Respiratory polygraphy for follow-up of obstructive sleep apnea in children

Effectiveness and safety of (adeno) tonsillectomy for pediatric obstructive sleep apnea in different age groups: A systematic review and meta-analysis

This meta-analysis aimed to assess the effectiveness and safety of (adeno)tonsillectomy (AT) for uncomplicated pediatric obstructive sleep apnea (OSA) across different age groups. Four electronic databases were searched until April 2022, and 93 studies (9087 participants) were selected, including before-after studies, cohort studies, and randomized controlled trials. It has been suggested that age, disease severity, and length of follow-up are associated with surgical effects. Compared with older children (>7 years), patients receiving AT surgery before the age of 7 exhibited a significantly greater release of disease severity, as well as a greater decrease in hypoxemic burden, improvement in sleep quality, and better cardiovascular function. Cognitive/behavioral performance also improved after AT, although it was more related to the length of follow-up than the age at surgery. Notably, the surgical complication rate was considerably higher in patients younger than 3 years old. Overall, we suggest that the age of 3-7 years might be optimal for AT in polysomnography-diagnosed uncomplicated OSA to maximize potential benefits for both disease and comorbidities and balance the risks of surgery.

ERS technical standards for using type III devices (limited channel studies) in the diagnosis of sleep disordered breathing in adults and children

For more than three decades, type III devices have been used in the diagnosis of sleep disordered breathing in supervised as well as unsupervised settings. They have satisfactory positive and negative predictive values for detecting obstructive and central sleep apnoea in populations with moderately high pre-test probability of symptoms associated with these events. However, standardisation of commercially available type III devices has never been undertaken and the technical specifications can vary widely. None have been subjected to the same rigorous processes as most other diagnostic modalities in the medical field. Although type III devices do not include acquisition of electroencephalographic signals overnight, the minimum number of physical sensors required to allow for respiratory event scoring using standards outlined by the American Academy of Sleep Medicine remains debatable. This technical standard summarises data on type III studies published since 2007 from multiple perspectives in both adult and paediatric sleep practice. Most importantly, it aims to provide a framework for considering current type III device limitations in the diagnosis of sleep disordered breathing while raising research- and practice-related questions aimed at improving our use of these devices in the present and future.

Should obstructive hypopneas be included when analyzing sleep studies in infants with Robin Sequence?

OBJECTIVE

We have used an obstructive apnea index of ≥3 as treatment indication for infants with Robin sequence (RS), while the obstructive apnea-hypopnea index (OAHI) and a threshold of ≥5 is often used internationally. We wanted to know whether these two result in similar indications, and what the interobserver variability is with either asessement.

METHODS

Twenty lab-based overnight sleep recordings from infants with isolated RS (median age: 7 days, range 2-38) were scored based on the 2020 American Academy of Sleep Medicine guidelines, including or excluding obstructive hypopneas.

RESULTS

Median obstructive apnea index (OAI) was 18 (interquartile range: 7.6-38) including only apneas, and 35 (18-54) if obstructive hypopneas were also considered as respiratory events (OAHI). Obstructive sleep apnea (OSA) severity was re-classified from moderate to severe for two infants when obstructive hypopneas were also considered, but this did not lead to a change in clinical treatment decisions for either infant. Median interobserver agreement was 0.86 (95% CI 0.70-0.94) for the OAI, and 0.60 (0.05-0.84) for the OAHI.

CONCLUSION

Inclusion of obstructive hypopneas when assessing OSA severity in RS infants doubled the obstructive event rate, but impaired interobserver agreement and would not have changed clinical management.

Validity and Cost-Effectiveness of Pediatric Home Respiratory Polygraphy for the Diagnosis of Obstructive Sleep Apnea in Children: Rationale, Study Design, and Methodology

Obstructive sleep apnea (OSA) in children is a prevalent, albeit largely undiagnosed disease associated with a large spectrum of morbidities. Overnight in-lab polysomnography remains the gold standard diagnostic approach, but is time-consuming, inconvenient, and expensive, and not readily available in many places. Simplified Home Respiratory Polygraphy (HRP) approaches have been proposed to reduce costs and facilitate the diagnostic process. However, evidence supporting the validity of HRP is still scarce, hampering its implementation in routine clinical use. The objectives were: Primary; to establish the diagnostic and therapeutic decision validity of a simplified HRP approach compared to PSG among children at risk of OSA. Secondary: (a) Analyze the cost-effectiveness of the HRP versus in-lab PSG in evaluation and treatment of pediatric OSA; (b) Evaluate the impact of therapeutic interventions based on HRP versus PSG findings six months after treatment using sleep and health parameters and quality of life instruments; (c) Discovery and validity of the urine biomarkers to establish the diagnosis of OSA and changes after treatment.

Self-setup of home respiratory polygraphy for the diagnosis of sleep apnea syndrome: cost-efficiency study

PURPOSE

To evaluate the differences in reliability and costs of home respiratory polygraphy (HRP) when installed by the patient and by a nurse, in order to determine the factors affecting and to consider the possible generalization of self-setup procedure. Several HRP devices have been validated for obstructive sleep apnea (OSA) diagnosis but convenience of a nurse intervention in HRP installation has been scarcely studied.

METHODS

This is a prospective and interventional study. About 301 participants were assigned to 2 groups: self-setup and nurse intervention. Sleep study, questionnaires, and diagnostic procedures were performed following the clinical practice in 2016. Signals were considered lost above 3 min, and success of the test was established according to guidelines. Costs were calculated according to a previous multicenter study.

RESULTS

Both groups (self-setup and nurse intervention) resulted homogeneous in age, gender, BMI, and final diagnosis of OSA. Signal losses during the test were similar in both groups. Slightly higher percentage of unsuccessful tests were obtained in the self-setup procedure (5.3 vs 2.0%, p = 0.121). The costs were similar (107 vs 105 €) in the self-setup group as compared to the nurse setup group.

CONCLUSIONS

The setup of HRP by either the patient or nurse had similar costs and data acquisition. Both installation procedures of HRP were similar regarding test reliability and costs. Main findings are that self-installation by the patient could be similarly reliable and economic as installation by a nurse, as far as consensus guidelines are followed. This study demonstrates that self-setup of HRP is a potentially viable option for the diagnosis of OSA.

Ambulatory clinical parameters and sleep respiratory events in a group of obese children unselected for respiratory problems

BACKGROUND

Obstructive sleep apnea in children is frequently due to tonsil and adenoid hypertrophy. This study aimed to investigate the relationship between ambulatory clinical parameters and sleep respiratory events in obese children.

METHODS

We carried out a prospective respiratory sleep study between 2013 and 2015. Nails obstruction, tonsils enlargement and palate position were subjectively measured. Italian attention deficit hyperactivity disorder (ADHD) rating scale for parents was also performed. The polygraph study was performed using a portable ambulatory device.

RESULTS

Forty-four obese children were consecutively recruited into this study. Mild sleep respiratory disturbance was showed in 31.8 % of patients; 18.2% previously had an adeno (tonsillectomy). In 50% of these obese children, both apnea-hypopnea index and oxygen desaturation index showed polygraph abnormal results. ADHD rating scale for parents scores were positive in 9.1% of patients.

CONCLUSIONS

We found a high rate of mild sleep respiratory disturbance and ADHD-like symptoms referred by parents. The respiratory disturbance was not totally cured by surgery. Finally, otorhinolaryngology variables were not able to explain mild sleep respiratory disturbance.

Automated Screening of Children With Obstructive Sleep Apnea Using Nocturnal Oximetry: An Alternative to Respiratory Polygraphy in Unattended Settings

STUDY OBJECTIVES

Nocturnal oximetry has become known as a simple, readily available, and potentially useful diagnostic tool of childhood obstructive sleep apnea (OSA). However, at-home respiratory polygraphy (HRP) remains the preferred alternative to polysomnography (PSG) in unattended settings. The aim of this study was twofold: (1) to design and assess a novel methodology for pediatric OSA screening based on automated analysis of at-home oxyhemoglobin saturation (SpO₂), and (2) to compare its diagnostic performance with HRP.

METHODS

SpO₂ recordings were parameterized by means of time, frequency, and conventional oximetric measures. Logistic regression models were optimized using genetic algorithms (GAs) for three cutoffs for OSA: 1, 3, and 5 events/h. The diagnostic performance of logistic regression models, manual obstructive apnea-hypopnea index (OAHI) from HRP, and the conventional oxygen desaturation index ≥ 3% (ODI3) were assessed.

RESULTS

For a cutoff of 1 event/h, the optimal logistic regression model significantly outperformed both conventional HRP-derived ODI3 and OAHI: 85.5% accuracy (HRP 74.6%; ODI3 65.9%) and 0.97 area under the receiver operating characteristics curve (AUC) (HRP 0.78; ODI3 0.75) were reached. For a cutoff of 3 events/h, the logistic regression model achieved 83.4% accuracy (HRP 85.0%; ODI3 74.5%) and 0.96 AUC (HRP 0.93; ODI3 0.85) whereas using a cutoff of 5 events/h, oximetry reached 82.8% accuracy (HRP 85.1%; ODI3 76.7) and 0.97 AUC (HRP 0.95; ODI3 0.84).

CONCLUSIONS

Automated analysis of at-home SpO₂ recordings provide accurate detection of children with high pretest probability of OSA. Thus, unsupervised nocturnal oximetry may enable a simple and effective alternative to HRP and PSG in unattended settings.

Indoor/outdoor not-voluptuary-habit pollution and sleep-disordered breathing in children: a systematic review

BACKGROUND

Exposure to environmental pollutants is advocated to be a major risk factor, with increased morbidity and mortality in humans due to acute and chronic airway inflammation. The aim of the present review is to show the literature research regarding the link between the sleep-disordered breathing and exposure to indoor/outdoor pollution in children. We hypothesized that environmental air pollution can play a role in childhood sleep-disordered breathing.

METHODS

We conducted an electronic search in Medline (with PubMed interface), Scopus and the ISI Web of Science using the keywords "sleep" or "sleep apnea" or "sleep disordered breathing" and "pollution" and "children" in "Title/Abstract/Keywords", with language restriction (non-English paper) and no date limitation to present. The tobacco smoke pollution is well established linking and is not considered for the present subject. We examined the strength of the evidence according to the Oxford Centre for Evidence-Based Medicine [2011] and the Centre for Evidence-Based Medicine [2009].

RESULTS

A total of 105 articles were identified, but 97 of these had to be excluded after an accurate reading of the title, abstract or full text. In the end, eight studies were selected for our analysis for a total of a total of 5,826 children. The results suggest an involvement (grade C) of environmental (not from voluptuary habits) pollution in the worsening of sleep-disordered breathing in children.

CONCLUSIONS

To date, some studies reported significant differences between areas with higher and lower pollutants and the interventions on indoor pollution reduced sleep-disordered breathing in children. Therefore, although the relevance of the argument is high, the number of studies and the interest in the subject seems at this time quite limited.

Obstructive sleep apnea in children: update on the recognition, treatment and management of persistent disease

Adenotonsillectomy (AT) is the recommended first-line treatment for pediatric obstructive sleep apnea (OSA) in children with adenotonsillar hypertrophy. It is now clearly established that AT results in improvement in the severity of OSA in most children. However, a significant number of OSA children undergoing AT exhibit residual persistent OSA post-surgery. Patients at increased risk of persistent OSA include those with severe disease at initial review, older or obese patients, children with underlying asthma or allergic rhinitis, and those who have concurrent underlying medical conditions, such as Trisomy 21, craniofacial syndromes or cerebral palsy. Here, we aim to highlight recent research findings into those who have persistent OSA disease, and suggest a practical approach to the management of these children.

Pediatric Home Sleep Apnea Testing: Slowly Getting There!

Pediatric OSA can result in significant neurocognitive, behavioral, cardiovascular, and metabolic morbidities. Prompt diagnosis and treatment are, therefore, of paramount importance. The current gold standard for diagnosis of OSA in children is in-laboratory polysomnography (PSG). Home sleep apnea testing has been considered as an alternative as it is potentially more cost effective, convenient, and accessible. This review concentrates mainly on the use of type 2 and 3 portable monitoring devices. The current evidence on the feasibility and diagnostic accuracy of home testing in the diagnosis of pediatric OSA was examined. Overall, the evidence in children is limited. Feasibility studies that have been performed have on the whole shown good results, with several reporting > 90% of their home recordings as meeting predetermined quality criteria regarding signal artifact and minimum recording time. The limited data comparing type 2 studies with in-laboratory PSG have shown no significant differences in respiratory parameters. The results pertaining to diagnostic accuracy of type 3 home sleep apnea testing devices are conflicting. Although more research is needed, home testing with at least a type 3 portable monitor offers a viable alternative in the diagnosis of otherwise healthy children with moderate to severe OSA, particularly in settings where access to polysomnography is scarce or unavailable. Of note, since most studies have been performed in habitually snoring healthy children, home sleep apnea testing may not be applicable to children with other comorbid conditions. In particular, CO2 monitoring is important in children in whom there is concern regarding nocturnal hypoventilation, such as children with neuromuscular disease, underlying lung disease, or obesity hypoventilation, and most home testing devices do not include a transcutaneous or end-tidal CO2 channel.

Treatment outcomes of obstructive sleep apnoea in obese community-dwelling children: the NANOS study

The first line of treatment of obstructive sleep apnoea syndrome (OSAS) in children consists of adenotonsillectomy (T&A). The aim of the present study was to evaluate treatment outcomes of OSAS among obese children recruited from the community.A cross-sectional, prospective, multicentre study of Spanish obese children aged 3-14 years, with four groups available for follow-up: group 1: non-OSAS with no treatment; group 2: dietary treatment; group 3: surgical treatment; and group 4: continuous positive airway pressure treatment.117 obese children (60 boys, 57 girls) with a mean age of 11.3±2.9 years completed the initial (T0) and follow-up (T1) assessments. Their mean body mass index (BMI) at T1 was 27.6±4.7 kg·m(-2), corresponding to a BMI Z-score of 1.34±0.59. Mean respiratory disturbance index (RDI) at follow-up was 3.3±3.9 events·h(-1). Among group 1 children, 21.2% had an RDI ≥3 events·h(-1) at T1, the latter being present in 50% of group 2, and 43.5% in group 3. In the binary logistic regression model, age emerged as a significant risk factor for residual OSAS (odds ratio 1.49, 95% confidence interval 1.01-2.23; p<0.05) in obese children surgically treated, and RDI at T0 as well as an increase in BMI emerged as significant risk factors for persistent OSAS in obese children with dietary treatment (OR 1.82, 95% CI 1.09-3.02 (p<0.03) and OR 8.71, 95% CI 1.24-61.17 (p=0.03)).Age, RDI at diagnosis and obesity are risk factors for relatively unfavourable OSAS treatment outcomes at follow-up.

Reliability of home respiratory polygraphy for the diagnosis of sleep apnea in children

OBJECTIVE

The objective of this study was to evaluate the diagnostic reliability of home respiratory polygraphy (HRP) in children with a clinical suspicion of OSA-hypopnea syndrome (OSAS).

METHODS

A prospective blind evaluation was performed. Children between the ages of 2 to 14 years with clinical suspicion of OSAS who were referred to the Sleep Unit were included. An initial HRP followed by a later date, same night, in-laboratory overnight respiratory polygraphy and polysomnography (PSG) in the sleep laboratory were performed. The apnea-hypopnea index (AHI)-HRP was compared with AHI-PSG, and therapeutic decisions based on AHI-HRP and AHI-PSG were analyzed using intraclass correlation coefficients, Bland-Altman plots, and receiver operator curves (ROCs).

RESULTS

Twenty-seven boys and 23 girls, with a mean age of 5.3 ± 2.5 years, were studied, and 66% were diagnosed with OSAS based on a PSG-defined obstructive respiratory disturbance index ≥ 3/h total sleep time. Based on the availability of concurrent HRP-PSG recordings, the optimal AHI-HRP corresponding to the PSG-defined OSAS criterion was established as ≥ 5.6/h The latter exhibited a sensitivity of 90.9% (95% CI, 79.6%-100%) and a specificity of 94.1% (95% CI, 80%-100%).

CONCLUSIONS

HRP recordings emerge as a potentially useful and reliable approach for the diagnosis of OSAS in children. However, more research is required for the diagnosis of mild OSAS using HRP in children.

Usefulness of cerebral NIRS in detecting the effects of pediatric sleep apnea

BACKGROUND

Children with sleep apnea have increased morbidity if the sleep apnea is untreated. Polysomnography (PSG) is used to detect sleep apnea, but in children, there are technical difficulties that make the diagnosis more difficult. Cerebral near infrared spectroscopy (NIRS) has the ability to detect tissue hypoxia by measuring regional oxygen saturation (rSO2 ). We hypothesized that when used as an adjunct to PSG testing, cerebral NIRS would better detect the effects of sleep apnea in children than arterial pulse oximetry (SpO2 ). Specifically, we aimed to show that the apnea/hypopnea index (AHI) calculated with rSO2 from the NIRS would be greater than that calculated with SpO2 .

METHODS

Forty-seven patients under 18 years of age who underwent PSG testing for sleep apnea were evaluated. Cerebral NIRS was utilized in addition to PSG. The AHI was calculated using SpO2 and compared to the AHI calculated using the rSO2 . A pediatric pulmonologist who was unaware of the NIRS data evaluated each patient for sleep apnea. Data are median (interquartile range).

RESULTS

The median AHI(rSO2 ) was 2.4(1.2,5.1), significantly greater (P < 0.0001) than the AHI(SpO2 ) of 0.7(0.4,1.2). Four patients were diagnosed with sleep apnea; however, only one had an AHI(SpO2 ) ≥ 5, a typical threshold for the diagnosis of sleep apnea. All 4 subjects had an AHI(rSO2 ) ≥ 5 but 10 patients without sleep apnea had a value ≥5. The sensitivity and specificity for using the AHI(rSO2 ) to diagnose sleep apnea was 100% and 76.7%, respectively.

CONCLUSION

Consistent with the ability of NIRS to detect tissue hypoxia, we found that the AHI calculated with rSO2 was greater than that using SpO2 . We conclude that NIRS has potential as a valuable adjunct to PSG in evaluating patients for sleep apnea and warrants further investigation for this purpose.

Obstructive sleep apnea in obese community-dwelling children: the NANOS study

INTRODUCTION

Obesity in children is assumed to serve as a major risk factor in pediatric obstructive sleep apnea syndrome (OSAS). However, the prevalence of OSAS in otherwise healthy obese children from the community is unknown.

AIM

To determine the prevalence of OSAS in obese children identified and recruited from primary care centers.

METHODS

A cross-sectional, prospective, multicenter study. Spanish children ages 3-14 y with a body mass index (BMI) greater than or equal to the 95th percentile for age and sex were randomly selected, and underwent medical history, snoring, and Pediatric Sleep Questionnaire (PSQ) assessments, as well as physical examination, nasopharyngoscopy, and nocturnal polysomnography (NPSG) recordings.

RESULTS

Two hundred forty-eight children (54.4% males) with mean age of 10.8 ± 2.6 y were studied with a BMI of 28.0 ± 4.7 kg/m(2) corresponding to 96.8 ± 0.6 percentile when adjusted for age and sex. The mean respiratory disturbance index (RDI), obstructive RDI (ORDI), and obstructive apnea-hypopnea index (OAHI) were 5.58 ± 9.90, 5.06 ± 9.57, and 3.39 ± 8.78/h total sleep time (TST), respectively. Using ≥ 3/h TST as the cutoff for the presence of OSAS, the prevalence of OSAS ranged from 21.5% to 39.5% depending on whether OAHI, ORDI, or RDI were used.

CONCLUSIONS

The prevalence of obstructive sleep apnea syndrome (OSAS) in obese children from the general population is high. Obese children should be screened for the presence of OSAS. ClinicalTrials.gov identifier: NCT01322763.

Overnight polysomnography versus respiratory polygraphy in the diagnosis of pediatric obstructive sleep apnea

BACKGROUND

Substantial discrepancies exist in the type of sleep studies performed to diagnose pediatric obstructive sleep apnea (OSA) in different countries. Respiratory polygraphic (RP) recordings are primarily performed in sleep laboratories in Europe, whereas polysomnography (PSG) constitutes the majority in the US and Australia. Home RP show consistent apnea-hypopnea index (AHI) underscoring, primarily because the total recording time is used as the denominator when calculating the AHI compared to total sleep time (TST). However, laboratory-based RP are less likely affected, since the presence of sleep technicians and video monitoring may enable more accurate TST estimates. We therefore examined differences in AHI in PSG and in-lab RP, and whether RP-based AHI may impact clinical decision making.

METHODS

Of all the children assessed for possible OSA who underwent PSG evaluation, 100 were identified and divided into 4 groups: (A) those with AHI < 1/h TST (n = 20), (B) 1 ≤ AHI < 5/h TST (n = 40), (C) 5 ≤ AHI < 10/h TST (n = 20), and (D) AHI ≥ 10/h TST (n = 20). Electroencephalography, electrooculography, and electromyography channels were deleted from the original unscored recordings to transform them into RP, and then rescored in random sequence. AHI-RP were compared to AHI-PSG, and therapeutic decisions based on AHI-RP and AHI-PSG were formulated and analyzed using clinical details derived from the patient's clinic letter.

RESULTS

Bland Altman analysis showed that in lab RP underestimated the AHI despite more accurate estimates of TST. This underestimation was due to missed hypopneas causing arousals without desaturation. Basing the therapeutic management decision on RP instead of PSG results changed the clinical management in 23% of all patients. The clinical management for patients in groups A and D was unaffected. However, 27.5% of patients in group B would have been given no treatment, as they would be diagnosed as having no OSA (AHI < 1/h TST) when they should have received a trial of anti-inflammatory therapy or been referred for ear, nose, and throat (ENT) review. Sixty percent of patients in group C would have received either a trial of medical treatment to treat mild OSA or no treatment, instead of referral to ENT services or commencement of continuous positive airway pressure.

CONCLUSION

Apnea-hypopnea index (AHI) is underestimated in respiratory polygraphy (RP), and the disparity in AHI-RP and AHI-polysomnography can significantly affect clinical management decisions, particularly in children with mild and moderate obstructive sleep apnea (1 < AHI < 10/h total sleep time).