Titration Protocol for Upper Airway Stimulation in Pediatric Patients With Down Syndrome

Importance Upper airway stimulation (UAS) was recently approved to treat persistent obstructive sleep apnea in pediatric patients with Down syndrome. Appropriate titration of the UAS implantable device is essential to achieve optimal outcomes, but standardized titration protocols for young patients are lacking. Objective To develop and share a UAS titration protocol for pediatric patients with Down syndrome. Design, Setting, and Participants This small cohort study of pediatric patients with Down syndrome presents a standardized UAS stimulation titration protocol for conducting postimplantation polysomnograms. The protocol was developed through a multidisciplinary collaboration at a tertiary children’s hospital with a dedicated pediatric polysomnogram laboratory. The initial titration polysomnogram was performed on the night of device activation, with subsequent titration polysomnograms performed at 1 month, 2 to 3 months, 6 months, and 12 months after implantation. The initial titration goal is acclimation, promoting AHI optimization in later polysomnograms. Pediatric patients with Down syndrome and persistent obstructive sleep apnea who have undergone UAS titration from June 2022 to January 2024 participated in this study. Exposure A novel standardized UAS titration polysomnogram protocol. Main Outcomes and Measures The main outcomes were apnea-hypopnea index (AHI) change and nightly device use in hours. Results This study included 5 pediatric patients with Down syndrome who have undergone UAS implantation. Three patients were male, and 4 identified as White. The median (range) age at implantation was 15 years (12-20 years), and the median (range) preoperative AHI was 20.1 (15.6-38.8). The median (range) incoming voltage for a 1-month postimplant UAS titration polysomnogram was 1.7 V (0.4-1.7 V). All 5 patients completed UAS titration polysomnograms at the aforementioned postoperative time course; all patients also experienced an AHI reduction from baseline and adequate tolerance of UAS (ie, nightly device use of more than 6 hours). A titration protocol for UAS in pediatric patients with Down syndrome, a sample polysomnogram report form, and general information for sleep technologists are provided. Conclusions and Relevance In this study, a standardized UAS protocol for device titration during polysomnogram promoting acclimation and optimized AHI reduction demonstrated UAS efficacy in pediatric patients with Down syndrome. The protocol can be used as a model for other institutions creating programs for UAS titration in pediatric patients with Down syndrome. As more pediatric patients undergo UAS device implants, protocols can be refined to ensure optimal outcomes.