Central sleep apnea in children with obstructive sleep apnea syndrome and improvement following adenotonsillectomy

Long Term Ventilation in Pediatric Central Apnea: Etiologies and Therapeutic Approach over a Decade

OBJECTIVE

This retrospective study aimed to analyze the clinical characteristics, ventilatory strategies, and effectiveness of ventilation in pediatric patients with central apneas treated at the Sleep Medicine and Long-Term Ventilation Unit of the Bambino Gesù Children's Hospital in Rome from 2012 to 2022.

METHODS

Among all ventilated patients at our Center from January 2012 to December 2022, we retrospectively included children with a cAHI ≥ 1 events/h on baseline poly(somno)graphic study. Additional parameters assessed included the underlying disease, type of ventilation (non-invasive vs. invasive), age at ventilation onset, ventilation mode, and transcutaneous capnometry parameters. To assess the effectiveness of ventilation on central apneas, we compared the cAHI at baseline and on ventilation.

RESULTS

Sixty-seven patients met the inclusion criteria for central apnea (cAHI > 1 events/h). Diagnoses included hypoxic-ischemic encephalopathy, 15 (22.4%); Ondine syndrome, 14 (20.9%); polymalformative syndrome, 10 (14.9%); Prader-Willi syndrome, 8 (11.9%); brain tumor, 6 (9.0%); Down syndrome, 4 (6.0%); ROHHAD syndrome, 2 (3.0%); other infrequent pathologies were, Arnold-Chiari II, primary central apnea, epilepsy, lisosomal diseases, hydrocephalus, myopathy, obesity, Rett Syndrome. Pressure-supported ventilation (PSV) was the most common mode used (45 out 67 patients, 67.2%), followed by pressure-controlled ventilation (PCV) (15 out 67 patients, 22.4%) and continuous positive airway pressure (CPAP) (7 out 67 patients, 10.4%). Statistically significant improvement (p < 0.05) in cAHI was observed in patients with polymalformative syndrome (3.5 vs. 0.3, p = 0.01), hypoxic-ischemic encephalopathy (3.1 vs. 0.1, p = < 0.01), and Prader-Willi syndrome (3.5 vs. 0.1, p = 0.03), while there was no significant improvementn in children with brain tumor (6.2 vs. 1.5, p = 0.21).

CONCLUSION

Central apneas are present in children with various underlying pathologies. Ventilatory strategies tailored to the specific diagnosis and severity of central apneas yield significant improvements in cAHI. PSV was the preferred ventilation mode in this study and there was notable effectiveness across different diagnostic categories. PCV was employed in most severe cases. CPAP was exclusively used in patients with predominantly obstructive sleep apneas.

Persistent and symptomatic periodic breathing beyond the neonatal period in full-term infants: A case series

INTRODUCTION

Periodic breathing (PB) is considered physiological in the neonatal period and usually disappears in the first months of life. There are few data available on persistent PB after the neonatal period. The objective of this study was to characterize infants born at term with persistent PB after the age of 1 month through polysomnography (PSG) performed during symptoms.

METHODS

This retrospective case series included infants born at term between 2012 and 2021, without an underlying disease, who presented with symptoms of persistent PB during a PSG. Persistent PB was defined as more than 1 % of total sleep time (TST) of PB after 1 month of life, and PB was defined as a succession of at least three episodes of central apnea lasting more than 3 s and separated by less than 20 s of normal breathing.

RESULTS

A total of 10 infants born at term were included. They underwent PSG for brief resolved unexplained events, desaturation, pauses in breathing, cyanosis, and/or signs of respiratory distress. The percentage of TST spent with PB was 18.1 % before 3 months of age (n = 7), and 4.7 % between 3 and 6 months of age (n = 10). During the first PSG, ≥3 % of desaturation events were observed in 77-100 % of the PB episodes. At the first PSG, nine of the 10 infants had an obstructive apnea-hypopnea index of >10/h and five of 10 infants had a central apnea index of >5/h. Gastroesophageal reflux (GER) was suspected in eight infants. All infants showed improvement in the initial symptoms during the first year of life.

CONCLUSION

This study presents cases of persistent and symptomatic PB after 1 month of life in infants born at term. The interesting finding was the presence of obstructive sleep apnea syndrome and/or central apnea syndrome in the majority of children, along with GER.

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.

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.

Distribution Characteristics and Influencing Factors of Central Apnea in Chinese Pediatric Patients With Obstructive Sleep Apnea: A Single-Center Study

Background

Central apnea (CA) events always can be seen in the polysomnographic (PSG) reports of children with obstructive sleep apnea (OSA), and sometimes the central apnea index (CAI) is higher than the obstructive apnea and hypopnea index (OAHI). Commonly, the clinicians only attribute it to the age. This study aims to elucidate the distribution characteristics and major factors associated with CA in pediatric OSA.

Methods

A retrospective chart review of PSG data of children with OSA from January 2017 to March 2018 was performed.

Results

856 children (317 girls and 539 boys, 4.9 ± 2.4 years) were involved. 50.1% (429/856) had a CAI > 1, and 2.9% (25/856) had a CAI >5. Children with a CAI >1 had a higher OAHI, arousal index (AI), oxygen desaturation index (ODI), and a longer REM period, but a younger age and a shorter slow-wave sleep (SWS) phase. Multivariate binary logistic regression showed that with a 1% increased REM period, the risk of the CAI being >1 increased by 5.3% (p < 0.001). The CAI increased with an increasing OAHI (p = 0.003). The possibility of a CAI ≤ 1 increased with age (p < 0.001), and boys were more likely to have a CAI ≤ 1 (p = 0.001).

Conclusions

In addition to obstructive apnea (OA), almost all children with OSA also had CA, and a CAI > 1 was most likely to occur. The OAHI and REM period were risk factors for an increased CAI, and age and male sex were protective factors.

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.

Improvement in Central Sleep Apnea Following Adenotonsillectomy in Children

OBJECTIVE

Previous studies examining changes in central sleep apnea (CSA) following adenotonsillectomy (T&A) performed for obstructive sleep apnea (OSA) in children have been limited by sample size and analysis of only certain populations. The aim of this study was to determine whether CSA improves following T&A and what factors mediate this change.

METHODS

This was a retrospective case series from 1994 to 2020 of children undergoing primary T&A for OSA (obstructive apnea-hypopnea index ≥1) with CSA (central apnea index [CAI] ≥1) and preoperative and postoperative polysomnograms within 12 months of T&A. Polysomnograms were analyzed for improvement in CSA, defined as: 1) if preoperative CAI >5, a postoperative CAI <5; or 2) if preoperative CAI <5, a postoperative CAI <1.

RESULTS

One hundred twenty-three patients were included. Median age was 5.5 years (interquartile range, 2.9-8.4). Most patients were overweight/obese (58.5%). Nineteen (15.4%) had a syndromic condition. Preoperative CAI was ≥5 in 21 (17.1%) patients. CAI significantly decreased following T&A (preoperative 2.1, postoperative 0.4; P < .001). Thirty-two (26.0%) patients had CSA postoperatively. Improvement in the microarousal index and older age were significantly associated with improvement in CSA.

CONCLUSIONS

T&A led to resolution of CSA in most children with OSA. Improvement in the microarousal index was associated with improvement in CAI, suggesting that preoperative central apneas may be postarousal and thus resolve following T&A.

LEVEL OF EVIDENCE

4 Laryngoscope, 132:478-484, 2022.

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.

Analysis of polysomnogram findings in children with concurrent obstructive and central sleep apnea

OBJECTIVE

Increasing evidence suggests overlap in mechanisms of obstructive and central sleep apnea. Our objective was to compare the patient characteristics and polysomnographic findings of children with concurrent obstructive and central sleep apnea (obstructive sleep apnea + central sleep apnea [OSA + CSA]), to those with OSA only.

METHODS

A retrospective case series of polysomnogram (PSG) from 30 June 2013 to 30 June 2018 of patients 18 years and younger was performed. PSG parameters were analyzed per standard protocol. There were two groups, OSA only group and OSA + CSA group. OSA + CSA was subdivided into groups of central apnea index (CAI) ≤5, and CAI >5. Differences in the age, sex, body mass index (BMI) percentile, prevalence of medical conditions, and PSG parameters between OSA only and OSA + CSA were assessed for statistical significance.

RESULTS

The mean age of the OSA only group was 8.2 years, significantly higher than that of the OSA + CSA group, 5.0 years, P < .00001. The proportion of underweight, normal weight, overweight, and obese patients according to BMI percentiles was not statistically significantly different between the two groups, P > .05. Most common comorbidity in the two groups was pulmonary conditions, which included asthma. Of the PSG parameters, arousals due to respiratory events and obstructive apnea hypopnea index of all OSA + CSA groups were significantly higher than those of the OSA only group, P < .05. Rapid eye movement (REM) sleep was significantly higher in total OSA + CSA group and OSA + CSA subgroup with CAI ≤5, P < .05, compared to OSA only.

CONCLUSION

Children with concurrent OSA + CSA are younger, but there appears to be no difference in BMI percentiles between OSA only and OSA + CSA. Compared to OSA only group, children with concurrent OSA + CSA have significantly different sleep architecture-higher REM %-and experience significantly higher respiratory arousals and obstructive events, especially in the subgroup with CAI >5. There appears to be overlap in mechanisms of CSA and OSA in this cohort.

LEVEL OF EVIDENCE

4.

Central breathing abnormalities in children with trisomy 21: Effect of age, sex, and concomitant OSA

BACKGROUND

Trisomy 21 (TS21) is a condition with a high risk for sleep apnea. In the pediatric population, the risk also includes central breathing disorders. The aim of this study was to define the clinical and polysomnographic characteristics of central apnea in infants, children, and adolescents with TS21.

METHODS

Retrospective review of baseline polysomnograms (PSGs) in children with TS21 in the sleep center at Children's National Medical Center in Washington DC.

RESULTS

We included a total of 158 infants, children, and adolescents (0-18 years) with TS21 in this study. The median age was 4.82 years and 62% were male. The primary findings of the study are that (1) 12% of all pediatric subjects with TS21 included had a central apnea index (CAI) > 2/h; (2) the proportion of TS21 individuals with central breathing abnormalities progressively decreased with age being common in young individuals (≤2 years of age) but rare after 10 years of age; (3) additional sleep breathing disturbances (e.g., OSA and/or hypoxemia) are often present in children with TS21 and central apnea; and (4) the prevalence of central breathing abnormalities in TS21 is influenced by sex, being more likely to persist beyond early childhood (>2 years of age) in females than in males.

CONCLUSION

Central breathing abnormalities are common in TS21 among young children (≤2 years of age) and in females older than 2 years of age. Central apnea is often associated with concomitant obstructive sleep apnea and/or hypoxemia in children with TS21.

Polysomnographic characteristics and sleep-disordered breathing in Schaaf-Yang syndrome

INTRODUCTION

Schaaf-Yang syndrome (SYS) is a genetic disorder caused by truncating variants in the MAGEL2 gene located in the maternally imprinted Prader-Willi syndrome (PWS) region at 15q11-13. The SYS phenotype shares features with PWS, a syndrome with known high incidence of sleep disorders. However, the spectrum of sleep-disorders in SYS has not been described.

METHODS

We performed a retrospective analysis of polysomnograms from 22 patients in an international SYS cohort. Sleep characteristics for individuals with the common c.1996dupC variant (n = 10) were compared to other truncating variants (n = 11).

RESULTS

We collected 33 sleep study reports from 22 patients, ages 2 months - 18.5 years (mean 6.5 years). Mean sleep efficiency was 70.5% (range 45%-93%) with arousal index 14.1/h (1.2-45/h). The mean apnea-hypopnea index (AHI) was 19.1/h (0.9-49/h) with mean obstructive AHI (oAHI) of 16.3/h (0.6-49/h). Mean central apnea index was 2.8/h (0-14/h). Mean oxygen desaturation index was 20.8/h (range 0-85/hr). Obstructive sleep apnea (OSA) was diagnosed in 81%, and 62% had moderate or severe OSA. Elevated central apnea index occurred in 9.5%. Comparison by genotype groups and age did not reveal any difference in OSA findings. Periodic limb movement index (PLMI) was elevated in 4/15 (26%).

CONCLUSION

OSA is frequently identified on polysomnography in patients with SYS. The mean PLMI is elevated compared to normative data. Patients with SYS should have routine polysomnography screening due to high risk of sleep disorders.

Pediatric pulmonology year in review 2019: Sleep medicine

Pediatric Pulmonology publishes original research, review articles as well as case reports on a wide variety of pediatric respiratory disorders. In this article, we summarize the past year's publications in sleep medicine and we review selected literature from other journals within this field. Articles highlighted are topics on risk factors of sleep-disordered breathing, diagnosis, and treatment of obstructive sleep apnea as well as the utility of polysomnography in various complex conditions.

Etiologies of apnea of infancy

BACKGROUND

To date there are limited data in the literature to guide the initial evaluation for etiologies of apnea in full-term infants born at greater than or equal to 37 weeks conceptional age (apnea of infancy [AOI]). Pediatricians and pediatric pulmonologists are left to pursue a broad, rather than targeted and a stepwise approach to begin diagnostic evaluation.

METHODS

We performed a retrospective chart review of 101 symptomatic full-term infants (age under 12 months) diagnosed with apnea with an inpatient multichannel pneumogram (six channels) or a fully attended overnight pediatric polysomnogram in our outpatient sleep center accredited by American Academy of Sleep Medicine (AASM), scored using the standards set forth by the AASM. The infant was diagnosed as having AOI if the apnea hypopnea index (AHI) was greater than 1 (AHI is defined as the number of apnea and hypopnea events per hour of sleep). The final diagnosis/etiology was determined based on physician clinical assessment and work up. We then determined the frequency for each diagnosis.

RESULTS

We found that the three most common etiologies were gastroesophageal reflux disease (GERD) (48/101), upper airway abnormalities/obstruction (37/101), and neurological diseases (19/101). There were significant numbers of infants with multiple etiologies for AOI.

CONCLUSION

Based on the frequencies obtained, pediatric practitioners caring for full-term infants with apnea of unknown etiology are advised to begin with evaluation of more likely causes such as GERD and upper airway abnormalities/obstruction before evaluating for less common causes.