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Characteristics and Surgical and Clinical Outcomes of Severely Obese Children with Obstructive Sleep Apnea
Abstract
To describe characteristics and surgical and clinical outcomes of obese children with obstructive sleep apnea (OSA).
At our institution from 2000 to 2010, 143 obese children with an overnight polysomnography (OPSG) diagnosis of OSA, excluding children with comorbidities, were identified. Relationships between demographics, clinical findings, and the severity of OSA were assessed. Pre- and post-surgery OPSG indices were compared. We defined cure as an apnea hypopnea index (AHI) <1.5/h on the post-surgery OPSG, and we compared the cure rates of different surgeries.
A total of 143 children, median age 12.4 y (IQR 9.6-14.9) and BMI z-scores 2.8 (IQR 2.6-2.9), were included. Seventy-eight (55%) (Median age 12 [IQR 9-15] years) underwent surgery: 1 had tonsillectomy; 1 tonsillectomy + uvulopharyngopalatoplasty (UPPP); 23 adenotonsillectomy (AT); 27 AT + UPPP; 11 adenoidectomy + UPPP; 8 UPPP; and 7 AT +turbinate trim± tongue base suspension. Overall, surgery cured 19 children (26%), but AHI improved in the majority of children (p = 0.001). Similarly, the arousal index, PETCO2, and SpO2 nadir improved significantly (p < 0.002, p = 0.019, p < 0.001, respectively). AHI improved significantly in children with mild-to-moderate OSA in comparison to severe OSA (p < 0.001). Children with enlarged tonsils and no history of prior surgery benefitted more often from surgery (p < 0.004 and p = 0.002, respectively). AT was the only surgery reducing the AHI significantly (p = 0.008). Children did not lose weight despite intervention. Adherence with PAP was poor.
Surgery improved OPSG indices in the majority of obese children with OSA.
© 2014 American Academy of Sleep Medicine.
... When OSA is associated with obesity, though, the interaction of these disorders leads to a higher risk of metabolic and cardiovascular alterations, complicating therapy. AT may provide a general improvement of PSG parameters and thereby OSA, although it is curative only in a minority of obese patients, mostly in mild or moderate OSA cases [29,65]. Furthermore, patients with severe OSA (OAHI ≥ 10) or morbid obesity are more at risk of complications. ...
... AT and PAP therapy for OSA reportedly have some beneficial effects on several metabolic parameters affected by obesity, confirming the impact of OSA on metabolism. However, PAP is not sufficient by itself as a weight-loss measure [65,90], and AT can lead to weight gain instead, particularly if OSA is not resolved [68]. More research is needed to expand the knowledge on the reciprocal correlations between OSA and obesity in adolescence to improve the management of these patients. ...
... Surgery often helps to reduce OSA severity, though it is curative only in about half of obese subjects and risky in the severely obese [65,66]. It is unknown if reducing OSA severity or curing it could also restore the typical pattern of cortical thickness decrease, seen during childhood development in healthy lean subjects, or if the effects of the disease would become permanent after a prolonged duration of OSA or after a certain age. ...
Obstructive sleep apnea (OSA) is a breathing disorder associated with obesity, characterized by recurrent episodes of apnea and/or hypopnea during sleep. Both obesity and OSA independently lead to systemic derangements; when combined, they may cause significant brain structure alterations, particularly in childhood. This study investigated cortical thickness alterations in obese youths with no, mild, and moderate/severe OSA. We hypothesized that OSA is associated with global and regional alterations (with sex differences), and that it causes a deviation from the typical trajectory of age-related cortical thickness decrease reported in lean subjects. Overall, there were no differences in global and regional cortical thickness between groups or sexes. However, the trajectory of the expected age-related cortical thickness decrease was significantly altered: absent in mild OSA, it presented a significant increase in moderate/severe OSA, involving several areas of the cortex. Therefore, cortical alterations caused by OSA in obese youths appear significantly associated with age. iii
... Obesity is a risk for residual and persistent OSA after T&A. Children with residual OSA showed greater weight gain after T&A compared to children without residual OSA [22][23][24]. For Adults tonsillectomy is not usually considered an isolated option to treat OSA as recommended by the American academy of sleep medicine [25]. ...
... For Adults tonsillectomy is not usually considered an isolated option to treat OSA as recommended by the American academy of sleep medicine [25]. However BMI is one of the outcome predictors to success for T&A in treating OSA similarly as with obese adolescents and children [23,26]. BMI change in adults following treatment for OSA (for example with CPAP or oral appliance) is inconsistent, and studies had reported changes in all directions [27,28]. ...
Background
Characteristics of obstructive sleep apnea (OSA) changes with age. Infants, toddlers and prepubertal children with OSA are usually underweight and may suffer from failure to thrive (FTT). Adenotonsillectomy (T&A) is the first line of treatment for OSA in childhood. In adults OSA is commonly associated with obesity and the metabolic syndrome. The change in body mass index (BMI) in adolescents with OSA following T&A was only sporadically studied. Thus, we peruse to examine the BMI z-score change following T&A in adolescents.
Methods
Clalit Health Services is the largest health care organization in Israel with the largest patient registry (more than 50% of the population). Two hundred and forty two adolescents aged 12–18 who underwent T&A between 2006 and 2015 were identified in the Clalit registry and their characteristics including height and weight were retrieved. The BMI z-score of these adolescents at baseline (up to 3 months prior to T&A) and during the consecutive 3 years after T&A were analyzed and compared.
Results
Changes in BMI Z-score were observed to all directions following T&A with overall small increase, not statistically significant ( P = 0.26) from a median of 0.79 prior to T&A to a median of 0.835 after it. There was a minimal trend toward BMI z-score reduction in overweight children ( n = 74) from 1.508 to 1.48 following T&A ( p = NS), and in obese children ( n = 33) from 2.288 to 2.000 ( P = 0.06, 2 tailed). Interestingly thin individuals ( n = 6) increased their BMI z-score following T&A from − 2.4 to − 0.59 ( p = 0.046).
Conclusions
Adolescents show variable changes in their BMI z-score following T&A. In this aspect their BMI z-score change is closer to the change seen in adults treated for OSA and not that of young children. The changes observed show a trend toward normalization of the BMI z-score such that overweight children tend to decrease their BMI z-score while thin individuals tend to increase it.
... Obesity is a risk for residual and persistent OSA after T&A. Children with residual OSA showed greater weight gain after T&A compared to children without residual OSA 22,23,24 . For Adults tonsillectomy is not usually considered an isolated option to treat OSA as recommended by the American academy of sleep medicine 25 . ...
... For Adults tonsillectomy is not usually considered an isolated option to treat OSA as recommended by the American academy of sleep medicine 25 . However BMI is one of the outcome predictors to success for T&A in treating OSA similarly as with obese adolescents and children 23,26 . BMI change in adults following treatment for OSA (for example with CPAP or oral appliance) is inconsistent, and studies had reported changes in all directions 27,28 Of note, recurrence of OSA was reported in adults after bariatric surgery even without concomitant weight increase 29 . ...
Background: obstructive sleep apnea (OSA) is associated with different patient characteristics according to age groups. OSA in babies and in prepubertal children is usually accompanied by a failure to thrive (FTT) and underweight. Adenotonsillectomy (T&A) is the first line of treatment for obstructive sleep apnea (OSA) in childhood. In the adult population and partly in adolescents OSA is commonly associated with obesity and the metabolic syndrome. In adolescents with OSA managed with a T&A the change in BMI was only occasionally studied. Thus, we peruse to examine the BMI z-score change following T&A in adolescents.
Methods: in Israel, Clalit Health Services is the largest health care organization with the largest patient registry (more than 50% of the population). From the Clalit registry, 242 adolescents aged 12-18 who underwent T&A between 2006-2015 were retrospectively studied. BMI z-score changes from up to 3 months prior to T&A were compared to BMI measures in the following 3 years post T&A.
Results: there were changes to all directions with overall small increase, not statistically significant (P=0.26) in BMI Z-score with a median of 0.79 prior to and 0.835 following T&A. Overweight children (n=74) tended to reduce their BMI z-score from 1.508 to 1.48 following T&A (p=NS), and in obese children (n=33) BMI z-score decreased from 2.288 to 2.000 accordingly (P=0.06, 2 tailed). Interestingly thin individuals (n=6) increased their BMI z-score following T&A from -2.4 to -0.59 (p=0.046).
Conclusions: adolescents managed with T&A show variable changes in their BMI z-score following the procedure. In this regard their BMI z-score change is closer to the change seen in adults treated for OSA and not young children. The changes observed show trend to normalize the BMI z-score such that overweight children tend to decrease their BMI z-score while thin individuals tend to increase it.
... Obesity is a risk for residual and persistent OSA after T&A. Children with residual OSA showed greater weight gain after T&A compared to children without residual OSA [22][23][24]. For Adults tonsillectomy is not usually considered an isolated option to treat OSA as recommended by the American academy of sleep medicine [25]. ...
... For Adults tonsillectomy is not usually considered an isolated option to treat OSA as recommended by the American academy of sleep medicine [25]. However, BMI is one of the outcome predictors to success for T&A in treating OSA similarly as with obese adolescents and children [23,26]. BMI change in adults following treatment for OSA (for example with CPAP or oral appliance) is inconsistent, and studies had reported changes in all directions [27,28]. ...
Background: obstructive sleep apnea (OSA) is associated with different patient characteristics according to age groups. OSA in babies and in prepubertal children is usually accompanied by a failure to thrive (FTT) and underweight. Adenotonsillectomy (T&A) is the first line of treatment for obstructive sleep apnea (OSA) in childhood. In the adult population and partly in adolescents OSA is commonly associated with obesity and the metabolic syndrome. In adolescents with OSA managed with a T&A the change in BMI was only occasionally studied. Thus, we peruse to examine the BMI z-score change following T&A in adolescents.
Methods: in Israel, Clalit Health Services is the largest health care organization with the largest patient registry (more than 50% of the population). From the Clalit registry, 242 adolescents aged 12-18 who underwent T&A between 2006-2015 were retrospectively studied. BMI z-score changes from up to 3 months prior to T&A were compared to BMI measures in the following 3 years post T&A.
Results: there were changes to all directions with overall small increase, not statistically significant (P=0.26) in BMI Z-score with a median of 0.79 prior to and 0.835 following T&A. Overweight children (n=74) tended to reduce their BMI z-score from 1.508 to 1.48 following T&A (p=NS), and in obese children (n=33) BMI z-score decreased from 2.288 to 2.000 accordingly (P=0.06, 2 tailed). Interestingly thin individuals (n=6) increased their BMI z-score following T&A from -2.4 to -0.59 (p=0.046).
Conclusions: adolescents managed with T&A show variable changes in their BMI z-score following the procedure. In this regard their BMI z-score change is closer to the change seen in adults treated for OSA and not young children. The changes observed show trend to normalize the BMI z-score such that overweight children tend to decrease their BMI z-score while thin individuals tend to increase it.
... Though tonsillectomy does not increase the odds of being overweight or obese, 44 children who were overweight or obese before surgery still often gain weight, or at least fail to lose weight, after surgery. 7,45 Thus, T&A does not address the obesity component of OSA when present. Additionally, although T&A improves the AHI scores in obese children, it does not decrease C-reactive protein levels, which suggests it may not reduce the underlying chronic inflammation. ...
... [48][49][50] T&A may be less effective in children with obesity; however, it can be curative and improve comorbidities in some. 45,51 Thus, there may be a role for more individualized surgical treatment. One way to optimize surgical success may be through drug-induced sleep endoscopy (DISE). ...
Objectives
For more than a century, pediatric obstructive sleep apnea (OSA) was associated with failure to thrive. However, that association has faded over the last few decades. A 21st century child with OSA is much more likely to be overweight than underweight. This raises the question: Has pediatric OSA changed over time, or has the rise of childhood obesity in the United States created a new, separate disease? This literature review explores the historical shift in the relationship between weight and OSA, and the associated changes in treatment.
Results
We demonstrate a clear transition in the prevalence of failure to thrive and obesity in the OSA literature in the mid‐2000s. What is less clear is whether these two clinical phenotypes should be considered two distinct diseases, or whether subtle differences in one set of pathophysiologic pathways—adenotonsillar hypertrophy, altered inflammation, and increased energy expenditure—can lead to divergent metabolic outcomes. More research is needed to fully elucidate the pathophysiology of OSA in children with obesity.
Conclusions
We may need new and different treatments for obesity‐associated OSA as adenotonsillectomy—which is effective at reversing failure to thrive in OSA—is not as effective at treating OSA in children with obesity. One option is drug‐induced sleep endoscopy, which could personalize and improve surgical treatment of OSA. There is some evidence that therapies used for OSA in adults (e.g., weight loss and positive airway pressure) are also helpful for overweight/obese children with OSA.
Laryngoscope, 129:2414–2419, 2019
... The escalating global obesity epidemic represents one of the most serious public health challenges, not only in adults but also in children (7). Overweight and obese children have an increased risk of OSA (also called OSA-II), with OSA being in general more severe than in lean children, and associated with a greater risk of residual OSA after adeno-tonsillectomy (8). If weight loss cannot be obtained, CPAP has shown to be an efficient treatment for severe persistent OSA (5). ...
Objective The aim of the study was to describe the characteristics of otherwise healthy children with obstructive sleep apnea (OSA; OSA-I) and children with OSA and obesity (OSA-II) treated with long term continuous positive airway pressure (CPAP) or noninvasive ventilation (NIV) in 2019 in France. Design National cross-sectional survey. Patients Children with OSA-I and OSA-II. Main outcome measures Initiation criteria, age, adherence, equipment and settings Results Patients with OSA-I and OSA-II represented 6% (n=84, 71% males) and 10% (n=144, 72% males) of the national cohort, respectively. The apnea-hypopnea index (63% vs 76%), alone or combined with nocturnal gas exchange (25% vs 21%, for OSA-II and OSA-I patients respectively) were used as initiation criteria of CPAP/NIV. OSA-II patients were older at CPAP/NIV initiation (mean age 11.0±4.0 vs 6.8±4.5 years, p<0.001) and were treated for a longer time (2.3±2.6 vs 1.3±1.5 years, p=0.008) than OSA-I patients. NIV was used in 6% of OSA-I patients and 13% of OSA-II patients (p=0.142). Nasal mask was the most used interface in both groups. Mean CPAP level was higher in OSA-II patients as compared to OSA-I patients (8.7±2.0 vs 7.7±2.4 cmH O, p=0.02). Objective compliance was comparable (mean use 6.8±2.6 vs 5.9±3.0 hours/night in OSA-I and OSA-II, respectively, p=0.054). Conclusion Six and 10% of children treated with long term CPAP/NIV in France in 2019 had OSA-I and OSA-II, respectively. Both groups were preferentially treated with CPAP and were comparable except for age, with OSA-II patients being older.
... [40][41][42][43][44][45][46][47][48][49][50][51] Most of the 34 studies were conducted in North America (23 of 34 studies) and had a retrospective study design (20 of 34 studies). The longest duration for CPAP adherence evaluation was four years 22 with an average duration of 10.04 (SD 9.82) months. ...
Introduction
Obstructive sleep apnea (OSA) is a public health problem that affects children. Although continuous positive airway pressure (CPAP) therapy is effective, the CPAP adherence rate in children is varied. This study aimed to evaluate the CPAP adherence rate and factors associated with CPAP adherence in children with OSA using a systematic review.
Methods
The inclusion criteria were observational studies conducted in children with OSA and assessed adherence of CPAP using objective evaluation. The literature search was performed in four databases. Meta-analysis using fixed-effect model was conducted to combine results among included studies.
Results
In all, 34 studies that evaluated adherence rate and predictors of CPAP adherence in children with OSA were included, representing 21,737 patients with an average adherence rate of 46.56%. There were 11 calculations of factors predictive of CPAP adherence: age, sex, ethnicity, body mass index, obesity, income, sleep efficiency, the apnea-hypopnea index (AHI), severity of OSA, residual AHI, and lowest oxygen saturation level. Three different factors were linked to children with adherence and non-adherence to CPAP: age, body mass index, and AHI.
Conclusion
The CPAP adherence rate in children with OSA was 46.56%. Young age, low body mass index, and high AHI were associated with acceptable CPAP adherence in children with OSA.
... or had low-SQI (59%), fewer children were healthy weight (38%). Surgery was successful in 44% of children that were overweight or obese, similar to what has been demonstrated in earlier studies [34]. Table 2 Comparison of changes in metabolic characteristics of children randomized to early adenotonsillectomy (eAT) stratified to (1) group 1 : children with high sleep quality (SQI ≥ 75) and mild-sleep obstructive sleep apnea (OSA) (AHI < 5) and (2) group 2 : children with low-SQI < 75 and moderate to severe OSA (AHI ≥ 5) ...
PurposeThe aim of this study was to determine if cardiopulmonary coupling (CPC) calculated sleep quality (SQI) may predict changes in metabolic health in children treated with early adenotonsillectomy (eAT) for obstructive sleep apnea (OSA).Methods
Secondary analysis of the Childhood Adenotonsillectomy Trial (CHAT) was performed including children 5.0–9.9 years with OSA assigned to eAT. The cohort was stratified based on SQI and AHI to evaluate (1) response to eAT in children with high sleep quality (SQI ≥ 75) and mild-OSA, AHI < 5.0 (group1) and children with moderate-OSA AHI ≥ 5.0 or SQI < 75 (group2) at baseline and (2) effect of eAT therapy on metabolic health, GroupRemission (AHI < 1.0, SQI ≥ 75) compared to GroupResidual.ResultsAt baseline group2 (n=124) had higher average heart rate during sleep (AHRSleep), 87 vs. 81 beats/minute (p < 0.001) compared to group1 (n=72). After surgery, group2 on average had less increase in BMI z-score 0.13 vs. 0.27, (p = 0.025), improved their SQI + 2.06 compared to decline − 3.75 in group1, (p = 0.015), decreased AHRSleep—− 2.90 vs. − 0.34 (p = 0.025) and AHI − 5.00 vs. − 0.36 (p = 0.002).GroupRemission was younger 6.59 vs. 7.41; p < 0.001; with lower BMI z-score 0.90 vs. 1.34; p = 0.021; AHRSleep 80.60 vs. 83.50; p = 0.032; fasting insulin (µIU/ml) 7.54 vs. 12.58; p = 0.017 and glucose (mmol/L) 4.45 vs. 4.60; p = 0.049, with better lipid metabolism though not statistically significantly, low-density-lipoprotein 90.26 mg/dL vs. 97.94; p = 0.081 and cholesterol 154.66 mg/dL vs. 164.36; p = 0.076.Conclusion
The results may indicate that children with mild-OSA and high-SQI may be less likely to benefit from eAT than children with moderate-OSA. To improve metabolic health, successfully treating both AHI and SQI is likely needed. CPC-calculated SQI may have a role to identify children less likely to benefit from eAT and to evaluate success of therapy.Trial registrationClinicalTrials.gov Identifier: NCT00560859.
... The apnea-hypopnea index (AHI) is the most widely used tool to establish the diagnosis, evaluate the severity, and estimate the treatment response of OSA [7]. However, calculating AHI generally requires a sleep study, polysomnography (PSG), or sleep laboratory to where the study takes place. ...
We aimed to identify the association between obstructive sleep apnea (OSA), insulin resistance (IR), and metabolic syndrome (MetS) in a nationwide population-based sample. A total of 7,900 adults with information on the STOP-Bang score and MetS (3,341 men and 4,469 women) were identified from the dataset of the Korea National Health and Nutrition Examination Survey 2019–2020. The association between OSA, IR, MetS, and its components was estimated using complex sample logistic regression analysis with adjustments for age, body mass index, residence, smoking status, alcohol consumption, household income, education, and the presence of diabetes. Participants with a high OSA score were more likely to have IR (odds ratio [OR] 2.78, 95% confidence interval [CI] 1.96–3.95 in men and OR 2.64, 95% CI 0.55–12.80 in women), MetS (OR 6.05, 95% CI 4.23–8.69 in men and OR 4.20, 95% CI 1.23–15.70 in women), and components of MetS, compared to individuals with a low OSA score. Compared to premenopausal women, postmenopausal women had a more intense association between OSA and IR (OR 1.78, 95% CI 0.13–24.43 for premenopausal women and OR 3.64, 95% CI 0.60–22.28 for postmenopausal women) and MetS (OR 2.58, 95% CI 0.23–29.55 for premenopausal women and OR 5.36, 95% CI 1.42–20.21 for postmenopausal women). OSA was associated with abdominal obesity and hypertension in premenopausal women, while all components of MetS were associated with OSA in postmenopausal women. Further studies are necessary to elucidate the underlying mechanisms of these findings.
... These authors postulated that adolescents/families are more likely to accept PAP therapy if they know surgery is not an option. 29 A key benefit of surgical intervention is immediate improvement in airway patency which does not require "nightly" intervention by the family. Although the goal of any sleep surgery is to cure OSA, a positive outcome is to convert a child from moderate/severe obstruction to mild. ...
Objectives/Hypothesis
To determine the success of an adenotonsillectomy (T&A) in treating children with severe obesity utilizing a more accurate obesity scale.
Study Design
Retrospective cohort.
Methods
A retrospective cohort of children with obesity between 5 and 10 years of age who underwent a T&A at Children's Hospital of Colorado (CHCO) was used. This study also utilized publicly available data from the Childhood Adenotonsillectomy Trial (CHAT) study. The cohort was divided into three obesity classes using age‐ and sex‐specific body mass index (BMI) expressed as a percentage of the 95th percentile (%BMIp95) and compared for operative success differences.
Results
There were 132 patients included in our primary analysis, with obesity distribution as follows: Class 1 to 53 patients (40%), Class 2 to 45 patients (34%), and Class 3 to 34 patients (26%). Overall, 52 patients (35.9%) experienced a cure (obstructive apnea/hypopnea index [OAHI] <1), with 27 (52%) patients in Class 1 obesity, 18 (35%) in Class 2, and 7 (13%) in Class 3. Class 3 had a significantly lower obstructive sleep apnea cure rate compared with Class 1 patients (P = .013), but after adjusting for covariates, this difference was no longer present (P > .05). There was no significant difference in the preoperative to postoperative percent change in mean oxygen saturation (P = .82 CHCO, P = .43 CHAT), oxygen nadir (P = .20 CHCO, P = .49 CHAT), or OAHI (P = .12 CHCO, P = .26 CHAT) between the obesity classes.
Conclusion
After adjusting for covariates, children with Class 3 obesity are as likely to be cured with a T&A as those with Class 1 obesity. A T&A should be considered a first line treatment for all children with obesity.
Level of Evidence
3 Laryngoscope, 132:461–469, 2022
... Historically, uvulopalatopharyngoplasty (UPPP), which shortens the palate in order to improve anterior-posterior collapse, was the primary procedure used to address palatal obstruction in OSA, with documented improvements in PSG parameters [44,45]. For both adults and children, expansion sphincter pharyngoplasty (ESP) has evolved to become the technique of choice for children with lateral pharyngeal collapse. ...
Purpose of Review
Review current evidence-based treatment outcomes and future management directions for children with obstructive sleep apnea (OSA).
Recent Findings
Effective medical therapies include weight loss, leukotriene modifiers, nasal corticosteroids, oral appliances, and positive airway pressure. The first randomized controlled trials for adenotonsillectomy in childhood OSA show improved polysomnography results but no postoperative change in neurocognitive outcomes when compared to watchful waiting. Factors have been identified (e.g., craniofacial disorders and obesity) which can lead to decreased adenotonsillectomy success. The tongue base and supraglottis are common additional sites of obstruction, and supraglottoplasty and lingual tonsillectomy are commonly performed procedures for persistent OSA. Additional surgical targets include the nasal cavity, palate/pharynx, tongue base, and larynx.
Summary
The management of pediatric OSA is multidisciplinary and includes a variety of medical and surgical therapies. Although adenotonsillectomy remains first-line treatment, favorable outcomes exist for nonsurgical modalities. In children with persistent OSA after adenotonsillectomy, several procedures exist to address additional obstruction, but further investigation to delineate their appropriate indications is warranted.
... 25 Without parental acceptance of these lifestyle modifications, these children are also at high risk for becoming obese as adults. 25,43,44 Although AT is still the main surgical intervention to relieve upper airway obstruction in this population, recent reports have demonstrated improved outcomes with early use of DISEdirected adjuvant airway procedures at the time of AT, suggesting a paradigm shift in the surgical approach for obese children with oSDB. 36 This study is limited by its retrospective nature and its narrow scope due to the limited nature of the questionnaire's investigation into parental perceptions of their child's weight. ...
Objective
Weight status can affect outcomes in pediatric adenotonsillectomy performed for obstructive sleep disordered breathing. Parents frequently underestimate their child's weight and are unaware weight status may affect adenotonsillectomy success. Accurate understanding of a child's weight status is important for shared decision making with the family and perioperative care. The purpose of this study is to analyze the accuracy of the parent's perception of their child's weight status.
Methods
A retrospective analysis was performed of prospective data collected from families of children undergoing adenotonsillectomy from June 2018 through June 2019.
Results
A total of 522 children met the inclusion criteria. Two hundred and thirty‐two children were either overweight (n = 46, 9%) or obese (n = 186, 36%). Among parents of this cohort whose children were overweight or obese, 74 (32%) erroneously reported that their child was normal weight. For the 290 nonoverweight children, 99% of parents accurately reported weight status. After adjusting for ethnicity, race, BMI%, and sex, for every 1‐year increase in age of the child, the odds of the parent correctly identifying their child as overweight increased by a factor of 1.18 (95% CI: 1.09, 1.27).
Conclusion
One‐third of families with children who were overweight or obese undergoing adenotonsillectomy for obstructive sleep disordered breathing underestimated their child's weight. This study highlights the need to facilitate family understanding of weight status' potential impact on both obstructive sleep disordered breathing severity and adenotonsillectomy success, especially for younger children.
Level of Evidence
4 Laryngoscope, 131:2121–2125, 2021
... Typically these children have significant residual adenoid tissue and an increase in the volume of the tongue and soft palate, which to some degree explains a lower surgical success rate [110]. Moreover, children do not loose weight after adenoidectomy, therefore they require further control condition and evaluation of their [111]. Adenoidectomy alone without adenotonsillectomy is a reasonable option since the majority of the cases are due to AH alone [112]. ...
Age-related (physiological) AH is an important problem in pediatric otorhinolaryngolo-gy. Since the beginning of the 70s, there has been an increase in the proportion of children with pharyngeal tonsil hypertrophy. Functional disorders of the oropharynx in children occupy the second place based on their incidence (after disorders of the musculoskeletal system). In previous years, there has been an increase in the incidence and prevalence of obstructive sleep apnea syndrome (OSAS) among children. In most cases of pediatric OSAS, upper airway obstruction occurs from the nasopharynx to the oropharynx, caused by upper airway stenosis. Consequences of untreated OSAS in children can be inattention and behavioral problems, daytime sleepiness, and in more severe cases are associated with a variety of comorbidities. The current review discusses the links between hypertrophied adenoids, craniofacial development and OSAS in children taking into account physiological and pathophysiological aspects as well as clinical evaluation of the problem.
... Obstruction at the level of the tongue base can be addressed using a number of procedures including lingual tonsillectomy and posterior midline glossectomy. Obstruction may also be addressed at the level of the palate (uvulopalatopharyngoplasty [61]), lateral pharyngeal walls (expansion sphincter pharyngoplasty [62]), nasal cavity (turbinate reduction [63]), or adenoids (revision adenoidectomy [64]). ...
Obstructive sleep apnea syndrome (OSAS) is a common pediatric disorder characterized by recurrent events of partial or complete upper airway obstruction during sleep which result in abnormal ventilation and sleep pattern. OSAS in children is associated with neurobehavioral deficits and cardiovascular morbidity which highlights the need for prompt recognition, diagnosis, and treatment. The purpose of this state-of-the-art review is to provide an update on the evaluation and management of children with OSAS with emphasis on children with complex medical comorbidities and those with residual OSAS following first-line treatment. Proposed treatment strategies reflecting recommendations from a variety of professional societies are presented. All children should be screened for OSAS and those with typical symptoms (e.g., snoring, restless sleep, and daytime hyperactivity) or risk factors (e.g., neurologic, genetic, and craniofacial disorders) should undergo further evaluation including referral to a sleep specialist or pediatric otolaryngologist and overnight polysomnography, which provides a definitive diagnosis. A cardiology and/or endocrinology evaluation should be considered in high-risk children. For the majority of children, first-line treatment is tonsillectomy with or without adenoidectomy; however, some children exhibit multiple levels of airway obstruction and may require additional evaluation and management. Anti-inflammatory medications, weight loss, and oral appliances may be appropriate in select cases, particularly for mild OSAS. Following initial treatment, all children should be monitored for residual symptoms and polysomnography may be repeated to identify persistent disease, which can be managed with positive airway pressure ventilation and additional surgical approaches if required.
... Indeed, studies have demonstrated improvements in the AHI and other PSG parameters on PSG in children undergoing this procedure. 43,44 However, persistent disease has been identified in many children and adults following UPPP, which has driven the use of DISE to identify all areas of collapse. DISE allows for the determination of pattern of palatal collapse, that is, anterior-posterior or circumferential. ...
Pediatric obstructive sleep apnea (OSA) affects 2% to 4% of American children, and is associated with metabolic, cardiovascular, and neurocognitive sequelae. The primary treatment for pediatric OSA is adenotonsillectomy. Children with obesity, craniofacial syndromes, and severe baseline OSA are at risk for persistent disease. Evaluation of persistent OSA should focus on identifying the causes of upper airway obstruction. Interventions should be tailored to address the patient's symptomatology, sites of obstruction, and preference for surgical versus medical management. Further research is needed to identify management protocols that result in improved outcomes for children with persistent OSA.
... Avant l'âge de 12-13 ans, cette intervention doit être réservée aux déviations majeures, en utilisant des techniques endoscopiques préservant au maximum le cartilage et la muqueuse de cloison (résections modelantes limitées, ciblées sur les zones septales obstructives). L'efficacité de ces deux dernières interventions au niveau des fosses nasales reste à déterminer précisément [34] mais permet d'améliorer le confort du patient en améliorant la perméabilité nasale. ...
Although the prevalence of the obstructive sleep apnoea syndrome (OSAS) is high in adolescents, studies pertaining to adolescent OSAS are less numerous than childhood studies. Cases of adolescent OSAS may consist of residual OSAS after adenotonsillectomy, but most often are de novo cases. Major pathophysiological factors are weight excess or even high-grade obesity, and the association of upper airway narrowing and tonsillar hypertrophy (pharyngeal, palatal or even lingual). ENT and systematic orthodontic assessments are the main points. In case of predisposing factors such as dental, occlusal or dento-facial abnormalities, a specific orthodontic treatment can be discussed. First line treatment is surgical adenotonsillectomy; surgical reduction of the lingual tonsils is seldom required. CPAP treatment may be indicated in the case of severe comorbidities (craniofacial malformations, neuromuscular diseases…) or in obese adolescents with severe residual OSAS. Treatment of adolescent OSAS has to be comprehensive and multidisciplinary, taking into account the specific treatments of obesity and abnormal sleep/wake rhythms.
Copyright © 2019. Published by Elsevier Masson SAS.
... Obesity is rare in children with apnea, with prevalence around 10%, but much more frequent in adolescents [34] (level of evidence, 1). It is a comorbidity increasing the risk of severe apnea, functional failure or complications of adenotonsillectomy, and metabolic disorder associated with OSAHS (level of evidence, 1) [35][36][37]. • delayed ponderal or statural growth is a well-established complication of childhood OSAHS (level of evidence, 1) [38,39], assessed on weight and height charts in the health records. Low weightgain for age is more frequent in infants than in older children (level of evidence, 3) [40]. ...
Objectives:
To present the 2017 Clinical Practice Guidelines of the French Society of Otorhinolaryngology concerning the role of the ENT specialist in the diagnosis of pediatric obstructive sleep apnea-hypopnea syndrome. This article focuses specifically on medical history and physical examination.
Methods:
A multidisciplinary work-group drew up a first version of the guidelines, graded according to level of evidence following the GRADE grading system. The final version was obtained by including the suggestions and comments from the editorial group.
Results:
At the end of the process, guidelines were established and graded regarding the following points: interview and analysis of the various interview scores recommended in the literature; clinical examination with awake upper-airway endoscopy; and indications for referral to non-ENT specialists.
... One study investigated the effects of uvulopalatopharyngoplasty (UPPP) in obese children with persistent OSA following adenotonsillectomy. 21 This retrospective chart review included 143 children who underwent a variety of surgical procedures for OSA; 8 had UPPP alone, 11 had UPPP with adenoidectomy, and 27 had UPPP with adenotonsillectomy. The reported median age of these children was 12 years (interquartile range [IQR], 10-15 years), and the median BMI z score was 2.8 (IQR, 2.6-2.9). ...
Objectives:
Surgical intervention for obstructive sleep apnea (OSA) in overweight and obese children may not be as effective as it is in normal-weight children. The purpose of this study was to systematically review the effects of various surgical interventions for OSA in obese children and to meta-analyze the current data.
Data sources:
PubMed, OVID, and Cochrane databases.
Review methods:
Databases were searched for studies examining adenotonsillectomy, uvulopalatopharyngoplasty, supraglottoplasty, or tongue base surgeries and combinations in obese children with OSA. Adenotonsillectomy was the only procedure with enough data for meta-analysis; polysomnographic data were extracted and analyzed using a random-effects model.
Results:
For adenotonsillectomy, 11 studies were included in the meta-analysis. Despite significant improvement in the apnea-hypopnea index (22.9 to 8.1 events/h, P < .001), respiratory disturbance index (24.8 to 10.4 events/h, P < .001), and oxygen saturation nadir (78.4% to 87.0%, P < .001), rates of persistent OSA ranged from 51% to 66%, depending on the outcome criterion used. There was evidence of limited effectiveness for surgical interventions to treat OSA in obese children using uvulopalatoplasty (12.5%) and tongue base surgery (74%-88%).
Conclusions:
Surgical interventions for OSA in overweight and obese children are effective at reducing OSA but with higher rates of persistent OSA than reported for normal-weight children. However, the amount of reduction appears to vary by surgical procedure. More attention should be paid toward preoperative weight loss and patient selection, and parents should be provided with realistic postoperative expectations in this difficult-to-treat population.
... Pacientes con SAHOS establecido también se beneficiarían de amigdalectomía en términos de reducción del índice apnea-hipopnea 21,22 , siendo el beneficio mayor en pacientes no obesos que obesos 23,24 y menor en pacientes con comorbilidades neurológicas, adolescentes y anormalidades craneofaciales 22 . En efecto, ha sido descrita una relación inversa entre el grado de obesidad medido por IMC y la reducción de los eventos de apnea nocturnos, perdiéndose el beneficio en aquellos pacientes con obesidad de mayor severidad 23,25 . Por otro lado, otro reporte muestra que la disminución del índice apnea-hipoapnea dependería más del valor inicial (mayor valor, mayor porcentaje de éxito) que del grado de obesidad inicial 26 , siendo esto aún objeto de controversia 19 . ...
Introducción:
En población pediátrica con malnutrición por exceso, existe controversia respecto al rol de la hiperplasia adenoamigdalina en la etiología de los trastornos del sueño y de la efectividad de la adenoamigdalectomía sobre dicha sintomatología.
Objetivo:
Comparar la efectividad de la adenoamigdalectomía entre pacientes pediátricos eutróficos y con malnutrición por exceso sometidos a adenoamigdalectomía por hiperplasia adenoamigdalina, en relación a la disminución de la sintomatología.
Materiales y método:
Estudio retrospectivo mediante revisión de fichas clínicas entre junio de 2016 y enero de 2017 de pacientes operados de adenoamigdalectomía por hiperplasia adenoamigdalina sintomática. Se clasificaron los pacientes de acuerdo a edad y estado nutricional en 4 grupos y se evaluó la resolución de la sintomatologia mediante interrogación a padres/tutores.
Resultados:
Se incluyeron 98 pacientes, con una edad media de 6,3 años. 44,9% de los pacientes fueron eutróficos y 55,1% con malnutrición por exceso. El análisis estadístico entre pacientes eutróficos y aquellos con malnutrición no demostró diferencias significativas en relación a la resolución de la sintomatología.
Conclusión:
La adenoamigdalectomía por hiperplasia adenoamigdalina sintomática se asocia a una reducción de la frecuencia de roncopatía con pausas en pacientes pediátricos, independientemente del estado nutricional.
... The success rate of AT is higher among children who do not have co-morbidities and are of normal weight. There is a higher incidence of persistent OSA after AT among obese children and children with Trisomy 21 [18,19]. This study was designed to evaluate the relative efficacy of sleep surgery, inclusive of AT among children with Trisomy 21 and OSA as a function of their weight status and OSA severity. ...
Objectives: To assess the effect of weight status and obstructive sleep apnea (OSA) severity on polysomnographic (PSG) outcomes following sleep surgery inclusive of adenotonsillectomy (AT) in children with Trisomy 21. Methods: A retrospective chart review was completed on thirty-six children ages 1-13 years with Trisomy 21 and OSA who underwent at a tertiary care academic hospital between 2005 to 2015 and had both preoperative and postoperative PSGs. Postoperative changes in apnea hypopnea index (AHI) and other PSG parameters, including percentage of various sleep stages, were compared between children who were normal weight, overweight and obese.Results: The mean preoperative AHIs for normal weight, overweight and obese children were 15.6, 12.2 and 15.0, respectively while the mean postoperative AHIs were 10.6, 9.4 and 10.2, respectively. Improvement in AHI was significant only among children with severe OSA (AHI >10), but not among children with mild (AHI 1.5 to 5) or moderate OSA (AHI 5 to 10), both with and without controlling for weight status (p=0.01, p=0.009). There were no significant differences in postoperative PSG parameters comparing obese vs. non-obese and overweight vs. normal weight children. Conclusion: Weight status does not appear to affect sleep surgery outcomes in children with Trisomy 21. This subset of children was found to have persistent OSA following sleep surgery regardless of weight. Other factors associated with Trisomy 21, such as macroglossia, glossoptosis and hypotonia, may play a greater role in the pathogenesis of OSA in this patient population. Only those children with severe OSA were found to have a significant improvement in AHI after sleep surgery, inclusive of AT.
Objective:
To develop an expert consensus statement regarding persistent pediatric obstructive sleep apnea (OSA) focused on quality improvement and clarification of controversies. Persistent OSA was defined as OSA after adenotonsillectomy or OSA after tonsillectomy when adenoids are not enlarged.
Methods:
An expert panel of clinicians, nominated by stakeholder organizations, used the published consensus statement methodology from the American Academy of Otolaryngology-Head and Neck Surgery to develop statements for a target population of children aged 2-18 years. A medical librarian systematically searched the literature used as a basis for the clinical statements. A modified Delphi method was used to distill expert opinion and compose statements that met a standardized definition of consensus. Duplicate statements were combined prior to the final Delphi survey.
Results:
After 3 iterative Delphi surveys, 34 statements met the criteria for consensus, while 18 statements did not. The clinical statements were grouped into 7 categories: general, patient assessment, management of patients with obesity, medical management, drug-induced sleep endoscopy, surgical management, and postoperative care.
Conclusion:
The panel reached a consensus for 34 statements related to the assessment, management and postoperative care of children with persistent OSA. These statements can be used to establish care algorithms, improve clinical care, and identify areas that would benefit from future research.
Obstructive sleep apnea affects a large proportion of otherwise healthy children in the context of interactions between craniofacial elements, adenotonsillar hypertrophy and other anatomical factors, and neuromuscular reflexes of the upper airway. In light of the adverse consequences of sleep apnea, it is important not only to proceed with early diagnosis but also to implement adequate treatment that is guided by the pathophysiological determinants of the disease in each child. Here, we will describe the current standard of care approaches to the treatment of pediatric obstructive sleep apnea, and will also explore novel management strategies that should enable more personalized therapy in the near future.
Study objectives:
(1) To assess adenotonsillectomy (AT) outcomes in obese adolescents with obstructive sleep apnea (OSA); (2) To identify clinical factors predicting OSA in adolescents following AT.
Methods:
Obese adolescents 12 to 18 years old that underwent AT for OSA were included. Subjects had pre- and post-AT polysomnogram. Non-obese adolescents with OSA that underwent AT were included as a comparison.
Results:
Seventy obese adolescents with a mean age of 14.2 years and a mean BMI of 38.0 were included. Patients in the non-obese group (n=32) were similar demographically to the obese group with the exception of BMI. The majority of obese adolescents (74%) had severe OSA (AHI ≥ 10) with a mean baseline AHI of 33.9 (SD 28.5). The obese and control groups experienced clinically meaningful improvements in AHI following AT with median change scores of 18.3 (95% CI -29.2, -11.2, p<0.001) and 14.6 (95% CI -25.5, -8.5, p<0.001) respectively. 48% of obese adolescents had an AHI < 5 on post-operative PSG. However, obese adolescents were 7 times more likely (OR=7.1, 95% CI (2.24, 22.48), p=0.001) to have moderate or severe persistent OSA (AHI>5) after AT compared with non-obese patients. The need for post-AT positive airway pressure (PAP) therapy was significantly higher in obese adolescents, with 37.1% of subjects requiring this therapy (OR=8.3, 95% CI 1.8, 37.6, p<0.001).
Conclusions:
AT results in improvement in PSG parameters in obese adolescents with OSA. However, obese patients are at high risk for persistent OSA. Future research should include prospective trials to compare outcomes between AT and PAP therapy for obese adolescents.
Increasing recognition of anatomical obstruction has resulted in a large variety of sleep surgeries to improve anatomic collapse of obstructive sleep apnea (OSA) and the prediction of whether sleep surgery will have successful outcome is very important. The aim of this study is to assess a machine learning-based clinical model that predict the success rate of sleep surgery in OSA subjects. The predicted success rate from machine learning and the predicted subjective surgical outcome from the physician were compared with the actual success rate in 163 male dominated-OSA subjects. Predicted success rate of sleep surgery from machine learning models based on sleep parameters and endoscopic findings of upper airway demonstrated higher accuracy than subjective predicted value of sleep surgeon. The gradient boosting model showed the best performance to predict the surgical success that is evaluated by pre- and post-operative polysomnography or home sleep apnea testing among the logistic regression and three machine learning models, and the accuracy of gradient boosting model (0.708) was significantly higher than logistic regression model (0.542). Our data demonstrate that the data mining-driven prediction such as gradient boosting exhibited higher accuracy for prediction of surgical outcome and we can provide accurate information on surgical outcomes before surgery to OSA subjects using machine learning models.
Sleep curtailment and obesity are interrelated concurrent epidemics in children and adolescents that pose a major public health challenge. Cumulative data indicates that sleep is a modifiable risk factor that could potentially attenuate childhood obesity, which is a strong predictor of adult obesity. Short sleep duration, irregular sleep-wake patterns, poor sleep quality, and late bedtimes were all found to be associated with obesity, weight gain, and obesogenic behaviors in children and adolescents. Obesity also places children at risk for obstructive sleep apnea (OSA) and for residual OSA post adenotonsillectomy which frequently requires additional therapeutic measures. A change in the clinical paradigm for the obese child with OSA may be required. Interventions extending sleep duration in adjunct with healthy nutrition and physical activity may have a positive effect on weight status. Indeed, preliminary studies in youth are promising since improved sleep may improve obesity rates and is relatively inexpensive.
Study objectives:
Adults with obesity and obstructive sleep apnea (OSA) are at risk for cardiometabolic disease and this risk likely extends to children with both conditions. Non-invasive ventilation (NIV; including continuous and bilevel positive airway pressure) is often used to treat OSA in children with obesity. The aim of this study was to examine the impact of NIV treatment on heart rate variability, as a marker of cardiovascular risk, in children with obesity and newly diagnosed OSA.
Methods:
A prospective multi-center cohort study was conducted in children with obesity prescribed NIV therapy for newly diagnosed moderate-severe OSA. Measurements of HRV were derived from polysomnography recordings at baseline and after 12 months of treatment. HRV parameters were examined by sleep stage, before and after arousal and oxygen desaturation events. HRV parameters were compared between time points using pair t-tests as well as mixed model analysis.
Results:
Twelve subjects had appropriate data for analysis at baseline and 12 months. Heart rate decreased by 4.5 beats/min after NIV treatment with no change in HRV parameters. HRV parameters differed by sleep stage and showed an increase in arousal related sympathetic-parasympathetic balance after 12 months of NIV treatment. HRV parameters did not differ before and after oxygen desaturation events.
Conclusions:
NIV for the treatment in children with obesity and OSA resulted in a small decrease in heart rate and an increase in arousal related sympathetic-parasympathetic balance. These findings suggest small potentially positive impacts of NIV on cardiovascular risk in children with concurrent obesity and OSA.
Pediatric obstructive sleep apnea affects a large number of children and has multiple end-organ sequelae. Although many of these have been demonstrated to be reversible, the effects on some of the organ systems, including the brain, have not shown easy reversibility. Progress in this area has been hampered by lack of a preclinical model to study the disease. Therefore, perioperative and sleep physicians are tasked with making a number of difficult decisions, including optimal surgical timing to prevent disease evolution, but also to keep the perioperative morbidity in a safe range for these patients.
Background:
Positive airway pressure (PAP) is used to treat children with concurrent obesity and sleep-disordered breathing (SDB), but achieving adherence remains challenging. We aimed to identify factors associated with PAP adherence in a prospective cohort of children with obesity prescribed PAP for newly diagnosed SDB.
Methods:
A questionnaire to assess factors related to PAP adherence was administered to participants and their parent ≥ 12 months after enrolment. Adherence (PAP use ≥ 4 hours/night on > 50% of nights), was measured with PAP machine downloads, diaries and physician assessments. Questionnaire responses were compared between adherent/non-adherent participants and between children/parents. Age, total and obstructive apnea-hypopnea index (OAHI), lowest oxygen saturation, and highest CO₂ were compared between adherent/non-adherent children with univariate differences of medians, with 95% confidence intervals.
Results:
Fourteen children (median age 14.3 years, 93% male; all with obstructive sleep apnea) were included. Eleven (79%) were adherent to PAP. SDB symptom improvement was reported in 9/14 (64%); 8/14 (57%) had positive experiences with PAP. Most children assumed an active role in PAP initiation and felt supported by the clinical team. Responses between adherent/non-adherent groups and between children/parents were similar. Oxygen saturation nadir (median difference between non-adherent and adherent groups 8.9% (95% CI 1.7, 16.1)), but not age, AHI, OAHI or maximum CO₂, was associated with PAP adherence.
Conclusion:
Children with obesity-related SDB with lower nocturnal oxygen saturation nadir were more likely to adhere to PAP therapy. Ensuring adequate understanding of PAP therapy and medical team support are key factors in PAP success.
Background:
While positive airway pressure (PAP) is effective for treating sleep-disordered breathing (SDB) in children, adherence is poor. Studies evaluating predictors of PAP adherence have inconsistent findings, and no rigorous reviews have been conducted. This systematic review aims to summarize the literature on predictors of PAP therapy adherence in children.
Methods:
Studies evaluating baseline predictors of PAP therapy adherence in children (≤20 years) with SDB were included. We searched MEDLINE, Embase, CENTRAL, CINAHL, Clinicaltrials.gov, and the last four years of conference abstracts. Results were described narratively, with random-effects meta-analyses performed where feasible. Risk of bias and confidence in the evidence were assessed.
Results:
We identified 50 factors evaluated across 28 studies (21 full text articles, seven abstracts). The highest rates of PAP therapy adherence were most consistently found with female sex, younger age, Caucasian race, higher maternal education, greater baseline apnea-hypopnea index (AHI), and presence of developmental delay. Pooled estimates included odds ratios of 1.48 (95%CI: 0.75-2.93) favoring female sex, 1.26 (95%CI: 0.68-2.36) favoring Caucasian race, and a mean difference in AHI of 4.32 (95%CI: -0.61-9.26) events/hour between adherent and non-adherent groups. There was low quality evidence to suggest that psychosocial factors like health cognitions and family environment may predict adherence.
Conclusion:
In this novel systematic review, we identified several factors associated with increased odds of PAP therapy adherence in children. These findings may help guide clinicians to identify and support children less likely to adhere to PAP therapy and should be considered when developing interventions to improve adherence.
Résumé
Objectifs
Présenter les recommandations de pratique clinique (RPC) rédigées en 2017 sous l’égide de la Société française d’ORL-chirurgie de la face et du cou concernant le rôle de l’ORL dans le diagnostic du syndrome d’apnée-hypopnée obstructive du sommeil de l’enfant. Ce manuscrit porte spécifiquement sur les antécédents et l’examen clinique.
Méthodes
Un groupe de travail multidisciplinaire a rédigé des RPC classées en fonction de leur niveau de preuve scientifique selon le système grade. La première version du texte a été remaniée en fonction des remarques du groupe de lecture.
Résultats
À l’issue du processus de rédaction, des recommandations pondérées selon leur score GRADE de niveau de preuve scientifique ont été établies dans les domaines suivants : interrogatoire, avec notamment analyse de l’apport des différents scores d’interrogatoire proposés dans la littérature ; examen physique, y compris la fibroscopie ORL vigile en consultation ; indications d’adressage du patient vers d’autres spécialistes que l’ORL.
Background:
Systematic reviews (SRs) are often cited as the highest level of evidence available as they involve the identification and synthesis of published studies on a topic. Unfortunately, it is increasingly challenging for small teams to complete SR procedures in a reasonable time period, given the exponential rise in the volume of primary literature. Crowdsourcing has been postulated as a potential solution.
Objective:
The feasibility objective of this study was to determine whether a crowd would be willing to perform and complete abstract and full text screening. The validation objective was to assess the quality of the crowd's work, including retention of eligible citations (sensitivity) and work performed for the investigative team, defined as the percentage of citations excluded by the crowd.
Methods:
We performed a prospective study evaluating crowdsourcing essential components of an SR, including abstract screening, document retrieval, and full text assessment. Using CrowdScreenSR citation screening software, 2323 articles from 6 SRs were available to an online crowd. Citations excluded by less than or equal to 75% of the crowd were moved forward for full text assessment. For the validation component, performance of the crowd was compared with citation review through the accepted, gold standard, trained expert approach.
Results:
Of 312 potential crowd members, 117 (37.5%) commenced abstract screening and 71 (22.8%) completed the minimum requirement of 50 citation assessments. The majority of participants were undergraduate or medical students (192/312, 61.5%). The crowd screened 16,988 abstracts (median: 8 per citation; interquartile range [IQR] 7-8), and all citations achieved the minimum of 4 assessments after a median of 42 days (IQR 26-67). Crowd members retrieved 83.5% (774/927) of the articles that progressed to the full text phase. A total of 7604 full text assessments were completed (median: 7 per citation; IQR 3-11). Citations from all but 1 review achieved the minimum of 4 assessments after a median of 36 days (IQR 24-70), with 1 review remaining incomplete after 3 months. When complete crowd member agreement at both levels was required for exclusion, sensitivity was 100% (95% CI 97.9-100) and work performed was calculated at 68.3% (95% CI 66.4-70.1). Using the predefined alternative 75% exclusion threshold, sensitivity remained 100% and work performed increased to 72.9% (95% CI 71.0-74.6; P<.001). Finally, when a simple majority threshold was considered, sensitivity decreased marginally to 98.9% (95% CI 96.0-99.7; P=.25) and work performed increased substantially to 80.4% (95% CI 78.7-82.0; P<.001).
Conclusions:
Crowdsourcing of citation screening for SRs is feasible and has reasonable sensitivity and specificity. By expediting the screening process, crowdsourcing could permit the investigative team to focus on more complex SR tasks. Future directions should focus on developing a user-friendly online platform that allows research teams to crowdsource their reviews.
Pediatric Pulmonology covers a broad range of research and scholarly topics related to children's respiratory disorders. For updated perspectives on the rapidly expanding knowledge in our field, we will summarize the past year's publications in our major topic areas, as well as selected publications in these areas from the core clinical journal literature outside our own pages. The current review (Part 2) covers articles on sleep-disordered breathing. Pediatr Pulmonol. © 2016 Wiley Periodicals, Inc.
Background:
Many pediatric patients need positive airway pressure (PAP) for treatment of obstructive sleep-disordered breathing. Adherence to PAP (defined as percent of nights with PAP use of > 4 h) is often poor and not sustained long-term. With any chronic disease, education has been shown to help with patient outcomes. Education of patients and parents regarding PAP can be provided by different healthcare professionals. There is no published literature assessing the role of respiratory therapists (RTs) in improving adherence to PAP in children. We hypothesized that the addition of RT visits to a PAP clinic would improve PAP adherence.
Methods:
RT services for PAP patients were introduced in a multidisciplinary pediatric sleep clinic in May 2006. We identified children who had been followed in clinic, and had adherence download information before and after introduction of RT services. We collected demographic, polysomnography, and CPAP adherence data at clinic visits.
Results:
Forty-six subjects met criteria for inclusion. The mean ± SD age was 14.9 ± 6 y. The mean ± SD apnea-hypopnea index was 26.7 ± 30 events/h. Other than the addition of the RT intervention, all subjects continued to receive the same clinical services as before. Subjects were divided into 3 groups, based on baseline adherence: 0% use, use for 1-50% of nights, and use for > 50% of nights. There was a statistically significant improvement in PAP adherence in the subjects with baseline use of 0% and 1-50%, but no improvement in those with > 50% use at baseline. There was no significant change in PAP use at subsequent RT visits.
Conclusions:
Utilization at clinic visits of an RT trained in the use of PAP improved adherence in pediatric subjects with obstructive sleep-disordered breathing when their baseline PAP adherence was < 50%.
This technical report describes the procedures involved in developing recommendations on the management of childhood obstructive sleep apnea syndrome (OSAS).
The literature from 1999 through 2011 was evaluated.
A total of 3166 titles were reviewed, of which 350 provided relevant data. Most articles were level II through IV. The prevalence of OSAS ranged from 0% to 5.7%, with obesity being an independent risk factor. OSAS was associated with cardiovascular, growth, and neurobehavioral abnormalities and possibly inflammation. Most diagnostic screening tests had low sensitivity and specificity. Treatment of OSAS resulted in improvements in behavior and attention and likely improvement in cognitive abilities. Primary treatment is adenotonsillectomy (AT). Data were insufficient to recommend specific surgical techniques; however, children undergoing partial tonsillectomy should be monitored for possible recurrence of OSAS. Although OSAS improved postoperatively, the proportion of patients who had residual OSAS ranged from 13% to 29% in low-risk populations to 73% when obese children were included and stricter polysomnographic criteria were used. Nevertheless, OSAS may improve after AT even in obese children, thus supporting surgery as a reasonable initial treatment. A significant number of obese patients required intubation or continuous positive airway pressure (CPAP) postoperatively, which reinforces the need for inpatient observation. CPAP was effective in the treatment of OSAS, but adherence is a major barrier. For this reason, CPAP is not recommended as first-line therapy for OSAS when AT is an option. Intranasal steroids may ameliorate mild OSAS, but follow-up is needed. Data were insufficient to recommend rapid maxillary expansion.
This revised clinical practice guideline, intended for use by primary care clinicians, provides recommendations for the diagnosis and management of the obstructive sleep apnea syndrome (OSAS) in children and adolescents. This practice guideline focuses on uncomplicated childhood OSAS, that is, OSAS associated with adenotonsillar hypertrophy and/or obesity in an otherwise healthy child who is being treated in the primary care setting.
Of 3166 articles from 1999-2010, 350 provided relevant data. Most articles were level II-IV. The resulting evidence report was used to formulate recommendations.
The following recommendations are made. (1) All children/adolescents should be screened for snoring. (2) Polysomnography should be performed in children/adolescents with snoring and symptoms/signs of OSAS; if polysomnography is not available, then alternative diagnostic tests or referral to a specialist for more extensive evaluation may be considered. (3) Adenotonsillectomy is recommended as the first-line treatment of patients with adenotonsillar hypertrophy. (4) High-risk patients should be monitored as inpatients postoperatively. (5) Patients should be reevaluated postoperatively to determine whether further treatment is required. Objective testing should be performed in patients who are high risk or have persistent symptoms/signs of OSAS after therapy. (6) Continuous positive airway pressure is recommended as treatment if adenotonsillectomy is not performed or if OSAS persists postoperatively. (7) Weight loss is recommended in addition to other therapy in patients who are overweight or obese. (8) Intranasal corticosteroids are an option for children with mild OSAS in whom adenotonsillectomy is contraindicated or for mild postoperative OSAS.
Arkansas was among the first states to pass comprehensive legislation to combat childhood obesity, with Arkansas Act 1220 of 2003. Two distinct but complementary evaluations of the process, impact, and outcomes of Act 1220 are being conducted: first, surveillance of the weight status of Arkansas children and adolescents, using the statewide data amassed from the required measurements of students' body mass indexes (BMIs); and second, an independent evaluation of the process, impact, and outcomes associated with Act 1220. Various stakeholder groups initially expressed concerns about the Act, specifically concerns related to negative social and emotional consequences for students and an excessive demand on health care. Evaluation data, however, suggest that few adverse effects have occurred either in these areas of concern or in other concerns which have emerged over time. Schools are changing environments and implementing policies and programs to promote healthy behaviors and BMI levels have not increased since the implementation of Act 1220 in 2004. The Arkansas experience to date may serve to inform the efforts of other states to adopt policies to address the epidemic of childhood obesity.
Continuous positive airway pressure (CPAP) is a highly efficacious treatment for obstructive sleep apnea (OSA) but adherence to the treatment limits its overall effectiveness across all age groups of patients. Factors that influence adherence to CPAP include disease and patient characteristics, treatment titration procedures, technological device factors and side effects, and psychological and social factors. These influential factors have guided the development of interventions to promote CPAP adherence. Various intervention strategies have been described and include educational, technological, psychosocial, pharmacological, and multi-dimensional approaches. Though evidence to date has led to innovative strategies that address adherence in CPAP-treated children, adults, and older adults, significant opportunities exist to develop and test interventions that are clinically applicable, specific to sub-groups of patients likely to demonstrate poor adherence, and address the multi-factorial nature of CPAP adherence. The translation of CPAP adherence promotion interventions to clinical practice is imperative to improve health and functional outcomes in all persons with CPAP-treated OSA.
Obstructive Sleep Apnea (OSA) is associated with medical and neurobehavioral morbidity across the lifespan. Positive airway pressure (PAP) treatment has demonstrated efficacy in treating OSA and has been shown to improve daytime functioning in adults, but treatment adherence can be problematic. There are nearly no published studies examining functional outcomes such as academic functioning in adolescents treated with PAP. This study was conducted as an initial step towards determining whether PAP treatment improves daytime functioning among adolescents with OSA.
Self-reported academic grades, self- and parent-reported academic quality of life, and objectively-measured attention were assessed before and after PAP was clinically initiated in a sample of 13 obese adolescents with OSA, as well as 15 untreated obese Controls without OSA. Based on adherence data, the treated group was divided into PAP Users (n = 6) and Non-Adherent participants (n = 7).
Though demographically similar, the three groups significantly differed in how their academic performance and attention scores changed from baseline to follow-up. Non-Adherent participants showed worsening functioning over time, while PAP Users showed stable or improved functioning, similar to controls.
Although many adolescents prescribed PAP for OSA are non-adherent to the treatment, those who adhere to treatment can display improved attention and academic functioning.
The overall efficacy of adenotonsillectomy (AT) in treatment of obstructive sleep apnea syndrome (OSAS) in children is unknown. Although success rates are likely lower than previously estimated, factors that promote incomplete resolution of OSAS after AT remain undefined.
To quantify the effect of demographic and clinical confounders known to impact the success of AT in treating OSAS.
A multicenter collaborative retrospective review of all nocturnal polysomnograms performed both preoperatively and postoperatively on otherwise healthy children undergoing AT for the diagnosis of OSAS was conducted at six pediatric sleep centers in the United States and two in Europe. Multivariate generalized linear modeling was used to assess contributions of specific demographic factors on the post-AT obstructive apnea-hypopnea index (AHI).
Data from 578 children (mean age, 6.9 +/- 3.8 yr) were analyzed, of which approximately 50% of included children were obese. AT resulted in a significant AHI reduction from 18.2 +/- 21.4 to 4.1 +/- 6.4/hour total sleep time (P < 0.001). Of the 578 children, only 157 (27.2%) had complete resolution of OSAS (i.e., post-AT AHI <1/h total sleep time). Age and body mass index z-score emerged as the two principal factors contributing to post-AT AHI (P < 0.001), with modest contributions by the presence of asthma and magnitude of pre-AT AHI (P < 0.05) among nonobese children.
AT leads to significant improvements in indices of sleep-disordered breathing in children. However, residual disease is present in a large proportion of children after AT, particularly among older (>7 yr) or obese children. In addition, the presence of severe OSAS in nonobese children or of chronic asthma warrants post-AT nocturnal polysomnography, in view of the higher risk for residual OSAS.
The 2000 Centers for Disease Control and Prevention (CDC) growth charts included lambda-mu-sigma (LMS) parameters intended to calculate smoothed percentiles from only the 3rd to the 97th percentile.
The objective was to evaluate different approaches to describing more extreme values of body mass index (BMI)-for-age by using simple functions of the CDC growth charts.
Empirical data for the 99th and the 1st percentiles of BMI-for-age were calculated from the data set used to construct the growth charts and were compared with estimates extrapolated from the CDC-supplied LMS parameters and to various functions of other smoothed percentiles. A set of reestimated LMS parameters that incorporated a smoothed 99th percentile were also evaluated.
Extreme percentiles extrapolated from the CDC-supplied LMS parameters did not match well to the empirical data for the 99th percentile. A better fit to the empirical data was obtained by using 120% of the smoothed 95th percentile. The empirical first percentile was reasonably well approximated by extrapolations from the LMS values. The reestimated LMS parameters had several drawbacks and no clear advantages.
Several approximations can be used to describe extreme high values of BMI-for-age with the use of the CDC growth charts. Extrapolation from the CDC-supplied LMS parameters does not provide a good fit to the empirical 99th percentile values. Simple approximations to high values as percentages of the existing smoothed percentiles have some practical advantages over imputation of very high percentiles. The expression of high BMI values as a percentage of the 95th percentile can provide a flexible approach to describing and tracking heavier children.
To determine the prevalence of obstructive sleep apnea (OSA) in extremely overweight adolescents and to examine the effect of significant weight loss on OSA severity.
We reviewed the anthropometric and polysomnographic data on all extremely overweight adolescents who underwent laparoscopic Roux en Y gastric bypass surgery at Cincinnati Children's Hospital Medical Center from July 2001 to September 2004. Repeat polysomnograms were performed after significant weight loss. Comparisons were made between pre- and postoperative polysomnographic data.
Nineteen of 34 patients (55%) who underwent bariatric surgery were diagnosed with OSA. Subsequent to surgery, 10 of these patients returned for follow-up polysomnographic testing. After significant weight loss (mean, 58 kg), OSA severity markedly decreased in all patients (median apnea-hypopnea index at baseline vs. after weight loss, 9.1 vs. 0.65).
Our study indicated that OSA was highly prevalent in extremely overweight adolescents meeting eligibility criteria for bariatric surgery. The significant weight loss after gastric bypass was associated with a marked reduction in OSA severity.
Positive airway pressure therapy (PAP) is frequently used to treat children who have obstructive sleep apnea syndrome and do not respond to adenotonsillectomy. However, no studies have evaluated objectively adherence to PAP in children, and few studies have evaluated objectively the effectiveness of PAP. The objective of this study was to determine adherence and effectiveness of PAP (both continuous [CPAP] and bilevel [BPAP] pressure) in children with obstructive apnea.
A prospective, multicenter study was performed of children who were randomly assigned in a double-blind manner to 6 months of CPAP versus BPAP. Adherence was measured objectively using the equipment's computerized output. Effectiveness was evaluated using polysomnography.
Twenty-nine children were studied. Approximately one third of children dropped out before 6 months. Of the 21 children for whom 6-month adherence data could be downloaded, the mean nightly use was 5.3 +/- 2.5 (SD) hours. Parental assessment of PAP use considerably overestimated actual use. PAP was highly effective, with a reduction in the apnea hypopnea index from 27 +/- 32 to 3 +/- 5/hour, and an improvement in arterial oxygen saturation nadir from 77 +/- 17% to 89 +/- 6%. Results were similar for children who received CPAP versus BPAP. Children also had a subjective improvement in daytime sleepiness.
Both CPAP and BPAP are highly efficacious in pediatric obstructive apnea. However, treatment with PAP is associated with a high dropout rate, and even in the adherent children, nightly use is suboptimal considering the long sleep hours in children.
To prospectively evaluate the outcome of surgical treatment decisions made by a multidisciplinary team for children aged 18 months to 12 years with sleep-disordered breathing (SDB).
A multidisciplinary team evaluated children referred to a sleep clinic for suspicion of SDB using polysomnography, questionnaires, and clinical evaluations. Suggestions for treatment (surgical, medical, or orthodontic) were made and sent to referring providers. A follow-up evaluation, which included a repeat of all of the tests performed at baseline, was performed 3 months after treatment (and at 6 months for a subgroup of subjects). The clinical outcome of the recommended versus the performed treatment was compared.
56 successively evaluated children.
Based on insurance plans, 11 children were treated by a surgeon on the multidisciplinary team, who followed all treatment recommendations. After treatment, 1 of the 11 children still had SDB. Forty-five children were referred to other specialists. Only 1 of these children had the team's treatment recommendations implemented. Twenty-six of the 45 children had residual symptoms. Twelve children had polysomnographic abnormalities with or without symptoms or snoring. Sixteen children (28.6%) underwent a second surgical procedure.
There are misconceptions in the pediatric and otolaryngologic communities about the rationale for the surgical treatment of SDB. Interactions between mouth breathing, maxillofacial growth, and clinical symptoms associated with SDB are not well understood. Multidisciplinary evaluations of the anatomic abnormalities of children with SDB lead to better overall treatment.
Objective:
Children with cerebral palsy (CP) are commonly affected by obstructive sleep apnea (OSA). This study examines the efficacy of combined surgical techniques for OSA including tongue base suspension (TBS), using perioperative polysomnograms (PSG) in pediatric patients with CP.
Study design:
Case series with outcome analysis.
Setting:
University based tertiary care children's hospital.
Methods:
A 7-year retrospective chart review of children with CP who underwent surgical management for OSA. Surgical procedures, postoperative complications, and perioperative PSG data were examined. Only patients with both preoperative and postoperative PSG results were included in the study. Based upon procedures performed patients fell into 2 equal groups for analysis.
Results:
Fourteen children were identified. Seven patients (mean age = 6.0 years) underwent combined adenotonsillectomy (T&A), uvulopalatopharyngoplasty (UPPP), and tongue base suspension (TBS). Another 7 patients (mean age = 6.3 years) underwent T&A and UPPP alone. Those who received TBS had a mean preoperative AHI of 27.2 compared to 6.8 in the group that did not have TBS. The AHI decreased by a mean of 16.5 in the TBS group and 5.0 in the non-TBS group. The mean oxygen saturation nadir improved in both the TBS (74.0-84.0) and non-TBS (64.8-84.6) groups. The arousal index also improved in the TBS (33.1-20.7) and non-TBS (11.0-5.8) groups. No surgical complications occurred.
Conclusion:
This study suggests that concomitant surgical approaches for OSA in children with CP are effective. Moderate to severe OSA in this population may safely benefit from the added technique of tongue base suspension.
Objectives:
Positive Airway Pressure (PAP) devices are being increasingly used in pediatric populations for problems including Obstructive Sleep Apnea. There is limited literature regarding pediatric adherence with PAP treatment or successful interventions that improve adherence. This paper describes a clinical program for pediatric PAP users which was designed to improve adherence of patients prescribed PAP therapy and involves intensive assessment and behavioral intervention.
Method:
The design and implementation of the program is described, including the purpose, goals, programmatic structure, clinical content, type and training of personnel, strengths and limitations and financial concerns as well as the challenges with the development and application of the program's protocol.
Results:
Preliminary outcome data show short-term improvements in consistent usage for many of the patients.
Conclusions:
The program shows some promise and provides a framework for future program development and research.
The establishment of normal pediatric polysomnographic parameters is important for both clinical and research interests. Our objectives were to describe respiratory events, paradoxical breathing, periodic limb movements, and sleep architecture of children at the age of peak incidence of obstructive sleep apnea syndrome. We performed a retrospective cross-sectional analysis of a prospective cohort study of 66 children, 2–9 years old, at the Sleep Disorders Center at the Children's Hospital of Philadelphia. Subjects screened by questionnaire underwent a standard polysomnogram. The percent of total sleep time spent in sleep stages 1, 2, 3, 4, and rapid eye movement (REM) were 4 ± 3%, 44 ± 10%, 10 ± 6%, 22 ± 8%, and 21 ± 6%, respectively. The arousal and awakening index was 11.2 ± 4.3/hr. Respiratory events included a central apnea index of 0.08 ± 0.14/hr, obstructive apnea index of 0.01 ± 0.03/hr, and obstructive hypopnea index of 0.3 ± 0.5/hr. The baseline arterial oxygen saturation (SpO2) was 97 ± 1%, with a nadir of 92 ± 3%. The index of periodic limb movements in sleep (PLMS) was 1.3 ± 2.2/hr. Paradoxical breathing appeared significantly more frequent with piezo crystal effort belts (40 ± 24% of epochs) than with respiratory inductive plethysmography (1.5 ± 3% of epochs). We describe the occurrence of hypopneas during sleep, arousals and awakenings, and PLMS. We illustrate how different technologies can vary the apparent amount of paradoxical breathing. We also confirm previous data on the frequency distribution of sleep stages, SpO2, and relative rarity of respiratory events in this age group. © 2005 Wiley-Liss, Inc.
Although continuous positive airway pressure (CPAP) is the gold standard in the treatment of obstructive sleep apnea (OSA), its effectiveness depends on the regular use. In this retrospective study, the effectiveness of CPAP with regard to the reduction of the apnea-hypopnea index was calculated based on individual adherence data extracted from a cohort of patients with OSA METHODS: The electronic database was analyzed for follow-up visits of patients receiving CPAP for OSA. The following information was extracted the charts of 750 patients: apnea-hypopnea index (AHI) at diagnosis, AHI with CPAP, duration of therapy, hours of CPAP use, and subjective hours of sleep. Eighty-two successfully treated and stable CPAP patients (AHI/Epworth Sleepiness Scale (ESS) at baseline 35.6 ± 22.1/10.5 ± 5.1) could be further evaluated.
Mean AHI under CPAP was 2.4 ± 2.5 with an ESS of 6.9 ± 4.2. Subjective hours of sleep were 6.5 ± 1.1. The average treatment period was 584.6 ± 566.5 days (3,800 h of sleep). Mean hours of use was 2,712 ± 3,234 (4.69 ± 2.42 per night). This leads to the following calculated measures: hours of sleep without CPAP, 1,088; number of respiratory events with CPAP, 6508.8; number of respiratory events without CPAP, 38,732.8; total number or respiratory events, 45,241.6; average AHI, 11.91.
Even in an ideal group of patients, CPAP cannot eliminate respiratory events due to limited adherence. Adherence needs to be taken into account when comparing the effects of CPAP on the AHI with alternative treatment methods, especially those with 100% adherence (e.g., surgery).
Childhood obstructive sleep disordered breathing (OSDB), a sleep-related upper airway obstruction that degrades sleep quality, ventilation and/or oxygenation, in turn leads to a variety of daytime symptoms and morbidity. In the past, childhood OSDB was classified into primary snoring versus obstructive sleep apnea (OSA) syndrome and it was widely assumed that childhood OSA required treatment, while primary snoring did not. Pediatric polysomnography (PSG) was originally developed to distinguish primary snoring from childhood OSA. However, the late 1990s saw an explosion of new research on the daytime manifestations and long-term morbidity of childhood OSDB, which resulted in expanded, more comprehensive definitions of childhood OSDB syndromes. It is now clear that even primary snoring, in the absence of classically defined OSA, can be associated with neurobehavioral abnormalities in children. Thus, in retrospect, we realize that 'classical' childhood OSA was only a subset of a larger affected population and that children previously classified as having primary snoring may have serious neurobehavioral dysfunction. Now, in the era of the expanded definition of childhood OSDB, the role of PSG in the routine evaluation of the snoring child is controversial. Given that overnight PSG is widely regarded as the 'gold standard' for the diagnosis of OSDB in children, we review the current usage of PSG in children for the diagnosis of OSDB, its value, limitations and possibilities for future improvements.
Pediatric polysomnography is the diagnostic study of choice to evaluate for obstructive sleep apnea in children, and to evaluate cardiorespiratory function in infants and children with chronic lung disease, or neuromuscular disease when indicated. It is helpful to investigate atypical cases of parasomnias. It is important to understand that children are not just small adults when being studied in a sleep laboratory; they require a child friendly atmosphere and approach, need smaller and specialized equipment, and because of developmental and physiologic differences from adults, have age-adjusted rules for the scoring and interpretation of polysomnograms.
To determine the reproducibility of the Brodsky grading scale and the modified 3-grade and 5-grade scales in reporting the size of the tonsils.
Retrospective review of 60 video recordings of tonsil examination by 12 independent observers with different clinical backgrounds and various levels of training. The sizes of the tonsils were graded using different grading scales.
Tertiary care university hospital.
The video recordings were chosen from an ongoing epidemiologic study of sleep-related breathing disorder in children in Hong Kong. Main Outcomes Measures The intraobserver and interobserver reproducibility of each grading scale was determined using intraclass correlation. An intraclass correlation coefficient (ICC) exceeding 0.75 was set a priori to indicate an acceptable level of reliability.
The mean intraobserver ICCs for the Brodsky grading scale and the modified 3-grade and 5-grade scales were 0.858, 0.830, and 0.865, respectively. The mean interobserver ICCs for the Brodsky grading scale and the modified 3-grade and 5-grade scales were 0.763, 0.739, and 0.783, respectively.
The Brodsky grading scale and the modified 5-grade scale achieved acceptable intraobserver and interobserver reproducibility.
Perform an updated systematic review and meta-analysis to determine the cure rate of tonsillectomy and adenoidectomy (T&A) for pediatric obstructive sleep apnea/hypopnea syndrome (OSAHS).
A systematic review was performed to identify English-language studies that evaluate the treatment of pediatric (age < 20 years) OSAHS patients with T&A using polysomnography as a metric of cure. Twenty-three studies fit the inclusion criteria and a meta-analysis was performed to determine the overall success. Meta-analysis was also performed to determine the success in obese and comorbid populations vs cohorts of healthy children.
The meta-analysis included 1079 subjects (mean sample size of 42 patients) with a mean age of 6.5 years. The effect measure was the percentage of pediatric patients with OSAHS who were successfully treated (k = 22 studies) with T&A based on preoperative and postoperative PSG data. Random-effects model estimated the treatment success of T&A was 66.3 percent, when cure was defined per each individual study. When "cure" was defined as an apnea-hypopnea index (AHI) of <1 (k = 9 studies), random-effects model estimate for OSAHS treatment success with T&A was 59.8 percent. Postoperative mean AHI was significantly decreased from preoperative levels.
Contrary to popular belief, meta-analysis of current literature demonstrates that pediatric sleep apnea is often not cured by T&A. Although complete resolution is not achieved in most cases, T&A still offers significant improvements in AHI, making it a valuable first-line treatment for pediatric OSAHS.
The purpose of this study was to determine the effectiveness of adenotonsillectomy (T&A) for treating obstructive sleep apnea (OSA) in obese children.
PubMed and Ovid databases.
A meta-analysis of studies that reported sleep parameters in obese children with OSA before and after T&A. Data were analyzed using the random effects model. Statistical significance was P < or = 0.05.
Data from four studies that included 110 children were analyzed. The mean sample size was 27.5 (range, 18-33). The mean body mass index z score was 2.81. The mean pre- and postoperative apnea-hypopnea index (AHI) was 29.4 (range, 22.2-34.3) and 10.3 (range, 6.0-12.2), respectively. The weighted mean difference between pre- and postoperative AHI was a significant reduction of 18.3 events per hour (95% confidence interval [CI], 11.2-25.5). The mean pre- and postoperative oxygen saturation nadir was 78.4 percent (range, 73.9%-81.1%) and 85.7 percent (range, 83.6%-89.9%), respectively. The weighted mean difference was a significant increase of the oxygen saturation nadir of 6.3 percent (95% CI, 3.9-8.7). Forty-nine percent of children had a postoperative AHI <5, 25 percent of children had a postoperative AHI <2, and 12 percent of children had a postoperative AHI <1.
T&A improves but does not resolve OSA in the majority of obese children. The efficacy and role of additional therapeutic options require more study. The high incidence of obesity in children makes this a public health priority.
The objective of this study was to assess the effect of weight loss on sleep-disordered breathing (SDB) in obese teenagers attending a residential treatment center. We also assessed whether the presence of SDB at the start of the weight management therapy was correlated with the amount of weight loss achieved. Obese teenagers were recruited and underwent anthropometry and sleep screening. Subjects with SDB (apnea hypopnea index (AHI)>or=2) received a follow-up screening after weight loss therapy. Sixty-one obese subjects were included (age=14.8+/-2.3; BMI z score=2.7+/-0.4). Thirty-one subjects were diagnosed with SDB with 38% continuing to have residual SDB after a median weight loss of 24.0 kg. Subjects with SDB had a higher median relative decrease in BMI z score compared to subjects without SDB which was 30.5, 33.6, and 50.4% in the group with AHI of the baseline screening study<2, 2<or=AHI<5, and AHI>or=5, respectively (P=0.02). AHI of the baseline screening study correlated significantly with the relative decrease in BMI z score (partial r=0.37; P=0.003), controlling for gender, age, initial BMI z score, and time between both studies. In conclusion, weight loss was successful in treating SDB in obese teenagers. In addition, there was a positive association between the severity of SDB at the start of the treatment and the amount of weight loss achieved. These findings are in favor of considering weight loss as a first-line treatment for SDB in obese children and adolescents.
The relative importance of obesity and adenotonsillar hypertrophy in the pathogenesis of obstructive sleep-disordered breathing (SDB) in childhood is unclear. Adenotonsillectomy (AT) for SDB is not always curative, and obese children are at increased risk for residual disease postoperatively.
The aim of this investigation was to assess the efficacy of AT as treatment for SDB in obese and nonobese children.
Children with adenoidal and/or tonsillar hypertrophy who underwent AT for the treatment of SDB underwent polysomnography preoperatively and postoperatively. A body mass index (BMI) z score of > 1.645 was used to define obesity. The achievement of a postoperative obstructive apnea-hypopnea index (OAHI) of less than one episode per hour (ie, the cure of SDB) was the primary outcome measure.
Twenty-two obese children (mean [+/- SD] age, 5.8 +/- 1.8 years; mean BMI z score, 2.6 +/- 0.8; mean OAHI, 9.5 +/- 9.7 episodes per hour) and 48 nonobese children (mean age, 6.9 +/- 2.6 years; mean BMI z score, 0.09 +/- 1.1; OAHI, 6 +/- 5.4 episodes per hour) were recruited. After surgery, obese and nonobese subjects did not differ in the efficacy of AT (postoperative OAHI of less than one episode per hour, 22.7% vs 25% of subjects, respectively; p > 0.05). The presence of obesity, adenoidal or tonsillar hypertrophy, gender, and postoperative BMI change were not significant predictors of SDB cure.
Obesity does not necessarily predict an unfavorable outcome of AT as treatment for SDB.
Bona fide obstructive sleep apnea is rare in the pediatric age group. Traditional surgical management for pediatric obstructive sleep apnea (OSA) is adenotonsillectomy alone, however, severely affected children may require uvulopalatopharyngoplasty (UPPP) or tracheostomy to relieve their obstruction. Children with OSA along with other medical maladies (e.g. cerebral palsy, down syndrome) pose an additional challenge to the otolaryngologist due to poor muscular tone and other medical problems which may complicate postoperative management. We report on 15 children (aged 23 months-13 years, mean 7.4 years), 12 with severe mental insufficiency, with documented OSA who underwent classical or modified UPPP. Twelve of 15 had clinical and/or objective improvement. We conclude that UPPP has a role in the management of neurologically-impaired children with OSA.
Children with cerebral palsy are at risk of developing obstructive sleep apnea, which is initially managed by medical therapy but often requires tracheostomy for stabilization of the airway. We report preoperative and postoperative polysomnographic findings in a prospective series of 18 patients with cerebral palsy and obstructive sleep apnea who were refractory to medical management and underwent aggressive surgical treatment of upper airway obstruction. Fifteen of the 18 children (83 percent) in whom tracheostomy was recommended were spared the procedure. Eighteen children with cerebral palsy failed medical management of obstructive sleep apnea and were advised to have tracheostomy. There were 9 boys and 9 girls, ranging in age from 9 months to 17 years and 6 months at the time of operation. Tonsillectomy and adenoidectomy was performed in 9 patients, turbinectomy and/or septoplasty in 9, tongue-hyoid advancement in 13, uvulopalatoplasty in 13, conventional mandibular advancement in 2, distraction osteogenesis of the mandible in 2, and tongue reduction in 7. A concomitant Wilkes-Brody procedure for drooling was performed in 6 patients. Preoperative and postoperative polysomnographic data were compared by means of a paired t test. The mean preoperative apnea index, respiratory disturbance index, and lowest oxygen saturation were 3.61, 7.02, and 73.7, respectively. Mean postoperative apnea index, respiratory disturbance index, and lowest oxygen saturation were 0.67, 1.44, and 88.2, respectively. Lowest oxygen saturation and respiratory disturbance index were both improved significantly, with p values of 0.0367 and 0.0021, respectively. Fifteen patients are tracheostomy-free (83 percent) at a mean follow-up time of 30 months (range 14 to 49 months.) Two (11 percent) of the children ultimately required tracheostomy, and one (6 percent) died from respiratory failure following the parents' decision not to proceed with further treatment. Our results confirm the efficacy of an aggressive surgical approach to the treatment of obstructive sleep apnea in neurologically compromised children. Many children and their families may potentially avoid the long-term commitment and cumulative hazards of tracheostomy. Additional strategies that have been adopted include identification and aggressive management of seizures, esophageal reflux, and excessive oral secretions and the application of mandibular distraction and skeletal expansion whenever feasible. Close postoperative monitoring is necessary with reoperation for recurrent symptoms of obstructive sleep apnea if documented by sleep study and associated with evidence of recurrent or residual morphologic abnormalities.
This study examined risk factors for sleep-disordered breathing (SDB) in children and adolescents; specifically, quantifying risk associated with obesity, race, and upper and lower respiratory problems. Subjects were participants in a genetic-epidemiologic study of SDB and included 399 children and adolescents 2 to 18 yr of age, recruited as members of families with a member (a proband) with known sleep apnea (31 index families) or as members of neighborhood control families (30 families). SDB was assessed with home overnight multichannel monitoring and SDB was defined based on an apneahypopnea index >/= 10 (moderately affected) or < 5 (unaffected). SDB of moderate level was significantly associated with obesity (odds ratio, 4.59; 95% confidence interval [CI], 1.58 to 13.33) and African-American race (odds ratio, 3.49; 95% CI, 1.56 to 8.32) but not with sex or age. After adjusting for obesity, proband sampling, race and familial clustering, sinus problems and persistent wheeze each independently (of the other) predicted SDB. These data suggest the importance of upper and lower respiratory problems and obesity as risk factors for SDB in children and adolescents. Increased risk in African Americans appears to be independent of the effects of obesity or respiratory problems.
Assessment of the long-term effect of uvulopalatopharyngoplasty (UPPP) on snoring, excessive daytime sleepiness, and nocturnal oxygen desaturation index (ODI) in patients with obstructive sleep apnea syndrome.
Evaluation of snoring, excessive daytime sleepiness, and ODI in patients treated by UPPP earlier.
Patients (n = 58) with a follow-up period of 11 to 74 months (median, 34 mo) were included in this study. Snoring and excessive daytime sleepiness were scored on specially designed semiquantitative scales. In all patients ODI was calculated from pulse-oximetry combined with polysomnography at base line and by polygraphy (MESAM 4) during follow-up in 38 patients. Long-term response was compared with 6-month response in the same cohort.
There was a long-term improvement of snoring in 63% of patients, no change in 23%, and a deterioration in 14% (P < .00001). Overall snoring increased slightly between 6 months and long-term follow-up. There was an improvement of excessive daytime sleepiness in 38%, no change in 27%, and a deterioration in 35% (P = .80). Excessive daytime sleepiness showed a relapse to preoperative levels between 6 months and long-term follow-up. The median improvement of ODI was -1 (95% interpercentile range, 73-51) and was not significant (P = .35). In 5 of 13 patients in whom ODI at baseline exceeded 20, ODI was reduced to less than 20. In 4 of the 38 patients ODI was reduced to less than 5. The improvement of ODI decreased significantly between 6 months and long-term follow-up (P = .03). No relation was found between body mass index, Mueller maneuver, X-cephalometry, and long-term outcome. An additional finding was that the ODI decreased after UPPP in combination with tonsillectomy, compared with a slight increase after UPPP alone; the difference was significant (P = .008).
The response to UPPP for obstructive sleep apnea syndrome decreases progressively over the years after surgery. UPPP in combination with tonsillectomy was more effective than UPPP alone.
Our objective was to determine whether baseline polysomnography, cephalometry, and anthropometry data could predict uvulopalatopharyngoplasty (UPPP) success or failure.
We retrospectively reviewed polysomnography, cephalometry, and anthropometry data from patients who underwent UPPP for obstructive sleep apnea (OSA).
A university medical center.
OSA was diagnosed by polysomnography in 46 patients who underwent UPPP surgery for their sleep disorder.
UPPP surgery with/or without tonsillectomy. Measurements and results: The mean patient age was 43 years, and the mean body mass index was 32.5 kg/m(2). The mean presurgical apnea-hypopnea index (AHI) was 45, and the mean baseline nadir oxygen saturation was 81%. Successful surgery was defined as a reduction in AHI to < 10 or to < 20 with a 50% reduction from the patient's baseline AHI. Of the 46 patients, 16 were successfully treated and 30 did not respond to surgical treatment. A mandibular-hyoid distance (MP-H) > 20 mm was found to be significantly (p = 0.05) predictive of failure of UPPP. When stepwise regression analysis was performed utilizing postsurgical AHI as the dependent variable and presurgical AHI, age, body mass index, baseline nadir O(2) saturation, and five cephalometric measurements as independent variables, MP-H distance significantly (r = 0.524; p = 0.01) correlated positively with postsurgical AHI. The distance between the superior point of a line-constructed plane of the sphenoidale (parallel to Frankfort horizontal) and a point at the intersection of the palatal plane perpendicular to the hyoid correlated negatively with postsurgical AHI (r = 0.586; p = 0.05). By creating a logistic model of this data, an MP-H distance < 21 mm, an angle created by point A to the nasion to point B < 3 degrees, and the presence of a baseline AHI < 38 enhanced the predictability of UPPP success.
The presence of a baseline AHI < 38 and an MP-H < or = 20 mm, and the absence of retrognathia are predictors of improvement after UPPP. Based on these findings, we would advocate the continued evaluation of cephalometric measurements and careful consideration of surgical treatment options for OSA.
To increase both the within- and between-researcher agreement in sleep stage identification and to foster the development of computer algorithms for automatic analyses of sleep, a need for additional definitions was recognized. In 1991, the Subcommittee for Automatic Sleep Staging (SASS) was formed by the JSSR. The Subcommittee comprised 53 investigators and seven project leaders selected for their skill in scoring sleep records: S. Sugita (Chair), M. Okawa (co-Chair), T. Kobayashi, T. Hori, A. Miyasita, S. Shirakawa and Y. Atsumi. In 1995, based on their 5 year discussions, the Subcommittee proposed supplementary definitions and amendments for the Standard Scoring System to the JSSR. These proposals were reported in the JSSR Newsletter (1996; No. 13, February 1, pages 5–13).
During the past two decades, the prevalence of obesity in children has risen greatly worldwide. Obesity in childhood causes a wide range of serious complications, and increases the risk of premature illness and death later in life, raising public-health concerns. Results of research have provided new insights into the physiological basis of bodyweight regulation. However, treatment for childhood obesity remains largely ineffective. In view of its rapid development in genetically stable populations, the childhood obesity epidemic can be primarily attributed to adverse environmental factors for which straightforward, if politically difficult, solutions exist.
To study changes in sleep behavior and quality of life in obese children after adenotonsillectomy for obstructive sleep apnea. Study design and setting Prospective study at the University of New Mexico Children's Hospital.
Children who met inclusion criteria and had a respiratory distress index (RDI) greater than 5 were enrolled in the study and underwent adenotonsillectomy. All children underwent preoperative and postoperative full-night polysomnography. Age- and gender-specific percentile BMI was recorded at the time of polysomnography. Caregivers were asked to complete an OSA-18 quality of life survey prior to polysomnography and a second survey within 6 months of surgery. Scores from preoperative and postoperative polysomnography and OSA-18 surveys were compared using the paired Student's t test.
The study population included 30 children. Twenty-six children (86%) were male. The mean age of the children at the time of inclusion in the study was 9.3 years; range, 3.0 to 17.2. The mean preoperative BMI was 28.6 (range, 19.2 to 47.1) and the mean postoperative BMI was 27.9 (range, 17.8 to 27.9). A 2-tailed paired t test showed that this difference is not statistically significant (P = 0.06). The mean preoperative RDI was 30.0 and the mean postoperative RDI was 11.6 (P < 0.001). The preoperative mean total OSA-18 score was 78.2 and the postoperative mean total score was 39.8 (P < 0.001).
Obese children with OSA who undergo adenotonsillectomy show a marked improvement in RDI and in quality of life with no change in BMI. However, in the majority of children, OSA does not resolve.
Present and evaluate the currently available literature reporting on the effectiveness of adenotonsillectomy (T/A) in treating obstructive sleep apnea/hypopnea syndrome (OSAHS) in uncomplicated pediatric patients.
Systematic review of the literature and meta-analysis of the reduction of the polysomnogram (PSG)-measured Apnea Hypopnea Index (AHI events/hour) resulting from T/A and the overall success rate of T/A in normalizing PSG measurements (%).
Fourteen studies met the inclusion criteria. Mean sample size was 28. All were case series (level 4 evidence). The summary change in AHI was a reduction of 13.92 events per hour (random effects model 95% CI 10.05-17.79, P < 0.001) from T/A. The summary success rate of T/A in normalizing PSG was 82.9% (random effects model 95% CI 76.2%-89.5%, P < 0.001).
T/A is effective in the treatment of OSAHS. However, success rates are far below 100%, which could have far-reaching pediatric public health consequences.
B-2a.
For a subpopulation of children with obstructive sleep apnea, the mainstay of treatment is nasal continuous positive airway pressure (nCPAP). Accurate measures of "time in use" have not been used to assess compliance with nCPAP in large numbers of children. Data from a comprehensive nCPAP program are used to describe nCPAP use among children aged 6 months to 18 years and provide time-in-use compliance rates.
Retrospective cohort study
University Pediatric Teaching Hospital
Initiation of nCPAP treatment
Seventy-nine children were identified as requiring treatment with nCPAP, with 65 (82%) successfully established on nCPAP during the 46-month study period. Objective compliance data were available on 50 children: 66% were boys, 78% had a complicating medical disorder, the mean age was 10 +/- 5.1 years, and the median apnea-hypopnea index was 11.3 (interquartile range, 5.4-25.9). Follow-up ranged from 8 to 979 days. Forty-eight percent of children used nCPAP immediately. Seventy-six percent of children used nCPAP for at least half the days, with use defined as 1 or more hours of recording during a 24-hour period. Mean daily use was 4.7 hours (interquartile range, 1.4-7.0), and mean daily use on days nCPAP was used was 6.3 hours (interquartile range, 3.3-8.5)
With patience, a behavioral modification approach, and parental commitment, children will be accepting of nCPAP and reasonably compliant with treatment.
To evaluate the impact of obesity at diagnosis on treatment outcomes in paediatric obstructive sleep apnea (OSA).
Children were included if they had both diagnostic and follow-up studies for OSA. Anthropological and polysomnographic data were collected at the time of both studies. Polysomnograms were scored using standard criteria and OSA was defined as a respiratory disturbance index (RDI) >or=5. Obesity was defined as a body mass index standard deviation (z-)score (BMIsds) greater than 2, adjusted for age and gender.
For 69 children (49 males), mean age was 7.1+/-4.2 years and 29 (42%) children were obese. There was no significant difference in RDI between obese and non-obese children at diagnostic study. Following adenotonsillectomy the obese children had a significantly higher mean RDI (10.7+/-15.6 versus 3.7+/-4.3; p=0.01). Disease resolution occurred in 77.5% of non-obese compared to 45% of obese children (p=0.011). The odds ratio (OR) for persistent OSA in obese compared to non-obese children was 4.2 (95% CI: 1.5-11.9; p=0.005). Using initial RDI as a covariate, these data show that obesity in children has an adjusted OR for persistent OSA after adenotonsillectomy 3.7 (95% CI: 1.3-10.8, p=0.016).
For children, obesity at the time of diagnosis is a major risk for persisting OSA after treatment, regardless of the severity of initial disease.
To assess the efficacy of adenotonsillar surgery on respiratory sleep parameters and avoiding continuous positive airway pressure (CPAP) treatment in morbidly obese children with obstructive sleep apnea syndrome (OSAS).
Retrospective.
Tertiary referral institution.
Children aged 2 to 18 years, with a body mass index (BMI) at or higher than the 95th percentile (adjusted for age and sex), undergoing adenotonsillar surgery for OSAS.
Adenotonsillectomy.
Preoperative and postoperative respiratory disturbance index, oxygen saturation nadir, overall severity of OSAS (mild, moderate, or severe) and candidacy for CPAP treatment were assessed and compared. Variables such as age, severity of disease, adenotonsillar size, and BMI z scores were compared between responders and nonresponders to surgical treatment.
A total of 19 patients with full preoperative and postoperative data for evaluation were identified. The median (SD) age was 78 months (53.3 months). The median (SD) BMI z score was 2.84 (0.94). Eighteen patients (95%) had OSAS preoperatively to warrant CPAP treatment. Surgery reduced the overall median (SD) respiratory disturbance index from 20.7 (24.5) to 7.3 (14.9) (P<.001) and improved the median (SD) oxygen saturation nadir from 77.5% (16.3%) to 88.5 (13.1%) (P<.01). A total of 7 patients (37%) were cured by surgery. Ten patients (53%) had postoperative disease of sufficient severity to require CPAP. Surgery obviated the need for further treatment in only 8 (44%) of the 18 patients with preoperative disease warranting CPAP. No differences were identified between responders and nonresponders to surgical treatment.
Adenotonsillar surgery improves sleep respiratory parameters in morbidly obese children with OSAS. Most patients have residual OSAS requiring further treatment.
The purpose of this review is to discuss the nature of adherence to continuous positive airway pressure (CPAP), identify measurement modalities, consider factors that have been identified in the literature associated with nonadherence and present interventions that may promote use.
Patient characteristics associated with CPAP adherence include self-reported daytime sleepiness, level of disease severity, nasal resistance and perception of symptomatic benefit. Heated humidification and flexible pressure also promote use. Feelings of claustrophobia affect adherence in a small proportion of patients. Adherence was better with nasal mask than nasal pillows and full face mask and equal to oral interface. Patients who employed an active coping style and those with perceived self-efficacy, especially following exposure to treatment, had higher levels of adherence. A videotape targeted to improve self-efficacy and other interventions to enhance cognitions related to CPAP has generated greater use. Intensive support utilizing several days of titration, education and home visits also improves adherence.
Adherence to CPAP treatment is an important clinical issue that needs to be routinely assessed and addressed. Frequent patient contact to troubleshoot problems will contribute to adherence. Further study is needed to identify factors that affect adherence and cost-effective interventions.
To investigate the relative contribution of various risk factors to the surgical outcome of adenotonsillectomy for obstructive sleep apnea syndrome in children.
Children (n = 110; mean age, 6.4 +/- 3.9 years) underwent two polysomnographic evaluations before and after adenotonsillectomy. In addition, 22 control children were studied. History for allergy and family history of sleep-disordered breathing was taken before each polysomnographic evaluation.
Significant changes in sleep stage percentages and sleep fragmentation were found in the postsurgery study compared with the presurgery study; 25% of the children had apnea/hypopnea index (AHI) </=1, 46% had AHI >1 and <5, and 29% had AHI >/=5 in the postsurgery study. The frequency of subjects with AHI </=1 after surgery was significantly lower among obese subjects (P < .05). Comparison between the children who had AHI </=1 after surgery and 22 control children showed complete normalization of sleep architecture after surgery.
Adenotonsillectomy yields improvements in respiratory abnormalities in children with obstructive sleep apnea syndrome. Complete normalization occurs in only 25% of the patients. Obesity and AHI at diagnosis are the major determinant for surgical outcome. When normalization of respiratory measures occurs after surgery, normalization of sleep architecture will also ensue.
1) To evaluate the relative severity of obstructive sleep apnea (OSA) in obese and normal-weight children; 2) to compare changes in respiratory parameters after adenotonsillectomy in obese and normal-weight children.
Prospective controlled trial that included children aged 3 to 18 years. All study participants underwent pre- and postoperative polysomnography.
The study population included 33 obese children and 39 normal-weight controls. Preoperatively, the median obstructive apnea-hypopnea index (AHI) was 23.4 (range 3.7-135.1) for obese and 17.1 (range 3.9-36.5) for controls (P < 0.001). Postoperatively, the AHI was 3.1 (range 0-33.1) for obese and 1.9 (range 0.1-7.0) for controls (P < 0.01). Twenty-five obese children (76%) and 11 controls (28%) had persistent OSA.
AHI scores are higher in obese than in normal-weight children with OSA. Both groups show a dramatic improvement in AHI after adenotonsillectomy, but persistent OSA is more common in obese children.
To evaluate the outcome of adenotonsillectomy for obstructive sleep apnea (OSA) in children using objective data from polysomnography supplemented by subjective proxy reports from the OSA-18 quality of life instrument.
Prospective cohort study.
Children 3 to 14 years of age with OSA diagnosed principally on the basis of polysomnography as having an obstructive apnea/hypopnea index (AHI) of 5 or greater underwent adenotonsillectomy. OSA was classified as mild (AHI > or = 5 < 10), moderate (AHI > or = 10 < 20), or severe (AHI > or =20). Children enrolled in the study also had postoperative polysomnography 3 to 6 months after surgery. Caregivers completed the OSA-18 survey before surgery and within 6 months after surgery. Pearson correlation was used to compare the pre- and postoperative AHI values with the pre- and postoperative OSA-18 total scores. SAS procedures (SAS Corp., Cary, NC) were used for statistical analyses. A P value less than or equal to .05 was considered significant.
The study population included 79 healthy children, 40 of who were male. The mean age was 6.3 (range, 3.0-14.0) years. Only tonsillar size was correlated significantly with a high preoperative AHI. For all children, the preoperative AHI value was higher than the postoperative value. The mean preoperative AHI for the study population was 27.5, whereas the mean postoperative AHI was 3.5. This change was highly significant (P < .001). The percentage of children with normal polysomnography parameters after adenotonsillectomy ranged from 71% to 90% as a function of the criteria used to define OSA. It was highest when an obstructive apnea index less than 1 was used and lowest when an AHI less than 1 was used to define resolution of OSA. Overnight respiratory parameters after adenotonsillectomy were normal for all children with mild OSA. Three (12%) children with moderate preoperative OSA, and 13 (36%) children with severe preoperative OSA had persistent OSA after adenotonsillectomy. Resolution of OSA occurred in all children with a preoperative AHI less than or equal to 10 and in 73% of children with a preoperative AHI greater than 10. The mean total OSA-18 score and the mean scores for all domains showed significant improvement after surgery (P < .001). The preoperative AHI values had a fair correlation with the preoperative total OSA-18 scores (r = 0.28), but postoperative AHI values had a poor correlation with the postoperative total OSA-18 scores (r = 0.16). Caregivers reported snoring some, most, or all of the time in 22 (28%) children; this group included all children with persistent OSA.
Adenotonsillectomy for OSA results in a dramatic improvement in respiratory parameters as measured by polysomnography in the majority of healthy children. Quality of life also improves significantly after adenotonsillectomy for OSA in children. However, the correlation between improvements in respiratory parameters and improvements in quality of life is poor. Severe preoperative OSA is associated with persistence of OSA after adenotonsillectomy. Postoperative reports of symptoms such as snoring and witnessed apneas correlate well with persistence of OSA after adenotonsillectomy.
This review examines in detail progress made regarding our understanding of the presence and pathophysiology of cognitive and behavioral morbidities among children with sleep disorders in general. Particular focus is given to pediatric obstructive sleep apnea.
In recent years, increased awareness of the morbid consequences of respiratory sleep disturbances in children has emerged. Evidence suggesting a causal association of intermittent hypoxia and sleep fragmentation with alterations in memory, attention, and intelligence has accumulated. Research has also identified a link between sleep disorders, and problematic and hyperactive behaviors and mood disturbances. Furthermore, there is considerable inter-individual variability in the presence and magnitude of neurobehavioral morbidity at any given level of disease severity. This further suggests that, in addition to the disease per se, both genetic (individual susceptibility) and environmental modifiers play a role in determining morbidity.
A more individually tailored approach to detecting morbidity associated with sleep disorders in children, employing biomarkers and gene-related single nucleotide polymorphisms, may ultimately be required to allow more rational prioritization of treatment.
Although many children with obstructive sleep apnea syndrome have complete resolution of obstructive sleep apnea syndrome after adenotonsillectomy, some patients have persistent obstructive sleep apnea syndrome requiring positive airway pressure treatment. Little is known about positive airway pressure adherence among school-aged children and adolescents.
We retrospectively reviewed records from January 2000 through December 2004 to assess positive airway pressure adherence following a comprehensive patient- and parent-focused positive airway pressure education program for children 7 to 19 years of age with persistent obstructive sleep apnea syndrome subsequent to indicated adenotonsillectomy. A polysomnogram was obtained before and after initiation of positive airway pressure therapy. Adherence was defined as > 4 hours per night and > or = 5 nights per week of positive airway pressure use. Clock-counter meters determined hours per night and nights per week of positive airway pressure use; parents estimated hours per night of positive airway pressure use. Nonparametric tests assessed associations between adherence and various clinical parameters and symptoms.
Forty-six patients (56% male; 39% black, 61% white; mean age: 13.6 years; mean BMI: 39.8 kg/m2) were included. Two refused positive airway pressure. Meter readings were available for 27 patients (59%); positive airway pressure was used, on average, 7.0 hours per night, 73% of the week, and for a mean of 18.1 months. Nineteen (70%) were adherent regardless of age. There was good agreement between parental report and meter readings. Patients with greater improvement in apnea-hypopnea index were more likely to be adherent. Clinical parameters and symptoms improved after positive airway pressure therapy regardless of age or adherence.
In this retrospective study, positive airway pressure adherence and symptom improvement among school-aged children and adolescents was achieved with comprehensive patient and parent education and follow-up.