MOTNJE DIHANJA PRI NOVOROJENČKIH Z OSNOVAMI KARDIORESPIRATORNE POLIGRAFIJE
Enodnevni mednarodni tečaj z delavnico
BREATHING DISORDERS IN NEONATES WITH THE BASIC PRINCIPLES OF NEONATAL CARDIORESPIRATORY POLYGRAPHY
One-day international course with hands-on workshop
20.10.2023
ZAHVALA
Spoštovani ustvarjalci in udeleženci tečaja Motnje dihanja z osnovami poligrafije pri novorojenčkih!
Veseli smo, da smo tečaj uspešno izpeljali do konca. Posebej ponosni smo na učbenik, ki je izšel skupaj s tečajem.
Iskreno se zahvaljujemo vsem slovenskim in tujim avtorjem za vrhunske strokovne članke in odlična predavanja, ki so jih pripravili.
Posebno zahvalo si zaslužita oba recenzenta, prof. dr. David Neubauer in prof. dr. Irena Hočevar Boltežar ter lektorici za slovenski in angleški jezik, Cvetana Tavzes in Sara Hajdarević.
Vrhunsko avtorsko delo je opravil Matevž Trdan, ki je oblikoval učbenik, ga opremil s fotografijami in poskrbel za celostno grafično in video podobo tečaja.
Brez pomoči sponzorjev takšnega finančnega zalogaja ne bi zmogli. Na prvem mestu se zahvaljujemo glavnemu sponzorju podjetju Medicotehna, d.o.o. iz Ljubljane ter ostalim podjetjem: Chiesi Slovenija, d.o.o., Sapio plini, d.o.o., Mediasi, d.o.o., Pulmodata, d.o.o. in Inspira, d.o.o. Vsem iskrena hvala.
Najbolj pa smo veseli smo dobrega obiska tečaja. Iskreno upamo, da ste bili udeleženci s tečajem zadovoljni. Za udeležbo se vsem še posebej zahvaljujemo. Upamo, da ste na tečaju pridobili nova strokovna znanja, da ste se pri nas dobro počutili, in da ste spletli nove strokovne in osebne stike.
Uredniki ter člani strokovnega in organizacijskega odbora
V Ljubljani, 27. oktobra 2023
Dear authors, co-workers, and participants of the course Breathing Disorders with Basic Principles of Neonatal Polysomnography!
We are pleased that we have successfully completed the course. We are especially proud of the textbook that was published alongside the course.
We would sincerely like to thank all Slovenian and foreign authors for their excellent professional articles and outstanding presentations. Special thanks are due to both reviewers, Prof. Dr. David Neubauer and Prof. Dr. Irena Hočevar Boltežar, as well as the Slovene and English language proofreaders, Cvetana Tavzes and Sara Hajdarević.
Outstanding creative work was carried out by Matevž Trdan, who designed the textbook, accompanied it with photographs, and designed the overall graphic and video presentation of the course.
Such a financial endeavour would not have been possible without the support of our sponsors. We express our gratitude, first and foremost, to the main sponsor, Medicotehna, d.o.o. from Ljubljana, and other companies: Chiesi Slovenija, d.o.o., Sapio plini, d.o.o., Mediasi, d.o.o., Pulmodata, d.o.o., and Inspira, d.o.o. Sincere thanks to all.
We are especially pleased that the course was so well attended. We sincerely hope that the participants were satisfied with the scientific content and organisation of the course. A special thanks to all of you for your attendance. We hope that you have gained new professional knowledge and made new professional and personal contacts.
Editors and members of the Professional and Organising Committee
Ljubljana, October 27, 2023.
Razvoj pediatrične poligrafije v Sloveniji
V članku so opisani prvi začetki uporabe zapisovanja srčno-dihalnih vzorcev s poligrafijo v Sloveniji. Najprej se seznanimo z metodo preproste kardiorespirografije, ki smo jo dolga leta uporabljali na neonatalnem oddelku, predvsem za diagnostiko in spremljanje učinka kofeinske terapije za idiopatsko apnejo nedonošenosti. V nadaljevanju je predstavljena »prava« poligrafija, ki s spremljanjem različnih parametrov: dihanja na treh ravneh, srčnega ritma, oksigenacije, položaja telesa, detekcije smrčanja in izkoristka ali učinkovitosti spanja omogoča diagnostiko tako centralnih kot obstrukcijskih dihalnih premorov. Kot taka je bila odličen pripomoček pri ugotavljanju ogroženosti zaradi premorov dihanja pri dojenčkih s sumom na idiopatsko apnejo (tudi v sklopu proučevanja nenadne nepričakovane smrti dojenčka) in pri vseh starostih otrok s sumom na težave zaradi obstrukcijskih premorov zaradi povečane žrelnice ali mandljev. Na koncu je omenjena tudi možnost uporabe poligrafije na znanstvenoraziskovalnem področju.
Historical Review of Paediatric Polygraphy in Slovenia
The article describes the first implementation of recording cardio-respiratory patterns by poligraphy in Slovenia. The first method to be described is the simple cardiorespirography (CRG), which has been introduced and used for years at the neonatal unit of the UMC Ljubljana’s Division of Paediatrics. It was mainly used for follow-up of neonates which have been treated with caffeine for idiopathic apnoea of prematurity. After CRG the method of full-scale polygraphy has been introduced which enables registration of different parameters: breathing at three different levels (nasal, thoracic, and abdominal), heart rate, oxygenation, body position, detection of snoring and effectiveness of sleep and as such can differentiate between central and obstructive apnoeas. As such it has been used in diagnostic of infants at risk for apnoeas due to infantile idiopathic apnoea (also including those with suspicion of near-death events in infants at risk for sudden infant death syndrome), and for children at different ages who have had problems with breathing due to obstructive apnoea, mainly because of enlarged adenoids and tonsils. A possible application of polygraphy to scientific research is also discussed at the end.
David Neubauer
Fiziološki principi uravnavanja ventilacije od dojenčka do odraslega
Dihanje je homeostatski mehanizem, ki primarno nasprotuje spremembam pO2 in pCO2 v organizmu, ki jih povzroča okolje ali organizem, in vključuje izmenjavo plinov z okoljem (ventilacijo), prenos plinov skozi alveolokapilarno pregrado (difuzija), transport plinov v krvi in celično uporabo pO2 oziroma proizvodnjo pCO2. Dihanje je uravnavano na vseh teh ravneh, čeprav uravnavanje dihanja običajno enačimo z uravnavanjem ventilacije. Ventilacijo uravnava zapleten sistem, ki vključuje generator centralnega dihalnega ritma / vzorca in integrator v podaljšani hrbtenjači in ponsu. Ta avtomatično generira bazalni ritem za krčenje dihalnih mišic, ki ga nato, glede na informacije iz kemoreceptorjev in mehanoreceptorjev ter drugih struktur, prilagaja spreminjajočim se presnovnim potrebam, mehaničnim razmeram ali vedenju. Uravnavanje ventilacije je primarno nezavedno in avtomatično, vendar lahko nanj do neke mere vplivamo tudi z voljo, kar je je mogoče med budnostjo, ko lahko z voljo celo preglasimo avtomatično uravnavanje ventilacije. Med spanjem se dražljaji budnosti in volje umaknejo, tako da je dihanje odvisno predvsem od avtomatskega uravnavanja. Uravnavanje dihanja se razvije zgodaj v fetalnem obdobju in še naprej dozoreva po rojstvu. Sistem za uravnavanje ventilacije pri dojenčkih, zlasti pri nedonošenčkih, je nezrel in sam po sebi nestabilen, kar povzroča nepravilno dihanje, pogoste apneje in periodično dihanje, zaradi česar so dojenčki bolj dovzetni za dihalno odpoved. V tem prispevku obravnavamo fiziološke osnove zrelega uravnavanja ventilacije pri odraslih in razlike pri dojenčkih.
Physiological Principles of Ventilatory Control from Infants to Adults
Breathing is a homeostatic mechanism that primarily counteracts environment- or organism-induced changes in pO2 and pCO2 in the organism, and involves exchange of gases with the environment (ventilation), transfer of gases across the alveolocapillary barrier (diffusion), transport of gases in blood, and cellular utilization or production of pO2 and pCO2, respectively. Breathing is regulated at all these levels, although breathing regulation is usually equated with the ventilatory control. Ventilation is controlled by a complex system involving a central respiratory rhythm/pattern generator and integrator in the medulla oblongata and pons, which automatically generates the basic rhythm for contraction of the respiratory muscles and then adjusts this rhythm according to changing metabolic needs, varying mechanical conditions, and a range of episodic non-ventilatory behaviours, according to the inputs from chemoreceptors, mechanoreceptors, and other structures. It is primarily involuntary and automatic and can be, to some degree, also influenced by voluntary inputs that are prominent during wakefulness and can even override automatic ventilatory control. During sleep, however, wakefulness stimuli and voluntary influences are withdrawn, so that ventilation depends predominantly on automatic control. Breathing regulation develops early in foetal life and continues to mature after birth. The infantile ventilatory control system, especially in preterm infants, is immature and inherently unstable, resulting in irregular breathing, frequent apnoeas, and periodic breathing, making infants more susceptible to respiratory failure. The article aims to review the physiological principles of mature ventilatory control in adults and the differences in infants.
Katja Pavšič, Fajko F. Bajrović
Genetski vzroki dihalnih premorov pri novorojenčku
Genetski vzroki dihalnih premorov pri novorojenčkih so zelo heterogeni. Geni, vpleteni v nastanek, večinoma nosijo zapis za beljakovine, ki so vključene v razvoj lobanjskih in obraznih kosti, razvoj in funkcijo osrednjega in perifernega živčnega sistema in mišic. V diagnostičnem procesu ima pomembno vlogo zgodnja genetska obravnava in genetsko testiranje. Opredelitev genetskega vzroka dihalnih premorov lahko omogoči usmerjeno zdravljenje, boljšo napoved poteka bolezni in reproduktivno svetovanje družini.
Genetic Causes of Apnoea in the Neonate
The genetic causes of neonatal apnoea are very diverse. Genes responsible for neonatal apnoea include, among others, those encoding proteins important for craniofacial development, proteins involved in the development and function of the central and peripheral nervous systems, and muscles. Genetic testing plays a significant part in the diagnostic process, as identifying the genetic cause of apnoea can provide important information for the treatment, prognosis, and reproductive counselling for the family.
Karin Writzl
Pred prvim vdihom
Razvoj človeških pljuč je razdeljen na pet stopenj: embrionalno, psevdoglandularno, kanalikularno, sakularno in alveolarno. Pri rasti in razvoju pljuč sodelujejo številni fizikalni, biokemični, cirkadiani in genetski dejavniki. Razvoj nevronskih povezav s pljuči, ki omogočajo ritmično dihanje, še ni razjasnjen.
Before the first breath
The development of the human lung is divided into five stages: embryonic, pseudoglandular, canalicular, saccular, and alveolar. Numerous physical, biochemical, circadian, and genetic factors are involved in the growth and development of the lung. However, the development of neural connections with the lung, which allows for rhythmic breathing, remains to be fully elucidated.
Tanja Premru-Sršen
Normalni vzorci in motnje spanja nedonošenih in donošenih novorojenčkov v kardiorespiratornih poligrafskih posnetkih
Za novorojenčke je med spanjem značilna ranljivost dihal s posledično občasno hipoksijo. Ta je globlja pri nedonošenčkih in doseže vrh v drugem do tretjem tednu postnatalnega življenja, česar še vedno ne znamo povsem pojasniti. Sodobni pulzni oksimetri, ki vsebujejo algoritme za zavrnitev artefaktov in kratke čase povprečenja, so zelo učinkoviti pri zaznavanju kratkih desaturacij. Kljub temu pa lahko etiologijo desaturacij določimo le z bolj natančnim nadzorom, kot je srčno-dihalna poligrafija (CRP), ki razlikuje med obstrukcijskimi in centralnimi dogodki. Normalna referenčna območja za obstrukcijske in centralne dihalne premore ter indekse hipopneje so omejeni na manj kot 5 raziskav, ki so vse vključevale majhen vzorec otrok. Vse te raziskave so pokazale širok spekter normalnih vrednosti, bodisi zaradi majhnega števila vključenih otrok, združevanja otrok ob hitrih spremembah ali dejansko heterogene populacije. Definicija normalnosti je pomembna za usmerjanje vodenja otrok, predvsem tistih, ki so odpuščeni z neonatalnih enot. Raziskave CRP pri dojenčkih predstavljajo izziv, vendar potrebujemo več raziskav, da bi lahko določili referenčni spekter vrednosti. Razumevanje spektra motenj dihalnih vzorcev bi lahko predstavljalo podlago za raziskave vpliva dihalnih vzorcev na nevrokognitivne izide in prehrano.
Normal Sleep Patterns and Sleep Disturbances in Preterm and Term Neonates – the Role of Cardiorespiratory Sleep Studies
Neonates demonstrate respiratory vulnerability during sleep with resultant intermittent hypoxia. This is more profound in preterm infants and appears to peak in the second to third week of postnatal life the cause of which is unclear. Modern pulse oximeters which contain artefact rejecting algorithms and short averaging times are very effective at detecting brief desaturations. However, the aetiology of desaturations can only be determined by more detailed monitoring such as cardiorespiratory polygraphy (CRP) that discriminates between obstructive and central events. Normal reference ranges for obstructive and central apnoea and hypopnoea indices are limited to less than five studies all of which have recruited small numbers of babies. These studies all demonstrate a wide range of normal values due either to the small numbers of babies included in the studies, grouping babies together at times of rapid change, or a genuinely heterogenous population. Defining normality is important for guiding management of infants particularly those discharged from neonatal units. CRP studies in infants are challenging but more research is needed to determine reference ranges. Additionally, understanding the spectrum of respiratory pattern disturbance might support research into the impact of this on neurocognitive outcomes and nutrition.
Hazel Evans
Centralne motnje dihanja in vloga poligrafije pri diagnostiki in spremljanju
Centralna apneja (CA) je opredeljena kot prenehanje toka zraka za vsaj 20 sekund ali za vsaj dva vdiha in povezana s prebujanjem ali desaturacijo ali bradikardijo (pri dojenčkih). CA je pogosto fiziološka, vendar je lahko povezana s številnimi etiologijami. Navadno imamo za normalnega indeks centralne apneje (CAI) do 5 epizod na uro. S starostjo povezane referenčne vrednosti, predvsem za zgodnje obdobje dojenčka, so še vedno redke in praga za prepoznavo patoloških znanj še vedno ne poznamo. V tem prispevku smo povzeli trenutna spoznanja in priporočila.
Central Breathing Disorders – Role of Polygraphy in the Diagnosis and Follow-up
Central apnoea (CA) is defined as a cessation of airflow for at least 20 seconds or the duration of 2 breaths in association with arousal or oxygen desaturation or bradycardia (in case of infants). CA is frequently a physiological finding, however, various medical aetiologies could be underlying. Generally, a central apnoea index (CAI) up to 5 episodes/hour is considered as normal. Age-related normative values, especially regarding early infancy, are still rare, and the threshold value to identify a pathological condition is still unclear. This article summarizes the current findings and recommendations.
Astrid Sonnleitner
Farmakološko zdravljenje motenj dihanja pri novorojenčku
Motnje dihanje so heterogena skupina bolezni, ki se v največji meri pojavljajo zaradi nezrelih mehanizmov kontrole dihanja, zaradi česar so pogostejše pri nedonošenih novorojenčkih. Motnje dihanja so obenem lahko del klinične slike številnih drugih bolezni neonatalnega obdobja, ob čemer je etiološka opredelitev včasih težavna. Dihalni premori zaradi nedonošenosti so večinoma mešane narave in vsebujejo tako centralno kot obstruktivno komponento. Farmakološko zdravljenje motenj dihanja temelji na uporabi zdravil iz skupine metilksantinov, med katerimi je najpomembnejši kofein. V prispevku opisujemo mehanizme njegovega delovanja, indikacije za pričetek zdravljenja, priporočeno uporabo odmerkov ter indikacije za varno ukinitev zdravljenja. V nadaljevanju naštejemo še nekatere druge oblike farmakološkega zdravljenja dihalnih premorov zaradi nedonošenosti.
Pharmacological Treatment of Breathing Disorders in Neonates
Breathing disorders are a heterogeneous group of diseases that mostly occurr due to immature breathing control mechanisms, which makes them more common in preterm neonates. Breathing disorders can also be part of the clinical presentation of many other neonatal diseases, making their etiological definition sometimes challenging. Apnoeas due to prematurity are mostly of mixed nature, involving both central and obstructive components. The pharmacological treatment of breathing disorders is based on the use of methylxanthine drugs, the most important of which is caffeine. In article we describe the mechanisms of its action, indications for treatment initiation, recommended dosages, and indications for safe treatment discontinuation. We also list some other forms of pharmacological treatment for apnoeas of prematurity.
Mihael Rus
Zdravstvena nega novorojenčka z motnjami dihanja
Motnje dihanja so najpogostejša težava novorojenčkov, zaradi katerih je potrebna obravnava na oddelku za intenzivno nego ali trapijo. Dihalne težave novorojenčkov so lahko posledica akutno ali kronično prizadetih pljuč, dihanje pa je lahko prizadeto tudi zaradi motene regulacije, ki se pri novorojenčkih največkrat kažejo kot dihalni premori. Zdravstvena nega novorojenčka z dihalnimi premori temelji na dobrem kliničnem opazovanju, monitoriranju, zagotavljanju in vzdrževanju prehodnih dihalni poti in na rednem dajanju predpisane medikamentozne terapije. Posebna znanja in veščine so potrebni pri otrocih, zdravljenih z invazivno ali neinvazivno dihalno podporo. Posebej pomembno je v pacientovo dokumentacijo vpisovati evidenco apnoičnih dogodkov, da lahko spremljamo in ugotavljamo morebitni vzorec pojavljanja dihalnih premorov.
Nursing care of the neonate with breathing disorders
Breathing disorders are the most common neonatal complications that require admission to the Neonatal Intensive Care Unit (NICU). Breathing disorders can be caused by acute or chronic lung disease, or they can be caused by dysregulation, most commonly manifested as apnoeas in neonates. Nursing care of a neonate with apnoea consists of close clinical observation, monitoring, establishing and maintaining airway patency, and regular administration of medicamentous therapy. Special knowledge and skills are required in infants on invasive or non-invasive respiratory support. It is imperative to keep a record of apnoeic episodes in the patient’s medical records so that we can monitor and establish the likely pattern of apnoeic episodes.
Vlasta Lubej Kurtovič
Obstruktivne anomalije dihalnih poti pri novorojenčkih – otorinolaringološki pogled in obravnava
Obstruktivne anomalije dihalnih poti lahko ogrožajo življenje, saj lahko vplivajo na dihanje in hranjenje novorojenčka. V klinični sliki se lahko obstrukcija kaže v budnem stanju in v spanju. Ko dokažemo motnjo dihanja, ki bi lahko bila posledica obstrukcije v dihalnih poteh, je indicirana otorinolaringološka obravnava. Pri novorojenčkih in dojenčkih so prirojene anomalije zgornjih dihal pogost vzrok za motnjo dihanja, vendar je lahko obstrukcija dihal tudi pridobljena. Zapora dihal lahko nastane kjer koli od nosu do sapnika in je lahko posledica več različnih dejavnikov. Nekatere pridružene bolezni in sindromi imajo višje tveganje za nastanek obstrukcije v dihalnih poteh. Zdravljenje vključuje poleg konservativnih in medikamentoznih ukrepov tudi kirurške posege, ki so lahko ob pravilni indikaciji zelo učinkoviti.
Obstructive Airway Abnormalities in Neonates – Surgical Approach and Management
Obstructive airway abnormalities can be life-threatening as they can affect the breathing and feeding in neonates. In the clinical picture the obstruction may manifest during awakeness or sleep. An otorhinolaryngological examination is in order in a suspected breathing disorder due to airway obstruction. In neonates and infants, the common cause of respiratory distress are congenital anomalies of the upper airways, however, airway obstruction can also be acquired. An airway obstruction can occur anywhere from the nose to the trachea and can be caused by several factors. Specific comorbidities and syndromes have a higher risk of airway obstruction. Surgical interventions, in addition to conservative measures and treatments, can be very effective if indicated correctly.
Daša Gluvajić
Obstruktivne motnje dihanja pri novorojenčkih – vloga poligrafije pri diagnostiki in spremljanju obstruktivnih motenj dihanja
Novorojenčki in dojenčki predstavljajo posebno skupino otrok s sindromom obstruktivne apneje v spanju (OSAS). Polisomnografija (PSG) in respiratorna poligrafija (RP) sta standardni preiskavi pri diagnostiki OSAS in dajeta pomembne informacije o njeni resnosti. Še več, PSG in RP nas vodita pri izbiri zdravljenja in sta pomembni pri spremljanju teh otrok, ker pomagata pri izbiri med neinvazivnimi in invazivnimi načini zdravljenja. Izvid PSG ali RP je pomemeben pri ukinitvi neinvazivne dihalne podpore in pri dekanulaciji otroka s traheostomo. PSG ali RP imata tudi svoje omejitve, sta časovno dolgotrajni preiskavi, dragi, v večini centrov slabo dostopni in zahtevni za interpretacijo, tako na PSG ali RP pride le omejno število otrok. V prihodnosti bi bilo zato smiselno razvijati posebne algoritme in enostavne naprave, s katerimi bi presejalno izbirali otroke, ki potrebujejo napotitev na PSG ali RP.
Obstructive Breathing Disorders in Neonates – the Role of Polygraphy in the Diagnosis and Follow-up
Neonates and infants with upper airway obstruction represent a specific group of children with obstructive sleep apnoea syndrome (OSAS). Polysomnography (PSG) and respiratory polygraphy (RP) are the gold standard tests for the diagnosis of OSAS and provide important information about its severity. Moreover, PSG/RP guide treatment choices and are crucial for the follow up by allowing physicians to choose between invasive and non-invasive strategies. They also guide weaning from non-invasive respiratory supports or decannulation in children with a tracheostomy. However, PSG/RP are time consuming, expensive, poorly available in most centrs, and difficult to interpret. Thus, only a limited number of children will undergo a PSG. Therefore, it is imperative to develop specific algorithms that may prioritize children who must undertake such tests using more simple tools.
Alessandro Amaddeo
Otorinolaringološke diagnostične preiskave pri opredelitvi motenj dihanja novorojenčkov
Motnje dihanja pogosto nastopijo pri novorojenčkih zaradi specifičnih anatomskih in fizioloških razmer v zgornjih dihalih. Pomembno je, da motnje čimprej opazimo in ustrezno opredelimo. Najpomembnejšo vlogo pri tem ima pediater neonatolog. S podrobno anamnezo in kliničnim pregledom pridobi osnovne podatke, ki so bistveni za nadaljnjo izbiro diagnostičnih postopkov. Če sumi na zaporo v zgornjih dihalih, ima pomembno vlogo tudi specialist otorinolaringolog. Najprej se je treba odločiti, ali motnja novorojenčka akutno ogroža ali ne. Polisomnografija zagotovi pomembne podatke, ki pojasnijo vrsto in jakost motnje dihanja novorojenčka. Ob sumu na obstrukcijo na območju zgornjih dihal, so na voljo naslednje diagnostične metode: ambulantna fleksibilna nazolaringoskopija, endoskopska ocen zgornjih dihal v sedaciji pri spontanem dihanju, rigidna laringoskopija, fiberendoskopska ocena požiranja in slikovna diagnostika (rentgenski posnetek v lateralni projekciji s cefalometrijo, CT ali MRI). Cilj je pridobiti čimbolj popolno informacijo o tipu, lokaciji in jakosti zapore v zgornjih dihalih, ki povzroča motnjo dihanja, da se multidisciplinarni tim lahko čim lažje in čim ustrezneje odloča o terapevtskih možnostih za bolnika.
Otorhinolaryngological Diagnostic Methods in the Identification of Breathing Disorders in Neonates
Breathing disorders in neonates are common due to specific anatomical and physiological conditions of the upper respiratory tract. It is essential to detect and define them as soon as possible. Neonatal pediatricians play a critical part in this process as they collect the basic data to assist with further diagnostic options by thorough medical history-taking and clinical evaluation. In cases of suspected upper airway obstruction, ear, nose and throat (ENT) specialist joins the multidisciplinary team. First, it is necessary to assess whether or not the condition poses an immediate risk to the neonate. Polysomnography (PSG) provides the team with important information to define the type and significance of neonatal breathing disorder. The following diagnostic methods are available in suspected upper airway obstruction: outpatient flexible nasolaringoscopy, drug-induced sleep endoscopy (DISE), rigid direct laryngoscopy, fiberoptic endoscopic evaluation of swallowing (FEES), lateral cephalometric radiograph, coputed tomography (CT), and magnetic resonance imaging (MRI). The aim is to obtain as complete information as possible on the type, location and severity of the upper airway obstructin, so that the multidisciplinary team can make the best and most appropriate decisions about the therapeutic options for the patient.
Miha Zabret
Vloga poligrafije pri otrocih s kronično pljučno boleznijo
S pojmom kronična pljučna bolezen (KPB) pri novorojenčkih in dojenčkih zajemamo širok spekter različnih kliničnih stanj. Bronhopulmonalna displazija (BPD) je najpogostejši vzrok in je pogosto povezana z drugimi boleznimi in stanji, kot sta nedonošenost ali obstrukcijska apneja med spanjem (OSA). Zaradi tehničnih omejitev se snemanje dihalnih vzorcev v spanju – polisomnografija (PSG) ali respratorna poligrafija (RP) – v številnih centrih ne izvaja. Oksimetrija in kožno spremljanje ogljikovega dioksida se pogosto uporabljata kot nadomestek za PSG / RP. Indikacije za PSG / RP pri dojenčkih s KPB lahko razdelimo na 6 kliničnih sklopov: a) spremljanje centralne apneje in periodičnega dihanja, b) kratek izzvenel nepojasnjen dogodek pri novorojenčku (KINK), c) obstrukcijska apneja v spanju (OSA), d) odvajanje od kisika, e) spremljanje med ventilacijo in odvajanje od ventilacije, 7) dekanulacija traheostome.
The Role of Polygraphy in Infants with Chronic Lung Disease
Chronic lung disease (CLD) and infants is a broad spectrum of clinical conditions, however, bronchopulmonary dysplasia (BPD) is the most common cause of chronic respiratory insufficiency in infants and is often associated with other comorbidities like prematurity or obstructive sleep apnoea (OSA). Sleep studies are not currently performed in a lot of centres due to technical difficulties. Oximetry and transcutaneous carbon dioxide monitoring are often used as a surrogate of sleep studies. Indications for sleep studies in infants with CLD may be grouped in 6 clinical scenarios: a) central apnoea and periodic breathing monitoring b) brief resolved unexpected event (BRUE) c) OSA d) oxygen supplementation weaning e) ventilatory support monitoring and weaning f) tracheostomy decannulation.
Alessandro Amaddeo
Poligrafija pri zdravih, donošenih novorojenčkih v porodnišnici – uporabnost metode v testiranju varnosti avtomobilskega sedeža
Poligrafija je še vedno zlati standard za ocenjevanje obstruktivnih dihalnih premorov v spanju pri otrocih vseh starostnih skupin. Vendar je podatkov za skupino donošenih, zdravih novorojenčkov malo. Možna koristna uporaba poligrafije se kaže v oceni srčno-dihalnih vzorcev v različnih položajih telesa dojenčka, kot na primer pri preverjanju varnosti otroka v avtomobilskem varnostnem sedežu. Številne raziskave so pokazale, da namestitev dojenčka, še zlasti nedonošenčka, v ta položaj lahko privede do motenj v dihanju. Da bi ugotovili, ali pride do desaturacij tudi ob namestitvi zdravega, donošenega novorojenčka v avtomobilski varnostni sedež (lupinico) ali posteljico, smo v letih 2006 in 2007 izvedli dve veliki prospektivni randomizirani raziskavi v Porodnišnici UKC Ljubljana, Slovenija. Čeprav sta bili raziskavi omejeni, ker so manjkali podatki o fazi spanja med meritvami, smo v primerjavi s položajem v bolnišnični posteljici potrdili pomembne desaturacije tako v varnostnem sedežu kot v posteljici. Desaturacije pri dojenčkih so zaskrbljujoče v luči podatkov, ki kažejo vedenjske težave in kognitivni primanjkljaj tudi po blagih hipoksičnih dogodkih. Ker se avtomobilski sedeži pogosto uporabljajo tudi za druge namene kot za prevoz, so majhni dojenčki, ki so vanje nameščeni dlje časa, izpostavljeni povečanemu tveganju za ponavljajoče se desaturacije ali celo nepričakovano nenadno smrt dojenčka.
Polygraphy in Healthy Term Neonates in Maternity Hospital – Practical Implications in Car Seat Safety Testing
Polygraphy is still the gold standard for the evaluation of obstructive respiratory apnoeas during sleep in children of all ages. However, there are limited data in healthy term infants. A possible beneficial use of polygraphy is the assessment of the cardiorespiratory patterns in different positions of the infant’s body, such as in car safety seat testing. As shown in several studies, placement in the upright position, particularly in infant born preterm, may cause respiratory compromise. We conducted two large prospective randomized studies at the UMC Ljubljana’s Maternity Hospital, in Slovenia in 2006 and 2007 in order to ascertain whether oxygen desaturations also occur when healthy, term infants are positioned in car seats and car beds. Although the studies were limited by a lack of documentation of sleep stage, significant desaturations were observed in both car seats and car beds as compared with hospital cribs. Desaturations in infants are concerning in light of data demonstrating behavioural problems and IQ deficits even after mild hypoxic events. As car safety seats are often used for reasons other than transport, young infants placed in them for prolonged periods of time are at increased risk for recurrent desaturations or even unexpected sudden infant death.
Lilijana Kornhauser Cerar
Motnje dihanja in kardiorespiratorna poligrafija pri nedonošenčkih – naše izkušnje
Breathing disorders and cardiorespiratory polygraphy in preterm infants – our experiences
In preterm infants, apnoea is a universal manifestation of immature respiratory control. It is widely accepted that central control is the main factor in their occurrence. In preterm infants regardless of various factors, it is a single entity for which the term Apnoea of Prematurity (AOP) has been established. There are three types of AOP: central, obstructive, and mixed. The most important consequence of AOP are intermittent hypoxemic events that are associated with many poor outcomes, such as retinopathy of prematurity, bronchopulmonary dysplasia, and developmental delay. Many factors play a role in the pathogenesis of AOP, including immaturity or inhibition of the respiratory centre, wake-sleep state, chemoreceptors, the Hering-Breuer reflex, gastro-oesophageal reflux, and dynamic compliance of the upper airway. AOP is treated pharmacologically with methylxanthines and non-pharmacologically, using continuous positive airway pressure, of mechanosensory input optimization, and blood gas status optimization. Polysomnography (PSG) is a multichannel test used in sleep-related breathing disorders. A reduced set of signals is used in preterm infants: EKG, nasal thermistor or cannula, pulse oximetry, and thoracic inductive plethysmography, referred to as continuous monitoring of cardiorespiratory functions (CMCRF) or cardiorespiratory polygraphy (CRPG). The final section of the article discusses experiences with CRPG in preterm infants at Ljubljana Maternity Hospital’s NICU. The most common indications for CRPG are frequent desaturations, the need for oxygen therapy in children with BPD, and withdrawal of methylxanthine therapy. Among infants with AOP, the obstructive type of apnoea predominates in 43%, mixed type in 33 %, and central type in 14%.
Tomaž Križnar
Fizikalno-tehnične osnove zajemanja in obdelave fizioloških signalov pri kardiorespiratorni poligrafiji novorojenčkov in dojenčkov
Najpogostejši fiziološki signali pri poligrafiji novorojenčkov in dojenčkov so pretok zraka, gibanje prsnega koša, nasičenost arterijske krvi s kisikom, frekvenca srčnega utripa in elektrokardiogram. Odvisno od modela naprave lahko zapisujemo položaj pacienta, premikanje trebuha, elektroencefalogram, elektrookulogram, elektromiogram, pCO2, ali snemamo zvok in sliko z avdio in video snemalnikom. Za merjenje pretoka zraka pri novorojenčkih in dojenčkih priporočajo uporabo nosne kanile ali termistorja.
Physical and Technical Basis of Physiological Signals Capturing and Processing in Cardiorespiratory Polygraphy in Neonates and Infants
The most common physiological signals in neonates and infants polygraphy are airflow, chest movements, arterial blood oxygen saturation, heart rate, and electrocardiogram. Depending on the device model, it is also possible to measure body position, movement of the abdominal part of the body, electroencephalogram, electrooculogram, electromyogram, pCO2, and video and audio monitoring. In neonates it is recommended to use a nasal cannula and a thermistor for flow measurement.
Bojan Bazelj
Načela snemanja in odčitavanja poligrama pri novorojenčkih – sodobne smernice
Dihalni premori pri novorojenčkih so pogosti zlasti pri nedonošenčkih, srečamo pa jih tudi pri donošenih novorojenčkih. Novorojenčki so nagnjeni k dihalnim premorom v spanju zaradi različnih fizioloških posebnosti. Poznavanje normalnih vzorcev dihanja novorojenčkov je pomembno zato, da prepoznamo odstopanja od normale in uvedemo pravi način zdravljenja ali se za zdravljenje niti ne odločimo in se tako izognemo pretirani medikalizaciji in zaskrbljenosti staršev. Zlati standard za oceno dihalnih premorov v spanju je polisomnografija, vendar je v neonatalnem obdobju bolj uporabna nekoliko poenostavljena verzija, tj. poligrafija oz. CMCRF (iz angleščine Continuous Monitoring of Cardio-Respiratory Functions ali kontinuirano zapisovanje srčno-dihalnih vzorcev). Dihalni vzorci pri novorojenčku so odvisni od postkoncepcijske starosti, načina snemanja, trajanja preiskave, intervala povprečenja oksimetrije in definicije dogodka. Centralni dihalni premori in periodično dihanje so v neonatalnem obdobju pogosti, medtem ko so obstrukcijski in mešani dihalni premori redki. Za čim bolj natančne rezultate preiskave moramo skrbno upoštevati navodila za njeno izvedbo, ob interpretaciji pa se je treba držati okvirnih in objavljenih referenčnih vrednosti. V prihodnosti so potrebne še natančnejše raziskave na različnih populacijah novorojenčkov, da bomo lahko bolje ovrednotili, kaj je še normalno, kaj je del razvojnih posebnosti nedonošenih in donošenih novorojenčkov ter kaj predstavlja odstopanje od normale, ki zahteva zdravljenje.
Principles of Polygram Recording and Reading in Neonates – Current Guidelines
Respiratory pauses are especially common in preterm neonates, but can be encountered in term neonates as well. Different physiological characteristics predispose neonates to respiratory pauses during sleep. Knowledge of normal neonatal breathing patterns is important in order to recognize deviations from the norm and choose an appropriate treatment modality, or to avoid treatment altogether and thus avoid overtreatment and parental concern. The gold standard for categorizing sleep disordered breathing is polysomnography; however, in the neonatal period, a simplified version is more appropriate, i.e., polygraphy. Neonatal breathing patterns are influenced by postconceptional age, mode of recording, study duration, oximetry averaging interval, and the definition of an event. Central apnoea and periodic breathing are common in the neonatal period, whereas obstructive and mixed apnoeas are rare. To obtain the most accurate results, we must strictly adhere to the study protocol and follow indicative as well as published reference values in interpretation. Getting a better understanding of what is still normal, what is part of the developmental characteristics of preterm and term neonates, and what is not normal to the extent that treatment is necessary requires more precise studies in different neonatal populations in the future.
Tina Perme
Organizatorja:
Služba za neonatologijo, KO za perinatologijo, Ginekološka klinika UKC Ljubljana, Šlajmerjeva ulica 3, Ljubljana
Društvo za pomoč prezgodaj rojenim otrokom, Zaloška 11, Ljubljana
Vodja tečaja: Tomaž Križnar, dr. med.
Datum tečaja: 20. oktober 2023
Lokacija: Predavalnica Ginekološke klinike, Šlajmerjeva 3, Ljubljana
Strokovni tim: Tomaž Križnar; Štefan Grosek, Lilijana Kornhauser Cerar, Lev Bregant, Daša Gluvajić, Vlasta Lubej Kurtovič
Organizacijski tim: Ana Spirovska (predsednica), Domen Robek, Matevž Trdan, Tina Perme, Miha Rus
Kotizacija: 150 €, specializanti 100 €, za študente in medicinske sestre vstop prost.
Za udeležence in udeleženke bomo na Zdravniško zbornico Slovenije podali vlogo za pridobitev kreditnih točk.
Organisers
Neonatal Section, Department of Perinatology, Division of Gynaecology and Obstetrics, University Medical Centre Ljubljana, Slovenia
“Društvo za pomoč prezgodaj rojenim otrokom” Aid Society, Ljubljana, Slovenia
Course director: Tomaž Križnar, dr. med. (MD)
Course date: October 20th, 2023
Location: Lecture hall at the Division of Gynaecology and Obstetrics, Šlajmerjeva 3, 1000 Ljubljana, Slovenia
Scientific committee: Tomaž Križnar; Štefan Grosek, Lilijana Kornhauser Cerar, Lev Bregant,
Organising commitee: Ana Spirovska, Domen Robek, Matevž Trdan, Tina Perme, Miha Rus, Daša Gluvajić, Vlasta Lubej Kurtovič
Registration fee: 150 €, for residents 100 €, for students and nurses free entrance
Registracija: 8.00 – 8.25
Začetek srečanja – uvodne besede: 8.30
PROGRAM:
8.35 – 8.50
Razvoj pediatrične poligrafije v Sloveniji
Historical Review of Pediatric Polygraphy in Slovenia
prof. dr. David Neubauer, dr. med. (MD, PhD), senior councillor, Deapartemnt of neurology, Division of Paediatrics, UMC Ljubljana, Slovenia
8.50 – 9.10
Fiziologija regulacije dihanja in spanja in razvoj dihalnih vzorcev od novorojenčka do odraslega
Physiological principles of ventilatory control of breathing from neonates to adults
prof. dr. Fajko Bajrović, dr. med. (MD, PhD), Division of Neurology, UMC Ljubljana, Slovenia
9.10 – 9.30
Genetski vzroki dihalnih premorov pri novorojenčku
Genetic Causes of Apnoea in the Neonate
izr.prof. dr. Karin Writzl, dr. med. (MD, PhD), Clinical Institute of Genomic Medicine, UMC Ljubljana, Slovenia
9.30 – 9.50
Pred prvim vdihom
Before the First Breath
doc. dr. Tanja Premru Sršen, dr. med. (MD, PhD), Divison of Gynaecology and Obsteritcs, UMC Ljubljana, Slovenia
Odmor za kavo / Coffee break
Moderatorja / Moderators: Prof. dr. David Neubauer, Ana Spirovska, dr. med.
10.00 – 10.20
Normalni vzorci in motnje spanja nedonošenih in donošenih novorojenčkov v kadio-respiratornih poligrafskih posnetkih
Normal Sleep Patterns and Sleep Disturbances in Preterm and Term Neonates – theRole of Cardiorespiratory Sleep Studies
Dr. Hazel Evans, MBBCh, MRCPCH, MD, Department of Paediatric Respiratory Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK
10.20 – 10.40
Centralne motnje dihanja in vloga poligrafije pri diagnostiki in spremljanju
Central Breathing Disorders – Role of Polygraphy in the Diagnosis and Follow-up
Dr. med. Astrid Sonnleitner, (MD), Department of Paediatrics, Medical University of Graz, Austria
10.40 – 11.00
Farmakološko zdravljenje motenj dihanja pri novorojenčku
Pharmacological Treatment of Breathing Disorders in Neonates
Mihael Rus, dr. med. (MD), Neonatal Section, Departmen of Perinatology,Division of Gynaecology and Obstetrics, UMC Ljubljana, Slovenia
11.00 – 11.20
Zdravstvena nega novorojenčka z motnjami dihanja
Nursing Care of the Neonate with Breathing Disorders
Vlasta Lubej Kurtovič, dipl. med. sestra, mag. zdrav. nege (RN, MSN) Neonatal Section, Department of Perinatology, Division of Gynaecology and Obstetrics, UMC Ljubljana, Slovenia
Odmor za kavo / Coffee break
Moderatorja / Moderators: Asist. dr. Daša Gluvajić, dr. med., asist. Matevž Trdan, dr. med.
11.40 -12.00
Obstruktivne anomalije dihalnih poti pri novorojenčkih – otorinolaringološki pogled in obravnava
Obstructive Airway Abnormalities in Neonates – Surgical Approach and Management
asist. dr. Daša Gluvajić, dr. med. (MD, PhD), Department of Otorhinolaryngology and Cervicofacial Surgery, UMC Ljubljana, Slovenia
12.00 – 12.20
Obstruktivne motnje dihanja pri novorojenčkih – vloga poligrafije pri diagnostiki in spremljanju obstruktivnih motenj dihanja
Obstructive Breathing Disorders in Neonates – the Role of Polygraphy in the Diagnosis and Follow-up
Alessandro Amaddeo, MD, PhD, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
12.20 – 12.40
ORL diagnostične preiskave pri opredelitvi motenj dihanja pri novorojenčkih
Otorhinolaryngological Diagnostic Methods in the Identification of Breathing Disorders in Neonates
Miha Zabret, dr. med.(MD) Department of Otorhinolaryngology and Cervicofacial Surgery, UMC Ljubljana, Slovenia
12.40 – 13.00
Vloga poligrafije pri otrocih s kronično pljučno boleznijo
The Role of Polygraphy in Infants with Chronic Lung Disease
Alessandro Amaddeo, MD, PhD, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
Kosilo / Lunch
Moderatorja / Moderators: Dr. Lilijana Kornhauser Cerar, dr. med., Mihael Rus, dr. med.
14.00 – 14.20
Poligrafija pri zdravih, donošenih novorojenčkih v porodnišnici – uporabnost metode v testiranju varnosti avtomobilskega sedeža
Polygraphy in Healthy Term Neonates in Maternity Hospital – Practical Implications in Car Seat Safety Testing
dr. Lilijana Kornhauser Cerar, dr. med. (MD, PhD), Neonatal Section, Departmen of Perinatology, of the Division of Gynaecology and Obstetrics, UMC Ljubljana, Slovenia
14.20 – 14.40
Poligrafijia pri nedonošenčkih – naše izkušnje
Breathing disorders and cardiorespiratory polygraphy in preterm infants – our experiences
Tomaž Križnar, dr. med. (MD) Neonatal Section of the Division of Gynaecology and Obstetrics, UMC Ljubljana, Slovenia
14.40 – 15.00
Fizikalno tehnične osnove zajemanja in obdelave fizioloških signalov pri kardiorespiratorni poligrafiji novorojenčkov in dojenčkov
Physical and Technical Basis of Physiological Signals Capturing and Processing in Cardiorespiratory Polygraphy in Neonates and Infants
Bojan Bazelj, univ. dipl. inž. (BSE)
15.00 – 15.20
Načela snemanja in odčitavanja poligrama pri novorojenčkih – sodobne smernice
Principles of Polygram Recording and Reading in Neonates – Current Guidelines
asist. dr. Tina Perme, dr. med. (MD, PhD), Neonatal Section, Department of Perinatology, of the Division of Gynaecology and Obstetrics, UMC Ljubljana, Slovenia
Popoldanske delavnice (15.30 – 17.00)
Afternoon workshops (3.30 – 5.00 pm)
COURSE PUBLICATION – A reviewed textbook/book of proceedings
Editors: Tomaž Križnar, dr.med (MD), prof. dr. Štefan Grosek, dr. med.(MD, PhD), senior councillor, dr. Tina Perme, dr. med.
Technical editor: Matevž Trdan, dr. med,
Reviewers:
dr. David Neubauer, dr. med. (MD, PhD), senior councillor, Division of Paediatrics, UMC Ljubljana, Slovenia
dr. Irena Hočevar Boltežar, dr. med. (MD, PhD), councillor, Department of Otorhinolaryngology and Cervicofacial Surgery, UMC Ljubljana, Slovenia