Adenotonsillectomy to treat obstructive sleep apnea: Is it enough?

Sex differences in cardiac transcriptomic response to neonatal sleep apnea

Pediatric obstructive sleep apnea poses a significant health risk, with potential long-term consequences on cardiovascular health. This study explores the dichotomous nature of neonatal cardiac response to chronic intermittent hypoxia (CIH) between males and females, aiming to fill a critical knowledge gap in the understanding of sex-specific cardiovascular consequences of sleep apnea in early life. Neonates were exposed to CIH until p28 and underwent comprehensive in vivo physiological assessments, including whole-body plethysmography, treadmill stress-tests, and echocardiography. Results indicated that male CIH rats weighed 13.7% less than age-matched control males (p = 0.0365), while females exhibited a mild yet significant increased respiratory drive during sleep (93.94 ± 0.84 vs. 95.31 ± 0.81;p = 0.02). Transcriptomic analysis of left ventricular tissue revealed a substantial sex-based difference in the cardiac response to CIH, with males demonstrating a more pronounced alteration in gene expression compared to females (5986 vs. 3174 genes). The dysregulated miRNAs in males target metabolic genes, potentially predisposing the heart to altered metabolism and substrate utilization. Furthermore, CIH in males was associated with thinner left ventricular walls and dysregulation of genes involved in the cardiac action potential, possibly predisposing males to CIH-related arrhythmia. These findings emphasize the importance of considering sex-specific responses in understanding the cardiovascular implications of pediatric sleep apnea.

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.

International Pediatric Otolaryngology Group (IPOG) consensus on scoring of pediatric Drug Induced Sleep Endoscopy (DISE)

OBJECTIVES

To develop consensus statements for the scoring of pediatric drug induced sleep endoscopy in the diagnosis and management of pediatric obstructive sleep apnea.

METHODS

The leadership group identified experts based on defined criteria and invited 18 panelists to participate in the consensus statement development group. A modified Delphi process was used to formally quantify consensus from opinion. A modified Delphi priori process was established, which included a literature review, submission of statements by panelists, and an iterative process of voting to determine consensus. Voting was based on a 9-point Likert scale. Statements achieving a mean score greater than 7 with one or fewer outliers were defined as reaching consensus. Statements achieving a mean score greater than 6.5 with two or fewer outliers were defined as near consensus. Statements with lower scores or more outliers were defined as no consensus.

RESULTS

A total of 78 consensus statements were evaluated by the panelists at the first survey - 49 achieved consensus, 18 achieved near consensus, and 11 did not achieve consensus. In the second survey, 16 statements reached consensus and 5 reached near consensus. Regarding scoring, consensus was achieved on the utilization of a 3-point Likert scale for each anatomic site for maximal observed obstructions of <50% (Score 0, no-obstruction), ≥ 50% but <90% (Score 2, partial obstruction), and ≥ 90% (Score 3, complete obstruction). Anatomic sites to be scored during DISE that reached consensus or near-consensus were the nasal passages, adenoid pad, velum, lateral pharyngeal walls, tonsils (if present), tongue base, epiglottis, and arytenoids.

CONCLUSION

This study developed consensus statements on the scoring of DISE in pediatric otolaryngology using a modified Delphi process. The use of a priori process, literature review, and iterative voting method allowed for the formal quantification of consensus from expert opinion. The results of this study may provide guidance for standardizing scoring of DISE in pediatric patients.

Extracapsular Tonsillectomy versus Intracapsular Tonsillotomy in Paediatric Patients with OSAS

OBJECTIVE

The objective of our study was to compare our experience of intracapsular tonsillotomy performed with the help of a microdebrider usually used for adenoidectomy with results obtained from extracapsular surgery through dissection and from adenoidectomy in cases of people affected with OSAS, linked to adeno-tonsil hypertrophy, observed and treated in the last 5 years.

METHODS

3127 children with adenotonsillar hyperplasia and OSAS-related clinical symptoms (aged between 3 and 12 years) underwent tonsillectomy and/or adenoidectomy. A total of 1069 patients (Group A) underwent intracapsular tonsillotomy, while 2058 patients (Group B) underwent extracapsular tonsillectomy, from January 2014 to June 2018. The parameters considered in order to evaluate the effectiveness of the two different surgery techniques taken into consideration were as follows: the presence of possible postoperative complications, represented mainly by pain and perioperative bleeding; the level of postoperative respiratory obstruction compared with the original obstruction through night pulse oximetry, performed 6 months before and after the surgery; tonsillar hypertrophy relapse in Group A and/or the presence of residues in Group B with clinical evaluation performed 1 month, 6 months, and 1 year after the surgery; and postoperative life quality, evaluated through submitting to parents the same survey proposed before the surgery 1 month, 6 months, and 1 year after the surgery.

RESULTS

Regardless of the technique used (extracapsular tonsillectomy or intracapsular tonsillotomy), there was a clear improvement in both the obstructive respiratory symptomatology and quality of life in both patient groups, as highlighted by the pulse oximetry and the OSA-18 survey submitted later.

CONCLUSIONS

Intracapsular tonsillotomy surgery has improved in terms of a reduction in postoperative bleeding cases and pain reduction, with an earlier return to patients' usual lifestyle. Lastly, using a microdebrider with the intracapsular technique seems to be particularly effective in removing most of the tonsillar lymphatic tissue, leaving only a thin border of pericapsular lymphoid tissue and preventing lymphoid tissue regrowth during one year of follow-up.

Determinants of awake oropharyngeal volume reduction between sitting and supine positions in children evaluated for snoring

Pharyngeal collapsibility is a major determinant of obstructive sleep apnea (OSA) pathophysiology, but its anatomical predictors in children are largely unknown. We hypothesised that anatomical (tonsillar hypertrophy, narrow palate, nasal obstruction, dental/skeletal malocclusion, obesity) and OSA-related (apnea-hypopnea index, AHI) parameters could be related to a measure of awake pharyngeal collapsibility. We performed acoustic pharyngometry in children evaluated for suspected OSA, allowing us to measure the reduction of oropharyngeal volume in supine versus sitting position normalised for the volume in supine position (ΔV%), a measure of pharyngeal collapsibility. In addition to polysomnography and a clinical examination (anatomical parameters), acoustic rhinometry was used to assess nasal obstruction. A total of 188 snoring children were included, 118 (63%) of whom were obese and 74 (39%) of whom had moderate to severe OSA (AHI ≥5/h). The median (25th-75th percentiles) ΔV% in the whole population was 20.1% (4.7; 43.3). ΔV% was independently and positively associated with AHI (p = 0.023), z-score of BMI (p = 0.001), tonsillar hypertrophy (p = 0.007), narrow palate (p = 0.035), and African (p < 0.001) ancestry. By contrast, ΔV% was not modified by dental or skeletal malocclusion, Friedman palate position class or nasopharyngeal obstruction. Tonsillar hypertrophy, obesity, narrow palate and African ancestry are independently associated with an increase in pharyngeal collapsibility in snoring children, thus increasing the risk of OSA. Increased pharyngeal compliance in African children may explain the increased risk of residual OSA after adenotonsillectomy observed in this population.

Craniofacial and upper airway morphological characteristics associated with the presence and severity of obstructive sleep apnea in Chinese children

Objectives

To identify craniofacial and upper airway morphological characteristics associated with the presence and severity of obstructive sleep apnea (OSA) in children.

Methods

This study consisted of 82 OSA children and 77 controls (age 5-10 years). All subjects underwent cephalograms and were divided into a 5-7 age group and an 8-10 age group. Cephalometric variables were compared between OSA children and controls, and hierarchical regression analysis was performed to examine the relationship between cephalometric variables and OSA severity [expressed by the obstructive apnea-hypopnea index (OAHI)] in different age groups.

Results

Increased A/N ratio, narrowed posterior airway space, decreased SNA and SNB angles, and shortened ramus height were observed among OSA children in different age groups. In the 5-7 age group, the A/N ratio and a lower gonial angle explained 40.0% and 14.7% of the variance in the OAHI, respectively. In the 8-10 age group, the BMI z-score and A/N ratio explained 25.2% and 6.6% of the variance in the OAHI, followed by a lower gonial angle and the hyoid-retrognathion distance (19.1% in total).

Conclusions

Adenoid hypertrophy was a major factor associated with OSA in preschool children, whereas obesity replaced adenoid hypertrophy as the main contributor to OSA in late childhood. Several craniofacial skeletal variables such as the SNB angle, ramus height, lower gonial angle, and hyoid position are also associated with the presence and/or severity of OSA, which could be used to help recognize children at a higher risk for OSA.

Evaluation of Pharyngeal Airway Dimensions and Hyoid Bone Position in Children After Adenoidectomy or Adenotonsillectomy: A Cephalometric Study

Background. The study aimed to compare the airway morphology and hyoid bone position in children undergoing adenoidectomy or adenotonsillectomy with healthy individuals with no skeletal problems in similar age and development period. Methods. The subjects in the study were divided into three groups. These groups were defined as those having undergone adenoidectomy (53 children), those having undergone adenotonsillectomy (48 children), and the systemically healthy control group (63 children). Seventeen pharyngeal airway, nine hyoid, and four area measurements were used in the cephalometric radiographs of the children in all the groups. One-way analysis of variance was used to evaluate the children in each group. In addition, Tukey tests were used for a bilateral comparison of significant parameters. The results were considered statistically significant at P<0.05. Results. The mean age of 164 patients in the study group was 12.76±2.85 years. The vertical airway length significantly decreased in the adenotonsillectomy group compared to other groups, while the epiglottic pharyngeal length significantly increased in the former than in the latter (P<0.05). The area measurements showed that although the oropharynx area significantly increased in the adenotonsillectomy group compared to other groups, the hypopharynx and total area measurements were significantly different compared with the control group (P<0.05). No statistically significant difference was found between the three groups in all measurements of the hyoid bone position (P>0.05). Conclusion. The study showed that adenotonsillectomy operations caused more increases in the oropharynx and hypopharynx parts of the pharyngeal airway. Adenoidectomy and adenotonsillectomy operations did not contribute significantly to the hyoid bone position.

Sleep problems in fragile X syndrome: Cross-sectional analysis of a large clinic-based cohort

Fragile X syndrome (FXS), the leading cause of inherited intellectual disability and autism spectrum disorder, is associated with multiple neurobehavioral abnormalities including sleep difficulties. Nonetheless, frequency, severity, and consequences of sleep problems are still unclear. The Fragile X Online Registry with Accessible Research Database (FORWARD-version-3), including Clinician Report and Parent Report forms, was analyzed for frequency, severity, relationship with behavioral problems, and impact of sleep difficulties in a mainly pediatric cohort. A focused evaluation of sleep apnea was also conducted. Six surveyed sleep difficulties were moderately frequent (~23%-46%), relatively mild, affected predominantly younger males, and considered a problem for 7%-20% of families. Snoring was more prevalent in older individuals. All sleep difficulties were associated with irritability/aggression and most also to hyperactivity. Only severe snoring was correlated with sleep apnea (loud snoring: 30%; sleep apnea: 2%-3%). Sleep difficulties are prevalent in children with FXS and, although they tend to be mild, they are associated with behavioral problems and negative impact to families. Because of its cross-sectional nature, clinic-origin, use of ad hoc data collection forms, and lack of treatment data, the present study should be considered foundational for future research aiming at better recognition and management of sleep problems in FXS.

Pediatric Obstructive Sleep Apnea: What’s in a Name?

Obstructive sleep apnea is a highly prevalent disease across the lifespan and imposes substantial morbidities, some of which may become irreversible if the condition is not diagnosed and treated in a timely fashion. Here, we focus on the clinical and epidemiological characteristics of pediatric obstructive sleep apnea, describe some of the elements that by virtue of their presence facilitate the emergence of disrupted sleep and breathing and its downstream consequences, and also discuss the potential approaches to diagnosis in at-risk children.

Effects of the Two Doses of Dexmedetomidine on Sedation, Agitation, and Bleeding During Pediatric Adenotonsillectomy

Background

Due to the importance of dexmedetomidine and its different dosages, here, we aimed to investigate and compare the effectiveness of the doses of 1 µg/kg and 2 µg/kg of dexmedetomidine in sedation, agitation, and bleeding in pediatrics undergoing adenotonsillectomy.

Methods

This double-blinded randomized clinical trial was performed on 105 pediatric patients that were candidates for adenotonsillectomy. Then, the patients were divided into three groups receiving dexmedetomidine at a dose of 2 µg/kg, diluted dexmedetomidine at 1 µg/kg, and normal saline. The drugs were administered 15 minutes before operations via the intravenous method. The duration of extubation, mean arterial pressure (MAP), heart rate (HR), and SPO₂ in the recovery were recorded. We also collected data regarding patients’ sedation and agitation every 15 minutes.

Results

Our data showed no significant differences between the groups of patients regarding MAP, HR, and SPO₂. However, the mean sedation score was significantly higher in patients receiving dexmedetomidine (2 µg/kg), and this score was lowest in the control group at the time of entrance to the recovery room. The patients that received dexmedetomidine at a dose of 1 µg/kg had the lowest agitation score after 45 minutes of being in the recovery room, and the patients treated with dexmedetomidine at a dose of 2 µg/kg had the lowest agitation score after 60 minutes of being in the recovery compared to other groups of patients.

Conclusions

The use of the doses of 1 µg/kg and 2 µg/kg of dexmedetomidine was associated with proper sedation and a significant reduction in agitation. The patients also had lower amounts of bleeding. We recommend that anesthesiologists should pay more attention to dexmedetomidine at a dose of 2 µg/kg, especially in pediatric surgical procedures.

Continuous Positive Airway Pressure Titration During Pediatric Drug Induced Sleep Endoscopy

OBJECTIVE

To observe the degree of airway collapse at varying levels of continuous positive airway pressure (CPAP) during drug pediatric induced sleep endoscopy.

METHODS

Using our institutional anesthesia protocol for pediatric DISE procedures, patients were anesthetized followed by evaluation of the nasal airway, nasopharynx, velum, hypopharynx, arytenoids, tongue base, and epiglottis. CPAP titration was performed under vision to evaluate the degree of airway collapse at the level of the velum. Comparison was made with pre-operative polysomnography findings.

RESULTS

Twelve pediatric patients underwent DISE with intraoperative CPAP titration. In 7/12 patients, DISE observed CPAP titration was beneficial in elucidating areas of obstruction that were observed at pressures beyond those recommended during preoperative sleep study titrations. In 3 patients, DISE observations provided a basis for evaluation in children not compliant with sleep study CPAP titration testing. With regard to regions effected, airway collapse was observed at the velum and oropharynx to a greater degree when compared with the tongue base and epiglottis.

CONCLUSION

DISE evaluation of the pediatric patient with obstructive sleep apnea may present a source for further patient evaluation with respect to CPAP optimization and severity of OSA assessment, particularly in syndromic patients.

Sleep disordered breathing from preschool to early adult age and its neurocognitive complications: A preliminary report

Objective

The onset and development of sleep disordered breathing (SDB) remains unclear in an age - dependent manner. Despite treatment, persistent symptoms such as snoring and excessive daytime sleepiness, as well as cognitive impairment may be present. The aim of the research was to determine the prevalence of residual symptoms of SDB in adolescence and early adulthood, the predisposing factors and its neurocognitive complications.

Methods

In the present pilot study-cohort, a questionnaire was utilized to 154 people (average age: 17.9 ± 3), who as children (mean age: 5.3 ± 1.4) had AHI ≥2.5 episodes/h. They were divided into two groups based on AHI = 5 episodes/h. Depending on the results, they were invited to undergo a repeated polysomnography (PSG) and complete the Montreal Cognitive Assessment (MoCA) test. Statistical analysis was made with IBM SPSS software.

Results

Out of the total, 35.7% claimed to still snore. AHI was negatively correlated to the severity of residual symptoms (Mann-Witney U test, p <0.005). According to repeated PSGs, 9/17 met the criteria for OSAS, while high BMI was associated with the severity of new AHI (chi squared test, p<0.005). Additionally, 7/16 scored below the MoCA baseline (<26/30). The characteristics of cognitive declines were mapped, with most prominent having been visuospatial, short - term memory and naming/language deficits.

Discussion

A significant percentage of children with sleep breathing disorder present with residual symptoms during their transition to early adulthood, as well as undiagnosed neurocognitive complications. Clinicians suspicion for the underlying neurocognitive complications is required, even in young adults, while guidelines on monitoring pediatric OSAS patients after treatment should be addressed.

Efficacy and safety of montelukast for pediatric obstructive sleep apnea syndrome: A protocol for systematic review and meta-analysis

BACKGROUND

Pediatric obstructive sleep apnea syndrome (OSAS) is significant public concern. Clinical practice indicates that montelukast has certain therapeutic advantages, while there is a lack of evidence-based medicine support. The aim of this study is to synthesize related data to explore efficacy and safety of montelukast for pediatric OSAS.

METHODS

Data in Pubmed, EMBASE, CENTRAL, CBM, CNKI, WanFang, VIP databases were comprehensively searched. All the randomized controlled trials (RCTs) in OSAS children were identified, in which the effects of montelukast on a range of outcomes were compared. The search had a deadline of January 1, 2020. Two investigators independently conducted data extraction and assessed the literature quality of the included studies. The Revman5.3 software was used for meta-analysis of the included literature.

RESULTS

The efficacy and safety of montelukast in the treatment of pediatric OSAS were evaluated in terms of apnea hypopnea index (AHI), the Pittsburgh Sleep Quality Index, the Epworth Sleep Scale (ESS), neck circumference, important index in Polysomnography: sleep efficiency, desaturation index, total sleep time.

CONCLUSIONS

This study provides reliable evidence-based support for the clinical application of montelukast in the treatment of pediatric OSAS.

PROSPERO REGISTRATION NUMBER

CRD42020146940.

Effect of body weight on upper airway findings and treatment outcome in children with obstructive sleep apnea

OBJECTIVE/BACKGROUND

Surgical interventions for obstructive sleep apnea (OSA) are less effective in obese than in normal-weight children. However, the mechanisms that underpin this relationship are not fully understood. Therefore, this study aimed to explore how body weight influences upper airway collapse and treatment outcome in children with OSA.

METHODS

We conducted a retrospective analysis of prospectively collected data on polysomnography, drug-induced sleep endoscopy (DISE), and treatment outcome in otherwise healthy children with OSA. Associations between body mass index (BMI) z-score and upper airway collapse during DISE were assessed using logistic regression modelling. Treatment success was defined as obstructive apnea-hypopnea index (oAHI) < 5 events/hour and cure as oAHI < 2 events/hour with obstructive apnea index < 1 event/hour.

RESULTS

A total of 139 children were included [median (Q1─Q3); age 4.5 (3.1─8.4) years; BMI z-score 0.3 (-0.8 to 1.4); oAHI 10.8 (6.8─18.0) events/hour]. Twenty-five of them were overweight and 21 were obese. After adjusting for age and history of upper airway surgery, BMI z-score was significantly correlated with circumferential upper airway collapse during DISE (odds ratio 1.67; 95% confidence interval 1.12─2.65; P = 0.011). Outcome of DISE-directed treatment was similar in normal-weight (success: 91.4%; cure: 78.5%), overweight (success: 88.0%; cure: 80.0%), and obese (success: 90.5%; cure: 76.5%) children. Children with circumferential collapse responded better to continuous positive airway pressure than to (adeno)tonsillectomy.

CONCLUSION

Increasing body weight is associated with circumferential upper airway collapse during DISE and, accordingly, may require treatment strategies other than (adeno)tonsillectomy.

International Pediatric Otolaryngology group (IPOG) consensus on the diagnosis and management of pediatric obstructive sleep apnea (OSA)

OBJECTIVE

To develop an expert-based consensus of recommendations for the diagnosis and management of pediatric obstructive sleep apnea.

METHODS

A two-iterative Delphi method questionnaire was used to formulate expert recommendations by the members of the International Pediatric Otolaryngology Group (IPOG).

RESULTS

Twenty-six members completed the survey. Consensus recommendations (>90% agreement) are formulated for 15 different items related to the clinical evaluation, diagnosis, treatment, postoperative management and follow-up of children with OSA.

CONCLUSION

The recommendations formulated in this IPOG consensus statement may be used along with existing clinical practice guidelines to improve the quality of care and to reduce variation in care for children with OSA.

Drug-Induced Sleep Endoscopy in Children With Positional Obstructive Sleep Apnea

OBJECTIVE

Positional obstructive sleep apnea (POSA)-defined as obstructive sleep apnea twice as severe supine than nonsupine-may offer clues to the underlying pattern of upper airway collapse in children. We compared drug-induced sleep endoscopy (DISE) findings in children with and without POSA. We hypothesized that children with POSA would have significantly higher obstruction at the gravity-dependent palate and tongue base but not at the adenoid, lateral wall, or supraglottis.

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary pediatric hospital.

SUBJECTS AND METHODS

We included children aged 1 to 12 years with obstructive sleep apnea diagnosed by polysomnography who underwent DISE from July 2014 to February 2019. Scores were dichotomized as ≥50% obstruction (Chan-Parikh 2 or 3) vs <50% obstruction (Chan-Parikh 0 or 1).

RESULTS

Of 99 children included, 32 (32%) had POSA and 67 (68%) did not. Children with POSA did not differ from children without POSA in age, overall apnea-hypopnea index, sex, race, syndromic diagnoses, obesity, or history of adenotonsillectomy. In logistic regression models, odds of ≥50% obstruction were significantly higher at the tongue base (odds ratio, 2.77; 95% CI, 1.04-7.39) after adjustment for age, sex, obesity, previous adenotonsillectomy, and syndrome. No difference was noted at the adenoid, velum, lateral wall, or supraglottis.

CONCLUSION

POSA was associated with higher odds of obstruction on DISE at the tongue base but not at other levels.

Alternative Approaches to Adenotonsillectomy and Continuous Positive Airway Pressure (CPAP) for the Management of Pediatric Obstructive Sleep Apnea (OSA): A Review

Continuous positive airway pressure (CPAP) is considered first-line treatment in the management of pediatric patients without a surgically correctible cause of obstruction who have confirmed moderate-to-severe obstructive sleep apnea (OSA). The evidence supports its reduction on patient morbidity and positive influence on neurobehavioral outcome. Unfortunately, in clinical practice, many patients either refuse CPAP or cannot tolerate it. An update on alternative approaches to CPAP for the management of OSA is discussed in this review, supported by the findings of systematic reviews and recent clinical studies. Alternative approaches to CPAP and adenotonsillectomy for the management of OSA include weight management, positional therapy, pharmacotherapy, high-flow nasal cannula, and the use of orthodontic procedures, such as rapid maxillary expansion and mandibular advancement devices. Surgical procedures for the management of OSA include tongue-base reduction surgery, uvulopalatopharyngoplasty, lingual tonsillectomy, supraglottoplasty, tracheostomy, and hypoglossal nerve stimulation. It is expected that this review will provide an update on the evidence available regarding alternative treatment approaches to CPAP for clinicians who manage patients with pediatric OSA in daily clinical practice.

Treatment of Obstructive Sleep Apnea in Children: Handling the Unknown with Precision

Treatment approaches to pediatric obstructive sleep apnea (OSA) have remarkably evolved over the last two decades. From an a priori assumption that surgical removal of enlarged upper airway lymphadenoid tissues (T&A) was curative in the vast majority of patients as the recommended first-line treatment for pediatric OSA, residual respiratory abnormalities are frequent. Children likely to manifest persistent OSA after T&A include those with severe OSA, obese or older children, those with concurrent asthma or allergic rhinitis, children with predisposing oropharyngeal or maxillomandibular factors, and patients with underlying medical conditions. Furthermore, selection anti-inflammatory therapy or orthodontic interventions may be preferable in milder cases. The treatment options for residual OSA after T&A encompass a large spectrum of approaches, which may be complementary, and clearly require multidisciplinary cooperation. Among these, continuous positive airway pressure (CPAP), combined anti-inflammatory agents, rapid maxillary expansion, and myofunctional therapy are all part of the armamentarium, albeit with currently low-grade evidence supporting their efficacy. In this context, there is urgent need for prospective evidence that will readily identify the correct candidate for a specific intervention, and thus enable some degree of scientifically based precision in the current one approach fits all model of pediatric OSA medical care.

Ciliary beat frequency in children with adenoid hypertrophy

BACKGROUND

Children with adenoid hypertrophy (AH) have impaired respiratory system defense mechanisms, such as mucociliary clearance. We hypothesized that AH negatively affects one of the most important aspects of mucociliary clearance-ciliary beat frequency (CBF) and that adenoidectomy could potentially restore this essential defence mechanism of the airways. This study evaluated the influence of AH and endoscopic adenoidectomy on the CBF of the nasal respiratory epithelium in children.

METHODS

This prospective study included 64 children with confirmed AH aged 3 to 18 years and 43 age- and sex-matched healthy controls. Nasal CBF was analyzed using a digital high-speed video microscope and the software application Ciliary Analysis (NI LabVIEW). The preoperative adenoid size was assessed according to Cassano. Clinical symptoms of chronic rhinosinusitis were evaluated using the SNOT-20 questionnaire.

RESULTS

Children with AH had a median CBF of 5.35 ± 1.06 Hz. Six months after surgery, the median CBF was significantly higher (6.48 ± 0.88 Hz; P < .001) and reached the values of healthy children (6.37 ± 0.71 Hz; P = .512). The size of the adenoid tissue did not correlate with the CBF. No influence of age or gender on the CBF was found. After adenoidectomy, a significant reduction of the mean total SNOT-20 score was recorded (P < .01).

CONCLUSION

Children with clinically symptomatic AH have impaired mucociliary clearance due to decreased nasal CBF. Removal of hypertrophic adenoid tissue normalizes the CBF and reduces the presence of clinical symptoms of rhinosinusitis.

Primary site identification in children with obstructive sleep apnea by computational fluid dynamics analysis of the upper airway

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is a respiratory disorder caused by the obstruction of the upper airway during sleep. The identification of the primary site of OSA is essential to determine treatment strategy. This study aimed to establish computational fluid dynamics (CFD) analysis for determining the clinical severity of OSA and the primary site of OSA.

METHODS

Twenty children (mean age, 6 years) were divided into OSA and control groups according to their apnea-hypopnea index. Three-dimensional airways were constructed from computed tomography data. The pharyngeal airway morphology and the pressure and velocity of the upper airway were evaluated using CFD analysis.

RESULTS

The maximum velocity and negative pressure of the upper airway in the OSA group were significantly correlated with the severity of OSA (r_s = .741, P < .001; r_s = -.653, P = .002). A velocity higher than 12 m/s indicated the primary site of OSA. In addition, we found that the primary site of OSA is not necessarily the same as the collapsible conduit site.

CONCLUSIONS

CFD analysis allows both the evaluation of the disease severity of OSA and the identification of the primary site of OSA in children. The primary site of OSA is not necessarily the same as the collapsible conduit site; therefore, CFD analysis can be used to identify the appropriate intervention for treating OSA.

Long Term Continuous Positive Airway Pressure and Non-invasive Ventilation in Obstructive Sleep Apnea in Children With Obesity and Down Syndrome

This review will focus on non-invasive ventilation (NIV) and continuous positive airway pressure (CPAP) therapy in children with obstructive sleep apnea (OSA) due to obesity and underlying syndromes. These children have a high prevalence of OSA and residual OSA after adenotonsillectomy. Therefore, a high proportion of these children are treated with CPAP or NIV. This review will focus on treatment selection tools and will subsequently cover specific issues on CPAP treatment in obese and syndromic children with a major focus on Down syndrome.

Treatment of vagus nerve stimulator-induced sleep-disordered breathing: A case series

Objective

Vagus nerve stimulation (VNS) is a treatment option for patients with drug-resistant seizures, but it is also associated with sleep-disordered breathing (SDB). We present four patients with VNS who underwent polysomnography (PSG) concurrently with VNS stimulation monitoring and adjustment, and positive airway pressure (PAP) treatment. We demonstrate the importance of sleep apnea screening prior to VNS placement and the dilemma of optimizing VNS settings.

Background

VNS is a common adjunct therapy for refractory epilepsy. Despite its low side effect profile, complications of VNS include delayed arrhythmias, laryngopharyngeal dysfunction, obstructive sleep apnea, and tonsillar pain mimicking glossopharyngeal neuralgia. Risk of developing or exacerbating existing obstructive sleep apnea (OSA) limits the VNS settings, as there appears to be a dose dependent effect. OSA can further cause sleep fragmentation and cause hypoxia, potentially worsening seizures.

Methods

Four patients with drug-resistant epilepsy with VNS underwent PSG with concurrent VNS leads to monitor correlation of SDB and VNS. AHI was calculated to quantify SDB, and it was scored as non-VNS related when the VNS was off, and VNS-induced when the onset of SDB corresponded to VNS activation. Subsequent PAP and VNS adjustment was performed to treat the SDB episodes.

Results

Three out of four patients had non-VNS associated SDB, which improved with PAP treatment. All four patients had VNS-induced SDB episodes but none improved with PAP. The VNS-induced SDB events decreased in a dose dependent manner, when VNS was adjusted down and disappeared when turned off completely.

Conclusion

Our case series provides further evidence of VNS-induced SDB secondary to VNS. PAP treatment alone is ineffective for VNS-induced SDB. Screening for OSA before VNS implant is crucial; further research is needed to establish optimal VNS parameters for prevention andminimization of VNS-induced SDB along with other possible treatments.

•

Further evidence of VNS-induced SDB as a side effect of VNS

•

PAP treatment alone is not effective in eliminating VNS-induced SDB

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VNS setting titration showed dose-dependent effect on SDB

•

Screening of primary OSA before and after VNS implant is crucial

Diagnostic techniques and surgical outcomes for persistent pediatric obstructive sleep apnea after adenotonsillectomy: A systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy of upper airway surgery for children with persistent obstructive sleep apnea after adenotonsillectomy and to assess sleep study outcomes when Drug Induced Sleep Endoscopy, Cine MRI, or other imaging procedure is performed to assist in identifying the location of obstruction and planning surgery.

METHODS

Systematic review and meta-analysis was performed. Inclusion criteria was English-language studies with original data including pediatric patients with persistent OSA after T&A. Exclusion criteria included case reports and lack of pre and post-operative sleep study data. Data Sources were PubMed, Cochrane Central, and Embase from 2000 to 2018. PRISMA standards were followed for the selection and review of articles. The Newcastle-Ottawa Quality Assessment scale was used to score the quality of evidence of the studies. All manuscripts were reviewed independently by two investigators. Primary outcome measures were apnea-hypopnea index and minimum oxygen saturation. Data was pooled using a random-effects model.

RESULTS

Of the 1902 abstracts identified, 11 studies (214 patients) met inclusion criteria for systematic review, 5 with Drug Induced Sleep Endoscopy as the diagnostic technique, 4 with Cine MRI, and 2 with MRI/CT. All studies were case series. Most subjects had syndromic comorbidities and/or obesity. Ten studies (198 patients) were included in the meta-analysis. Overall, there was a change in apnea hypopnea index of -6.51 (95% CI, -8.17 to - 4.85; p < 0.001) and an increase in minimum oxygen saturation by 3.24% (95% CI, 1.49%-4.98%; p < 0.001) following surgical intervention. Both Drug Induced Sleep Endoscopy and Cine MRI directed surgeries resulted in significant improvement in sleep study parameters. The two techniques could not be directly compared due to significant differences in co-morbidity rates between patients.

CONCLUSIONS

Surgery for pediatric persistent obstructive sleep apnea improves apnea hypopnea index and minimum oxygen saturation but does not resolve the disease. This is true when both Drug Induced Sleep Endoscopy and Cine MRI findings were used to direct surgery.

Respiratory morbidity in children with cerebral palsy: an overview

Respiratory problems have a significant impact on morbidity and mortality in patients with cerebral palsy (CP). In particular, recurrent aspiration, impaired airway clearance, spinal and thoracic deformity, impaired lung function, poor nutritional status, and recurrent respiratory infections negatively affect respiratory status. Bronchopulmonary dysplasia may contribute to pulmonary problems, but asthma is not more common in CP than in the general population. We discuss treatment options for each of these factors. Multiple coexisting and interacting factors that influence the respiratory status of patients with CP should be recognized and effectively addressed to reduce respiratory morbidity and mortality. WHAT THIS PAPER ADDS: Respiratory problems are a significant cause of morbidity in patients with cerebral palsy (CP). Respiratory status in patients with CP is influenced by recurrent aspiration and impaired airway clearance. Spinal and thoracic deformity, impaired lung function, poor nutrition, and respiratory infections also negatively affect respiratory status. These factors should all be addressed to reduce respiratory problems in patients with CP.

Sleep-disordered breathing in paediatric setting: existing and upcoming of the genetic disorders

Childhood obstructive sleep apnea syndrome (OSAS) is characterized by anatomical and functional upper airway abnormalities as pathophysiological determinants, and clinical symptoms are frequently clear. OSAS is widely described in rare genetic disorders, such as achondroplasia, Down syndrome, Prader-Willi syndrome, Pierre Robin sequence, and mucopolysaccharidosis. Craniofacial and upper airway involvement is frequently morbid conditions. In children with genetic diseases, the clinical symptoms of OSAS are often slight or absent, and related morbidities are usually more severe and can be observed at any age. The present review is aimed to updating the discoveries regarding OSAS on Achondroplasia, Down syndrome, Prader-Willi syndrome, Pierre Robin sequence, Sickle cell disease, or encountered in our clinical practice (Ehlers-Danlos syndrome, Ellis-van Creveld syndrome, Noonan syndrome). Two additional groups of genetic disorders will be focused (mucopolysaccharidoses and osteogenesis imperfecta). The flowing items are covered for each disease: (I) what is the pathophysiology of OSAS? (II) What is the incidence/prevalence of OSAS? (III) What result from the management and prognosis? (IV) What are the recommendations? Considering the worries of OSAS, such as inattention and behavioural problems, daytime sleepiness, failure to thrive, cardiological and metabolic complications, the benefit of a widespread screening and the treatment in children with genetic diseases is undoubtful. The goals of the further efforts can be the inclusion of various genetic diseases into guidelines for the screening of OSAS, updating the shreds of evidence based on the research progression.

Pediatric pulmonology year in review 2017: Part 4 (Sleep medicine)

Pediatric Pulmonology publishes original research, case reports and review articles on topics related to a wide range of children's respiratory disorders. In this article (Part 4 of a 5-part series), we summarize the past year's publications in sleep medicine, in the context of selected literature in this area from other journals. Articles are highlighted on topics including diagnosis and treatment of OSAS, sleep duration and position, and sleep disorders in chronic disease.

Clinical Predictors of Residual Sleep Apnea after Weight Loss Therapy in Obese Adolescents

OBJECTIVE

To investigate clinical factors that could predict residual sleep-disordered breathing (SDB) after weight loss.

STUDY DESIGN

Obese subjects between 10 and 19 years of age were recruited while entering an in-patient weight loss treatment program. All subjects underwent anthropometry and sleep screening using a portable device at baseline and after 4-6 months of therapy. Sleep and International Study of Asthma and Allergies in Childhood questionnaires were completed at baseline.

RESULTS

A total of 339 patients were included. Median age was 15.4 years (10.1-19.1). Body mass index z score at baseline was 2.75 ± 0.42, and 35% of subjects were boys. SDB was present in 32%. After a mean decrease in body mass index z score of 32%, residual SDB was found in 20% of subjects with SDB at baseline. Subjects with more severe SDB (OR 1.18; CI 1.01-1.34; P = .02) and respiratory allergies (OR 7.85; CI 1.20-51.39; P = .03) were at higher risk of developing residual SDB, unlike age, sex, and anthropometric variables.

CONCLUSIONS

Weight loss was successful for treating SDB in 80% of patients. More severe SDB and the presence of respiratory allergies at baseline were associated with a higher risk of residual SDB after weight loss.

Sleep-Disordered Breathing in Children with Recurrent Wheeze/Asthma: A Single Centre Study

The relationship between asthma and sleep-disordered breathing is bidirectional due to common risk factors that promote airway inflammation. Obstructive sleep-disordered breathing and recurrent wheeze/asthma are conditions that involve the upper and the lower respiratory system, respectively. The aim of the present study was to investigate the sleep disordered breathing in children with recurrent wheeze/asthma. This was a retrospective study concerning children older than 2 years who underwent—between January 2014 and November 2016—an in-laboratory overnight polygraphic study. We match the children between those who do or do not have recurrent wheeze/asthma disease. We examined the clinical records of 137 children. We excluded eight patients because of neurological and genetic conditions. Children with recurrent wheeze/asthma (N = 28) were younger (p = 0.002) and leaner (p = 0.013) compared to non-affected children (N = 98). Children with wheeze/asthma and unaffected ones had a similar obstructive apnea-hypopnea index (p = 0.733) and oxygen desaturation index (p = 0.535). The logistic regression analysis, in which the condition of wheeze/asthma (yes/no) was a dependent variable, while demographic (age, sex, body mass index (BMI) Z-score) and polygraphic results during sleep (obstructive apnea-hypopnea index, central apnea index, peripheral oxygen saturation (SpO₂), and snoring) were covariates, showed that children with wheeze/asthma had higher central apnea index (Exp(B) = 2.212; Wald 6.845; p = 0.009). In conclusion, children with recurrent wheeze/asthma showed an increased number of central sleep apneas than unaffected children. This finding may suggest a dysfunction of the breathing control in the central nervous system during sleep. Systemic or central inflammation could be the cause.