tracheostomy was performed due to pressure intolerance. Utilization of neither PAP (as suggested by the residual events on PAP titration study), nor the positional device alone (as patient had severe OSA in non-supine body positions that would not have been treated by positional device alone) resolved the OSA in this subject, and concurrent use of both treatments prevented a second tracheostomy. By utilizing a commercially available positional device simultaneously with PAP therapy, BPAP pressures were able to be reduced to a level that was tolerated by the patient, while also successfully treating OSA by preventing supine sleep [9,10].

Use of a commercially available positional device may help management of difficult to treat OSA before proceeding to more invasive management, such as tracheostomy. There is a large amount of literature regarding positional OSA and the use of positional devices for treatment of OSA in adults; however, such literature documenting use of concurrent treatment is limited, with no studies in the pediatric population [4,10,11]. The authors of the current study had limited experience using positional therapy in clinical practice, however due to the severity of OSA in this patient, it was decided to attempt this therapy to prevent another tracheostomy. Goyal, et al. were able to utilize positional therapy in conjunction with PAP to successfully treat adult patients that previously failed titration in the supine position [8]. In addition, in these patients, OSA was resolved using lower pressures while the patients were kept in the lateral position [8]. OSA in adults is thought to be more severe in the supine position due to multiple factors including effect of gravity, anatomy of the upper airway including the relative size and shape of the tongue, soft palate, lateral pharyngeal fat pads in relation to the surrounding bony structures, as well as upper airway collapsibility, interacting with each other [9]. Other factors like lung volume and the compensatory capacity of the upper dilator muscles are also thought to be important [9]. This could contribute to why patients may require lower pressures in the lateral position, and also why our patient responded well to concomitant use of PAP and a positional device. Adherence to PAP therapy and positional devices independently is poor, so education as to the importance of treating the OSA and explaining more invasive treatments is necessary. Utilization of a positional device concurrently with PAP therapy may be an effective alternative for patients with difficult to treat OSA. Such use may prevent more invasive treatments such as tracheostomy, thereby improving quality of life. While Xiao, et al. reported that a positional device was effective in treating OSA in a small sample of children intolerant to PAP therapy [4], to the authors’ knowledge, this is the first report of the utilization of both a positional device in conjunction with PAP therapy to treat OSA in a pediatric patient who had tracheostomy. Additional research including randomized, controlled trials, is needed to determine the validity of this concomitant therapy in pediatric patients with OSA.

REFERENCES

1. Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012; 130(3): e714-e755. doi: 10.1542/ peds.2012-1672. Epub 2012 Aug 27. PMID: 22926176.

2. Watach AJ, Xanthopoulos MS, Afolabi-Brown O, Saconi B, Fox KA, Qiu M, et al. Positive airway pressure adherence in pediatric obstructive sleep apnea: A systematic scoping review. Sleep Med Rev. 2020; 51: 101273. doi: 10.1016/j.smrv.2020.101273. Epub 2020 Feb 8. PMID: 32120165; PMCID: PMC8849588.

3. Bhattacharjee R, Benjafield AV, Armitstead J, Cistulli PA, Nunez CM, Pepin JD, et al. Adherence in children using positive airway pressure therapy: a big-data analysis. Lancet Digit Health. 2020; 2(2): e94-e101. doi: 10.1016/S2589-7500(19)30214-6. Epub 2019 Dec 23. Erratum in: Lancet Digit Health. 2020 Sep;2(9):e455. PMID: 33334566; PMCID: PMC7847310.

4. Xiao L, Baker A, Voutsas G, Massicotte C, Wolter NE, Propst EJ, et al. Positional device therapy for the treatment of positional obstructive sleep apnea in children: a pilot study. Sleep Med. 2021; 85: 313- 316. doi: 10.1016/j.sleep.2021.07.036. Epub 2021 Jul 30. PMID: 34399395.

5. Amaddeo A, Khirani S, Griffon L, Teng T, Lanzeray A, Fauroux B. Non invasive Ventilation and CPAP Failure in Children and Indications for Invasive Ventilation. Front Pediatr. 2020; 8: 544921. doi: 10.3389/ fped.2020.544921. PMID: 33194886; PMCID: PMC7649204.

6. Ishman SL, Maturo S, Schwartz S, McKenna M, Baldassari CM, Bergeron M, et al. Expert Consensus Statement: Management of Pediatric Persistent Obstructive Sleep Apnea After Adenotonsillectomy. Otolaryngol Head Neck Surg. 2023; 168(2): 115-130. doi: 10.1002/ ohn.159. PMID: 36757810; PMCID: PMC10105630.

7. Verhelst E, Clinck I, Deboutte I, Vanderveken O, Verhulst S, Boudewyns A. Positional obstructive sleep apnea in children: prevalence and risk factors. Sleep Breath. 2019; 23(4): 1323-1330. doi: 10.1007/s11325- 019-01853-z. Epub 2019 May 7. PMID: 31065887.

8. Goyal A, Pakhare A, Subhedar R, Khurana A, Chaudhary P. Combination of positional therapy with positive airway pressure for titration in patients with difficult to treat obstructive sleep apnea. Sleep Breath. 2021; 25(4): 1867-1873. doi: 10.1007/s11325-021-02291-6. Epub 2021 Jan 23. PMID: 33486667.

9. Joosten SA, O’Driscoll DM, Berger PJ, Hamilton GS. Supine position related obstructive sleep apnea in adults: pathogenesis and treatment. Sleep Med Rev. 2014; 18(1): 7-17. doi: 10.1016/j.smrv.2013.01.005. Epub 2013 May 10. PMID: 23669094.

10. Permut I, Diaz-Abad M, Chatila W, Crocetti J, Gaughan JP, D’Alonzo GE, et al. Comparison of positional therapy to CPAP in patients with positional obstructive sleep apnea. J Clin Sleep Med. 2010; 6(3): 238- 243. PMID: 20572416; PMCID: PMC2883034.

11. Gambino F, Zammuto MM, Virzì A, Conti G, Bonsignore MR. Treatment options in obstructive sleep apnea. Intern Emerg Med. 2022;17(4): 971-978. doi: 10.1007/s11739-022-02983-1. Epub 2022 Apr 23. PMID: 35460431; PMCID: PMC9135849.

Scribner A, Pruss K, Jackson R, Jambhekar SK. (2023) Utilization of Positional Therapy for Management of Severe OSA in a Pediatric Patient. J Sleep Med Disord 8(1): 1130.

Received : 25 Jul 2023
Accepted : 04 Aug 2023
Published : 07 Aug 2023
Journals
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X