Tailoring therapy to improve the treatment of children with obstructive sleep apnea according to grade of adenotonsillar hypertrophy

Pharmacological interventions for pediatric obstructive sleep apnea (OSA): Network meta-analysis

IMPORTANCE

Pediatric obstructive sleep apnea (OSA) is a common disease that can have significant negative impacts on a child's health and development. A comprehensive evaluation of different pharmacologic interventions for the treatment of OSA in children is still lacking.

OBJECTIVE

This study aims to conduct a comprehensive systematic review and network meta-analysis of pharmacological interventions for the management of obstructive sleep apnea in pediatric population.

DATA SOURCES

PubMed, Web of Science, Embase, The Cochrane Library, and CNKI were searched from 1950 to November 2022 for pediatric OSA.

STUDY SELECTION

Multiple reviewers included Randomized controlled trials (RCTs) concerning drugs on OSA in children.

DATA EXTRACTION AND SYNTHESIS

Multiple observers followed the guidance of the PRISMA NMA statement for data extraction and evaluation. Bayesian network meta-analyses(fixed-effect model) were performed to compare the weighted mean difference (WMD), logarithmic odds ratios (log OR), and the surface under the cumulative ranking curves (SUCRA) of the included pharmacological interventions. Our protocol was registered in PROSPERO website (CRD42022377839).

MAIN OUTCOME(S) AND MEASURE(S)

The primary outcomes were improvements in the apnea/hypopnea index (AHI), while secondary outcomes included adverse events and the lowest arterial oxygen saturation (SaO2).

RESULTS

17 RCTs with a total of 1367 children with OSA aged 2-14 years that met the inclusion criteria were eventually included in our systematic review and network meta-analysis. Ten drugs were finally included in the study. The results revealed that Mometasone + Montelukast (WMD-4.74[95%CrIs -7.50 to -2.11], Budesonide (-3.45[-6.86 to -0.15], and Montelukast(-3.41[-5.45 to -1.39] exhibited significantly superior therapeutic effects compared to the placebo concerning apnea hypopnea index (AHI) value with 95%CrIs excluding no effect. Moreover, Mometasone + Montelukast achieved exceptionally high SUCRA values for both AHI (85.0 %) and SaO2 (91.0 %).

CONCLUSIONS AND RELEVANCE

The combination of mometasone furoate nasal spray and oral montelukast sodium exhibits the highest probability of being the most effective intervention. Further research is needed to investigate the long-term efficacy and safety profiles of these interventions in pediatric patients with OSA.

Local Atopy in Childhood Adenotonsillar Hypertrophy

Background Although the cause of adenotonsillar hypertrophy remains unknown, some studies have shown that allergy may be a risk factor. Purpose This study determined the levels of allergen-specific immunoglobulin E (sIgE) in the adenotonsillar tissues of children with adenotonsillar hypertrophy and evaluated the clinical significance of local atopy in adenotonsillar tissues. Methods We measured 21 types of specific immunoglobulin E in the serum and adenotonsillar tissues of 102 children with adenotonsillar hypertrophy and compared the sensitization patterns of the serum and local tissues. The patients were divided into three groups-atopy, local atopy, and nonatopy-according to the sensitization of serum and adenotonsillar tissues, and the clinical symptoms among the groups were analyzed. Results Seventy-two (70.6%) children with adenotonsillar hypertrophy were sensitized to more than one allergen in the serum and/or adenotonsillar tissue. Thirty (29.4%) children had no IgE positivity to any allergen in both serum and adenotonsillar tissues. Fifty-five (53.9%) were sensitized to at least one allergen in the serum. Seventy (68.6%) were sensitized to at least one allergen in the adenotonsillar tissue. Seventeen (36.2%) of 47 children with specific immunoglobulin E-negative serum had specific immunoglobulin E-positive adenotonsillar tissues. The rate of specific immunoglobulin E was significantly higher in local tissues than in serum. The rate of inhalant allergen specific immunoglobulin E was significantly higher in the adenoids than in the tonsils. However, the rate of food allergen specific immunoglobulin E was significantly higher in the tonsils than adenoids. The lifetime prevalence of asthma and allergic rhinitis, recent symptoms or treatment of allergic rhinitis, and severity of nasal symptoms (rhinorrhea, sneezing, and nasal itching) were significantly higher in children with local atopy than with nonatopy. Conclusions These results confirm that allergic response may be a risk factor for adenotonsillar hypertrophy. Local allergic inflammation may play an important role in childhood adenotonsillar hypertrophy, and local atopy in adenotonsillar tissues can cause respiratory allergic symptoms in children.

Therapeutic effects of different drugs on obstructive sleep apnea/hypopnea syndrome in children

BACKGROUND

This study aimed to compare the therapeutic effects of different drugs on obstructive sleep apnea/hypopnea syndrome (OSAHS) in children by using a network meta-analysis approach.

METHODS

PubMed, Embase and Cochrane Library were searched from the inception of each database to November 2015. Randomized controlled trials (RCTs) concerning the comparisons in the therapeutic effects of eight placebo-controlled drugs on OSAHS in children were included in this study. Network meta-analysis combined direct evidence and indirect evidence to evaluate the weighted mean difference (WMD) and surface under the cumulative ranking curves (SUCRA) of therapeutic effects of eight drugs on OSAHS in children.

RESULTS

A total of seven RCTs were finally incorporated into our network meta-analysis. Pairwise meta-analysis results revealed that therapeutic effect of placebo was significantly poorer than that of intranasal mometasone furoate, montelukast, budesonide and fluticasone concerning apnea hypopnea index (AHI) value [WMD=1.40, 95% confidence interval (CI)=1.17-1.63; WMD=2.80, 95% CI=1.01-4.59; WMD=3.50, 95% CI=3.34-3.66; WMD=7.20, 95% CI=5.26-9.14, respectively], and fluticasone is better than placebo concerning sleep efficiency (WMD=3.50, 95% CI=2.42-4.58); regarding visual analogue scale, the therapeutic effect of placebo was poorer compared with sucralfate and clindamycin (WMD=1.94, 95% CI=1.13-2.75; WMD=1.06, 95% CI=0.22-1.90), and sucralfate is better than clindamycin (WMD=-0.88, 95% CI=-1.65 to -0.11). However, network meta-analysis results showed no obvious difference in the therapeutic effects of different drugs on OSAHS regarding AHI and sleep efficiency. Furthermore, the best SUCRA value was very high for fluticasone concerning AHI (86.6%) and budesonide concerning sleep efficiency (94.0%) for OSAHS treatment.

CONCLUSIONS

Fluticasone and budesonide have relatively good effects in the treatment of OSAHS in children, thus providing an important guiding significance for the treatment of OSAHS in children.

Adenotonsillectomy for Obstructive Sleep Apnea and Quality of Life: Systematic Review and Meta-analysis

Objective To determine the impact of adenotonsillectomy on the quality of life of pediatric patients with obstructive sleep apnea (OSA) and to identify gaps in the current research. Data Sources The MEDLINE, EMBASE, and Cochrane databases were systematically searched via the Ovid portal on June 18, 2016, for English-language articles. Review Methods Full-text articles were selected that studied boys and girls <18 years of age who underwent adenotonsillectomy for OSA or sleep-disordered breathing and that recorded validated, quantitative quality-of-life outcomes. Studies that lacked such measures, performed adenotonsillectomy for indications other than OSA or sleep-disordered breathing, or grouped adenotonsillectomy with other procedures were excluded. Results Of the 328 articles initially identified, 37 were included for qualitative analysis. The level of evidence was generally low. All studies involving short-term follow-up (≤6 months) showed improvement in quality-of-life scores after adenotonsillectomy as compared with preoperative values. Studies involving long-term follow-up (>6 months) showed mixed results. Modifications to and concurrent procedures with conventional adenotonsillectomy were also identified that showed quality-of-life improvements. Three studies were identified for meta-analysis that compared pre- and postoperative Obstructive Sleep Apnea-18 scores. Short- and long-term follow-up versus preoperative scores showed significant improvement ( P < .001). Short- and long-term scores showed no significant difference. Conclusion This systematic review and meta-analysis demonstrate adenotonsillectomy's effectiveness in improving the quality of life of pediatric patients with OSA. This is well demonstrated in the short term and has strong indications in the long term.

Is the difference in the volume of the pharyngeal space, as measured by acoustic pharyngometry, before and after tonsillectomy proportional to the volume of the excised tonsils?

OBJECTIVE

Adenotonsillectomy is recognized as an effective therapy for snoring and sleep disorders in children. It is important to understand whether adenotonsillectomy significantly increases the volume of the pharyngeal space. The goal of this study was to evaluate the change in oropharyngeal volume after adenotonsillectomy and the correlation of this change with the objective volume of the tonsils and body mass index.

METHODS

We included 27 subjects (14 males) with snoring caused by tonsil and adenoid hypertrophy. The mean age of the subjects was 7.92 (±2.52) years. Children with craniofacial malformations or neuromuscular diseases or syndromes were excluded. The parents/caregivers answered an adapted questionnaire regarding sleep-disordered breathing. All patients were subjected to weight and height measurements and body mass index was calculated. The subjects underwent pharyngometry before and after adenotonsillectomy and the volume of both excised tonsils together was measured in cm3 in the operating room.

RESULTS

Pharyngometric analysis showed that the mean pharyngeal volume was 28.63 (±5.57) cm3 before surgery and 31.23 (±6.76) cm3 after surgery; the volume of the oropharynx was significantly increased post-surgery (p=0.015, Wilcoxon test). No correlation was found between the objective tonsil volume and the post-surgical volume increase (p=0.6885). There was a fair correlation between the oropharyngeal volume and body mass index (p=0.0224).

CONCLUSION

Adenotonsillectomy increases the volume of the pharyngeal space, but this increase does not correlate with the objective tonsil size. Furthermore, greater BMI was associated with a smaller increase in the pharyngeal volume. Oropharyngeal structures and craniofacial morphology may also play a role in the increase in oropharyngeal volume.