Polysomnogram Is a Poor Predictor of Future Respiratory Failure in Patients with Cerebral Palsy

Introduction: Children with cerebral palsy frequently demonstrate symptoms of severe upper airway obstruction including apneic events, hypoxia, death and/or requirement of tracheostomy. However, not all meet criteria for severe obstructive sleep apnea (OSA). Our objective is to determine whether features of clinical history or other metrics from the polysomnogram (PSG) correlate with a severe obstructive phenotype requiring tracheostomy.

Methods: Retrospective chart review was conducted between 2008-2023 for pediatric patients with cerebral palsy, clinical concern for severe airway obstruction, but a baseline PSG that did not demonstrate severe OSA (apnea-hypopnea index, AHI < 10). The most recent baseline PSG without supplemental oxygen was analyzed. Measures of central tendency (mean, median) with standard deviation (SD) were calculated.

Results: 47 patients met criteria for inclusion. Overall mortality was 8.5% and 17% required tracheostomy. Comparison of tracheostomy versus non-tracheostomy groups revealed no significant difference in PSG indices. However, patients who required tracheostomy were hospitalized more often (trach=15 days; non-trach=8 days, p=0.02). Admissions for respiratory illnesses were similar (trach=5 admits; non-trach=2.5 admits, p=0.1), but for the trach group were significantly longer (trach=115 days; non-trach=30 days, p=0.001). Similarly, intubation events were similar (trach=1.4 intubations; non-trach=0.6 intubations, p=0.07), but were significantly longer for the trach group (trach=47.5 days; non-trach=7 days, p=0.0005).

Conclusions: Initial analysis suggests that standard PSG may not identify patients with clinically severe upper airway obstruction requiring tracheostomy and prolonged hospitalization. We recommend multidisciplinary evaluation of children with cerebral palsy and recognition of need for continued evaluation if there is discordance between symptoms of airway obstruction, yet a relatively reassuring PSG. Future directions include exploring other means of identifying at-risk patients and exploring potential mitigating interventions.