Overnight pulse oximetry in normal children and in children undergoing adenotonsillectomy

Evaluation and Management of Children with Obstructive Sleep Apnea Syndrome

Obstructive sleep apnea syndrome (OSAS) is a common pediatric disorder characterized by recurrent events of partial or complete upper airway obstruction during sleep which result in abnormal ventilation and sleep pattern. OSAS in children is associated with neurobehavioral deficits and cardiovascular morbidity which highlights the need for prompt recognition, diagnosis, and treatment. The purpose of this state-of-the-art review is to provide an update on the evaluation and management of children with OSAS with emphasis on children with complex medical comorbidities and those with residual OSAS following first-line treatment. Proposed treatment strategies reflecting recommendations from a variety of professional societies are presented. All children should be screened for OSAS and those with typical symptoms (e.g., snoring, restless sleep, and daytime hyperactivity) or risk factors (e.g., neurologic, genetic, and craniofacial disorders) should undergo further evaluation including referral to a sleep specialist or pediatric otolaryngologist and overnight polysomnography, which provides a definitive diagnosis. A cardiology and/or endocrinology evaluation should be considered in high-risk children. For the majority of children, first-line treatment is tonsillectomy with or without adenoidectomy; however, some children exhibit multiple levels of airway obstruction and may require additional evaluation and management. Anti-inflammatory medications, weight loss, and oral appliances may be appropriate in select cases, particularly for mild OSAS. Following initial treatment, all children should be monitored for residual symptoms and polysomnography may be repeated to identify persistent disease, which can be managed with positive airway pressure ventilation and additional surgical approaches if required.

Executive summary of respiratory indications for polysomnography in children: an evidence-based review

OBJECTIVE

This comprehensive, evidence-based review provides a systematic analysis of the literature regarding the validity, reliability, and clinical utility of polysomnography for characterizing breathing during sleep in children. Findings serve as the foundation of practice parameters regarding respiratory indications for polysomnography in children.

METHODS

A task force of content experts performed a systematic review of the relevant literature and graded the evidence using a standardized grading system. Two hundred forty-three evidentiary papers were reviewed, summarized, and graded. The analysis addressed the operating characteristics of polysomnography as a diagnostic procedure in children and identified strengths and limitations of polysomnography for evaluation of respiratory function during sleep.

RESULTS

The analysis documents strong face validity and content validity, moderately strong convergent validity when comparing respiratory findings with a variety of relevant independent measures, moderate-to-strong test-retest validity, and limited data supporting discriminant validity for characterizing breathing during sleep in children. The analysis documents moderate-to-strong test-retest reliability and interscorer reliability based on limited data. The data indicate particularly strong clinical utility in children with suspected sleep related breathing disorders and obesity, evolving metabolic syndrome, neurological, neurodevelopmental, or genetic disorders, and children with craniofacial syndromes. Specific consideration was given to clinical utility of polysomnography prior to adenotonsillectomy (AT) for confirmation of obstructive sleep apnea syndrome. The most relevant findings include: (1) recognition that clinical history and examination are often poor predictors of respiratory polygraphic findings, (2) preoperative polysomnography is helpful in predicting risk for perioperative complications, and (3) preoperative polysomnography is often helpful in predicting persistence of obstructive sleep apnea syndrome in patients after AT. No prospective studies were identified that address whether clinical outcome following AT for treatment of obstructive sleep apnea is improved in association with routine performance of polysomnography before surgery in otherwise healthy children. A small group of papers confirm the clinical utility of polysomnography for initiation and titration of positive airway pressure support.

CONCLUSIONS

Pediatric polysomnography shows validity, reliability, and clinical utility that is commensurate with most other routinely employed diagnostic clinical tools or procedures. Findings indicate that the "gold standard" for diagnosis of sleep related breathing disorders in children is not polysomnography alone, but rather the skillful integration of clinical and polygraphic findings by a knowledgeable sleep specialist. Future developments will provide more sophisticated methods for data collection and analysis, but integration of polysomnographic findings with the clinical evaluation will represent the fundamental diagnostic challenge for the sleep specialist.

Diagnostic issues in pediatric obstructive sleep apnea

Obstructive sleep apnea syndrome (OSAS) in children includes a spectrum of respiratory disorders with significant morbidities. Diagnosis of OSAS is based on clinical suspicion, history, and physical findings, and confirmation is made by polysomnography. There has been significant progress in recent years in technologies available for diagnosis of OSAS since the consensus statement of the American Thoracic Society in 1996. The current review describes methodologies that are available today for assessment and diagnosis of OSAS in children and summarizes the most recent recommendations of the American Academy of Sleep Medicine Task Force regarding scoring sleep-related respiratory events in children.

Unattended home sleep studies for the evaluation of suspected obstructive sleep apnoea syndrome in children

Children suspected of obstructive sleep apnoea syndrome (OSAS) are traditionally investigated in hospital with overnight sleep studies, and single-channel pulse oximetry is the commonest form of initial study. A prospective study was conducted comparing unsupervised sleep studies, using a Nellcor N-395 pulse oximeter, performed in hospital and at home. Two hundred and eleven patient studies were completed in 18 months, 158 in hospital and 53 at home. The median age of patients was four years in both groups. The mean study duration was 9 h 5 min in hospital and 9 h 12 min at home (P = 0.75). The mean time in pulse search was 0.4% (SD = 0.7) in hospital and 0.2% (SD = 0.4) at home (P = 0.008). The number of failed studies was 96 of 254 (38%) in hospital and three of 56 (5%) at home (P < 0.001). Overall, 149 hospital bed days were saved (at pounds 690 per bed day), representing pounds 68,540 saved annually. The results show that unattended home sleep studies in the form of overnight pulse oximetry can be performed to a standard better than hospital studies, where local community nursing facilities exist.

Reference values for nocturnal home pulse oximetry during sleep in primary school children

OBJECTIVE

To provide reference values for pulse oximeter saturation (SpO(2)) in primary school children, measured at home during sleep.

METHODS

Recordings of SpO(2) and signal quality from 100 children were randomly selected from a larger population-based sample intended to study the prevalence of sleep-disordered breathing. Recordings were analyzed for the duration of artifact-free recording time (AFRT), minimum SpO(2) (SATmin) and median SpO(2) (SAT(50)), the SpO(2) below which the child spent 5% of AFRT (SAT(5)), and the SpO(2) below which the child spent 10% of AFRT (SAT(10)). In addition, the time in seconds with SpO(2) <or= 90% per hour of AFRT (TI(90)) was calculated, as were the number of falls in SpO(2) by >or= 4% per hour of AFRT (DI(4)), the number of falls in SpO(2) to <or= 90% per hour of AFRT (DI(90)), and the number of falls in SpO(2) to <or= 92% per hour of AFRT (DI(92)).

RESULTS

Ten recordings had to be excluded because of insufficient AFRT (< 5 h). Mean age of the remaining 90 children (54 girls) was 9.3 years (SD, 0.6). Median (range; fifth centile) values for SATmin, SAT(5), SAT(10), and SAT(50) were 93% (76 to 97; 87.5), 97% (88 to 99; 95), 97% (89 to 99; 96), and 98% (94 to 100; 97). Median values (range; 95th centile) for TI(90), DI(4), DI(90), and DI(92) were 0.0 s (0.0 to 5.8; 1.6), 0.8 (0.0 to 6.1; 3.9), 0.0 (0.0 to 1.2; 0.2), and 0.0 (0.0 to 2.0; 0.6).

CONCLUSION

Baseline SpO(2) values < 97% were uncommon in these children, as were intermittent desaturations to <or= 90%. These data may serve as a basis for the interpretation of clinical recordings of SpO(2) in children referred for sleep-related breathing disorders.