Pediatric obstructive sleep apnea syndrome (OSAS) for the allergist: update on the assessment and management

Effect of positive end-expiratory pressure ventilation on plasma nitric oxide, endothelin-1 and vascular celladhesion molecule-1 levels in patients undergoing uvulopalatopharyngoplasty

BACKGROUND

During uvulopalatopharyngoplasty (UPPP), cardiovascular adverse events may occur which can be harmful to patients.

OBJECTIVE

To evaluate the effect of the protective ventilation strategy on the function of vascular endothelial cells.

METHODS

Forty obstructive apnea syndrome (OSA) patients who underwent uvulopalatopharyngoplasty (UPPP) were enrolled. Patients were randomly divided into the control group (group C, PEEP = 0 cm H2O) and PEEP group (group P, PEEP = 5 cm H2O). Each group (n= 20) received intermittent volume controlled ventilation (VCV) with tidal volume 6 ml/kg of the predicted body weight, I:E 1:2, rate titrated for ETCO2 35-45, FiO2 0.7. Blood from the radial artery was sampled for blood gas analysis at four time points: the fifth minute of inhaling pure oxygen (T0), after tracheal intubation (T1), at the end of the operation (T2), and 20 minutes after extubation (T3). Three ml of arterial blood was retained, preserved at -20∘C after serum isolation, and plasma nitric oxide (NO), endothelin-1 (ET-1) and vascular celladhesion molecule-1 (VCAM-1) levels were determined by enzyme linked immunosorbent assay (ELISA).

RESULTS

Compared with group C, plasma ET-1 at T3 decreased in group P, and plasma NO levels at T2 and T3 increased (P< 0.05). Compared with samples collected at T0, plasma VCAM-1 levels at T1, T2 and T3 increased in group C, while plasma VCAM-1 levels at T2 and T3 decreased in group P (P< 0.05). Compared with group C, plasma VCAM-1 levels T2 and T3 decreased in group P (P< 0.05).

CONCLUSIONS

Positive end-expiratory pressure (PEEP) ventilation has a protective effect on vascular endothelial cell function in patients during UPPP.

Poor sleep quality has an adverse effect on childhood asthma control and lung function measures

BACKGROUND

It is unclear as to whether sleep respiratory breathing disorder (SRBD) is a risk factor for uncontrolled asthma in children. The aim of this study was therefore to investigate whether SRBD may have an adverse effect on childhood asthma control and lung function measures.

METHODS

This was a cross-sectional study of 220 children with well-controlled (n = 108), partly controlled (n = 92), and uncontrolled asthma (n = 20) according to the Global Initiative for Asthma guideline. SRBD was assessed using the Pediatric Sleep Questionnaire (PSQ). The association of SRBD with partly controlled/uncontrolled asthma was investigated on multivariate logistic regression analysis.

RESULTS

Of 220 children with asthma, 43 (19.6%) had SRBD: well-controlled, 16.7% (18/108); partly controlled, 21.7% (20/92); and uncontrolled, 25.0% (5/20; P = 0.54). There was a significant difference in forced expiratory volume in 1 s/forced vital capacity (FEV₁ /FVC; P = 0.007) and childhood asthma control test (C-ACT) score (P < 0.001) according to asthma control status, but not in PSQ score (P = 0.18). Children with obstructive sleep apnea (PSQ >0.33) had a lower C-ACT score compared with controls (PSQ ≤0.33; 19.6 ± 5.1 vs 22.0 ± 4.2, P = 0.002). PSQ score was negatively correlated with FEV₁ /FVC (r = -0.16, P = 0.02). On multivariate logistic regression analysis, high PSQ score increased the odds of having partly controlled/uncontrolled asthma by 9.12 (95% CI: 1.04-79.72, P = 0.046) after adjusting for confounding factors.

CONCLUSION

SRBD is an independent risk factor for partly controlled/uncontrolled asthma and has an adverse effect on lung function measures in children. Further research is warranted to determine whether the improvement of sleep quality may also enhance level of asthma control and lung function in children.

Pediatric Sleep Apnea Syndrome: An Update

Obstructive sleep apnea syndrome (OSAS) may be central neurologic (<5%) or obstructive (>95%) in origin and is a relatively prevalent condition in children. It affects 1%-5% of children aged 2-8 years and is caused by a variety of different pathophysiologic abnormalities. Cardiovascular, metabolic, and neurocognitive comorbidities can occur in both children and adults when left untreated. It also can cause severe behavioral problems in children. The American Academy of Pediatrics recommends that all children be screened with an appropriate history and physical examination for symptoms and signs suggestive of OSAS. The diagnosis is primarily made clinically and confirmed by polysomnographic findings. Treatment depends on the child's age, underlying medical problems, polysomnography findings, and whether or not there is upper airway obstruction usually secondary to enlarged adenoids and/or tonsils, allergic and nonallergic rhinitis, acute and chronic sinusitis, and other upper airway pathology. If enlarged adenoid or tonsils or both conditions exist, an adenoidectomy, tonsillectomy, or adenotonsillectomy remains the treatment of choice. Pharmacotherapy of OSAS has shown some effect in children with mild symptoms. This paper reviews the prevalence, pathophysiology, clinical presentation, diagnosis, and treatment of OSAS.

The Role of Co-Morbidities

Medical conditions can impact sleep and breathing in children. Gastroesophageal reflux disease, allergic rhinitis and asthma are common in children and often coexist with obstructive sleep apnea. Appropriate identification and management of these conditions can improve nocturnal and diurnal symptoms of sleep disordered breathing. We discuss the relationship between these medical conditions and obstructive sleep apnea in children.

Pediatric allergic rhinitis

Allergic rhinitis is a common pediatric problem with significant comorbidities and potential complications. This article is an overview of the epidemiology, pathophysiology, and current therapeutic strategies. Allergic rhinitis management in a specific child is age dependent and influenced by the severity and frequency of the symptoms and the presence of any concurrent conditions. Current strategies permit symptomatic control and improved quality of life for most patients.

Microbiological profile of adenoid hypertrophy correlates to clinical diagnosis in children

Objective. Adenoid hypertrophy is a common condition in childhood, which may be associated with recurring acute otitis media (RAOM), otitis media with effusion (OME), and obstructive sleep apnea syndrome (OSAS). These different clinical characteristics have some clinical overlap; however, they might be explained by distinct immunologic and infectious profiles and result in various histopathologic findings of adenoid specimens. Methods. A total of 59 children with adenoid hypertrophy undergoing adenoidectomy were studied. Three series of identical adenoid specimens were processed to hematoxylin-eosin (H.E.) and Gram staining and to respiratory virus specific real-time PCR, respectively. Results. According to the clinical characteristics, patients were recruited into three groups: RAOM (n = 25), OME (n = 19), and OSAS (n = 15). Bacterial biofilms were detected in 21 cases, while at least one of the studied respiratory viruses was detected in 52 specimens. RAOM cases were significantly associated with biofilm existence (n = 20, P < 0.001). In contrast, OME group was characterized by the absence of bacterial biofilm and by normal mucosa. Showing a statistically significant correlation, all OME cases were positive for human bocavirus (HBoV, P < 0.001). Conclusions. Bacterial biofilms might contribute to the damage of respiratory epithelium and recurring acute infections resulting in RAOM. In OME cases persisting respiratory viruses, mainly HBoV, can cause subsequent lymphoid hyperplasia leading to ventilation disorders and impaired immunoreactivity of the middle ear cleft.

Challenges in paediatric ambulatory anesthesia

PURPOSE OF REVIEW

Clinical studies and new guidelines are frequently being published in the area of preoperative fasting. A growing population of patients with obstructive sleep apnea is being referred for outpatient procedures including adenotonsillectomy.

RECENT FINDINGS

Recently published preoperative fasting guidelines for pediatric patients are covered along with studies comparing gastric volume following different fasting intervals. Pediatric obstructive sleep apnea is discussed. Clinical presentation, severity, perioperative risks, and controversies as whether outpatient procedures are suitable for these patients are presented. New data covering different perioperative aspects are presented.

SUMMARY

A more liberal preoperative intake is encouraged with fasting for 2 h for clear liquids, 4  h for breast milk, 6  h for formula and light meals, and 8  h for heavy meals is widely accepted. Interpersonal variation in residual gastric volume exists. Children with obstructive sleep apnea under 3 years of age and those with severe obstructive sleep apnea and comorbidities are not candidates for ambulatory surgery. Polysomnography has specific preoperative indications. Dexmedetomidine can decrease emergence agitation and has an opioid-sparing effect. Intravenous acetaminophen is presented as an opioid-sparing analgesic. Dexamethasone is effective in preventing postoperative nausea without increased risk of bleeding. Surgical techniques may affect postoperative pain.