Diagnosis and perioperative management in pediatric sleep-disordered breathing

Factors affecting polysomnography compliance and delays to surgical treatment of obstructive sleep apnea

OBJECTIVE

To evaluate adherence to polysomnography in pediatric patients and determine if demographics, socioeconomic status, polysomnography indication, or prior otolaryngology intervention are associated with polysomnography adherence and time to definitive surgery.

STUDY DESIGN

Retrospective review study.

SETTING

Tertiary-care children's hospital.

METHODS

Electronic medical record was queried to identify patients ordered for a sleep study between January and May 2019. Demographic information, time to sleep study, and time to surgery were collected and calculated.

RESULTS

304 patients were recommended to obtain polysomnography, with adherence rate of 65.4%. There was no significant difference in adherence or loss to follow-up rates based on patient sex, age, language, socioeconomic status, state of residence, single-parent status, or polysomnography indication. There was no difference between time to surgery for patients who did or did not obtain polysomnography (181 vs. 161 days, P = .51). Patients with prior otolaryngology intervention were more likely to obtain polysomnography and less likely to be lost to follow-up (P < .05). Median household income demonstrated a significant inverse relationship with time to polysomnography (P < .05) as well as time to surgery (P < .05). Medically complex patients tended to experience longer time to surgery compared with non-complex patients.

CONCLUSION

Families with lower socioeconomic status or medically complex children may require assistance to obtain polysomnography and pursue surgery for sleep-disordered breathing. Patients without prior otolaryngology intervention may be less likely to follow up and may need assistance with navigating the polysomnography process.

Association of Obstructive Sleep Apnea With Unanticipated Admission Following Nonotolaryngologic Pediatric Ambulatory Surgery

BACKGROUND

Approximately 2% of ambulatory pediatric surgeries require unanticipated postoperative admission, causing parental dissatisfaction and suboptimal use of hospital resources. Obstructive sleep apnea (OSA) occurs in nearly 8% of children and is known to increase the risk of perioperative adverse events in children undergoing otolaryngologic procedures (eg, tonsillectomy). However, whether OSA is also a risk for unanticipated admission after nonotolaryngologic surgery is unknown. The objectives of this study were to determine the association of OSA with unanticipated admission after pediatric nonotolaryngologic ambulatory surgery and to explore trends in the prevalence of OSA in children undergoing nonotolaryngologic ambulatory surgery.

METHODS

We used the Pediatric Health Information System (PHIS) Database to evaluate a retrospective cohort of children (<18 years) undergoing nonotolaryngologic surgery scheduled as ambulatory or observation status from January 1, 2010, to August 31, 2022. We used International Classification of Diseases codes to identify patients with OSA. The primary outcome was unanticipated postoperative admission lasting ≥1 day. Using logistic regression models, we estimated the odds ratio (OR) and 95% confidence intervals (CIs) for unanticipated admission comparing patients with and without OSA. We then estimated trends in the prevalence of OSA during the study period using the Cochran-Armitage test.

RESULTS

A total of 855,832 children <18 years underwent nonotolaryngologic surgery as ambulatory or observation status during the study period. Of these, 39,427 (4.6%) required unanticipated admission for ≥1 day, and OSA was present in 6359 (0.7%) of these patients. Among children with OSA, 9.4% required unanticipated admission, compared to 5.0% among those without. The odds of children with OSA requiring unanticipated admission were more than twice that in children without OSA (adjusted OR, 2.27; 95% CI, 1.89-2.71; P < .001). The prevalence of OSA among children undergoing nonotolaryngologic surgery as ambulatory or observation status increased from 0.4% to 1.7% between 2010 and 2022 (P trends < .001).

CONCLUSIONS

Children with OSA were significantly more likely to require unanticipated admission after a nonotolaryngologic surgery scheduled as ambulatory or observation status than those without OSA. These findings can inform patient selection for ambulatory surgery with the goal of decreasing unanticipated admissions, increasing patient safety and satisfaction, and optimizing health care resources related to unanticipated admission.

Pediatric T-cell Lymphoblastic Leukemia/Lymphoma Diagnosed at Routine Adenoidectomy Specimen

Postoperative routine pathologic evaluation of tonsillectomy and adenoidectomy specimens rarely reveals a diagnosis of malignancy. The object of this case report is to highlight this rare clinical occurrence. A 4-year-old boy presented with symptoms of sleep-disordered breathing and had a history of recurrent tonsillitis. Physical examination revealed adenoid hypertrophy and Brodsky Grade 1 bilateral tonsillar hypertrophy. The patient underwent adenoidectomy and tonsillectomy. The adenoids were found to be MAGS Grade 4 (Modified Adenoid Grading System) hypertrophic causing 100% obstruction. After the histologic examination, T-cell lymphoblastic leukemia/lymphoma was diagnosed. Proper treatment allowed full recovery. Currently, no consensus has been made about routine pathological evaluation. To achieve a cost-effective and precautionary approach, we recommend pathological follow-up of cases with unusual intraoperative findings with/without clinical malignancy suspicion.

Association between sleep-disordered breathing and periodontal diseases: A systematic review protocol

Background

Sleep-disordered breathing (SDB) is a chronic sleep-related breathing disorder, considered associated with increased risk of cardiovascular disorders, metabolic disorders, cognitive dysfunction and behavior changes. Periodontal diseases are chronic infectious diseases that are also believed to be associated with cardiovascular diseases, metabolic syndrome and cognitive dysfunction. Several studies have indicated that SDB may be associated with periodontal diseases through certain mechanisms such as inflammation response, oxidative stress and oral dryness. The aim of this systematic review is to explore the association between SDB and periodontal diseases in an integrated approach.

Materials and Methods

This systematic review will include cohort studies, cross-sectional studies and case-control studies that are identified by electronic and manual searches. Electronic searches will be conducted in the following databases: PubMed, Embase, Scopus and Web of Science. Our search will cover articles published from inception of databases to March 2022 without restrictions in language and settings. Pre-determined eligibility criteria include: participants (participants without a history of respiratory diseases, history of periodontal treatment within the past 6 months and history of medication that is known to influence SDB or periodontal diseases); exposure (participants who have been diagnosed with SDB or at high-risk for SDB); comparison (participants without SDB); and outcome (periodontal parameters, such as probing depth, clinical attachment level, bleeding on probing, radiographic bone loss). Two authors will perform study screening and data extraction independently and in duplicate. All discrepancies will be solved by discussion. The methodological quality of included studies will be assessed using the Newcastle-Ottawa Scale.

Discussion

This systematic review will summarize the existing evidence on the association between SDB and periodontal diseases, a topic of controversy and clinical significance. Its findings can provide evidence for the development of relevant prevention and treatment strategies. The results will be disseminated through peer-reviewed journals.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022313024. Registered on March 28th 2022.

Perioperative considerations for adult patients with obstructive sleep apnea

PURPOSE OF REVIEW

Obstructive sleep apnea (OSA) is a common, but often undiagnosed, sleep breathing disorder affecting approximately a third of adult surgical patients. OSA patients have increased sensitivity to anesthetic agents, sedatives, and opioid analgesics.

RECENT FINDINGS

Newer technologies (e.g., bedside capnography) have demonstrated that OSA patients have repetitive apneic spells, beginning in the immediate postoperative period and peaking in frequency during the first postoperative night. Compared to patients without OSA, OSA patients have double the risk for postoperative pulmonary as well as other complications, and OSA has been linked to critical postoperative respiratory events leading to anoxic brain injury or death. Patients with OSA who have respiratory depression during anesthesia recovery have been found to be high-risk for subsequent pulmonary complications. Gabapentinoids have been linked to respiratory depression in these patients.

SUMMARY

Surgical patients should be screened for OSA and patients with OSA should continue using positive airway pressure devices postoperatively. Use of shorter acting and less sedating agents and opioid sparing anesthetic techniques should be encouraged. In particular, OSA patients exhibiting signs of respiratory depression in postanesthesia recovery unit should receive enhancer respiratory monitoring following discharge to wards.

Use of the Snoring, Trouble Breathing, Un-Refreshed questionnaire to predict perioperative respiratory adverse events in children

STUDY OBJECTIVES

The Snoring, Trouble Breathing, Un-Refreshed (STBUR) screening questionnaire has been validated in identifying pediatric surgical patients with symptoms of sleep-disordered breathing who may be at risk of perioperative respiratory adverse events. We sought to assess the performance of the STBUR questionnaire when adjusting for potential confounders such as patient comorbidities or surgical service.

METHODS

This was a retrospective cohort study of children aged 2-18 years undergoing elective procedures under general anesthesia over a 3-month period. Procedure specialties included general surgery, urology, orthopedic surgery, neurosurgery, plastic surgery, otolaryngology, dentistry, and gastroenterology. Preoperative STBUR questionnaire responses and perioperative respiratory adverse events were documented prospectively. Multivariate logistic regression was used to quantify associations between preoperative questionnaire responses, other potential risk factors (including age, sex, surgical specialty, comorbidities), and risk of perioperative respiratory adverse events.

RESULTS

Of 555 children, 17% had a positive STBUR screen. The prevalence of perioperative respiratory adverse events with a positive questionnaire screen was significantly greater than with a negative screen (29% vs 9%, respectively; P < .001). A positive questionnaire screen was associated with a significantly increased risk of a perioperative respiratory adverse event (adjusted odds ratio 3.47 [95% confidence interval 1.53-7.84], P = .003).

CONCLUSIONS

A positive screen on the STBUR questionnaire was associated with a 3.5-fold increased risk of perioperative respiratory adverse events in pediatric surgical patients. The STBUR questionnaire should be considered as a routine preoperative screening tool in children undergoing elective procedures.

CITATION

Huerta J, Taleu H, Norton R, Gries H, Yun P, Lam D. Use of the Snoring, Trouble Breathing, Un-Refreshed questionnaire to predict perioperative respiratory adverse events in children. J Clin Sleep Med. 2022;18(3):695-701.

Reduced circulating growth hormone and insulin-like growth factor-1 and delayed growth of premature rats are aggravated by longer daily duration of chronic intermittent hypoxia exposure

OBJECTIVE

This study mainly aimed to investigate the effect of daily duration of chronic intermittent hypoxia (CIH) exposure on circulating growth hormone (GH)/insulin-like growth factor-1 (IGF-1) concentrations and body weight changes of premature rats.

METHODS

40 healthy male SD rats aged six weeks were enrolled in this study. These rats were randomly divided into four groups (n = 10 per group), including normal control (NC) group (normal oxygen exposure every day), CIH-1 group (daily CIH exposure for 2 h), CIH-2 group (daily CIH exposure for 4 h), and CIH-3 group (daily CIH exposure for 8 h). The serum GH/IGF-1 concentrations and body weights in all rats were determined after 30 days of normal oxygen or CIH exposure.

RESULTS

No significant difference was found with respect to the baseline body weight among the four groups of rats. After establishments of animal models with a duration of 30 days, significant differences were found respect to body weight, body weight changes, and serum GH/IGF-1 concentrations among the four groups of rats with a same trend (all P < 0.05): the highest values were all in NC group rats, followed CIH-1 group, CIH-2 group, and CIH-3 group rats. Among all the rats, the body weight changes correlated significantly with both serum GH and IGF-1 concentrations (both P < 0.05).

CONCLUSION

CIH decreases circulating GH/IGF-1 concentrations and causes growth delay in premature rats. Such effects could be aggravated by increased daily duration of CIH exposures.

Adenotonsillectomy as a treatment for sleep-disordered breathing in children with ADHD

Sleep-disordered breathing (SDB) and attention deficit hyperactivity disorder (ADHD) are common disorders diagnosed in children. Although these diagnoses were previously considered unrelated, research now is showing that some symptoms of ADHD, specifically oppositional behavior, hyperactivity, and impulsivity, can be related to SDB in children and differs from bona fide ADHD. This article explores the connection between the two disorders and the importance of identifying and screening for SDB in children presenting with similar symptoms related to ADHD. The article also examines symptom improvement in patients with ADHD symptoms after an adenotonsillectomy, one of the first-line treatments for children diagnosed with SDB; this procedure may reduce the need for long-term stimulant use in some children with ADHD.

[Obstructive sleep apnea syndrome in children]

Pediatric obstructive sleep apnea syndrome (OSAS) has a high prevalence in the general population. Risk factors are adenotonsillar hyperplasia, preterm birth, obesity, and craniofacial dysmorphia. A special feature of pediatric OSAS is that it can manifest in behavioral problems. These patients also have an increased risk of perioperative anesthesiologic complications. Diagnostic and therapeutic options should be defined individually using the "Snoring in childhood" algorithm of the German Sleep Research and Sleep Medicine Society (DGSM). Diagnosis based on polysomnography (PSG) is reserved for specialized pediatric sleep centers. The most common surgical treatment for pediatric OSAS is adenoidectomy with tonsillotomy. Positive airway pressure (PAP) therapy in children is only indicated in individual cases. Monitoring of treatment success is important after OSAS therapy.

Addition of dexmedetomidine to ropivacaine for local infiltration anaesthesia improves analgesic efficacy after tonsillectomy and adenoidectomy: A randomized controlled trial

OBJECTIVES

The aim of this study was to determine whether the addition of dexmedetomidine to ropivacaine for local infiltration anaesthesia was more effective than ropivacaine alone in attenuating pain after tonsillectomy and adenoidectomy.

METHODS

This was a double-blind randomized clinical trial. One hundred and twenty children scheduled for tonsillectomy and adenoidectomy using a combination of general anaesthesia and local infiltration anaesthesia were randomized into the dexmedetomidine plus ropivacaine group (DR) and ropivacaine group (R). The children were locally infiltrated with 1 μg kg^-1 dexmedetomidine and 0.25% ropivacaine in the DR group or 0.25% ropivacaine alone in the R group. In both groups, local infiltration anaesthesia was performed using 5 ml of solution. The pain scores were recorded at the 1st, 4th, 8th, 12th, 16th, 20th, and 24th hours after surgery using the Face Legs Activity Cry Consolability (FLACC) scale. When the pain score exceeded 4, paracetamol syrup (15 mg kg^-1) was administered as a rescue analgesic. Time to the first administration of analgesic was recorded.

RESULTS

8th, 16th, 20th, and 24th hours after surgery, the children in the DR group had lower pain scores than those in the R group (P<0.05). The time to the first administration of analgesic was significantly longer in the DR group (mean: 10.4 h, range: 9.4-11.4 h) than in the R group (mean: 8.1 h, range: 7.3-8.8 h) (P < 0.001).

CONCLUSION

The addition of dexmedetomidine to ropivacaine for local infiltration anaesthesia effectively improved the efficacy of analgesia and extended the duration of analgesia after tonsillectomy and adenoidectomy.

Associations of Sedentary Behaviour, Physical Activity, Cardiorespiratory Fitness and Body Composition with Risk of Sleep-Related Breathing Disorders in Children with Overweight/Obesity: A Cross-Sectional Study

The aim of this study was to examine the associations of sedentary behaviour, physical activity, cardiorespiratory fitness (CRF), and body composition parameters with risk of sleep-related breathing disorders (SRBD) in children with overweight/obesity. One-hundred and nine children (10.0 ± 1.1 years old, 45 girls) with overweight (n = 27) and obesity (n = 82) were included. Television viewing time was self-reported by using the Spanish adaptation of the "Youth Activity Profile" (YAP) questionnaire. Sedentary time and physical activity were measured with accelerometry. CRF was assessed with the 20-m shuttle-run test and body composition parameters with Dual-energy X-ray absorptiometry. SRBD were evaluated by using the Spanish version of the Pediatric Sleep Questionnaire. Television viewing time was positively associated with risk of SRBD (r = 0.222, p = 0.021). CRF was negatively correlated with risk of SRBD (r = -0.210, p = 0.030). Body composition parameters were positively associated with risk of SRBD (all p < 0.05), except fat mass index. Stepwise regression analyses showed that body mass index (BMI) explained the largest proportion of the variance in SRBD (r² = 0.063, p = 0.01) and television viewing time was the only one added after BMI (r² change = 0.048, p = 0.022). This study supports the notion that higher body weight status negatively influences risk of SRBD and adds that unhealthy behaviours could contribute to worsen SRBD, related to an increased risk of cardiovascular diseases. All the significant association observed in this manuscript were of small magnitude, indicating than other factors in addition to the one hereby studied contribute to explain the variance in SRBD.

Postoperative admission to paediatric intensive care after tonsillectomy

Objectives:

To review interventions required by children admitted for intensive care management following tonsillectomy or adenotonsillectomy either as elective or unplanned admission in a tertiary children’s hospital.

Methods:

A retrospective chart review over a 10-year period between April 2007 and March 2017 was performed. Charts were interrogated for treatments that were administered in the paediatric intensive care unit. Respiratory support therapies such as supplemental oxygen administration, high-flow nasal oxygen, positive pressure ventilation, continuous positive airway pressure, airway interventions and tracheal intubation were reviewed.

Results:

There were 103 children admitted to the paediatric intensive care unit following tonsillectomy or adenotonsillectomy. The average age was 6.2 years (range 7 months–17 years). The main indications for the procedure were sleep disordered breathing or obstructive sleep apnoea syndrome. In all, 53 children had syndromes with medical comorbidities, 31 were current continuous positive airway pressure users and 5 had a tracheostomy in situ. Forty children admitted to paediatric intensive care unit did not require any high-level care. Ten children who had an unplanned admission had their respiratory interventions started in the theatre or in the post-anaesthetic care unit, before paediatric intensive care unit admission, and did not require escalation of care.

Conclusion:

Children may not require admission for intensive care after tonsillectomy if they have had an incident-free period in the post-anaesthetic care unit. Some of those who required high-flow nasal oxygen could have been managed on the ward provided with adequate training and monitoring facilities. The level of care they require in post-anaesthetic care unit reflected the level of care for the immediate postoperative period in the paediatric intensive care unit.

The performance of a postinduction fentanyl test in identifying severe obstructive sleep apnea syndrome

BACKGROUND

Children with severe obstructive sleep apnea syndrome (OSAS) are more sensitive to opioids. Identifying such children and reducing or even eliminating opioids are necessary but difficult. We have previously shown that patients sensitive to intraoperative fentanyl require less opioids postoperatively.

AIM

The objective of this study was to evaluate the performance of a postinduction fentanyl test in identifying severe obstructive sleep apnea syndrome.

METHODS

A prospective, observational, assessor-blinded study was carried out with 104 sleep study assessed children undergoing elective adenotonsillectomy. Intravenous fentanyl (1 µg/kg) was administered as a test in nonpremedicated, spontaneously breathing, sevoflurane-induced patients before endotracheal intubation. The respiratory rates before and after fentanyl administration were studied. The primary outcome was the sensitivity and specificity of the postinduction fentanyl test in identifying severe OSAS compared with polysomnography.

RESULTS

A postinduction fentanyl test had a likelihood ratio of 7.2 (95% CI: 3.6-14.6) and an area under the curve value of 0.896 (95% CI: 0.821-0.947) to identify severe obstructive sleep apnea syndrome. The pragmatic cut-off value for the postinduction fentanyl test was found to be 50%. Using a reduction in respiratory rate of >50%, the postinduction fentanyl test detected severe OSAS with a sensitivity of 87%, a specificity of 88%, a positive predictive value of 85%, and a negative predictive value of 89%.

CONCLUSION

Our study showed that a postinduction fentanyl test had good predictive value in identifying severe obstructive sleep apnea syndrome and early postoperative adverse respiratory events and could provide a reference for postoperative analgesia in children undergoing adenotonsillectomy.