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Escobar NS, Lim AYL, Amin R. The latest on positive airway pressure for pediatric obstructive sleep apnea. Expert Rev Respir Med 2024:1-13. [PMID: 38949916 DOI: 10.1080/17476348.2024.2375428] [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: 04/05/2024] [Accepted: 06/28/2024] [Indexed: 07/03/2024]
Abstract
INTRODUCTION Obstructive sleep apnea (OSA) is an important and evolving area in the pediatric population, with significant sequelae when not adequately managed. The use of positive airway pressure (PAP) therapy is expanding rapidly and is being prescribed to patients with persistent OSA post adenotonsillectomy as well as those children who are not surgical candidates including those with medical complexity. AREAS DISCUSSED This article provides a state-of-the-art review on the diagnosis of pediatric OSA and treatment with positive airway pressure (PAP). The initiation of PAP therapy, pediatric interface considerations, PAP mode selection, administration and potential complications of PAP therapy, factors influencing PAP adherence, the use of remote ventilation machine downloads, considerations surrounding follow-up of patients post PAP initiation and evaluation of weaning off PAP will be reviewed. The literature search was conducted via PubMed, Cochrane Library and Google Scholar databases through to March 2024. EXPERT OPINION Further research is required to address barriers to adherence. Further innovation of home monitoring devices for both the diagnosis and assessment of OSA is required, given the limited pediatric sleep medicine resources in several countries worldwide.
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Affiliation(s)
- Natalia S Escobar
- Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, The University of Toronto, Toronto, Canada
| | - Adeline Y L Lim
- Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, The University of Toronto, Toronto, Canada
| | - Reshma Amin
- Division of Respiratory Medicine, Department of Pediatrics, The Hospital for Sick Children, The University of Toronto, Toronto, Canada
- Child Health and Evaluative Science, SickKids Research Institute, Toronto, Canada
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2
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Parikh SR, Boudewyns A, Friedman NR, Schwartz SR, Baldassari CM, Benedek P, Carr MM, Chan DK, Chan KC, Cheng AT, Couloigner V, Diala OR, DeRowe A, El-Hakim H, Fayoux P, Hsu WC, Ishman S, Kirkham EM, Mitchell RB, Thevasagayam R, Lam D. International Pediatric Otolaryngology Group (IPOG) consensus on scoring of pediatric Drug Induced Sleep Endoscopy (DISE). Int J Pediatr Otorhinolaryngol 2023; 171:111627. [PMID: 37441992 DOI: 10.1016/j.ijporl.2023.111627] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/10/2023] [Accepted: 06/05/2023] [Indexed: 07/15/2023]
Abstract
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.
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Affiliation(s)
- Sanjay R Parikh
- Department of Otolaryngology, University of Washington, Seattle Children's Hospital, USA.
| | - An Boudewyns
- Department of Otolaryngology, Antwerp University Hospital, University of Antwerp, Belgium
| | - Norman R Friedman
- Department of Otolaryngology, University of Colorado, Children's Hospital Colorado, USA
| | - Seth Roslow Schwartz
- Department of Otolaryngology, University of Washington, Virginia Mason Hospital, Seattle, USA
| | - Cristina M Baldassari
- Department of Otolaryngology, Eastern Virginia Medical School, Children's Hospital of The King's Daughters, USA
| | - Palma Benedek
- Department of Otolaryngology, Heim Pal National Pediatric Institute, Hungary
| | - Michele M Carr
- Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, USA
| | - Dylan K Chan
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, USA
| | - Kate C Chan
- Department of Paediatrics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Alan T Cheng
- Department of Otolaryngology, The University of Sydney, The Children's Hospital at Westmead, Australia
| | - Vincent Couloigner
- Department of Otolaryngology, Hôpital Necker-Enfants Malades, Université Paris Cité, France
| | - Obinna R Diala
- Department of Otolaryngology, University of Colorado, Children's Hospital Colorado, USA
| | - Ari DeRowe
- Department of Otolaryngology Head and Neck and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Dana-Dwek Children's Hospital, Israel
| | - Hamdy El-Hakim
- Department of Otolaryngology, University of Alberta, Stollery Children's Hospital, Canada
| | - Pierre Fayoux
- Pediatric Otolaryngology - Head Neck Surgery, Jeanne de Flandre Hospital, CHU Lille, France
| | - Wei-Chung Hsu
- Department of Otolaryngology, National Taiwan University Hospital and Children's Hospital, Taiwan
| | - Stacey Ishman
- Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Erin M Kirkham
- Department of Otolaryngology, University of Michigan, Mott Children's Hospital, USA
| | - Ron B Mitchell
- Department of Otolaryngology, University of Texas, Southwestern Medical Center, Children's Medical Center Dallas, USA
| | - Ravi Thevasagayam
- Department of Otolaryngology, Sheffield Children's Hospital, United Kingdom
| | - Derek Lam
- Department of Otolaryngology, Oregon Health and Science University, USA
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Ergenekon AP, Gokdemir Y, Ersu R. Medical Treatment of Obstructive Sleep Apnea in Children. J Clin Med 2023; 12:5022. [PMID: 37568423 PMCID: PMC10419369 DOI: 10.3390/jcm12155022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/17/2023] [Accepted: 07/24/2023] [Indexed: 08/13/2023] Open
Abstract
Obstructive sleep apnea (OSA) is characterized by recurrent complete or partial obstruction of the upper airway. The prevalence is 1-4% in children aged between 2 and 8 years and rising due to the increase in obesity rates in children. Although persistent OSA following adenotonsillectomy is usually associated with obesity and underlying complex disorders, it can also affect otherwise healthy children. Medical treatment strategies are frequently required when adenotonsillectomy is not indicated in children with OSA or if OSA is persistent following adenotonsillectomy. Positive airway pressure treatment is a very effective modality for persistent OSA in childhood; however, adherence rates are low. The aim of this review article is to summarize medical treatment options for OSA in children.
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Affiliation(s)
- Almala Pinar Ergenekon
- Division of Pediatric Pulmonology, Marmara University, 34890 Istanbul, Turkey; (A.P.E.); (Y.G.)
| | - Yasemin Gokdemir
- Division of Pediatric Pulmonology, Marmara University, 34890 Istanbul, Turkey; (A.P.E.); (Y.G.)
| | - Refika Ersu
- Division of Respirology, Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON K1N 6N5, Canada
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Ersu R, Chen ML, Ehsan Z, Ishman SL, Redline S, Narang I. Persistent obstructive sleep apnoea in children: treatment options and management considerations. THE LANCET. RESPIRATORY MEDICINE 2023; 11:283-296. [PMID: 36162413 DOI: 10.1016/s2213-2600(22)00262-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 05/15/2022] [Accepted: 07/05/2022] [Indexed: 10/14/2022]
Abstract
Unresolved obstructive sleep apnoea (OSA) after an adenotonsillectomy, henceforth referred to as persistent OSA, is increasingly recognised in children (2-18 years). Although associated with obesity, underlying medical complexity, and craniofacial disorders, persistent OSA also occurs in otherwise healthy children. Inadequate treatment of persistent OSA can lead to long-term adverse health outcomes beyond childhood. Positive airway pressure, used as a one-size-fits-all primary management strategy for persistent childhood OSA, is highly efficacious but has unacceptably low adherence rates. A pressing need exists for a broader, more effective management approach for persistent OSA in children. In this Personal View, we discuss the use and the need for evaluation of current and novel therapeutics, the role of shared decision-making models that consider patient preferences, and the importance of considering the social determinants of health in research and clinical practice. A multipronged, comprehensive approach to persistent OSA might achieve better clinical outcomes in childhood and promote health equity for all children.
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Affiliation(s)
- Refika Ersu
- Division of Respiratory Medicine, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada; Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - Maida L Chen
- Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Zarmina Ehsan
- Division of Pulmonary and Sleep Medicine, Children's Mercy Hospital, Kansas City, MO, USA; Department of Pediatrics, University of Missouri, Kansas City, KS, USA
| | - Stacey L Ishman
- Division of Pulmonary and Sleep Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Division of HealthVine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Otolaryngology, Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Susan Redline
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Indra Narang
- Division of Respiratory Medicine, Department of Paediatrics, Hospital for Sick Children, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada.
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Lackey TG, Tholen K, Pickett K, Friedman N. Residual OSA in Down syndrome: does body position matter? J Clin Sleep Med 2023; 19:171-177. [PMID: 36081330 PMCID: PMC9806788 DOI: 10.5664/jcsm.10288] [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] [Received: 04/30/2022] [Revised: 09/06/2022] [Accepted: 09/06/2022] [Indexed: 01/07/2023]
Abstract
STUDY OBJECTIVES To examine children with Down syndrome with residual obstructive sleep apnea (OSA) to determine if they are more likely to have positional OSA. METHODS A retrospective chart review of children with Down syndrome who underwent adenotonsillectomy at a single tertiary children's hospital was conducted. Children with Down syndrome who had a postoperative polysomnogram with obstructive apnea-hypopnea index (OAHI) > 1 event/h, following adenotonsillectomy with at least 60 minutes of total sleep time were included. Patients were categorized as mixed sleep (presence of ≥ 30 minutes of both nonsupine and supine sleep), nonsupine sleep, and supine sleep. Positional OSA was defined as an overall OAHI > 1 event/h and a supine OAHI to nonsupine OAHI ratio of ≥ 2. Group differences are tested via Kruskal-Wallis test for continuous variables and Fisher's exact tests for categorical. RESULTS There were 165 children with Down syndrome who met inclusion criteria, of which 130 individuals had mixed sleep. Patients who predominately slept supine had a greater OAHI than mixed and nonsupine sleep (P = .002). Sixty (46%) of the mixed-sleep individuals had positional OSA, of which 29 (48%) had moderate/severe OSA. Sleeping off their backs converted 14 (48%) of these 29 children from moderate/severe OSA to mild OSA. CONCLUSIONS Sleep physicians and otolaryngologists should be cognizant that the OAHI may be an underestimate if it does not include supine sleep. Positional therapy is a potential treatment option for children with residual OSA following adenotonsillectomy and warrants further investigation. CITATION Lackey TG, Tholen K, Pickett K, Friedman N. Residual OSA in Down syndrome: does body position matter? J Clin Sleep Med. 2023;19(1):171-177.
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Affiliation(s)
- Taylor G. Lackey
- Department of Otolaryngology and Head and Neck Surgery, University of Colorado Denver, Aurora, Colorado
| | - Kaitlyn Tholen
- Louisiana State University Health Shreveport School of Medicine, Shreveport, Louisiana
| | - Kaci Pickett
- Center for Research Outcomes in Children’s Surgery, Center for Children’s Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Norman Friedman
- Department of Pediatric Otolaryngology, Children’s Hospital Colorado, Aurora, Colorado
- Department of Pediatric Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado
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The Effects of Barbed Repositioning Pharyngoplasty in Positional and Non-Positional OSA Patients: A Retrospective Analysis. J Clin Med 2022; 11:jcm11226749. [PMID: 36431226 PMCID: PMC9697864 DOI: 10.3390/jcm11226749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 11/05/2022] [Accepted: 11/11/2022] [Indexed: 11/17/2022] Open
Abstract
PURPOSE The aim of our retrospective study is evaluating the effectiveness of barbed repositioning pharyngoplasty (BRP) in a consecutive cohort of patients and assessing its impact on positional indexes in order to potentially identify specific obstructive sleep apnea (OSA) phenotypes for patients who might benefit more significantly from this intervention. METHODS A single-center retrospective study with baseline and follow-up type III sleep tests evaluating the Apnea Hypopnea Index (AHI), supine AHI, non-supine AHI, oxygen desaturation index (ODI), mean SaO2, percentage of time spent at SaO2 below 90% (CT90), and lowest oxygen saturation (LOS) were performed. The patients were then divided into groups according to Sher's criteria and Amsterdam Positional OSA Classification (APOC). Parametric and non-parametric tests and univariate and multivariate analyses were conducted. RESULTS The study finally included 47 patients. The statistical analysis showed significant improvement in AHI, supine AHI, non-supine AHI, and ODI after surgery. The linear regression showed that high values of baseline AHI, AHI supine, and AHI non supine predict more significant postoperative reductions in AHI, AHI supine, and AHI non supine, respectively. Therapeutic success was achieved in 22 patients out of 47. The logistic regression did not find any independent risk factors for success. The most significant reduction in AHI, supine AHI, and non-supine AHI was observed in the APOC 3 group while the APOC 1 patients experience a substantially lower improvement. CONCLUSIONS BRP appears to be an effective surgical procedure for the treatment of OSA. The non-positional patients might benefit more from BRP in comparison with positional patients. Moreover, OSA severity should not be considered an absolute contra-indication for this surgical procedure.
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Wu Y, Zheng L, Cui G, Xu Z, Ni X. Subtypes of obstructive sleep apnea in children and related factors. J Clin Sleep Med 2022; 18:2397-2404. [PMID: 35808945 PMCID: PMC9516574 DOI: 10.5664/jcsm.10124] [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] [Received: 01/11/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES To investigate the prevalence of positional obstructive sleep apnea (P-OSA) and rapid eye movement-related OSA (REM-OSA) in children with OSA and identify related factors. METHODS This was a cross-sectional study among children aged 2-12 years diagnosed with OSA using overnight polysomnography (PSG) between August 1, 2020, and July 31, 2021. Demographics, anthropometrics, PSG, and OSA-18 questionnaire data were recorded. RESULTS Data from a total of 474 children were available for analysis. Children had a median age of 4.8 (4.1, 6.4) years, 66.7% were male, and 23.2% were obese. The prevalence of P-OSA was 38.2% and that of REM-OSA was 43.0%. P-OSA was correlated with age and obstructive apnea-hypopnea index (OAHI; odds ratio [OR] = 1.172, 0.947; P = .005, < 0.001, respectively), but not sex, obesity, and adenoid and tonsil size (OR = 1.265, 0.785, 0.826, 0.989; P = .258, 0.327, 0.153, 0.905, respectively). REM-OSA was correlated with age, adenoid size, tonsil size, and OAHI (OR = 0.876, 1.320, 1.387, 1.021; P = .024, 0.040, 0.001, 0.042) but not with sex and obesity (OR = 0.910, 1.281; P = .643, 0.315). CONCLUSIONS The prevalence of P-OSA was 38.2% and that of REM-OSA was 43.0% in children with OSA. Age was correlated with both the prevalence of P-OSA and REM-OSA, with an increasing and decreasing prevalence as children grew older, respectively. The severity of OSA was significantly associated with the prevalence of both P-OSA and REM-OSA. Adenoid and tonsil size were correlated with the prevalence of REM-OSA but not P-OSA. Obesity and sex were not associated with the prevalence of P-OSA or REM-OSA. CITATION Wu Y, Zheng L, Cui G, Xu Z, Ni X. Subtypes of obstructive sleep apnea in children and related factors. J Clin Sleep Med. 2022;18(10):2397-2404.
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Affiliation(s)
- Yunxiao Wu
- Beijing Key Laboratory of Pediatric Diseases of Otolaryngology, Head, and Neck Surgery, Beijing Pediatric Research Institute, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing, China
| | - Li Zheng
- Department of Otolaryngology, Head, and Neck Surgery, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing, China
| | - Guanqun Cui
- Department of Respiratory Medicine, Qilu Children’s Hospital of Shandong University, Jinan, China
| | - Zhifei Xu
- Department of Respiratory Medicine, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing, China
| | - Xin Ni
- Department of Otolaryngology, Head, and Neck Surgery, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing, China
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Friedman NR, Meier M, Tholen K, Crowder R, Hoefner-Notz R, Nguyen T, Derieg S, Campbell K, McLeod L. Tonsillectomy for Obstructive Sleep-Disordered Breathing: Should They Stay, or Could They Go? Laryngoscope 2022; 132:1675-1681. [PMID: 34672364 DOI: 10.1002/lary.29909] [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] [Received: 06/11/2021] [Revised: 10/05/2021] [Accepted: 10/12/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Children who do not require oxygen beyond 3 hours after surgery and pass a sleep room air challenge (SRAC) are safe for discharge regardless of polysomnogram (PSG) results or comorbidities. STUDY DESIGN Cross-sectional prospective study. METHODS All children observed overnight undergoing an adenotonsillectomy for obstructive sleep-disordered breathing were prospectively recruited. Demographic, clinical, and PSG characteristics were stratified by whether the patient had required oxygen beyond 3 hours postoperatively (prolonged oxygen requirement [POR]) and compared using t test, chi-squared test, or Fisher's exact test depending on distribution. Optimal cut points for predicting POR postsurgery were calculated using receiver operating characteristic curves. The primary analysis was performed on the full cohort via logistic regression using POR as the outcome. Significant characteristics were analyzed in a logistic regression model, with significance set at P < .05. RESULTS A total of 484 participants met the inclusion criteria. The mean age was 5.65 (standard deviation = 4.02) years. Overall, 365 (75%) did not have a POR or any other adverse respiratory event. In multivariable logistic regression, risk factors for POR were an asthma diagnosis (P < .001) and an awake SpO2 <96% (P = .005). The probability of a POR for those without asthma and a SpO2 ≥ 96% was 18% (95% confidence interval: 14-22). Age, obesity, and obstructive apnea/hypopnea index were not associated with POR. CONCLUSIONS In conclusion, all children in our study who are off oxygen within 3 hours of surgery and passed a SRAC were safe for discharge from a respiratory standpoint regardless of age, obesity status, asthma diagnosis, and obstructive apnea/hypopnea index. Additional investigations are necessary to confirm our findings. LEVEL OF EVIDENCE 3 Laryngoscope, 132:1675-1681, 2022.
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Affiliation(s)
- Norman R Friedman
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
- Division of Pediatric Otolaryngology, Children's Hospital Colorado, Aurora, Colorado, U.S.A
| | - Maxene Meier
- The Center for Research in Outcomes for Children's Surgery, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Kaitlyn Tholen
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
- Division of Pediatric Otolaryngology, Children's Hospital Colorado, Aurora, Colorado, U.S.A
| | - Renee Crowder
- University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Regina Hoefner-Notz
- Perioperative Services, Children's Hospital Colorado, Aurora, Colorado, U.S.A
| | - Thanh Nguyen
- Division of Pediatric Anesthesia, Children's Hospital Colorado, Aurora, Colorado, U.S.A
- Department of Anesthesiology, School of Medicine, University of Colorado, Aurora, Colorado, U.S.A
| | - Sarah Derieg
- Ambulatory Services, Children's Hospital Colorado, Aurora, Colorado, U.S.A
| | - Kristen Campbell
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Lisa McLeod
- Pediatric Center of Excellence, Global Product Development, Pfizer, Inc., New York, New York, U.S.A
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Chamnanpet S, Tovichien P, Tanphaichitr A, Chotinaiwattarakul W. Prevalence and Risk Factors for Rapid Eye Movement-Related Obstructive Sleep Apnea in Children. Front Pediatr 2022; 10:869986. [PMID: 35573955 PMCID: PMC9097965 DOI: 10.3389/fped.2022.869986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 03/22/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Different pathophysiological mechanisms and the distribution of respiratory events among rapid eye movement (REM) and non-rapid eye movement (NREM) sleep modulate the effect of obstructive sleep apnea (OSA). We aimed to study the prevalence and risk factors for REM-related OSA in children. STUDY DESIGN Retrospective, cross-sectional study. METHODS We recruited 366 children with OSA confirmed by polysomnography (PSG) over a 5-year period. REM-related OSA is defined by an obstructive apnea-hypopnea index (OAHI) in the REM sleep ≥2× than during NREM sleep. RESULTS The prevalence of REM-related OSA in children was 50.3%. Children with REM-related OSA were more likely to be female (P = 0.042), and had lower prevalence of adenotonsillar hypertrophy (P = 0.043) compared with children with other OSA subtypes. Children with REM-related OSA slept longer in the supine position (P = 0.003), had shorter duration of NREM1 sleep (P = 0.018), lower nadir SpO2 (P = 0.005), and a higher oxygen desaturation index 3% (ODI3%) (P = 0.014), and lower arousal index (P = 0.034) compared with other OSA subtypes. Female gender and supine sleep was the independent risk factors for REM-related OSA. CONCLUSION The prevalence of REM-related OSA was 50.3%. OAHIREM should be considered as an important parameter in future clinical research studies done in children with OSA.
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Affiliation(s)
- Surisa Chamnanpet
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Prakarn Tovichien
- Division of Pulmonology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Archwin Tanphaichitr
- Department of Otorhinolaryngology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Wattanachai Chotinaiwattarakul
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.,Siriraj Sleep Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Xiao L, Baker A, Voutsas G, Massicotte C, Wolter NE, Propst EJ, Narang I. Positional device therapy for the treatment of positional obstructive sleep apnea in children: a pilot study. Sleep Med 2021; 85:313-316. [PMID: 34399395 DOI: 10.1016/j.sleep.2021.07.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 07/21/2021] [Accepted: 07/23/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND There is a critical gap in identifying effective interventions for children with obstructive sleep apnea (OSA) who do not tolerate continuous positive airway pressure therapy. Positional OSA (POSA) is a common clinical phenotype whereby OSA occurs predominantly while sleeping in supine position. POSA may be amenable to treatment with a positional device, a belt worn around the chest with cushions on the back to prevent supine positioning, but no data exists in children. The primary aim of this study was to evaluate the efficacy of positional device therapy for the treatment of POSA in children. METHODS This observational study included children aged 4-18 years with POSA and an obstructive apnea-hypopnea index (OAHI) ≥ 5 events/hour on baseline polysomnogram (PSG) who underwent a second PSG to evaluate the efficacy of a positional device. The primary outcome was the change in OAHI. RESULTS Ten children were included (8 male, median age 11.2 years, median body mass index z-score 1.6). Compared to the baseline PSG, PSG data obtained while using a positional device showed a reduced median (interquartile range) OAHI (15.2 [8.3-25.6] versus 6.7 [1.0-13.7] events/hour respectively; p = 0.004) and percentage of total sleep time in supine position (54.4 [35.0-80.6]% versus 4.2 [1.1-25.2]% respectively; p = 0.04). Despite observed improvements in the oxygen desaturation index, these results were not statistically significant. SIGNIFICANCE AND CONCLUSIONS In this novel pilot study, positional device therapy was effective for the treatment of POSA. Positional device therapy may potentially change clinical practice as a cost-efficient and non-invasive treatment option for POSA.
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Affiliation(s)
- Lena Xiao
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada
| | - Adele Baker
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Giorge Voutsas
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada
| | - Colin Massicotte
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Nikolaus E Wolter
- University of Toronto, Toronto, ON, Canada; Department of Otolaryngology - Head and Neck Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Evan J Propst
- University of Toronto, Toronto, ON, Canada; Department of Otolaryngology - Head and Neck Surgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Indra Narang
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada.
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Hines S, Pickett K, Tholen K, Handley E, Friedman NR. Tonsillectomy Outcomes for Children With Severe Obesity. Laryngoscope 2021; 132:461-469. [PMID: 34191279 DOI: 10.1002/lary.29712] [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: 05/06/2021] [Revised: 06/14/2021] [Accepted: 06/21/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS To determine the success of an adenotonsillectomy (T&A) in treating children with severe obesity utilizing a more accurate obesity scale. STUDY DESIGN Retrospective cohort. METHODS A retrospective cohort of children with obesity between 5 and 10 years of age who underwent a T&A at Children's Hospital of Colorado (CHCO) was used. This study also utilized publicly available data from the Childhood Adenotonsillectomy Trial (CHAT) study. The cohort was divided into three obesity classes using age- and sex-specific body mass index (BMI) expressed as a percentage of the 95th percentile (%BMIp95) and compared for operative success differences. RESULTS There were 132 patients included in our primary analysis, with obesity distribution as follows: Class 1 to 53 patients (40%), Class 2 to 45 patients (34%), and Class 3 to 34 patients (26%). Overall, 52 patients (35.9%) experienced a cure (obstructive apnea/hypopnea index [OAHI] <1), with 27 (52%) patients in Class 1 obesity, 18 (35%) in Class 2, and 7 (13%) in Class 3. Class 3 had a significantly lower obstructive sleep apnea cure rate compared with Class 1 patients (P = .013), but after adjusting for covariates, this difference was no longer present (P > .05). There was no significant difference in the preoperative to postoperative percent change in mean oxygen saturation (P = .82 CHCO, P = .43 CHAT), oxygen nadir (P = .20 CHCO, P = .49 CHAT), or OAHI (P = .12 CHCO, P = .26 CHAT) between the obesity classes. CONCLUSION After adjusting for covariates, children with Class 3 obesity are as likely to be cured with a T&A as those with Class 1 obesity. A T&A should be considered a first line treatment for all children with obesity. LEVEL OF EVIDENCE 3 Laryngoscope, 2021.
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Affiliation(s)
- Susan Hines
- Breathing Institute, Children's Hospital Colorado, Aurora, Colorado, U.S.A.,Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Kaci Pickett
- Center for Research in Outcomes for Children's Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Kaitlyn Tholen
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado School, Aurora, Colorado, U.S.A.,University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, U.S.A
| | - Elyse Handley
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado School, Aurora, Colorado, U.S.A.,University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, U.S.A
| | - Norman R Friedman
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado School, Aurora, Colorado, U.S.A.,University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, U.S.A
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Tholen K, Meier M, Kloor J, Friedman N. Persistent OSA in obese children: does body position matter? J Clin Sleep Med 2021; 17:227-232. [PMID: 33094724 DOI: 10.5664/jcsm.8902] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
STUDY OBJECTIVES The objective of this study was to determine if positional therapy is a viable treatment alternative for obese children with persistent obstructive sleep apnea (OSA). METHODS A retrospective review was performed of children who underwent an adenotonsillectomy for OSA from 2014 to 2017. Children were included if they had a body mass index ≥ 95th percentile and underwent a postoperative polysomnogram. Subjects fell into one of three categories: mixed sleep (the presence of ≥ 30 minutes of both nonsupine and supine sleep), nonsupine sleep, and supine sleep. Cure was defined as an OSA/apnea-hypopnea index of < 1 events/h. Paired t tests were used to assess the differences, and a linear model adjusting for obesity class, age at procedure, and sex was performed to assess the differences between nonsupine and supine sleep. RESULTS There were 154 children who met the inclusion criteria. Using a paired t test, supine sleep position had a significantly higher average OSA/apnea-hypopnea index (7.9 events) compared with nonsupine (OSA/apnea-hypopnea index of 4.1); P value was < .01 for the 60 children with mixed sleep. Forty-three children had predominantly nonsupine sleep and 33 predominantly supine sleep, and a McNemar's test comparing these children showed that those sleeping in the nonsupine position were significantly more likely to be cured than those in the supine position (P < .001). CONCLUSIONS Sleep physicians and otolaryngologists should be cognizant of positional treatment when consulting with families and note that the postoperative polysomnography may be inaccurate if it does not include supine sleep. Positional therapy as a potential treatment option for obese children with persistent OSA after adenotonsillectomy warrants further investigation.
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Affiliation(s)
- Kaitlyn Tholen
- Department of Pediatric Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado.,Department of Pediatric Otolaryngology, Children's Hospital Colorado, Aurora, Colorado
| | - Maxene Meier
- Center for Research Outcomes in Children's Surgery, Center for Children's Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Jackson Kloor
- University of Colorado School of Medicine, Aurora, Colorado
| | - Norman Friedman
- Department of Pediatric Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado.,Department of Pediatric Otolaryngology, Children's Hospital Colorado, Aurora, Colorado
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Li C, Kou YF, Ishman SL. Pediatric OSA: Evidence-Based Review of Treatment Results. CURRENT OTORHINOLARYNGOLOGY REPORTS 2021. [DOI: 10.1007/s40136-021-00348-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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14
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Effect of body weight on upper airway findings and treatment outcome in children with obstructive sleep apnea. Sleep Med 2020; 79:19-28. [PMID: 33465738 DOI: 10.1016/j.sleep.2020.12.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 11/20/2022]
Abstract
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.
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Selvadurai S, Voutsas G, Massicotte C, Kassner A, Katz SL, Propst EJ, Narang I. Positional obstructive sleep apnea in an obese pediatric population. J Clin Sleep Med 2020; 16:1295-1301. [PMID: 32807295 PMCID: PMC7446091 DOI: 10.5664/jcsm.8496] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 04/09/2020] [Accepted: 04/09/2020] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Positional obstructive sleep apnea (POSA) is a phenotype of obstructive sleep apnea (OSA) where sleep-related obstructive events occur predominantly in the supine position. Limited knowledge exists regarding the presence of POSA in children with obesity. The study objective was to determine the prevalence of POSA while identifying factors associated with POSA in children with obesity. METHODS This was a cross-sectional study of children with obesity, aged 8 to 18 years, with a diagnostic polysomnogram (PSG) between 2012 to 2019, who were referred for the evaluation of sleep-related breathing. POSA was defined as an overall obstructive apnea-hypopnea index (OAHI) ≥5 events/h and a supine OAHI to nonsupine OAHI ratio of ≥2. Patient demographics, anthropometrics, and PSG data were recorded. RESULTS Of the 112 children with obesity with a diagnostic PSG, 43 (38%) had OSA. Among those with OSA, 25 of 43 (58%) had POSA (mean age: 14.6 ± 2.3 years; mean body mass index: 37.7 ± 7.6 kg/m²; 68% male) and 18 of 43 (42%) had non-POSA (mean age: 13.9 ± 2.8 years; mean body mass index: 37.9 ± 7.2 kg/m²; 78% male). Among those with POSA, 13 of 25 (52%) had mild OSA, 7 of 25 (28%) had moderate OSA, and 5 of 25 (20%) had severe OSA. No significant differences were found in age, sex, and anthropometric measures between POSA and non-POSA groups. Time spent in supine and nonsupine sleep did not differ significantly between groups. CONCLUSIONS In children with obesity and OSA, POSA occurs frequently. Identifying POSA allows for potential targeted positional therapy for children with obesity.
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Affiliation(s)
- Sarah Selvadurai
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Giorge Voutsas
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, Canada
- University of Toronto, Toronto, Canada
| | - Colin Massicotte
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Canada
| | - Andrea Kassner
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, Canada
- University of Toronto, Toronto, Canada
| | - Sherri Lynne Katz
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, Canada
- University of Ottawa, Ottawa, Canada
| | - Evan J. Propst
- University of Toronto, Toronto, Canada
- Department of Otolaryngology, Head and Neck Surgery, Hospital for Sick Children, Toronto, Canada
| | - Indra Narang
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, Canada
- University of Toronto, Toronto, Canada
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Canada
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Kirkham EM, Melendez JB, Hoi K, Chervin RD. Drug-Induced Sleep Endoscopy in Children With Positional Obstructive Sleep Apnea. Otolaryngol Head Neck Surg 2020; 164:191-198. [PMID: 32746692 DOI: 10.1177/0194599820941018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
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.
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Affiliation(s)
- Erin M Kirkham
- Department of Otolaryngology-Head & Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Jonathan B Melendez
- University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan, USA
| | - Karen Hoi
- University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan, USA
| | - Ronald D Chervin
- Sleep Disorders Center and Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
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