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Riha RL, Singh A, Hill EA, Evans H, O'Regan D. Sleep-disordered breathing in children and adults with intellectual disability: mind the gap! Thorax 2024:thorax-2023-220032. [PMID: 38937106 DOI: 10.1136/thorax-2023-220032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 05/08/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND In adults and children with intellectual disability (ID), sleep -disordered breathing (SDB) is thought to be common. However, large epidemiological studies are lacking, and there are few studies on optimal methods of investigation and even fewer randomised, controlled intervention trials of treatment. METHOD Peer-reviewed publications from various databases were examined in line with search terms relevant to ID and SDB spanning the years 200-2024. RESULTS Findings suggest that, due to comorbid conditions, children and adults with ID may experience both an increased risk of SDB, as well as lower frequency of diagnosis. SDB can compromise the emotional, physical and mental health of individuals with ID. Appropriate treatment when tolerated leads to an improvement in health and well-being and several studies emphasized the importance of consistent follow-up of people with ID - something that is not universally occurring during childhood, in the transition to adulthood and during adulthood itself. As the most frequently occurring form of ID worldwide, we use Down syndrome as a specific example of how diagnosing and treating SDB can lead to improved outcomes. CONCLUSIONS This review highlights the importance of identifying SDB in this heterogenous population, recognising the multi-faceted, deleterious consequences of untreated SDB in people with ID, and presents some strategies that can be harnessed to improve diagnosis and management. Until further ID-specific research is available, we urge flexibility in the approach to people with ID and SDB based in guidelines and standard practice developed for the typically developing population.
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Affiliation(s)
- Renata L Riha
- Department of Sleep Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Ankur Singh
- Department of Sleep Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Elizabeth A Hill
- School of Applied Sciences, College of Health, Science and Society, University of the West of England, Bristol, UK
| | - Hazel Evans
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - David O'Regan
- Sleep Disorders Centre, Guy's and St Thomas' Hospital NHS Foundation Trust; Faculty of Life and Sciences Medicine, King's College London, London, UK
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Fauroux B, Cozzo M, MacLean J, Fitzgerald DA. OSA type-III and neurocognitive function. Paediatr Respir Rev 2024:S1526-0542(24)00053-8. [PMID: 38908984 DOI: 10.1016/j.prrv.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 06/04/2024] [Indexed: 06/24/2024]
Abstract
Obstructive sleep apnea (OSA) due to a hypertrophy of the adenoids and/or the tonsils in otherwise healthy children is associated with neurocognitive dysfunction and behavioural disorders with various degrees of hyperactivity, aggressiveness, sometimes evolving to a label of attention-deficit hyperactivity disorder. Children with anatomical and/or functional abnormalities of the upper airways represent a very specific population which is at high risk of OSA (also called complex OSA or OSA type III). Surprisingly, the neurocognitive consequences of OSA have been poorly studied in these children, despite the fact that OSA is more common and more severe than in their healthy counterparts. This may be explained by that fact that screening for OSA and sleep-disordered breathing is not systematically performed, the performance of sleep studies and neurocognitive tests may be challenging, and the respective role of the underlining disease, OSA, but also poor sleep quality, is complex. However, the few studies that have been performed in these children, and mainly children with Down syndrome, tend to show that OSA, but even more disruption of sleep architecture and poor sleep quality, aggravate the neurocognitive impairment and abnormal behaviour in these patients, underlining the need for a systematic and early in life assessment of sleep and neurocognitive function and behaviour in children with OSA type III.
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Affiliation(s)
- Brigitte Fauroux
- Pediatric Noninvasive Ventilation And Sleep Unit, AP-HP, Hôpital Necker Enfants Malades, Paris, France; EA 7330 VIFASOM (Vigilance Fatigue Sommeil et Santé Publique), Paris University, Paris, France.
| | - Mathilde Cozzo
- Pediatric Noninvasive Ventilation And Sleep Unit, AP-HP, Hôpital Necker Enfants Malades, Paris, France
| | - Joanna MacLean
- Divisions of Respiratory Medicine, Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
| | - Dominic A Fitzgerald
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, New South Wales, Australia
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Wasserman I, Chieffe DJ, Gipson KS, Skotko BG, Hartnick CJ. Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea in a Young Child With Down Syndrome. Pediatrics 2024; 153:e2023063330. [PMID: 38602032 DOI: 10.1542/peds.2023-063330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2024] [Indexed: 04/12/2024] Open
Abstract
Obstructive sleep apnea (OSA) is common in children with Down syndrome (DS). Adenoidectomy and/or tonsillectomy are the usual first interventions employed to treat OSA in children with DS but sometimes do not achieve adequate resolution of clinical signs. Positive airway pressure treatment is often used next, but this treatment is poorly tolerated by this population. Persistent OSA can adversely affect a child's health and cognitive development. Hypoglossal nerve stimulation (HGNS), previously shown to be safe and effective in adults with OSA, has been used in children as young as 10 years old with DS and has achieved measurable neurocognitive benefits. The US Food and Drug Administration recently lowered the age for HGNS implantation to 13 years for children with DS. However, questions remain regarding treatment of refractory OSA in younger children. Here, we report the case of a 4-year-old boy with DS and treatment-refractory OSA who underwent successful HGNS implantation. The decision to proceed with HGNS implantation in such a young child involved discussions about anatomic feasibility and potential neurocognitive benefits. The device was implanted without complication and with minimal postoperative bulk. This case suggests a possible treatment option that can be discussed in the course of shared decision-making between clinicians and families of young children with DS and treatment-refractory OSA.
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Affiliation(s)
- Isaac Wasserman
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts
| | - Douglas J Chieffe
- Department of Otolaryngology, Massachusetts Eye and Ear, Boston, Massachusetts
| | - Kevin S Gipson
- Department of Pediatric Pulmonary Medicine, Massachusetts General Hospital for Children, Boston, Massachusetts
- Division of Sleep Medicine
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Brian G Skotko
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Down Syndrome Program, Division of Medical Genetics and Metabolism, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
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Rodriguez Lara F, Carnino JM, Cohen MB, Levi JR. Advances in the Use of Hypoglossal Nerve Stimulator in Adolescents With Down Syndrome and Persistent Obstructive Sleep Apnea-A Systematic Review. Ann Otol Rhinol Laryngol 2024; 133:317-324. [PMID: 38062678 DOI: 10.1177/00034894231216287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
INTRODUCTION The Hypoglossal Nerve Stimulator (HNS) is a novel therapy that has been extensively studied in adults and more recently, it has been incorporated in children with Down Syndrome (DS) with persistent obstructive sleep apnea after adenotonsillectomy and trial of continuous positive airway pressure treatment. This systematic review article aims to examine the existing literature on HNS use in children to explore the benefits, efficacy, and parental experiences. METHODS MEDLINE, Web of Science and EMBASE were searched to include all studies published up to March 2nd, 2023, on the topic of HNS use in pediatric population under 21 years old. RESULTS A total of 179 studies were initially identified from which 10 articles were consistent with the inclusion criteria. Nine articles addressed outcomes after implantation of the HNS device in children with DS and 1 article explored the parental experiences. Findings were similar across studies where after implantation of HNS, there was marked improvement in polysomnographic outcomes and quality of life scores with high level of compliance. CONCLUSIONS HNS holds promise as an effective treatment option for pediatric patients with DS and persistent OSA after AT and CPAP trials. It significantly improves sleep-disordered breathing, quality of life, and neurocognitive measures, leading to substantial and sustained benefits for these children. While the findings are encouraging, further research is needed to explore the potential of HNS in other pediatric populations without DS and to raise awareness among healthcare providers about this treatment option. Overall, HNS may offer significant long-term benefits for the overall well-being and health of pediatric patients with DS and persistent OSA.
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Affiliation(s)
| | - Jonathan M Carnino
- Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Michael B Cohen
- Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Jessica R Levi
- Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
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Crowson MG, Gipson KS, Katz Kadosh O, Hartnick E, Grealish E, Keamy DG, Kinane TB, Hartnick CJ. Paediatric sleep apnea event prediction using nasal air pressure and machine learning. J Sleep Res 2023; 32:e13851. [PMID: 36807952 PMCID: PMC10363180 DOI: 10.1111/jsr.13851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 02/23/2023]
Abstract
Sleep-disordered breathing is an important health issue for children. The objective of this study was to develop a machine learning classifier model for the identification of sleep apnea events taken exclusively from nasal air pressure measurements acquired during overnight polysomnography for paediatric patients. A secondary objective of this study was to differentiate site of obstruction exclusively from hypopnea event data using the model. Computer vision classifiers were developed via transfer learning to either normal breathing while asleep, obstructive hypopnea, obstructive apnea or central apnea. A separate model was trained to identify site of obstruction as either adeno-tonsillar or tongue base. In addition, a survey of board-certified and board-eligible sleep physicians was completed to compare clinician versus model classification performance of sleep events, and indicated very good performance of our model relative to human raters. The nasal air pressure sample database available for modelling comprised 417 normal, 266 obstructive hypopnea, 122 obstructive apnea and 131 central apnea events derived from 28 paediatric patients. The four-way classifier achieved a mean prediction accuracy of 70.0% (95% confidence interval [67.1-72.9]). Clinician raters correctly identified sleep events from nasal air pressure tracings 53.8% of the time, whereas the local model was 77.5% accurate. The site of obstruction classifier achieved a mean prediction accuracy of 75.0% (95% confidence interval [68.7-81.3]). Machine learning applied to nasal air pressure tracings is feasible and may exceed the diagnostic performance of expert clinicians. Nasal air pressure tracings of obstructive hypopneas may "encode" information regarding the site of obstruction, which may only be discernable by machine learning.
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Affiliation(s)
- Matthew G. Crowson
- Department of Otolaryngology-Head & Neck Surgery, Mass Eye & Ear, Boston, Massachusetts
- Department of Otolaryngology-Head & Neck Surgery, Harvard Medical School, Boston, Massachusetts
| | - Kevin S. Gipson
- Department of Pediatric Pulmonary Medicine, MassGeneral Hospital for Children, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Orna Katz Kadosh
- Department of Otolaryngology-Head & Neck Surgery, Mass Eye & Ear, Boston, Massachusetts
- Department of Otolaryngology-Head & Neck Surgery, Harvard Medical School, Boston, Massachusetts
| | | | | | - Donald G. Keamy
- Department of Otolaryngology-Head & Neck Surgery, Mass Eye & Ear, Boston, Massachusetts
- Department of Otolaryngology-Head & Neck Surgery, Harvard Medical School, Boston, Massachusetts
| | - Thomas Bernard Kinane
- Department of Pediatric Pulmonary Medicine, MassGeneral Hospital for Children, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Christopher J. Hartnick
- Department of Otolaryngology-Head & Neck Surgery, Mass Eye & Ear, Boston, Massachusetts
- Department of Otolaryngology-Head & Neck Surgery, Harvard Medical School, Boston, Massachusetts
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Liu P, Kong W, Fang C, Zhu K, Dai X, Meng X. Hypoglossal nerve stimulation in adolescents with down syndrome and obstructive sleep apnea: A systematic review and meta-analysis. Front Neurol 2022; 13:1037926. [PMID: 36388229 PMCID: PMC9640576 DOI: 10.3389/fneur.2022.1037926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 10/11/2022] [Indexed: 11/25/2022] Open
Abstract
Objective To evaluate the efficacy and adverse effects of hypoglossal nerve stimulation in adolescents with down syndrome and obstructive sleep apnea. Methods A systematic search was conducted using PubMed, Web of Science, Embase, and Scopus databases. The systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive search strategy used a combination of Medical Subject Headings and free words with “OR” and “AND.” Articles were screened to extract data reporting apnea-hypopnea index, quality of life, voltage, follow-up duration, and complications. All included participants were adolescents with down syndrome and obstructive sleep apnea. Results A total of 92 articles were identified, of which 9 articles met the inclusion criteria. A total of 106 patients were included. All the studies showed that patients receiving hypoglossal nerve stimulation experienced a significant decrease in apnea-hypopnea index (at least 50%). The pooled AHI was significantly lower in patients following treatment (mean AHI reduction 17.43 events/h, 95% confidence interval 13.98–20.88 events/h, P < 0.001) after 2 case reports were excluded. The pooled OSA-18 were significantly decreased in 88 patients after treatment (mean OSA-18 reduction 1.67, 95% confidence interval 1.27–2.08, P < 0.001) after excluding 5 studies. Four investigations examined the necessity to optimize stimulation voltage for arousal during treatment. The most common complication was pain or discomfort in the tongue or mouth. Most studies had relatively short patient follow-up periods, with the most extended follow-up being 44–58 months. Conclusion Hypoglossal nerve stimulation significantly reduces apnea-hypopnea index and improves the quality of life; and thus, could be a potential alternative therapy for obstructive sleep apnea in adolescents with down syndrome. The adolescent's age, potential complications, adverse events, long-term efficacy, and comfort, needs to be considered while performing hypoglossal nerve stimulation.
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Affiliation(s)
- Pan Liu
- Department of Emergency or ICU, Anhui Provincial Hospital of Integrated Traditional and Western Medicine, Hefei, China
| | - Weiguo Kong
- Graduate School of Anhui University of Traditional Chinese Medicine, Hefei, China
| | - Caijing Fang
- Graduate School of Anhui University of Traditional Chinese Medicine, Hefei, China
| | - Kangxu Zhu
- Department of Otolaryngology, Wuxi Huishan District People's Hospital, Wuxi, China
| | - Xiaohua Dai
- Branch Center of the National Clinical Research Center for Cardiovascular Disease, The First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Cardiovascular Institute of Anhui Academy of Chinese Medicine, Hefei, China
- *Correspondence: Xiangming Meng
| | - Xiangming Meng
- Department of Otolaryngology, Wuxi Huishan District People's Hospital, Wuxi, China
- Xiaohua Dai
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Garde AJ, Gibson NA, Samuels MP, Evans HJ. Recent advances in paediatric sleep disordered breathing. Breathe (Sheff) 2022; 18:220151. [PMID: 36340818 PMCID: PMC9584598 DOI: 10.1183/20734735.0151-2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/02/2022] [Indexed: 11/06/2022] Open
Abstract
This article reviews the latest evidence pertaining to childhood sleep disordered breathing (SDB), which is associated with negative neurobehavioural, cardiovascular and growth outcomes. Polysomnography is the accepted gold standard for diagnosing SDB but is expensive and limited to specialist centres. Simpler tests such as cardiorespiratory polygraphy and pulse oximetry are probably sufficient for diagnosing obstructive sleep apnoea (OSA) in typically developing children, and new data-processing techniques may improve their accuracy. Adenotonsillectomy is the first-line treatment for OSA, with recent evidence showing that intracapsular tonsillectomy results in lower rates of adverse events than traditional techniques. Anti-inflammatory medication and positive airway pressure respiratory support are not always suitable or successful, although weight loss and hypoglossal nerve stimulation may help in select comorbid conditions. Educational aims To understand the clinical impact of childhood sleep disordered breathing (SDB).To understand that, while sleep laboratory polysomnography has been the gold standard for diagnosis of SDB, other diagnostic techniques exist with their own benefits and limitations.To recognise that adenotonsillectomy and positive pressure respiratory support are the mainstays of treating childhood SDB, but different approaches may be indicated in certain patient groups.
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Affiliation(s)
- Alison J.B. Garde
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Martin P. Samuels
- Staffordshire Children's Hospital, Royal Stoke University Hospital, Stoke-on-Trent, UK,Great Ormond Street Hospital, London, UK
| | - Hazel J. Evans
- University Hospital Southampton NHS Foundation Trust, Southampton, UK,Corresponding author: Hazel J. Evans ()
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