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Langley RJ*1, Pabary R1, Trucco F1, Bush A1.
Department of Respiratory Paediatrics and Sleep Medicine, Royal Brompton Hospital, London, UK
*Corresponding author - email@example.com
No conflicts of interest
Whilst we recognise the need for caution and careful planning when considering the ongoing use of home non-invasive ventilation (NIV) and continuous positive airway pressure (CPAP) in children during the COVID-19 pandemic, we read with some concern the recent views by Barker et al.1 recommending the discontinuation of respiratory support unless “medically necessary to support life”.
There is undoubtedly a risk to caregivers and relatives of potential aerosolisation of infectious material. This is true not just of COVID-19, but also potentially harmful viruses such influenza A, respiratory syncytial virus (RSV) and many other respiratory viral pathogens which commonly infect children. This is not a new threat, but a new virus.
However, advising withdrawal of CPAP/NIV support, which is always prescribed for sound medical reasons in children, is not just misplaced but potentially dangerous.
Firstly, there is a real danger in providing such advice at time of crisis when one cannot fully assess or appreciate the impact of withdrawing treatment on “peacetime” health. Children requiring respiratory support often struggle to comply and reduced use over time would undoubte...
Firstly, there is a real danger in providing such advice at time of crisis when one cannot fully assess or appreciate the impact of withdrawing treatment on “peacetime” health. Children requiring respiratory support often struggle to comply and reduced use over time would undoubtedly result in long-term non-engagement. We may further stigmatise children requiring home carers, thereby affecting the quality and level of support we can provide for families. Our role should be to continue managing complexity, encourage adherence with prescribed NIV/CPAP in the home whilst ensuring we assess risks and benefits to make the process as safe as possible. Access to standardised or modified operating procedures and appropriate PPE should be compulsory for carers.
Secondly, one must recognise that children derive significant clinical benefit from regular NIV/CPAP use in terms of airway clearance, prevention of atelectasis and improvement in sleep quality and architecture. Untreated OSA in children may have significant effects on cognition and behaviour,2 which may be further negatively affected with the psychological and educational impact of widespread lockdown.
Thirdly, we must recognise the risk factors for severe COVID-19 disease including obesity and hypertension. Although respiratory support for obstructive sleep apnoea (OSA) may not be seen as “life sustaining”, there is a growing body of evidence that OSA in childhood is a risk factor for adult hypertension.3 Furthermore, OSA is known to be a risk factor for pulmonary embolism;4 severe COVID-19 disease is associated with thromboembolic events.5 CPAP use may also modify lipid profiles reducing cardiovascular morbidity 6 and improve quality of life. 7 In addition, untreated OSA is associated with a pro-inflammatory status.8 Given severe COVID-19 disease appears to be associated with a pro-inflammatory cytokine cascade, potentially linked to a “Kawasaki-like” syndrome in children,9 cessation of CPAP support may have an impact on disease severity.
Therefore, advising discontinuation of respiratory support that may modify or reduce childhood risk for severe COVID-19 disease and improve quality of life would seem ill-advised.
Our fear is that, whilst the COVID alarm is sounding and resources are rightly being channelled to stem the tide of adult mortality, we fail to recognise the surge, not of coronavirus infections, but of the wave of worsening non-COVID pathology, especially in children. Before COVID, the NHS was struggling to cope with existing paediatric morbidity, particularly during RSV season when critical care beds are in high demand with short supply; the situation is worse now, with loss of paediatric critical care beds to adult COVID patients.
What is required is a consensus on how we should move forward and continue to deliver respiratory support in the patient’s home whilst recognising the risk of acquisition of viral and bacterial pathogens to care providers and families. Advising cessation of treatment is ill-advised and may have a significant impact on long-term morbidity and mortality in both children and adults.
1. Barker J , Oyefeso O , Koeckerling D , et al . COVID-19: community CPAP and NIV should be stopped unless medically necessary to support life. Thorax 2020;75:367 doi:10.1136/thoraxjnl-2020-214890 pmid:32273335
2. Gozal D1, Crabtree VM, Sans Capdevila O et al. C-reactive protein, obstructive sleep apnea, and cognitive dysfunction in school-aged children. Am J Respir Crit Care Med. 2007;176:88-93.
3. Ching-Ching Chan K, Ting au C, Hui L, et al. Childhood OSA is an independent determinant of blood pressure in adulthood: longitudinal follow- up study. Thorax 2020; 75:422-431 doi:10.1136/thoraxjnl-2020-214594
4. Toledo-Pons N, Alonso-Fernández A de la Peña M et al. Obstructive sleep apnea is associated with worse clinical-radiological risk scores of pulmonary embolism. Journal of Sleep Research 2020;29:e12871 https://doi.org/10.1111/jsr.12871
5. Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost 2020;18: 844–47.
6. Simon B, Gabor B, Barta I, et al. Effect of 5‐year continuous positive airway pressure treatment on the lipid profile of patients with obstructive sleep apnea: A pilot study. Journal of Sleep Research 2020;29: e12874 https://doi.org/10.1111/jsr.12874
7. McMillan A, Bratton DJ, Faria R et al. Continuous positive airway pressure in older people with obstructive sleep apnoea syndrome (PREDICT): a 12-month, multicentre, randomised trial. Lancet Respir Med 2014;10:804-12. doi: 10.1016/S2213-2600(14)70172-9.
8. Gozal D, Serpero LD, Sans Capdevila O, et al. Systemic inflammation in non-obese children with obstructive sleep apnea. Sleep Med. 2008;9:254-9
9. Jones VG, Mills M, Suarez D, et al. COVID-19 and Kawasaki Disease: Novel Virus and Novel Case. Hosp Pediatr 2020; doi: 10.1542/hpeds.2020-0123.