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SLEEP MEDICINE: David A. Bradshaw, Gregory A. Ruff, and David P. Murphy An Oral Hypnotic Medication Does Not Improve Continuous Positive Airway Pressure Compliance in Men With Obstructive Sleep Apnea Chest 2006; 130: 1369-1376 [Abstract] [Full text] [PDF]

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Oral clonidine as a sedative agent to establish children on non-invasive ventialtion

Jayesh M Bhatt, Robert Primhak, Anton Mayer. Sheffield Children's Hospital   (6 December 2006)

Oral clonidine as a sedative agent to establish children on non-invasive ventialtion 6 December 2006
Jayesh M Bhatt, Respiratory Paediatrcian Nottingham University Hospitals, Robert Primhak, Anton Mayer. Sheffield Children's Hospital Send letter to journal: Re: Oral clonidine as a sedative agent to establish children on non-invasive ventialtion jayesh.bhatt{at}nuh.nhs.uk Jayesh M Bhatt, et al.	Dear Sir We read with interest the paper by Bradshaw et al1 regarding the use of an oral hypnotic medication to improve compliance with CPAP therapy in men with obstructive sleep apnea. They found no increase in initial compliance with CPAP after 14 days treatment with a relatively short acting nonbenzodiazepine hypnotic agent. The initiation of any nocturnal non-invasive ventilation (NIV) can be even more challenging in small children and may not be successful on the first attempt, even when the need for such intervention may be pressing 2,3. In such situations we have used clonidine to establish children on non- invasive ventilation. Clonidine, an a2-adrenoceptor agonists is a non-respiratory depressant sedative and has been used as a sedative agent in various settings including ventilated patients in combination with intravenous morphine and lorazepam 4, in patients with burns5. It produces sedation comparable to diazepam and causes less effect on psychomotor function6. We urgently needed to initiate non-invasive ventilation in two young children with nocturnal respiratory failure. Case 1. A 2 year 7 month old girl with an axonal neuropathy with predominant cervical distribution, diaphragmatic weakness and nocturnal hypoventilation was suffering significant desaturations during sleep. Case 2. A 3 year 2 month old child with a repaired thoracolumbar spina bifida, shunted hydrocephalus, mild developmental delay, right vocal cord palsy had persistent severe sleep disordered breathing with hypoxaemia and a mixed pattern of apnoeas, despite previous surgical decompression of her formanen magnum, tonsillectomy, and medical treatment for gastro- oesophageal reflux. In both cases we were unable to initate NIV despite the involvement of play therapists and parents in acclimatisation. We therefore tried clonidine as a sedating agent to allow initiation. The clonidine was instituted in the following regimen: After a test dose of 1 microgram/kg, the dose was escalated incrementally (1 to 3 to 5 micrograms/kg/dose) every eight hours (maximum dose of 5 micrograms/kg/dose six hourly) Successful nasal mask ventilation was established within 24 hours in both cases, and by day 5, withdrawal of Clonidine was started in the following manner: Halve dose but keep frequency the same until on 0.25mcg/kg tds then Reduce frequency to twice daily for 1 day then Reduce frequency to once daily for 1 day then stop Both continued to tolerate NIV after withdrawal of the drug. During the weaning period blood pressure and heart rate were monitored 4 hourly, and patients were observed for development of agitation and sweating. No adverse effects occurred. In our cases the children were totally intolerant of NIV and yet were safely and successfully established on it with the use of clonidine as a non-respiratory depressant sedative. As far as we know this is the first described use of clonidine as a sedative for establishment of NIV in very young children. Clearly in most cases such an approach will be unnecessary, but in young children who refuse NIV, we suggest that attempts should not be abandoned without a trial of clonidine. We agree with Bradshaw et all that further studies to evaluate the potential roles of hypnotic agents in subpopulations of patients in the need for establishing NIV are needed and suggest that the role of clonidine is worth exploring in a randomised trial setting. References 1.Bradshaw DA, Ruff GA, Murphy DP. An Oral Hypnotic Medication does not improve continous positive airway pressure compliance in men with obstructive sleep apnea. Chest 2006;130:1369-1376 2.Simonds AK, Ward S, Heather S, Bush A, Muntoni F. Outcome of paediatric domiciliary mask ventilation in neuromuscular and skeletal disease. European Respiratory Journal 2000;16:476-81 3.Massa F, Gonsalez S, Laverty A, Wallis C, Lane R. The use of nasal continuous positive airway pressure to treat obstructive sleep apnoea. Archives of Disease in Childhood 2002;87:438-43 4.Arenas-Lopez S, Riphagen S, Tibby S, Durwald A, Tomlin S, Davies G, Murdoch I. Use of oral clonidine for sedation in ventilated paediatric intensive care patients. Intensive Care Medicine 2004;30:1625-9. 5.Kariya N, Shindoh M, Nishi S, Yukioka H, Asada A. Oral clonidine for sedation and analgesia in a burn patient. J Clin Anesth 1998;10:514-7 6.Jatti K, Batra Y, Bhardwaj N, Malhotra S. Comparison of psychomotor functions and sedation following premedication with oral diazepam and clonidine in children. Int J Clin Pharmacol Ther 1998;36:336-9