Sleep-disordered breathing and asthma: evidence from a large multicentric epidemiological study in China

The complex link between sleep-disordered breathing and asthma control in pediatric patients: A cross-sectional study

BACKGROUND

In children, asthma and sleep-disordered breathing (SDB) may affect quality of life (QoL), and SDB may complicate asthma management.

OBJECTIVE

To evaluate the prevalence of SDB, its association with asthma control, and risk factors associated with SDB in a cohort of asthmatic children. The effects of asthma control and SDB on QoL were also investigated.

METHODS

We consecutively recruited asthmatic children referred to our Pulmonology Service from December 1, 2022 to May 31, 2023. Data on anthropometrics, respiratory function, and allergies were collected. The prevalence of SDB was assessed by the Pediatric Sleep Questionnaire (PSQ). Asthma control status was assessed by the Childhood Asthma Control Test (C-ACT), while QoL was evaluated by the Pediatric Quality of Life Inventory (PedsQL) questionnaire. Factors associated with SDB were analyzed.

RESULTS

A total of 78 asthmatic children aged 5-12 years were included. SDB was found in 37.2% of them, with a higher prevalence in children with uncontrolled versus well-controlled asthma (60.1% vs. 27.3%; p-value = 0.005). The C-ACT score was significantly lower in SDB-positive versus SDB-negative group, and uncontrolled asthma (C-ACT ≤19) was associated with a 4.15-fold increased risk of SDB. The PedsQL score was significantly lower in asthmatic children with than without SDB and was associated with lower SDB risk. SDB increased the risk of uncontrolled asthma in children, and asthmatic children with SDB had lower QoL.

CONCLUSION

In asthmatic children, SDB affects both asthma control and QoL. Children with uncontrolled asthma should be referred for polysomnography to identify a possible underlying SDB.

Risk factors of sleep-disordered breathing and poor asthma control in children with asthma

BACKGROUND

Sleep-disordered breathing (SDB) may lead to poor asthma control in children.

OBJECTIVE

To identify risk factors of SDB in children with asthma and assess its impact on asthma control.

METHODS

In this cross-sectional study, we collected data of outpatients with asthma at the Children's Hospital of Chongqing Medical University from June 2020 to August 2021. The Pediatric Sleep Questionnaire-Sleep-Related Breathing Disorder and the age-appropriate asthma control tests Childhood Asthma Control Test and Test for Respiratory and Asthma Control in Kids were completed.

RESULTS

We enrolled 397 children with a male-to-female ratio of 1.7:1 and a mean age of 5.70 ± 2.53 years. The prevalence of SDB was 21.6%. Allergic rhinitis (odds ratio OR = 3.316), chronic tonsillitis (OR = 2.246), gastroesophageal reflux (OR = 7.518), adenoid hypertrophy (OR = 3.479), recurrent respiratory infections (OR = 2.195), and a family history of snoring (OR = 2.048) were risk factors for the development of combined SDB in children with asthma (p < 0.05). Asthma was poorly controlled in 19.6% of the children. SDB (OR = 2.391) and irregular medication use (OR = 2.571) were risk factors for poor asthma control (p < 0.05).

CONCLUSIONS

Allergic rhinitis, chronic tonsillitis, gastroesophageal reflux, adenoid hypertrophy, recurrent respiratory infections, and a family history of snoring were independent risk factors for the development of SDB in children with asthma. SDB and irregular medication use were independent risk factors for poor asthma control.

Gastroesophageal reflux and snoring are related to asthma and respiratory symptoms: Results from a Nordic longitudinal population survey

AIM

To study if individuals with nocturnal gastroesophageal reflux (nGER) and habitual snoring are more likely to develop asthma and respiratory symptoms (i.e. wheeze, cough, chest tightness, breathlessness) than those without these conditions, and if these associations are additive.

METHODS

We used data from the population-based prospective questionnaire study Respiratory Health in Northern Europe (RHINE) (11,024 participants), with data from 1999 and 2011. Participants with heartburn or belching after going to bed, at least 1 night/week, were considered to have nGER. Participants reporting loud snoring at least 3 nights/week were considered to have habitual snoring. Participants were grouped into four groups by their nGER and snoring status: "never"; "former"; "incident"; "persistent". Incident respiratory symptoms were analyzed among participants without respective symptom at baseline.

RESULTS

Snoring and nGER were independently associated with incident asthma and respiratory symptoms. The risk of incident wheeze was increased in subjects with incident or persistent snoring (adjusted odds ratio (95 % CI): 1.44 (1.21-1.72)), nGER (2.18 (1.60-2.98)) and in those with both snoring and nGER (2.59 (1.83-3.65)). The risk of developing asthma was increased in subjects with incident or persistent snoring (1.44 (1.15-1.82)), nGER (1.99 (1.35-2.93)) and in those with both snoring and nGER (1.72 (1.06-2.77)). No significant interaction was found between snoring and nGER. A similar pattern was found for the incidence of all other respiratory symptoms studied, with the highest risk among those with both incident or persistent nGER and snoring.

CONCLUSION

The risk of developing asthma and respiratory symptoms is increased among subjects with nGER and habitual snoring. These associations are independent of each other and confounding factors. Snoring and nGER together are additive on respiratory symptoms.

The frequency of sleep-disordered breathing in preschool children with asthma and its effects on control of asthma

CONCLUSION

The frequency and score of SDB were higher in patients with uncontrolled asthma. Frequency and score of SDB were significantly affected by the severity of asthma. SDB must be evaluated in preschool children with uncontrolled asthma.

CONCLUSION

Sleep-disordered breathing (SDB) is more common in asthmatic patients than in non-asthmatic persons, and SDB affects negatively to control asthma. A limited number of studies are discovered on the effect of SDB in preschool asthmatic children. In this study, we aimed to investigate the prevalence of SDB and its effect on control and severity of asthma in preschool children. A pediatric sleep questionnaire was completed by parents of asthmatic children. Patients who received a score of 0.33 or higher were diagnosed with SDB. Control and severity of asthma was assessed by a pediatric allergy specialist based on the Global Initiative for Asthma (GINA) criteria. The study included 249 patients, with a mean±SD age of 4.37±1.04 (range: 2-5.9) years; 69% were boys; 56.6% children had uncontrolled asthma and 28.7% had SDB. The SDB score was significantly different between controlled and uncontrolled asthma (0.19 vs 0.28; P < 0.001). The frequency of uncontrolled asthma in patients with and without SDB was 74.3% and 49.4%, respectively (P < 0.010). Based on the severity of asthma, the frequency of SDB among patients with mild, moderate, and severe asthma was 23.4%, 35.2%, and 47.4%, respectively (P = 0.010).

Co-existence of OSA and respiratory diseases and the influence of gender

INTRODUCTION

Sleep-disordered breathing (SDB), especially obstructive sleep apnea (OSA), is commonly associated with respiratory diseases, such as COPD, asthma and interstitial lung disease.

AREAS COVERED

This narrative review aims to comprehensively synthesize the existing information on SDB in respiratory diseases, investigate the role of gender in this association, and highlight the importance of OSA management in improving sleep, quality of life, and disease prognosis in these specific patient populations.

EXPERT OPINION

Research indicates a synergistic link between OSA and chronic respiratory diseases, which leads to greater morbidity and mortality compared to each disorder alone. Given the lack of an optimal OSA screening tool for these patients, a comprehensive patient approach and overnight diagnostic sleep study are imperative. Despite the limited evidence available, it seems that gender has an impact on the prevalence, severity, and susceptibility of this coexistence. Recognizing the role of gender in the coexistence of OSA and other respiratory diseases can enhance everyday medical practice and enable clinicians to adopt a more personalized approach toward optimal screening and diagnosis of these patients.

Obstructive sleep apnea in asthmatic children: a cross-sectional study about prevalence and risk factors

OBJECTIVES

Primary objectives were to analyze the prevalence of obstructive sleep apnea in (1) boys and girls, and (2) severe asthma versus moderate and mild cases. The authors hypothesized that girls and severe asthma would have a higher prevalence of obstructive sleep apnea.

METHODS

Cross-sectional evaluation of asthmatic children attending a tertiary Pediatric Pulmonology clinic. The authors performed a history, physical examination, pulmonary function test, and home sleep apnea test.

RESULTS

The authors studied 80 consecutive patients, 7-18 years old, mean age of 11.6 years (standard deviation 2.7), 51.3% female, and 18.5% obese. Pulmonary function tests were obtained from 80 volunteers, 45% with obstruction pattern. Home sleep apnea tests were available from 76 volunteers, with a mean obstructive respiratory index of 1.8 events/h. Obstructive sleep apnea was found in 49 volunteers (61.2%). The authors did not find associations between obstructive sleep apnea and sex or asthma severity.

CONCLUSIONS

Obstructive sleep apnea was frequent among these asthmatic children. Sex and asthma severity were not risk factors. Considering the interrelationship of both diseases, it is worth keeping in mind the possibility of obstructive sleep apnea among children and teenagers with asthma.

Pediatric sleep-disordered breathing in Shanghai: characteristics, independent risk factors and its association with malocclusion

OBJECTIVES

This study aimed to determine the prevalence and independent risk factors of SDB, and explore its association with malocclusion among 6-11-year-old children in Shanghai, China.

METHODS

A cluster sampling procedure was adopted in this cross-sectional study. Pediatric Sleep Questionnaire (PSQ) was applied to evaluate the presence of SDB. Questionnaires including PSQ, medical history, family history, and daily habits/environment were completed by parents under instruction, and oral examinations were implemented by well-trained orthodontists. Multivariable logistic regression was applied to identify independent risk factors for SDB. Chi-square tests and Spearman's Rank Correlation were used to estimate the relationship between SDB and malocclusion.

RESULTS

A total of 3433 subjects (1788 males and 1645 females) were included in the study. The SDB prevalence was about 17.7%. Allergic rhinitis (OR 1.39, 95% CI 1.09-1.79), adenotonsillar hypertrophy (OR 2.39, 95% CI 1.82-3.19), paternal snoring (OR 1.97, 95% CI 1.53-2.53), and maternal snoring (OR 1.35, 95% CI 1.05-1.73) were independent risk factors for SDB. The SDB prevalence was higher in children with retrusive mandibles than in proper or excessive ones. No significant difference was observed in the correlation between SDB and lateral facial profile, mandible plane angle, constricted dental arch form, the severity of anterior overjet and overbite, degree of crowding and spacing, and the presence of crossbite and open bite.

CONCLUSIONS

The prevalence of SDB in primary students in the Chinese urban population was high and highly associated with mandible retrusion. The independent risk factors included Allergic rhinitis, adenotonsillar hypertrophy, paternal snoring, and maternal snoring. More efforts should be made to enhance public education about SDB and related dental-maxillofacial abnormalities.

Association of adenotonsillectomy with wheezing episodes in childhood: A secondary analysis of the Childhood Adenotonsillectomy Trial

BACKGROUND

Observational studies suggest that asthma/wheezing improves after adenotonsillectomy (AT). However, there is a paucity of randomized clinical trial (RCT) specifically studying the effects of AT in asthma/wheezing. Therefore, we conducted a post-hoc analysis of the Childhood Adenotonsillectomy Trial (CHAT), the largest RCT of AT in children with obstructive sleep apnea (OSA) to test the hypothesis that AT would result in fewer wheezing episodes.

METHODS

In the CHAT study, 464 children with OSA, aged 5-9 years, were randomized to early AT (n = 226) or watchful waiting with supportive care (WWSC) (n = 227). For this post-hoc analysis, children were categorized as having "any wheezing" versus "no wheezing" at baseline and at 7 months of follow-up. A multivariate analysis was conducted to evaluate the association between "any wheezing" at follow-up and treatment group after controlling for several potential confounders.

RESULTS

Children in the "any wheezing" group were predominantly black, had more allergic rhinitis, eczema, second-hand smoke exposure, body mass index, apnea-hypopnea index (AHI), and had lower maternal education and family income than those in the "no wheezing group." In the AT arm, the prevalence of wheezing significantly decreased from baseline to follow-up (at 7 months of the intervention) (47% vs. 21.6%, p < 0.001); while in the WWSC arms did not change (45.2% vs. 43.1%, p = 0.67). In the multivariate analysis, second-hand smoke exposure, wheezing at baseline, and belong to WWSC arm (odds ratio: 3.65 [2.16-6.19]) increase the risk of wheezing at follow-up.

CONCLUSION

This study demonstrated that AT decreased the risk of wheezing at 7 months of follow-up.

Clinical-functional characteristics of children with asthma and obstructive sleep apnea overlap associated with attention deficit hyperactivity disorder: A cross-sectional study

Background

Asthma and obstructive sleep apnea (OSA) are common chronic respiratory disorders in children. The relationship between asthma and OSA is bidirectional; these conditions share multiple epidemiological risk factors. Untreated OSA may cause attention deficit hyperactivity disorder (ADHD) symptoms. This study aimed to assess the prevalence of ADHD in asthmatic children with OSA and the link between asthma control and lung function of children with asthma and OSA.

Methods

A total of 96 children aged 6-15 years diagnosed with asthma, according to the Global Initiative for Asthma (GINA) 2020, were enrolled in this study. All demographic data, including age, gender, body mass index, asthma control status, therapy, the Vanderbilt ADHD Diagnostic Parent Rating Scale, lung function, and exhaled nitric oxide, were collected. In addition, home respiratory polygraphy was used to identify OSA in study subjects.

Results

A total of 96 patients (8.4 ± 2.4 years) were included in the present study. OSA was identified in 60.4% of asthmatic children with a mean apnea-hypopnea index (AHI) of 3.5 ± 3.0 event/h. The inattentive ADHD subtype was significantly lower in the non-OSA asthmatic group than in the OSA asthmatic group (7.9 vs. 34.5%, p < 0.05). ADHD had a higher probability of presence (OR: 3.355; 95% CI: 1.271-8.859; p < 0.05) in the OSA group (AHI >1 event/h). Children with poorly controlled asthma had a significantly high risk of OSA (83.0 vs. 17.0%, p < 0.001) than children with well-controlled asthma. Allergic rhinitis increased the odds of having OSA in patients with asthma [OR: 8.217 (95% CI: 3.216-20.996); p < 0.05].

Conclusion

The prevalence of OSA is increased among poorly controlled asthma. ADHD may have a higher prevalence in children with OSA. Therefore, prompt diagnosis of OSA will lead to an accurate asthma control strategy in patients with asthma.

Mediators linking obesity to childhood asthma

BACKGROUND

Obesity and asthma are highly associated, but the mechanisms underlying the association remain unknown. We examined five mediators linking obesity with childhood asthma: (1) pulmonary function impairment, (2) airway inflammation, (3) physical fitness, (4) sleep-disordered breathing (SDB), and (5) early puberty.

METHODS

A Mendelian randomization (MR) study with mediation analysis of data obtained from 5965 children as part of the Taiwan Children Health Study. Observational analysis, MR two-stage least-squares method, and MR sensitivity analysis were carried out to investigate each causal pathway. Prospective cohort analyses were used to strengthen the findings.

RESULTS

The increased asthma risk associated with obesity was found to be mostly mediated through impaired pulmonary function, low physical fitness, and early puberty. In the MR analysis, body mass index was negatively associated with FEV1/FVC and physical fitness index (β = -2.17 and -0.71; 95% CI, -3.92 to -0.42 and -1.30 to -0.13, respectively) and positively associated with early puberty (OR, 1.09; 95% CI, 1.02-1.17). High FEV1/FVC and physical fitness index reduced asthma risk (OR, 0.98 and 0.93; 95% CI, 0.97-0.99 and 0.88-0.98, respectively), whereas SDB and early puberty increased the risk of asthma (OR, 1.03 and 1.22; 95% CI, 1.01-1.05 and 1.05-1.42, respectively). Temporal causality was strengthened in prospective cohort analyses. The three main mediators were low physical fitness, impaired pulmonary function, and early puberty, with mediation proportions of 73.76%, 61.63%, and 27.66%, respectively.

CONCLUSIONS

Interventions promoting physical fitness and pulmonary function might effectively reduce obesity-induced asthma risk.

Trends and age-period-cohort effects on incidence and mortality of asthma in Sichuan Province, China, 1990-2019

Background

The provinces in western China have undergone rapid urbanization and industrialization, particularly since the Chinese government launched the Great Western Development Strategy in 2000. We examined the time trends and contributions of age, period, and cohort effects to asthma incidence and mortality in Sichuan Province, a populous province in western China, from 1990 to 2019.

Methods

The data of Sichuan Province from 1990 to 2019 were extracted from the Global Burden of Disease study 2019. Trends and average annual percentage change were estimated using joinpoint regression. Age, period, and cohort effects were estimated using an age-period-cohort model with the intrinsic estimator method.

Results

In the latest period (2015–2019), the highest incidence of asthma was 2004.49/100,000 in children aged < 5 years, and the highest mortality rate was 22.04/100,000 for elderly people aged > 80 years. Age-standardized rates generally remained stable (95% confidence interval [CI]  − 0.21, 0.11) for incidence and declined by 4.74% (95% CI − 5.09, − 4.39) for mortality over the last 30 years. After controlling for other effects, the age effect on asthma showed that the incidence rate ratio (RR) was highest in the < 5 years age group, and the mortality RR was highest in the > 80 years age group. The period effect on incidence and mortality decreased from 1990 to 2019, respectively. A cohort effect was found the incidence RR increased slowly from the early birth cohorts to the later birth cohorts, especially after the 2005 birth cohort, whereas the mortality RR continued to decline.

Conclusions

There was a significant effect of older age on the asthma mortality rate over the last 30 years, and the incidence rate in children aged < 5 years increased. The relative risk of asthma incidence in the later birth cohorts increased. Effective preventive measures and public health policies should be to protect children and elderly people from potentially harmful chronic diseases.

Sleep disorders in children with asthma

Asthma and sleep disorders are both common in childhood, and often co-exist in the same child. Moreover, studies have shown that in many children the rate of one is influenced by the other. Sleep disorders can be classified into six different groups-insomnia, hypersomnia, parasomnia, movement disorders, circadian disorders, and sleep-related breathing disorders. Children with asthma often present with complaints of insomnia with poor sleep quality, difficulty falling asleep and sleep disruptions. These complains are often associated with asthma control. They may also complain of daytime sleepiness and have higher rates of parasomnias, such as night terrors and nocturnal enuresis when compared with their healthy peers. Whether movement and circadian disorders are also more prevalent in children with asthma is less clear. Finally, there is a complex bidirectional interaction between sleep-related breathing disorders and asthma: poor sleep and sleep disorders may worsen asthma, and asthma, particularly when it is poorly controlled, may impair sleep. In the current review we examine the association of each of the sleep disorders with asthma and review the common pathophysiological pathways. We hope to convince the reader that appropriate management of asthma must include inquiries into the patient's sleep, and vice versa.

Asthma and obstructive sleep apnoea in adults and children - an up-to-date review

Obstructive sleep apnoea (OSA) and asthma are two common respiratory disorders in children and adults. Apart from common risk factors, such as obesity, gastroesophageal reflux disease and allergic rhinitis, emerging evidence suggest that the two diseases may complicate the clinical course of each other. On one hand, OSA modifies asthmatic airway inflammation and is associated with poor asthma control. On the other hand, asthma and its medications increase the collapsibility of the upper airways contributing to the development and worsening of OSA. The overnight respiratory symptoms of OSA and asthma are often similar, and an inpatient polysomnography is often necessary for a proper diagnosis, especially in children. Continuous positive pressure, the gold standard treatment for OSA can improve asthma control in patients suffering from both diseases. However, there is limited evidence how anti-asthma medications act in the same patients. Nevertheless, adenotonsillectomy seems to be effective in children with concomitant asthma and OSA. This review summarises the evidence for the bidirectional link between asthma and OSA, focuses on diagnostic and therapeutic challenges and highlights the need for further research.

Prevalence of high-risk for obstructive sleep apnea in attention deficit hyperactivity disorder children referred to psychiatry clinic and impact on quality of life

OBJECTIVES

To study the prevalence of high-risk obstructive sleep apnea (OSA) in attention deficit hyperactivity disorder (ADHD) children in a child and adolescent psychiatry clinic using the Thai version of the Pediatric Obstructive Sleep Apnea Screening Tool (POSAST) questionnaire. The secondary objective was to evaluate the quality of life and identify associated factors for high-risk OSA in ADHD children.

STUDY DESIGN

Prospective cross-sectional study.

MATERIAL AND METHOD

Caregivers of pediatric patients aged 5-18 years old and diagnosed with ADHD by child and adolescent psychiatrists were surveyed about their child's sleeping habits.

RESULTS

Two hundred and seventy-four subjects were included. The patients' mean age was 10.4 ± 2.6 years, and 82.8% were males. There were 30 children (10.9%) diagnosed with obesity, 46 (16.8%) with chronic rhinitis, and 9 (3.3%) with asthma. The median duration of ADHD symptoms was 22.1 months. The prevalence of high-risk OSA was 18.2% and was associated with significantly reduced quality of life (adjusted OR = 4.46, 95% CI: 2.26-8.81, P < 0.001). A significant association between high-risk OSA and obesity also emerged (adjusted OR = 2.84, 95% CI: 1.17-6.88, P = 0.021).

CONCLUSION

An elevated prevalence of high-risk OSA is present among Thai children with ADHD, and significantly impacts quality of life. A significant association between high-risk OSA and obesity is also detected in patients with ADHD. Therefore, screening for high-risk OSA in ADHD patients may likely facilitate early detection and treatment of OSA, and potentially prevent adverse consequences.

Obstructive sleep apnea in patients with severe asthma: Prevalence and association between severity and asthma control

INTRODUCTION:

Asthma and obstructive sleep apnea (OSA) are common respiratory disorders that can coexist and cause sleep disturbances. The strength of this association and the impact of OSA on asthma severity and control remain unclear. The study aims to estimate the prevalence of OSA in patients with severe asthma in Oman and to examine whether the severity of OSA contributed to the level of asthma control.

METHODS:

Adult patients with confirmed diagnosis of severe asthma who attended the respiratory clinic in a tertiary hospital in Oman over a period of 19 months were enrolled in the study. Eligible participants were screened by asthma control test (ACT) and Berlin questionnaire (BQ). Patients with high risk for OSA were subjected further to level 3 sleep study. The prevalence of OSA in patients with severe asthma and the associations between the severity of OSA and asthma control were calculated.

RESULTS:

We identified 312 adult asthma patients on Global Initiative for Asthma step 4 or 5 management out of 550 who were screened. The mean age of the study population was 56.59 ± 12.40 years and the mean body mass index (BMI) 40.30 ± 12.24 kg/m². The prevalence of OSA in asthma patients with severe asthma was found to be 32.4%. Out of the 138 well-controlled asthma patients (ACT ≥20), 35 had high risk of OSA based on BQ, and 32 were confirmed to have OSA (23%). Of the 174 uncontrolled patients, 80 patients had high risk of OSA and 69 patients were confirmed to have OSA (39.65%). Severe OSA was seen in 63.8% and 9.4% in uncontrolled and controlled asthma patients, respectively (P = 0.002). The median respiratory event index in the uncontrolled group was 43, and it was significantly higher than 12.5 in the controlled group (P < 0.001).

CONCLUSIONS:

The prevalence of OSA was high (32.37%) in patients with severe asthma. Uncontrolled severe asthma was significantly associated with severe OSA.

Sex differences in the relationship of sleep-disordered breathing and asthma control among children with severe asthma

OBJECTIVE

Children with severe asthma are underrepresented in studies of the relationship of sleep-disordered breathing (SDB) and asthma and little is known about sex differences of these relationships. We sought to determine the relationship of SDB with asthma control and lung function among boys and girls within a pediatric severe asthma cohort.

METHODS

Patients attending clinic visits at the Boston Children's Hospital Pediatric Severe Asthma Program completed the Pediatric Sleep Questionnaire (PSQ), Asthma Control Test (ACT) and Spirometry. The prevalence of SDB was defined as a PSQ score >0.33. We analyzed the association between PSQ score and both ACT score and spirometry values in mixed effect models, testing interactions for age and sex.

RESULTS

Among 37 subjects, mean age was 11.8 years (4.4) and 23 (62.2%) were male, the prevalence of SDB was 43.2% (16/37). Including all 80 observations, there was a moderate negative correlation between PSQ and ACT scores (r=-0.46, p < 0.001). Multivariable linear regression models revealed a significant sex interaction with PSQ on asthma control (p = 0.003), such that for each 0.10 point increase in PSQ there was a 1.88 point decrease in ACT score for females but only 0.21 point decrease in ACT score for males. A positive PSQ screen was associated with a 9.44 point (CI 5.54, 13.34, p < 0.001) lower ACT score for females and a 3.22 point (CI 0.56, 5.88, p = 0.02) lower score for males.

CONCLUSIONS

SDB is common among children with severe asthma. Among children with severe asthma, SDB in girls portends to significantly worse asthma control than boys.

Supplemental data for this article is available online at https://doi.org/10.1080/02770903.2021.1897838.

Relationship between Poorly Controlled Asthma and Sleep-Related Breathing Disorders in Children with Asthma: A Two-Center Study

Objective

Asthma and sleep-related breathing disorders (SRBD) are common chronic respiratory diseases in children. The relationship between asthma and SRDB is bidirectional. However, only a few studies have analyzed the relationship between asthma control status and risk of SRBD. The aim of this study was to evaluate the relationship between asthma control and SRBD and further assess the relationship between therapy/atopy/lung function of children with asthma and SRBD.

Methods

A total of 209 children aged 3-16 years were enrolled in this study. Pediatric sleep questionnaire (PSQ) scores were used to identify children at high risk of developing SRBD. Data on asthma control status, therapy, allergy, lung function, and exhaled nitric oxide were collected.

Results

A significantly higher risk of SRBD was found among children with poorly controlled asthma (34.25% vs. 13.97%, P < 0.01) and allergic rhinitis (AR) (34.29% vs. 13.92%, P < 0.01) than among children with well-controlled asthma and AR. The prevalence of SRBD was also significantly higher in asthmatic children with obesity than that with just obesity (42.11% vs. 20.00%, P < 0.05). Multiple logistic regression analysis showed that poorly controlled asthma (OR, 2.746 (95% CI, 1.215-6.209); P < 0.05) and poorly controlled AR (OR, 3.284 (95% CI, 1.430-7.544); P < 0.01) increased the odds of having SRBD.

Conclusion

Poorly controlled asthma and AR increase the risk of SRBD. A routine check of the level of asthma control and appropriate use of medication for AR are important because of their influence on SRBD.

Prevalence of Asthma and Sleep-Related Breathing Disorder in School-Going Children

Objective:

The main objective of the study was to determine the prevalence of asthma and sleep-related breathing disorder (SRBD) in school-going children.

Methods:

This school-based, cross-sectional study was conducted among children of age groups of 6–7 and 13–14 years from 31 public and private schools in rural and urban areas of Jodhpur. A pretested and validated questionnaire in Hindi for childhood asthma, International Study of Asthma and Allergies in Childhood questionnaire and 22-item pediatric SRBD scale were used to collect data.

Results:

A total of 2245 children were screened for asthma and SRBD. The overall prevalence of asthma and SRBD in school children in Jodhpur was 8.0% (95% confidence interval [CI]: 6.9%–9.2%) and 9.5% (95% CI: 8.4–10.8), respectively. Asthma was found to be significantly associated with SRBD in school-going children in Jodhpur (odds ratio: 4.8; 95% CI: 3.3–6.8) on multiple logistic regression analysis.

Conclusion:

There is a significantly high prevalence of asthma and SRBD with a good association between them in school-going children.

Observational studies assessing the pharmacological treatment of obstructive lung disease: strengths, challenges and considerations for study design

Randomised controlled trials (RCTs) are the gold standard for evaluating treatment efficacy in patients with obstructive lung disease. However, due to strict inclusion criteria and the conditions required for ascertaining statistical significance, the patients included typically represent as little as 5% of the general obstructive lung disease population. Thus, studies in broader patient populations are becoming increasingly important. These can be randomised effectiveness trials or observational studies providing data on real-world treatment effectiveness and safety data that complement efficacy RCTs. In this review we describe the features associated with the diagnosis of asthma and chronic obstructive pulmonary disease (COPD) in the real-world clinical practice setting. We also discuss how RCTs and observational studies have reported opposing outcomes with several treatments and inhaler devices due to differences in study design and the variations in patients recruited by different study types. Whilst observational studies are not without weaknesses, we outline recently developed tools for defining markers of quality of observational studies. We also examine how observational studies are capable of providing valuable insights into disease mechanisms and management and how they are a vital component of research into obstructive lung disease. As we move into an era of personalised medicine, recent observational studies, such as the NOVEL observational longiTudinal studY (NOVELTY), have the capacity to provide a greater understanding of the value of a personalised healthcare approach in patients in clinical practice by focussing on standardised outcome measures of patient-reported outcomes, physician assessments, airway physiology, and blood and airway biomarkers across both primary and specialist care.

Phenotype of ventilatory control in children with moderate to severe persistent asthma and obstructive sleep apnea

STUDY OBJECTIVES

To examine the role of ventilatory control in asthmatic children with obstructive sleep apnea (OSA) and the relationships between measures of ventilatory control, OSA severity, and pulmonary function.

METHODS

Five- to 18-year-old children with persistent asthma and nightly snoring were enrolled in the study. Children had physical examination, pulmonary function test, and polysomnography. Loop and controller gains were derived from 5 min segments which included a sigh during nonrapid eye movement sleep by applying a mathematical model that quantifies ventilatory control from the ensuing responses to the sighs. Plant gain was derived from 5 min segments of spontaneous breathing (i.e. without sighs). Nonparametric statistical tests were used for group comparisons. Cluster analysis was performed using Bayesian profile regression.

RESULTS

One hundred thirty-four children were included in the study, 77 with and 57 without OSA. Plant gain was higher in children with OSA than in those without OSA (p = 0.002). A negative correlation was observed between plant gain and forced expiratory volume in 1 second (p = 0.048) and the ratio of f forced expiratory volume to forced vital capacity (p = 0.02). Plant gain correlated positively with severity of OSA. Cluster analysis demonstrated that children with more severe OSA and abnormal lung function had higher plant gain and a lower controller gain compared with the rest of the population.

CONCLUSIONS

Children with OSA and persistent asthma with abnormal lung function have phenotypic characteristics which consist of diminished capacity of the lungs to maintain blood gas homeostasis reflected by an increase in plant gain and decreased chemoreceptor sensitivity.

Clinical features and risk factors in patients with asthma complicated with obstructive sleep apnea-hypopnea syndrome: a hospital-based study

PURPOSE

The current study was conducted to explore the clinical features and risk factors of patients with asthma complicated by obstructive sleep apnea-hypopnea syndrome (OSAHS).

METHODS

Patients with asthma who underwent polysomnography in our hospital from August 2017 to December 2019 were enrolled in the study. Data on demographics, pulmonary function testing, polysomnography, blood gases, mean pulmonary artery pressure, and vascular endothelial growth factor (VEGF) were compared between the two groups.

RESULTS

Of 238 patients with asthma, 93 who also had OSAHS formed the observation group and were subclassified into mild (n = 33), moderate (n = 41), and severe (n = 19) categories, while 145 patients with asthma alone were assigned to the control group. No significant differences were found in sex, age, course of disease, or pulmonary function between the two groups (P > 0.05), while the observation group showed more frequent allergic rhinitis and had greater BMI, neck circumference, mean pulmonary artery pressure (mPAP), and VEGF than those in the control group (P < 0.001). The peak expiratory flow (PEF), forced expiratory volume in 1 s (FEV₁), forced vital capacity (FVC), and FEV₁/FVC in the mild group and the moderate group were higher than those in the severe group (P < 0.001). The durations of AHI and SaO₂ < 90% in the mild group and the moderate group were shorter than that in the severe group, and the lowest level of SaO₂ in the mild group and the moderate group was higher than that in the severe group (P <  0.05). The mPAP and VEGF of the mild and moderate groups were lower than those of severe group (P < 0.001), with mild group lower than moderate group (P < 0.001).

CONCLUSION

Significant differences in allergic rhinitis, BMI, neck circumference, AHI, SaO2, mPAP, and VEGF were observed in patients with asthma complicated by OSAHS. These parameters are risk factors associated with asthma complicated by OSAHS.

Characteristics and risk factors of children with sleep-disordered breathing in Wuxi, China

Background

Sleep-disordered breathing (SDB) is a common syndrome in children, related to their immune responses, cardiovascular function, and neurocognitive function. This study aimed to determine the prevalence of SDB among children in Wuxi, China, and to evaluate the protective and risk factors of SDB in children.

Methods

A cross-sectional study was conducted on children attending different schools across Wuxi, China, aged 3–14 years old. Of a total of 5630 questionnaires distributed to the parents of the children, 3997 (71.0%) were deemed to be valid. The data on the general sociodemographic factors, children’s allergy and sleep characteristics, and the parents’ sleep characteristics were also collected. The Paediatric Sleep Questionnaire (PSQ) score was used to identify children at high risk of SDB. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by logistic regression.

Results

The prevalence of SDB in this cohort was 13.4% (N = 534). SDB prevalence significantly differed in children with asthma (28.2% vs. 12.8%, P < 0.001), eczema (19.0% vs. 10.0%, P < 0.001), urticaria (16.4% vs. 12.9%, P < 0.01) and rhinitis (21.4% vs. 10.7%, P < 0.001). No significant differences were found in SDB prevalence with respect to pillow material or quilt material. On multivariate logistic regression analysis, asthma (OR 1.986 (95% CI 1.312–3.007), P < 0.01), eczema (OR 1.675 (95% CI 1.377–2.037), P < 0.001), rhinitis (OR 1.998 (95% CI 1.635–2.441), suffered from familial sleep sickness (OR 2.416 (95% CI 1.975–2.955), P < 0.001) and whose mothers slept for a shorter duration (6 h–8 h: OR 1.370 (95% CI 1.089–1.724), P < 0.01; <6 h: OR 3.385(95% CI 2.098–5.461), P < 0.001) increased the odds of having SDB. The incidence of SDB significantly decreased with children’s age (6–11 years old: 0R 0.768 (95% CI 0.597–0.989), P < 0.05; 12–14 years old: OR 0.691 (95% CI 0.530–0.901), P < 0.01).

Conclusion

The results of this study demonstrated that atopic diseases (asthma, eczema, and rhinitis) and family sleep habits were risk factors for SDB in children in Wuxi, China.

Obstructive Sleep Apnea in Children and Adolescents and the Risk of Major Adverse Cardiovascular Events: A Nationwide Cohort Study in Taiwan

STUDY OBJECTIVES

This study has investigated the risk of major adverse cardiovascular events (MACEs), including acute myocardial infarction, coronary artery disease, peripheral artery disease, and acute stroke, among children and adolescents (age younger than 20 years) with obstructive sleep apnea (OSA).

METHODS

In this study, the population-based National Health Insurance Research Database of Taiwan was used to identify patients in whom OSA had been first diagnosed between 2000 and 2015. Children and adolescents with OSA (n = 6,535) were included with 1:3 ratio by age, sex, and index year of control participants without OSA (n = 19,605). The Cox proportional regression model was used to evaluate the risk of MACEs in this cohort study.

RESULTS

After a 15-year follow-up, the incidence rate of MACEs was higher in the OSA cohort when compared with the non-OSA control cohort (15.97 and 8.20 per 100,000 person-years, respectively). After adjusting for covariates, the risk of MACEs among children and adolescents with OSA was still significantly higher (hazard ratio = 2.050; 95% confidence interval = 1.312-3.107; P = .010). No MACEs were found in the children and adolescents with OSA who received continuous airway positive pressure treatment or pharyngeal surgery.

CONCLUSIONS

This study found a significantly higher risk of MACEs in children and adolescents with OSA. These findings strongly suggest that clinicians should provide careful follow-up and medical treatment for children and adolescents with OSA.

Differences in sleep problems between Japanese and Chinese preschoolers: a cross-cultural comparison within the Asian region

STUDY OBJECTIVES

Previous studies have performed cross-cultural comparisons of differences in childhood sleep problems between Asian and Western countries. However, whether such differences can be observed among Asian countries remains unclear. The present study aimed to investigate differences in the pattern of sleep problems between Japanese and Chinese preschoolers.

METHODS

Data were collected from one city in Japan and 10 cities in China. The present study recruited 438 Japanese and 1020 Chinese preschoolers aged four and five years. Sleep problems and patterns were assessed on the basis of parental reports using the Children's Sleep Habits Questionnaire (CSHQ).

RESULTS

Analysis of covariance revealed no significant difference in total CSHQ scores between Japanese and Chinese preschoolers, thus indicating that the total severity of sleep problems did not differ between the groups. Japanese preschoolers exhibited higher scores on the bedtime resistance subscale of the CSHQ than Chinese preschoolers. Conversely, Chinese preschoolers exhibited higher subscale scores for night wakings and sleep-disordered breathing. In addition, Japanese preschoolers exhibited earlier bedtimes and wake times and shorter total sleep times than Chinese preschoolers.

CONCLUSIONS

Our findings indicate that the patterns of sleep problems in preschoolers differ between Japan and China and that such differences may be due to differences in cosleeping practices, bedtime routines, and/or environmental conditions. Thus, investigators studying sleep in preschoolers should consider regional differences in the pattern of sleep problems, even among Asian countries.

Study of the clinical and functional characteristics of asthmatic children with obstructive sleep apnea

BACKGROUND AND OBJECTIVE

The obstructive sleep apnea (OSA) is a common respiratory disorder in children, especially those at preschool and school ages. This study aimed to describe the characteristics of asthmatic children with OSA and the symptoms for a high risk of OSA.

SUBJECTS AND METHODS

It was a prospective and descriptive study. The data of asthmatic children including medical history, clinical examination, blood tests, spirometry, exhaled nitric oxide (NO), and respiratory polygraphy were registered for analyses.

RESULTS

Eighty-five asthmatic children with a mean age of 9.5 ± 2.1 years were included. The prevalence of OSA was 65.9% (56/85) in study subjects. The prevalence of severe OSA in children with moderate asthma was significantly higher than intermittent and mild asthma. The percentage of asthmatic children with OSA who had snoring, sleep disturbance, and nocturnal sweats was significantly higher than that of asthmatic children without OSA (48.2% vs 17.2%, 71.4% vs 27.5%, and 55.1% vs 31.0%, respectively). The presence of allergic rhinitis and snoring was associated significantly with a high probability for the presence of OSA.

CONCLUSION

Children with asthma have a risk of OSA. Asthmatic children with suggested symptoms such as snoring or waking up at night should be screened for OSA.

Linear dimensions of normal upper airway structure by magnetic resonance imaging in Chinese Han infants and preschool children

OBJECTIVES

To establish normative data of upper airway structure in Chinese Han infants and preschool children.

METHODS

Magnetic resonance imaging (MRI) scans of 521 Chinese Han infants and preschool children (225 girls, 296 boys) aged from 1 day to 72 months were selected from the children who underwent head MRI at the Capital Institute of Pediatrics Affiliated Children Hospital, Beijing, China. No subjects had sleep-disordered breathing or associated conditions that may have affected the upper airway anatomy. The upper airway dimensions and surrounding soft tissue sizes were measured along the mid-sagittal and axial images.

RESULTS

On images from the mid-sagittal image, the normative values of the following were obtained for all age group: thickness of the adenoid and nasopharyngeal area, length and thickness of the soft palate, length and height of the tongue, length of upper airway, distance between the mental spine and clivus, and the adenoid oblique width, soft palate oblique width, and tongue oblique width along the mental spine-clivus line. Normative values of the mean tonsillar width and intertonsillar space on the axial images were also obtained. There were no differences in any measurements between boys and girls in either infants or preschool children. Older children had larger airway dimensions, as expected.

CONCLUSION

Normative values for upper airway structure in Chinese Han infants and preschool children assessed by MRI were established. The upper airway dimension and surrounding soft tissues size, including soft palate, adenoid, tongue, and tonsils, were increased with age. There were no gender differences during the first six years of life. These data may prove useful when studying airway disease in Chinese Han children.

Relation between asthma and sleep disordered breathing in children: is the association causal?

Over the last few decades, asthma and sleep disordered breathing (SDB) in children have experienced similar increases in prevalence, and have both been shown to have airway inflammation, leading investigators to postulate an association between asthma and SDB. However, whether this relationship is causal or not needs to be proven. In this manuscript, we use the most widely accepted epidemiologic criteria for causality, the Bradford Hill criteria, to test step-by-step whether the relation between asthma and SBD in children is causal or not. We found studies supporting 8 of the 9 criteria (strength, consistency, specificity, biological gradient, coherence and biological plausibility, experiment, and analogy) for association between asthma and SDB. However, we did not find any study showing temporality or directionality between asthma and SDB. Therefore, establishing a causal association between asthma and SDB is not yet possible.

The frequency of sleep-disordered breathing in children with asthma and its effects on asthma control

BACKGROUND

The presence of sleep-disordered breathing (SDB) in children with asthma may cause difficult to control asthma.

OBJECTIVES

The aim of this study was to determine the frequency of SDB in children with asthma, to evaluate its effects on asthma control and to assess the risk factors associated with the presence of SDB.

METHODS

Parents of children who Sleep Questionnaire (PSQ) and the Childhood Asthma Control Test (C-ACT). Asthma control level was assessed according to Global Initiative for Asthma (GINA). Same ear-nose-throat (ENT) specialist evaluated all patients. A 4-point tonsil grading method and adenoid-nasopharynx ratio were used to categorize tonsil and adenoid size, respectively.

RESULTS

A total of 408 children (275 male, 67.4%) with a mean age of 8.1 ± 3.2 years were included. Nearly 40% of asthmatic children were not-well-controlled according to GINA and 34.6% of all patients had SDB according to PSQ. Multivariate logistic regression analysis revealed that coexistence of SDB [OR: 6.62, 95% CI (4.21-10.41); p < 0.001)] and tonsillar hypertrophy [OR: 3.47; 95% CI (1.05-11.5); p < 0.041] were independent risk factors for not-well-controlled asthma in asthmatic children after other established contributors to asthma control were adjusted.

CONCLUSIONS

Our study showed that SDB is a strong risk factor for not-well-controlled asthma in asthmatic children independent of other confounders. In addition, tonsillar hypertrophy may have a role in the association between SDB and not-well-controlled asthma in childhood.

Asthma and subjective sleep disordered breathing in a large cohort of urban adolescents

OBJECTIVE

Sleep disordered breathing (SDB) has not been well studied in urban adolescents with asthma in community settings. Nor has the association of SDB symptoms and asthma severity been studied. We characterized self-reported symptoms suggesting SDB and investigated the association of SDB symptoms, probable asthma, and asthma severity.

METHODS

9,565 adolescents from 21 inner-city high schools were screened for an asthma intervention study. Students reported on symptoms suggesting SDB using questions from the 2007 NHANES, if they were ever diagnosed with asthma, and on asthma symptoms. Using generalized linear mixed models with logit link with school as a random intercept and adjusting for age, gender, and race/ethnicity, we examined associations of SDB symptoms, and demographic characteristics, probable asthma, and asthma severity.

RESULTS

12% reported SDB symptoms. Older and bi-racial participants (compared to Caucasian) had higher odds of symptoms suggesting SDB (p <.001). Compared to those without probable asthma, adolescents with probable asthma had 2.63 greater odds of reporting SDB symptoms (p <.001). Among those with probable asthma, the odds of reporting SDB symptoms increased with asthma severity. When exploring daytime severity and severity due to night wakening separately, results were similar. All results remained significant when controlling for age, gender, and ethnicity.

CONCLUSIONS

In a large urban community cohort of predominately ethnic minority adolescents, self-reported SDB symptoms were associated with probable asthma and increased asthma severity. This study highlights the importance of SDB as a modifiable co-morbidity of asthma.

Expiratory Snoring Predicts Obstructive Pulmonary Disease in Patients with Sleep-disordered Breathing

RATIONALE

Sleep-disordered breathing and chronic obstructive pulmonary disease are two common conditions that may present concomitantly. The effects of chronic obstructive pulmonary disease on the polysomnographic manifestation of sleep-disordered breathing have not been studied.

OBJECTIVES

We hypothesized that the presence of airflow obstruction could be predicted by the presence of expiratory upper airway narrowing during sleep in patients with sleep-disordered breathing.

METHODS

Ninety-three patients with sleep-disordered breathing (19 men; age, 51.6 yr; body mass index, 40.1 kg/m(2); apnea-hypopnea index, 37.4 events/h) were observed. Every patient had an in-lab polysomnography study and complete pulmonary function tests. Sleep and respiratory events were scored using American Academy of Sleep Medicine recommended scoring criteria. Expiratory snoring events were identified on polysomnography using microphone sensor and/or pressure flow sensor in each patient. The FEV1/FVC ratio less than 70 was used to define the presence of airflow obstruction.

MEASUREMENTS AND MAIN RESULTS

The proportion analysis demonstrated that patients with expiratory snoring have 11 times higher odds of having evidence of lower airway obstruction, defined as FEV1/FVC less than 70 (odds ratio [OR], 11.03; P < 0.001), whereas smokers have increased odds by 13 times (OR, 13.18; P < 0.001). Spearman correlation analysis showed that FEV1 was positively related to mean SaO2 (P < 0.05) and negatively related to expiratory snoring, smoking, 3% oxygen desaturation index, 2% oxygen desaturation index, and age (P < 0.05). Epworth sleepiness scale, sex, and body mass index did not have any association with FEV1. The multiple logistic regression analysis demonstrated that chronic obstructive pulmonary disease (FEV1/FVC < 70) correlated significantly with expiratory snoring and smoking (OR, 11.76; confidence interval, 3.23-42.83; and OR, 9.95; confidence interval, 2.67-37.09), respectively. The multiple linear regression analysis revealed that the linear combination of mean SaO2 and expiratory snoring (P < 0.05) predicted FEV1. However, age and 2% oxygen desaturation index did not predict FEV1.

CONCLUSIONS

The presence of expiratory snoring predicts obstructive airway disorders. Patients with expiratory snoring and low mean oxygen saturation during sleep should be carefully assessed for pulmonary disorders such as asthma and chronic obstructive pulmonary disease.

Sleep disordered breathing symptoms and daytime sleepiness are associated with emotional problems and poor school performance in children

This study examined the prevalence of sleep disordered breathing (SDB) symptoms and their associations with daytime sleepiness, emotional problems, and school performance in Chinese children. Participants included 3979 children (10.99±0.99 years old) from four elementary schools in Jintan City, Jiangsu Province, China. Children completed a self-administered questionnaire on sleep behavior and emotional problems, while parents completed the Child Sleep Habit Questionnaire (CSHQ). SDB symptoms included 3 items: loud snoring, stopped breathing, and snorting/gasping during sleep. Teachers rated the children's school performance. The prevalence rates of parent- and self-reported SDB symptoms were 17.2% and 10.1% for "sometimes" and 8.9% and 5.6% for "usually". SDB symptoms, more prevalent in boys than in girls, increased the risks for depression, loneliness, and poor school performance. Daytime sleepiness mediated the relationship between SDB symptoms and depression, loneliness, and poor school performance. This study suggests the importance of early screening and intervention of SDB and daytime sleepiness in child behavioral and cognitive development.

Sleep-disordered breathing in children with asthma: a systematic review on the impact of treatment

Background

The objective was to perform a systematic review in order to describe the relationship between asthma and sleep-disordered breathing (SDB) in children, especially regarding the impact of treatment and management.

Methods

We performed an electronic search in MEDLINE, EMBASE, and LILACS database. Study inclusion criteria were the following: 1) studies that examined the relationship between asthma/wheezing and SDB/obstructive sleep apnea (OSA); and 2) studies conducted in children <18 years of age. Primary outcomes were the prevalence of asthma and SDB, the tests used for diagnosis, and the influence of their treatment and management.

Results

One thousand and twenty studies were identified, among which 32 were selected (n=143,343 children; 51% males; age [mean ± standard deviation] 8.4±2.5 years). Most studies (n=26) diagnosed SDB using questionnaires or clinical history. Nine studies performed a sleep study for diagnosing OSA. The diagnosis of asthma was based on clinical history (n=16), previous medical diagnosis (n=4), questionnaires (n=12), and spirometry (n=5). Children with asthma were more likely to develop habitual snoring and OSA, and children with SDB were more likely to develop asthma. Moreover, asthma was associated with more severe OSA, and the presence of SDB was associated with severe asthma. Treatment of SDB with adenotonsillectomy was associated with significant asthma improvement.

Conclusion

The relationship between asthma and SDB appears to be bidirectional, and adenotonsillectomy appears to improve asthma control. Future trials on how asthma treatment could impact on SDB are needed.