ATS GUIDELINES Bundle

Diagnosis Treatment Recommendation 4a ➤ For infants with PPRD who are otherwise ready to be discharged from the NICU, the ATS suggests the use of polysomnogram (PSG) for patients with persistent apnea, intermittent desaturation, or bradycardia at greater than 40 weeks post-menstrual age (PMA) (conditional recommendation, very low-certainty evidence). Recommendation 4b ➤ For infants, children, and adolescents with PPRD, the ATS suggests the use of PSG and/or sleep medicine referral for those with symptoms of sleep disordered breathing including persistent snoring, failure to thrive, or persistent need for supplemental oxygen at two years of age (conditional recommendation, very low-certainty evidence). Recommendation 4c ➤ When a PSG is indicated but not available, the ATS recommends that an overnight or 24-hour oximetry be obtained to screen for SDB followed by a PSG and/or sleep medicine referral for further evaluation if needed. (conditional recommendation, very low-certainty evidence). Recommendation 5 ➤ For infants, children, and adolescents with PPRD, we suggest a swallow evaluation (videofluoroscopic swallow study) for those who are eating by mouth and have cough or persistent oxygen desaturation during feeding, suspected or confirmed vocal cord paralysis or other airway anomalies, failure to wean from oxygen therapy or ventilatory support as expected, persistent or worsening pulmonary hypertension, failure to thrive, or chronic pulmonary symptoms out of proportion to viral respiratory infections (conditional recommendation, very low-certainty evidence). Recommendation 6 ➤ For infants, children, and adolescents with PPRD, we suggest airway endoscopy for those with unexplained symptoms such as chronic cough, wheezing, ventilator dependence, persistent hypoxemia, or a history of patent ductus arteriosus (PDA) ligation with stridor and weak cry (conditional recommendation, very low-certainty evidence). Recommendation 7a ➤ For infants, children, and adolescents with PPRD who do not have symptoms suggestive of airway malacia, the ATS suggests that dynamic airway imaging (CT or MRI) NOT be used as a screening test for the routine diagnosis of TBM (conditional recommendation, very low-certainty evidence). Recommendation 7b ➤ The ATS suggests that unsedated, dynamic airway imaging (CT or MRI) be used for the diagnosis or re-evaluation of TBM in patients with PPRD who have recurrent symptoms suggestive of airway malacia as an alternative to bronchoscopy when the risk of anesthesia for bronchoscopy is judged to be more than risks from radiation or if bronchoscopy is not feasible or available (see Figure 1) (conditional recommendation, very low-certainty evidence).

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