Improvement in Central Sleep Apnea Following Adenotonsillectomy in Children

The effect of central sleep apnea on sleep architecture in children with obstructive sleep apnea

OBJECTIVE

This study aimed to investigate how central sleep apnea (CSA) impacts sleep patterns in children with obstructive sleep apnea (OSA).

METHODS

Children undergoing polysomnography (PSG) were enrolled and sorted into two groups: those with OSA alone (Group A) and those with both OSA and CSA (CAI <1 nd: children with 10 % CSA or more and less than 50 %, Group B). Statistical analysis was conducted to compare sleep structure and clinical features between Group A and Group B.

RESULTS

Group B exhibited significantly higher respiratory events, apnea hypoventilation index, apnea index and oxygen desaturation index (ODI) compared to Group A (p < 0.05). Group B also showed higher total sleep time and arousal index than Group A (P < 0.05). The proportion of time spent in stage N3 was lower in Group B than in Group A (P < 0.05). Moreover, mean heart rate and minimum heart rate were higher in Group B compared to Group A (P < 0.05).Minimum oxygenation levels (including non-rapid eye movement (NREM) stages) were lowe in Group B than in Group A (P < 0.05). Additionally, the prevalence of positional obstructive sleep apnea (P-OSA) was greater in Group B than in Group A (P < 0.05).

CONCLUSION

In comparison to those with OSA alone, children with OSA and concurrent CSA exhibited distinct sleep patterns, including reduced N3uration, higher arousal index, longer respiratory events, higher ODI, and lower oxygen saturation, higher heart rate.

Central and mixed apneas in children with obstructive sleep apnea: effect of adenotonsillectomy

PURPOSE

Investigate the effect of adenotonsillectomy on mixed apnea index (MAI) and central apnea index (CAI) in children with moderate-to-severe obstructive sleep apnea syndrome (OSAS).

METHODS

Observational retrospective analysis of polysomnographic data in children diagnosed with moderate-to-severe OSAS and without comorbidity, submitted to adenotonsillectomy.

RESULTS

Data were available for 80 children, 55 boys and 25 girls, with a median age of 3.6 years (2.1-5.9). Before surgery AHI was 14.1 (11.0-18.4) per hour, with a median preoperative OAI of 7.1 (4.1-10.6), MAI of 1.2 (0.6-1.6) and CAI of 1.0 (0.4-2.0). Adenotonsillectomy caused significant improvements in MAI, from 1.2 (0.6-1.6) to 0.5 (0.1-0.8) (p < 0.001) and CAI from 1.0 (0.4-2.0) to 0.5 (0.1-0.9) (p < 0.001). This represents a normalization of MAI in 91.7% and CAI in 75.6% of children that had an abnormal value prior surgery.

CONCLUSION

Non obstructive apneas are common in children with OSAS. Adenotonsillectomy caused significant decrease not only in OAI, but also in MAI and CAI in children with moderate-to-severe OSAS.

Effect of adenotonsillectomy on central sleep apnea: A scoping review

OBJECTIVE

The purpose of this study was to assess the effects of adenotonsillectomy (A&T) on reducing central sleep apnea (CSA) in children and adolescents with obstructive sleep apnea (OSA).

METHODS

A review of the PubMed database was conducted. Two researchers independently reviewed the articles from the literature search and selected papers for further review if they met inclusion criteria. Included studies were prospective studies and case series whose patients were children 18 years or younger undergoing adenotonsillectomy for obstructive sleep apnea with reported pre and postoperative central apnea indexes (CAI).

RESULTS

Of the 107 articles initially identified, 18 underwent full length review, and ultimately 15 for final review. All studies reported marked improvement of central sleep apnea indexes after adenotonsillectomy. Two studies found resolution of CSA in 66.7 % and 73.7 % of patients respectively. The remaining four studies found significant reductions in CAI in 43.9 %-93 % of patients. The degree of reduction varied from 40.9 % to 80 %.

DISCUSSION

Adenotonsillectomy improves and at times resolves CSA in pediatric patients with concomitant OSA.

An update on diagnosis and management of obstructive sleep apnoea in the first 2 years of life

The aim of this review is to summarise evidence that became available after publication of the 2017 European Respiratory Society statement on the diagnosis and management of obstructive sleep apnoea syndrome (OSAS) in 1- to 23-month-old children. The definition of OSAS in the first 2 years of life should probably differ from that applied in children older than 2 years. An obstructive apnoea-hypopnoea index >5 events·h-1 may be normal in neonates, as obstructive and central sleep apnoeas decline in frequency during infancy in otherwise healthy children and those with symptoms of upper airway obstruction. A combination of dynamic and fixed upper airway obstruction is commonly observed in this age group, and drug-induced sleep endoscopy may be useful in selecting the most appropriate surgical intervention. Adenotonsillectomy can improve nocturnal breathing in infants and young toddlers with OSAS, and isolated adenoidectomy can be efficacious particularly in children under 12 months of age. Laryngomalacia is a common cause of OSAS in young children and supraglottoplasty can provide improvement in children with moderate-to-severe upper airway obstruction. Children who are not candidates for surgery or have persistent OSAS post-operatively can be treated with positive airway pressure (PAP). High-flow nasal cannula may be offered to young children with persistent OSAS following surgery, as a bridge until definitive therapy or if they are PAP intolerant. In conclusion, management of OSAS in the first 2 years of life is unique and requires consideration of comorbidities and clinical presentation along with PSG results for treatment decisions, and a multidisciplinary approach to treatment with medical and otolaryngology teams.

Is adenotonsillectomy effective in improving central apnea events in patients with obstructive sleep apnea? A systematic review and meta-analysis

PURPOSE

To evaluate the effects of adenotonsillectomy on improving central sleep apnea events in children with obstructive sleep apnea (OSA).

METHODS

We searched four online databases for relevant articles published from inception until October 2022. We included studies that measured the number of central apnea events per sleep and central apnea-hypopnea index (CAHI) or central apnea index (CAI) scores in children with OSA before and after adenotonsillectomy. Our primary outcomes were changes in CAI scores, the number of central apnea events per sleep, and CAHI scores after surgery. Our secondary outcomes were changes in total and mixed apnea events, improvement of sleep outcomes, and differences in oxygen or carbon dioxide saturation during sleep. We performed meta-analyses by pooling the mean changes of all included studies with a 95% confidence interval using Stata 17. Subsequently, we performed subgroup analyses based on the presence of comorbidities.

RESULTS

We included 22 studies comprising 1287 patients. Central and total sleep apnea parameters, except for CAHI and mixed apnea index scores, showed significant improvements after surgery. In addition, all respiratory parameters and second and third stages of non-rapid eye movement sleep showed significant postsurgical improvements. Patients with comorbidities showed significant improvements only in the total apnea-hypopnea index, oxygen desaturation index, and minimal oxygen saturation.

CONCLUSION

Adenotonsillectomy improves central apnea events in patients with OSA but not in those with comorbidities.

An Assessment of the Relationship Between BMI and Children Undergoing Surgical Procedures: A Retrospective Study

Background: While multiple studies have documented that obesity increases the risk of operative complications among adults, little data exist on how obesity impacts surgical outcomes among children. We aimed to determine if children with obesity have different postoperative outcomes than their peers. Methods: A retrospective chart review was conducted of 875 patients aged between 2 and 18 years who underwent surgery during 2018. Patients were stratified, based on BMI percentile for age, as having less than healthy weight (<5th percentile), healthy weight (5th-84th percentile), excess weight (85th-94th percentile), or obesity (≥95th percentile). Demographic information and data on medical comorbidities and postoperative complications were collected. All analyses were conducted using chi-square or Kruskal-Wallis testing. Results: Eighty-two patients were excluded due to lack of BMI data and 56 were excluded as they had below healthy weight. Of the remaining 737 patients, 475 (64.4%) had healthy weight, 124 (16.8%) had excess weight, and 138 (18.70%) had obesity. Children with obesity had more tonsillectomy/adenoidectomy (p < 0.01) and vascular access (p = 0.04) procedures compared with peers. Additionally, patients with obesity were more likely to have a pre-existing history of liver disease (p < 0.01) and more frequently developed postoperative wound dehiscence (p < 0.01). No other complications occurred more frequently among children with obesity. Conclusions: Children with obesity required more tonsillectomy/adenoidectomy and vascular access procedures. Wound dehiscence was the only complication that was associated with obesity. This suggests that children with obesity are not inherently more prone to experience surgical complications and therefore elective procedures should likely not be deferred until preoperative weight loss is achieved.

Adenotonsillectomy: the good, the bad and the unknown

PURPOSE OF REVIEW

Adenotonsillar hypertrophy is the most common pathogenetic contributor to obstructive sleep apnea syndrome (OSAS) in childhood, and adenotonsillectomy is the standard initial treatment. Here, we summarize the most recent evidence on the efficacy and complications of adenotonsillectomy and explore knowledge gaps in clinical management.

RECENT FINDINGS

Favorable adenotonsillectomy effects have been reported in children with very severe OSAS [apnea-hypopnea index (AHI) >20 episodes/h] and extremely severe OSAS (AHI >100 episodes/h), without postoperative mortality, need for endotracheal intubation, prolonged hospital stay or re-admission after hospital discharge. However, the risk of residual OSAS after adenotonsillectomy, which may reach 30-60%, has not been thoroughly established. Behavior, OSAS-related symptoms and quality of life improve postoperatively even in children with AHI 1-5 episodes/h. Natural history of enuresis resolution is accelerated postadenotonsillectomy and office-based systemic blood pressure is decreased in OSAS and hypertension. However, which children younger than 2 years should undergo adenotonsillectomy instead of adenoidectomy only to prevent recurrence of OSAS symptoms and revision surgery remains unclear. Adenotonsillectomy in children with Prader-Willi syndrome is frequently accompanied by postoperative residual OSAS while complications are not uncommon.

SUMMARY

In the last 2 years, several studies have provided evidence supporting the efficacy and safety of adenotonsillectomy as treatment intervention for otherwise healthy children with OSAS.

Assessment of Central Sleep Apnea Events in Children with Sleep-Disordered Breathing

Purpose

To determine the prevalence of central apnea (CA) events and central sleep apnea (CSA) in children with sleep-disordered breathing (SDB) and to assess the effect of tonsillectomy and adenoidectomy (TA) on CSA in children with obstructive sleep apnea (OSA). Material and Methods. The medical charts of children with SDB were reviewed to obtain information on past medical history, polysomnography (PSG) findings, and surgical management. Counts and indexes of obstructive apnea, obstructive hypopnea, and central apnea were evaluated before and after TA. The prevalence of CSA and the effect of age, gender, obesity, and comorbid conditions on CSA were assessed in children with SDB as well as in children with PSG proven OSA.

Results

Seven hundred twelve children with SDB (age range: 1 to 18 yrs, mean: 5.8 ± 3.4) were identified. CA events occurred in 640 of 712 (89.5%) patients. Of the 712 patients, 315 (44.2%) met the criteria for the diagnosis of CSA. CSA was more prevalent in toddlers and preschoolers (p < 0.001). Obese children had a higher prevalence of CSA compared to nonobese children (p < 0.001). The prevalence of CSA in patients with OSA was 45.4%. The number of CA events, CAI, and OAHI after TA was less than that of before TA (p < 0.001). Residual CSA after TA occurred in 20 children (26%).

Conclusion

Central apnea events and central sleep apnea occur in children who present to a pediatric otolaryngology clinic for evaluation of sleep disordered breathing. Central sleep apnea and obstructive sleep apnea both improve after tonsillectomy and adenoidectomy.