Real-world data evaluation of PAP responsiveness in pediatric obstructive sleep apnea

We have evaluated the RWD responses to PAP based on AHI reductions in 195 children with OSA. These analyses allowed us to define individual determinants of pediatric PAP responsiveness in a real-world setting. Our results showed that children have an adequate response to PAP therapy, with a median AHI reduction of 85% compared to baseline PSG results. We have also identified substantial heterogeneity of the PAP responses, with around 30% showing < 75% AHI reductions. Interestingly, we found that in addition to OSA severity, heterogeneity in response is linked to obesity and biological sex. These new data suggest that individual parameters can be used to predict best real-world responses to PAP therapy and provide new insights into the pathogenesis of this condition.

The pathogenesis of OSA in children often involves upper airway narrowing leading to increased resistance and collapse. Our study demonstrates that PAP alleviates upper airway obstruction in the pediatric population but with substantial heterogeneity. RWD analyses may contribute to our understanding of the reasons behind heterogeneity in PAP responses and the factors that may play a role in this individual variability. Specifically, we found that obesity and biological sex were independent factors associated with a differential response to PAP therapy in children. We are unaware of studies specifically reporting these variables as predictors of AHI reductions with PAP therapy, but they have been examined in the context of OSA pathogenesis. Obesity is associated with a distinct pharyngeal critical closing pressure due to anatomical and functional features linked to OSA severity. Our results indicate high effectiveness of PAP for alleviating upper airway collapse caused by these obesity-related features. It is encouraging for clinicians and families that upper airway obstruction is highly responsive to PAP in children with obesity because this is the major risk factor for residual OSA after adenotonsillectomy and thus a common indication for PAP therapy in the pediatric population. Regarding biological sex, there is minimal, or no, information available discussing this factor as a predictor of response to PAP therapy. Our data showed that females have greater AHI reductions in response to PAP, which could be associated with anthropometric differences,including facial and airway dimensions linked to OSA severity that predispose males to pharyngeal collapse. Notably, prior data in BMI-matched adults identified that women had lower pharyngeal critical closing pressure than men This suggests that women have a less-collapsible pharynx for any given BMI,which might underlie why female participants had greater PAP response in our study. On the other hand, sex-related differences in the size and mechanical properties of the pharynx are complex because collapsibility and PAP responses may be influenced by multiple factors and thus further studies are required, particularly in the pediatric population.

https://jcsm.aasm.org/doi/full/10.5664/jcsm.10578