Technical report: diagnosis and management of childhood obstructive sleep apnea syndrome

Cross-cultural validity of the Dutch sleep-related breathing disorder scale of the Pediatric Sleep Questionnaire in a general population

BACKGROUND

Pediatric sleep-disordered breathing is associated with multiple health problems. Polysomnography is the reference standard for identifying this disorder, but availability is limited. Therefore, an alternative screening tool is needed. Globally, the Sleep-Related Breathing Disorder scale of the Pediatric Sleep Questionnaire (PSQ) has proven to be a feasible tool. Consequently, this study aimed to translate and culturally adapt the PSQ into Dutch and then to examine the cultural validity, internal consistency, and test-retest reliability of the Dutch version among a general population visiting oral healthcare centers.

METHODS

The translation, review, adaptation, pretest, and documentation approach was used to ensure cross-cultural adaptation of the PSQ. Then, 220 children (2.4-18 years) were sampled for clinimetric evaluation. We estimated the cross-cultural validity by comparing the factor analyses of the original PSQ and the Dutch version. Reliability was assessed using Cronbach's alpha, Spearman's correlation, the intraclass correlation coefficient, the standard error of measurement, and a Bland-Altman plot.

RESULTS

The factor loading patterns of the Dutch version matched with the original study around the four predetermined factors: breathing, sleepiness, behavior, and other. The internal consistency, with a Cronbach's α of 0.77, was acceptable. The test-retest reliability with an intraclass correlation coefficient and Spearman's correlation of 0.89 and 0.93, respectively, was good to excellent.

CONCLUSIONS

Cultural adaptation was ensured and the results support cross-cultural validity, internal consistency, and test-retest reliability of the Dutch Sleep-Related Breathing Disorder scale of the PSQ. This questionnaire could therefore be a valuable tool for screening disordered breathing in Dutch children.

A rat model of adenoid hypertrophy constructed by using ovalbumin and lipopolysaccharides to induce allergy, chronic inflammation, and chronic intermittent hypoxia

BACKGROUND

Adenoid hypertrophy (AH) is a common pediatric disease that significantly impacts the growth and quality of life of children. However, there is no replicable and valid model for AH.

METHODS

An AH rat model was developed via comprehensive allergic sensitization, chronic inflammation induction, and chronic intermittent hypoxia (CIH). The modeling process involved three steps: female Sprague-Dawley rats (aged 4-5 weeks) were used for modeling. Allergen sensitization was induced via intraperitoneal administration and intranasal provocation using ovalbumin (OVA); chronic nasal inflammation was induced through intranasal lipopolysaccharide (LPS) administration for sustained nasal irritation; CIH akin to obstructive sleep apnea/hypopnea syndrome was induced using an animal hypoxia chamber. Postmodel establishment, behaviors, and histological changes in nasopharynx-associated lymphoid tissue (NALT) and nasal mucosa were assessed. Arterial blood gas analysis and quantification of serum and tissue levels of (interleukin) IL-4 and IL-13, OVA-specific immunoglobulin E (sIgE), eosinophil cationic protein (ECP), tumor necrosis factor (TNF-α), IL-17, and transforming growth factor (TGF)-β were conducted for assessment. The treatment group received a combination of mometasone furoate and montelukast sodium for a week and then was evaluated.

RESULTS

Rats exhibited notable nasal symptoms and hypoxia after modeling. Histopathological analysis revealed NALT follicle hypertrophy and nasal mucosa inflammatory cell infiltration. Elevated IL-4, IL-13, IL-17, OVA-sIgE, ECP, and TNF-α levels and reduced TGF-β levels were observed in the serum and tissue of model-group rats. After a week of treatment, the treatment group exhibited symptom and inflammatory factor improvement.

CONCLUSION

The model effectively simulates AH symptoms and pathological changes. But it should be further validated for genetic, immunological, and hormonal backgrounds in the currently used and other strains and species.

Changes in behavioral and cognitive abilities after rapid maxillary expansion in children affected by persistent snoring after long-term adenotonsillectomy: A noncontrolled study

INTRODUCTION

The objective of this study was to verify changes in behavioral abilities and cognitive functions after rapid maxillary expansion (RME) in children with refractory sleep-disordered breathing (SDB) in the long term after adenotonsillectomy.

METHODS

A prospective clinical trial study using RME therapy was conducted. Participant inclusion criteria were children who had adenotonsillectomy with maxillary transverse deficiency and persistent SDB (obstructive apnea-hypopnea index ≥1). The study included 24 children aged 5-12 years, and of these 24 children, 13 had primary snoring and 11 had obstructive sleep apnea. The patients underwent laryngeal nasofibroscopy and a complete polysomnography. In addition, patients completed the Obstructive Pediatric Sleep Questionnaire and Obstructive Sleep Apnea 18-Item Quality-of-Life Questionnaire. Behavioral and neurocognitive tests were also completed before and after RME.

RESULTS

The Obstructive Pediatric Sleep Questionnaire and Obstructive Sleep Apnea 18-Item Quality-of-Life scores showed a statistically significant decrease in both groups (P <0.001) after RME. The results showed that neurocognitive and behavioral parameters (Child Behavior Checklist scale) were similar in primary snoring and obstructive sleep apnea (OSA) groups before RME. In the OSA group, the mean scores of the "Somatic" and "Aggressiveness" domains decreased significantly (P <0.05). The cognitive functions did not register significant differences pre- and post-RME in any of the cognitive functions, except for visuospatial function in the OSA group.

CONCLUSIONS

The noncontrolled design was a major limitation of our study. The need for treatment for SDB should consider the association of symptoms and behavioral disturbances with the child's obstructive apnea-hypopnea index. RME might prove to be an alternative treatment for children with SDB refractory to adenotonsillectomy, improving quality of life and behavioral aspects. However, a larger sample size with a control group is needed to substantiate these claims.

Adenotonsillectomy in Children with Obstructive Sleep Apnea Syndrome: Clinical and Functional Outcomes

Adenotonsillectomy (AT) is the first-line treatment for pediatric obstructive sleep apnea syndrome (OSAS). Relatively few studies have evaluated the clinical and functional outcomes of AT in children with OSAS, but these studies show that surgery improves behavior and quality of life (QOL). However, residual OSAS after AT is reported in severe cases. This study aimed to retrospectively evaluate the clinical and functional outcomes of AT in a cohort of children with OSAS. We consecutively enrolled children with OSAS who underwent AT and were admitted to our clinic from 1 July 2020 to 31 December 2022. For each participant, medical history and physical examinations were performed. Before and after surgery, all patients underwent a standard polygraphic evaluation, and caregivers completed the OSA-18 questionnaire. A total of 65 children with OSAS, aged 2-9 years, were included. After AT, 64 (98.4%) children showed a reduction in AHI, with median (IQR) values decreasing from 13.4/h (8.3-18.5/h) to 2.4/h (1.8-3.1/h) (p-value < 0.0001). Conversely, median (IQR) SpO2 nadir increased after surgery from 89% (84-92%) to 94% (93-95%) (p-value < 0.0001). Moreover, 27 children (18%) showed residual OSAS. The OSA-18 score decreased after AT from median (IQR) values of 84 (76-91) to values of 33 (26-44) (p-value < 0.0001). A positive significant correlation was found between OSA-18 post-operative scores and AHI post-operative scores (rho 0.31; p-value = 0.01). Our findings indicate that, in children with OSAS, AT is associated with significant improvements in behavior, QOL, and polygraphic parameters. However, long-term post-surgical follow-up to monitor for residual OSAS is highly recommended, especially in more severe cases.

Obstructive Sleep Apnea in Developmental Age: 22-Item Pediatric Sleep Questionnaire for an Observational Descriptive Investigation

The aim of this paper is to perform an observational descriptive study of the Obstructive Sleep Apnea Syndrome (OSAS) in a population of children by evaluating the prevalence and role of sex and age variables. The 22-item Pediatric Sleep Questionnaire (PSQ) was administered to parents of children aged 3 to 12 years. The questionnaire is a very simple tool since it allows for the indication of patients with possible OSAS diagnosis through a cut-off of 0.33. The anonymous diagnostic questionnaire, available in digital format, was administered to the population under study by a link or QR code. Only the questionnaires completed in all their parts were recorded and analyzed. Eight hundred and thirty-two questionnaires were collected. One hundred and fifty-four subjects obtained a PSQ score > 0.33 and the prevalence of OSAS was 18.51%. The Chi-square test showed a statistically significant association between the PSQ score > 0.33 and male sex. The higher prevalence of subjects with a value of PSQ > 0.33 (n = 277) are aged 3-4-5 years, followed by the 6-7-8 range in the group with PSQ score > 0.33, p < 0.05. The prevalence of OSAS was 18.51% in children aged 3 to 12 years. The variables male biological sex and the age group 3-8 year were statistically significant for subjects with OSAS diagnosis. This study underlines the use of the 22-item Pediatric Sleep Questionnaire as a first screening tool to identify children at risk of OSAS.

Topological Data Analysis of Electroencephalogram Signals for Pediatric Obstructive Sleep Apnea

Topological data analysis (TDA) is an emerging technique for biological signal processing. TDA leverages the invariant topological features of signals in a metric space for robust analysis of signals even in the presence of noise. In this paper, we leverage TDA on brain connectivity networks derived from electroencephalogram (EEG) signals to identify statistical differences between pediatric patients with obstructive sleep apnea (OSA) and pediatric patients without OSA. We leverage a large corpus of data, and show that TDA enables us to see a statistical difference between the brain dynamics of the two groups.Clinical relevance- This establishes the potential of topological data analysis as a tool to identify obstructive sleep apnea without requiring a full polysomnogram study, and provides an initial investigation towards easier and more scalable obstructive sleep apnea diagnosis.

Predictive Power of Oxygen Desaturation Index (ODI) and Apnea-Hypopnea Index (AHI) in Detecting Long-Term Neurocognitive and Psychosocial Outcomes of Sleep-Disordered Breathing in Children: A Questionnaire-Based Study

Pediatric obstructive sleep apnea can negatively affect children's neurocognitive function and development, hindering academic and adaptive goals. Questionnaires are suitable for assessing neuropsychological symptoms in children with sleep-disordered breathing. The study aimed to evaluate the effectiveness of using the Oxygen Desaturation Index compared to the Obstructive Apnea-Hypopnea Index in predicting long-term consequences of sleep-disordered breathing in children. We conducted a retrospective analysis of respiratory polysomnography recordings from preschool and school-age children (mean age: 5.8 ± 2.8 years) and followed them up after an average of 3.1 ± 0.8 years from the home-based polysomnography. We administered three validated questionnaires to the parents/caregivers of the children by phone. Our results showed that children with an Oxygen Desaturation Index (ODI) greater than one event per hour exhibited symptoms in four domains (physical, school-related, Quality of Life [QoL], and attention deficit hyperactivity disorder [ADHD]) at follow-up, compared to only two symptoms (physical and school-related) found in children with an Obstructive Apnea-Hypopnea Index greater than one event per hour at the time of diagnosis. Our study also found a significant correlation between the minimum SpO₂ (%) recorded at diagnosis and several outcomes, including Pediatric Sleep Questionnaire (PSQ) scores, physical, social, and school-related outcomes, and ADHD index at follow-up. These results suggest that the Oxygen Desaturation Index could serve as a valuable predictor of long-term symptoms in children with sleep-disordered breathing, which could inform treatment decisions. Additionally, measuring minimum SpO₂ levels may help assess the risk of developing long-term symptoms and monitor treatment outcomes.

Practical guide for safe sedation

This practical guide has been developed to ensure safe and effective sedation performed in adult patients outside of the operating room, for instance in intensive care units and dental treatment rooms and in the field of palliative care. Sedation levels are classified based on level of consciousness, airway reflex, spontaneous ventilation, and cardiovascular function. Deep sedation induces loss of consciousness and protective reflexes, and can cause respiratory depression and pulmonary aspiration. Invasive medical procedures necessitating deep sedation include cardiac ablation, endoscopic submucosal dissection, and internal radiation therapy. Appropriate analgesia is necessary for procedures that require deep sedation. The sedationist should evaluate the risks of the planned procedure, explain the sedation process to the patient, and obtain the patient's informed consent. Major parameters to be evaluated preoperatively are the patient's airway and general condition. Equipment, instruments, and drugs necessary for emergency situations should be defined and routinely maintained. To prevent aspiration, patients scheduled for moderate or deep sedation should fast preoperatively. In both inpatients and outpatients, biological monitoring should be continued until the discharge criteria are met. Anesthesiologists should be involved in management systems that ensure safe and effective sedation even if they do not personally perform all sedation procedures.

Effectiveness of Intranasal Mometasone Furoate vs Saline for Sleep-Disordered Breathing in Children: A Randomized Clinical Trial

Importance

Obstructive sleep-disordered breathing (SDB) in children is characterized by snoring and difficulty breathing during sleep. SDB affects at least 12% of otherwise healthy children and is associated with significant morbidity. Evidence from small clinical trials suggests that intranasal corticosteroids improve SDB as measured by polysomnography; however, the effect on symptoms and quality of life is unclear.

Objective

To determine whether intranasal mometasone furoate is more effective than intranasal saline for improving symptoms and quality of life in children with SDB.

Design, Setting, and Participants

The MIST trial was a multicenter, randomized, double-blind, placebo-controlled trial, recruiting participants from June 8, 2018, to February 13, 2020. Children aged 3 to 12 years who were referred to a specialist for significant SDB symptoms were included; exclusions were previous adenotonsillectomy, body mass index greater than the 97th percentile, and severe SDB. Randomization was stratified by site, and data were analyzed on an intention-to-treat basis from October 28, 2020, to September 25, 2022.

Interventions

Participants were randomly assigned to receive mometasone furoate, 50 μg, or sodium chloride (saline), 0.9%, 1 spray per nostril daily, dispensed in identical bottles.

Main Outcomes and Measures

The primary outcome was resolution of significant SDB symptoms (ie, reduction to a level no longer requiring referral to a specialist as per the American Academy of Pediatrics guidelines) at 6 weeks, measured by parental report of symptoms using the SDB Score.

Results

A total of 276 participants (mean [SD] age, 6.1 [2.3] years; 146 male individuals [53%]) were recruited, 138 in each treatment arm. Resolution of significant SDB symptoms occurred in 56 of 127 participants (44%) in the mometasone group and 50 of 123 participants (41%) in the saline group (risk difference, 4%; 95% CI, -8% to 16%; P = .51) with 26 participants lost to follow-up and missing values managed by multiple imputation. The main adverse effects were epistaxis, affecting 12 of 124 participants (9.7%) in the mometasone group and 18 of 120 participants (15%) in the saline group, and nasal itch/irritation, affecting 12 of 124 participants (9.7%) in the mometasone group and 22 of 120 participants (18%) in the saline group.

Conclusions and Relevance

Results of this randomized clinical trial suggest that there was no difference in treatment effect between intranasal mometasone and saline for the management of SDB symptoms. The results suggest that almost one-half of children with SDB could be initially managed in the primary care setting and may not require referral to specialist services, as is currently recommended.

Trial Registration

Australian New Zealand Clinical Trials Registry: ANZCTRN12618000448246.

Effectiveness of functional orthopedic appliances as an alternative treatment among children and adolescents with obstructive sleep apnea: Systematic review and meta-analysis

INTRODUCTION

The objective here was to review the efficacy of functional jaw orthopedic appliances for treating children/adolescents with obstructive sleep apnea (OSA), through correlating the apnea/hypopnea index (AHI) and oxygen saturation (SaO₂) in polysomnography (PSG), in addition to questionnaire scores from the obstructive sleep apnea-18 (OSA-18).

METHODS

The PRISMA 2020 guidelines¹ were followed. A search was conducted in October 2021, with updating to May 2022, in the MEDLINE/PubMed, BVS (LILACS/BBO), ISI, SciELO (Web of Science), COCHRANE, EMBASE, SCOPUS and WHO databases and the gray literature. Data selection and extraction were performed by two independent reviewers, with Cohen kappa testing. All articles included in the meta-analyses showed good quality and low risk of bias. Statistical analyses were performed in the "R" software, using means with standard deviations, and differences in the means were represented graphically in forest plots. Heterogeneity was tested using I², in random-effect models.

RESULTS

From before to after treatment, treated individuals showed improved AHI, SaO₂ and OSA-18 scores². Comparing treated individuals and controls, AHI decreased in treated individuals and increased in controls. For SaO₂, the increase in treated individuals was greater than in controls. For OSA-18, daytime/nighttime symptoms decreased in treated individuals and increased in controls.

CONCLUSION

Functional jaw orthopedic appliances are appropriate and effective for children/adolescents with OSA whose etiology is deficient maxillomandibular growth and development. Functional jaw orthopedics treats the form and function of the stomatognathic system, thereby enhancing quality of life.

PROSPERO REGISTRATION PROTOCOL

CRD42021253341.

Carotid Anomalies and Their Implication in ENT Surgery

Carotid Anomalies are with significant surgical implication to an Otorhinolaryngologist. The authors discuss the evaluation and management of a child with Pierre Robin Syndrome who presented with severe OSA, secondary to bilateral midline carotids that compromised the airway, and an adult with cervical bolus and dysphagia who presented similar to chronic tonsillitis but found to have Retropharyngeal Carotids. This case study emphasizes the need for awareness and a high index of suspicion to identify the variation of the carotid artery in nasopharyngeal and oropharyngeal surgery that has a propensity to result in catastrophic consequences if operated upon.

The risk of postoperative respiratory complications following adenotonsillar surgery in children with or without obstructive sleep apnea: A systematic review and meta-analysis

OBJECTIVES

Obstructive sleep apnea (OSA) appears in 2%-5% of children, with first-line treatment being adenotonsillar (AT) surgery. Our aim was to examine the risk of postoperative respiratory complications (PoRCs) in non-OSA and the different OSA severity (mild, moderate, severe) groups.

STUDY DESIGN

We conducted a systematic review and meta-analysis of studies comparing PoRCs following AT surgery in children with and without OSA.

METHODS

Nineteen observational studies were identified with the same search key used in MEDLINE, Embase, and CENTRAL. The connection between PoRCs, the presence and severity of OSA, and additional comorbidities were examined. Odds ratios (OR) were calculated with 95% confidence intervals (CI).

RESULTS

We found that PoRCs appeared more frequently in moderate (p = 0.048, OR: 1.79, CI [1.004, 3.194]) and severe OSA (p = 0.002, OR: 4.06, CI [1.68, 9.81]) compared to non-OSA patients. No significant difference was detected in the appearance of major complications (p = 0.200, OR: 2.14, CI [0.67, 6.86]) comparing OSA and non-OSA populations. No significant difference was observed in comorbidities (p = 0.669, OR: 1.29, CI [0.40, 4.14]) or in the distribution of PoRCs (p = 0.904, OR: 0.94, CI [0.36, 2.45]) between the two groups.

CONCLUSION

Uniform guidelines and a revision of postoperative monitoring are called for as children with moderate and severe OSA are more likely to develop PoRCs following AT surgery based on our results, but no significant difference was found in mild OSA. Furthermore, the presence of OSA alone is not associated with an increased risk of developing major complications.

Assessment of Quality of Life and Symptoms in Non Syndromic Paediatric Obstructive Sleep Apnoea Patients: Before and After Adenotonsillectomy

This study aims to assess the improvement in quality of life and symptoms in paediatric obstructive sleep apnoea patients before and after adenotonsillectomy. From all paediatric patients who presented to our OPD with complaints of mouth breathing and snoring, a subset of patients fulfilling our inclusion criteria were selected and evaluated with PSQSRBD scale, quality of life (QoL) inventory and PSG level-III. Later37 patients who had moderate to severe OSA were selected for study and underwent adenotonsillectomy. They were further followed up postoperatively at 3 months and 7 months with PSQSRBD Scale and QoL inventory. The study cohort had 37 patients with moderate to severe OSA, with a mean age of 8yrs.The postoperative (mean of 3rd and 7th month) values of PSQSRBD Scale and QoL inventory values was significantly (p < 0.001) reduced compared to preoperative Values after adenotonsillectomy. There is statistically significant correlation between adenoid and tonsil size to the relief of symptoms (PSQSRBD SCALE values) and improvement of quality of life. In our study, surgical (adenotonsillectomy) intervention has significant effect in management of moderate to severe non syndromic paediatric OSA patients.

Measurement of snoring and stertor using the Sonomat to assess effectiveness of upper airway surgery in children

STUDY OBJECTIVES

The success of surgical treatment for pediatric sleep-disordered breathing is typically assessed using the mixed and obstructive apnea-hypopnea index (MOAHI). Although an important metric, previous work has shown that snoring and stertor are also associated with sleep disruption. Our aim was to assess the efficacy of surgery using the Sonomat (Sonomedical Pty Ltd), a noncontact sleep assessment system, that accurately records complete and partial upper airway obstruction.

METHODS

Forty children (< 18 years) had a Sonomat study, in their own beds, before and after surgery. As an MOAHI ≥ 1 event/h is considered abnormal, the same threshold was applied to snore/stertor runs. Median (interquartile range) values are reported.

RESULTS

Respiratory event-induced movements decreased from 12.0 (8.7-19.0) to 0.5 (0.1-3.2) events/h (P < .01), with no significant change in spontaneous movements: 12.8 (9.8-17.9) to 16.5 (13.7-26.1) events/h (P = .07). The MOAHI decreased from 4.5 (1.9-8.6) to 0.0 (0.0-0.4) events/h (P < .01). Snoring and/or stertor runs decreased from 32.8 (23.4-44.4) to 3.0 (0.2-14.6) events/h (P < .01). Thirty-four children had an MOAHI < 1 event/h following surgery; however, 20 had snore and/or stertor runs ≥ 1 event/h and 11 had snore and/or stertor runs ≥ 5 events/h. Only 14 (35%) children had a postsurgery MOAHI < 1 event/h combined with snoring and/or stertor < 1 runs/h.

CONCLUSIONS

Although surgery is effective in improving breathing, success rates are overestimated using the MOAHI. Our results indicate that snoring and/or stertor are still present at levels that may disrupt sleep despite a normalization of the MOAHI and that when obstructed breathing was objectively measured, there was a large variation in its response to surgery.

CITATION

Norman MB, Harrison HC, Sullivan CE, Milross MA. Measurement of snoring and stertor using the Sonomat to assess effectiveness of upper airway surgery in children. J Clin Sleep Med. 2022;18(6):1649-1656.

Obstructive sleep apnea in children with non-syndromic cleft palate: a systematic review

STUDY OBJECTIVES

To characterize obstructive sleep apnea (OSA) in children with non-syndromic cleft palate based on polysomnographic parameters relative to primary palatoplasty.

METHODS

A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The following databases were searched: PubMed, Scopus, CINAHL, and Cochrane. Studies were only considered for inclusion if they examined exclusively non-syndromic cleft palate patients and reported polysomnogram data.

RESULTS

Seven studies met inclusion criteria, providing information on a total of 151 patients with a weighted mean age of 5.2 ± 5.0 years old (range 0.1- 12 years). Five studies presented data from either the pre- or post-operative period. Two studies investigated both pre- and post-palatoplasty polysomnogram data, and neither observed a significant change in apnea hypopnea index (AHI) values following surgery (mean pre-operative AHI of 2.7, mean improvement of 0.6 events/hour). The entire cohort had a pre-palatoplasty weighted mean AHI of 11.4 (range 1.5 -16.1) and post-palatoplasty AHI of 1.5 (range 0.2 - 5.2). Interpretation of polysomnographic data was limited by heterogeneity; however, the AHI values of children with non-syndromic cleft palate largely demonstrated mild to moderate OSA following palatoplasty.

CONCLUSIONS

The full effect of cleft palate repair on OSA in children with non-syndromic cleft palate remains understudied. While published data are heterogenous, few studies support the worsening of obstructive AHI after palatoplasty in children with non-syndromic cleft palate. Further studies with standardized polysomnographic parameters are needed to provide guidance for management of this population.

Comparison of home ambulatory type 2 polysomnography with a portable monitoring device and in-laboratory type 1 polysomnography for the diagnosis of obstructive sleep apnea in children

STUDY OBJECTIVES

To compare type 2 polysomnography (T2PSG) to the gold standard type 1 in-laboratory polysomnography (T1PSG) for diagnosing obstructive sleep apnea (OSA) in children; validate home T2PSG in children with suspected OSA.

METHODS

Eighty-one participants (ages 6-18) with suspected OSA had simultaneous T1PSG and T2PSG in the sleep laboratory, 47 participants (ages 5-16) had T1PSG in the sleep laboratory and T2PSG performed at home. Sleep scientists staged and scored polysomnography data, and pediatric sleep physicians assigned a diagnosis of normal or OSA. Participant demographics, polysomnography variables, and diagnoses were compared using chi-square and Fisher's exact tests for nominal variables, t test for continuous variables and Cohen's kappa to assess concordance.

RESULTS

Acceptable recordings were obtained for every home T2PSG. When T1PSG and T2PSG were simultaneous, correlation between the number of arousals, respiratory disturbance index, and sleep stages was excellent. T2PSG at home demonstrated less stage 2 sleep, more rapid eye movement sleep, and higher sleep efficiency. Comparison of home T2PSG to T1PSG for diagnosing OSA showed a false-positive rate of 6.6% and false-negative rate of 3% for those performed at home.

CONCLUSIONS

T2PSG in the home is feasible with excellent concordance with T1PSG for the purposes of diagnosing OSA in children aged 5-18 years. Home T2PSG may be more representative of a "normal" night for children and could benefit those suspected of having OSA by reducing waiting times for laboratory PSG, improving access to PSG and possibly reducing costs of investigating and treating OSA.

CITATION

Withers A, Maul J, Rosenheim E, O'Donnell A, Wilson A, Stick S. Comparison of home ambulatory type 2 polysomnography with a portable monitoring device and in-laboratory type 1 polysomnography for the diagnosis of obstructive sleep apnea in children. J Clin Sleep Med. 2022;18(2):393-402.

Clinical application of home sleep apnea testing in children: a prospective pilot study

STUDY OBJECTIVES

(1) To determine the sensitivity and specificity of the home sleep apnea test (HSAT) performed in typically developing children who were diagnosed with moderate to severe obstructive sleep apnea during overnight attended laboratory polysomnography (LPSG). (2) To determine the utility of a screening questionnaire to identify children at increased risk for obstructive sleep apnea.

METHODS

Participants completed 2 consecutive study nights, the first night with the HSAT followed by LPSG on the second night. The SHOOTS questionnaire, composed of 6 questions (snoring, hyperactivity, obesity, observed apnea, tonsillar hypertrophy, and sleepiness) concerning sleep-disordered breathing, was administered by the clinician before the first study night.

RESULTS

Thirty-eight participants completed both studies. The mean age was 13.8 ± 3.0 years. Twenty (53%) were male. Most participants were obese. The mean LPSG total sleep time was 7.34 ± 1.19 hours; the mean HSAT total recording time was 8.86 ± 1.73 hours (P < .001). The median obstructive apnea-hypopnea index for LPSG and HSAT was 6.6 and 0.8 events/h, respectively. For an obstructive apnea-hypopnea index ≥ 3.1 events/h by HSAT, the sensitivity was 71.43% (95% confidence interval, 41.9-91.6) and the specificity was 95.83% (95% confidence interval, 78.9-99.9) for identifying those with an LPSG obstructive apnea-hypopnea index of ≥ 10 events/h. For a SHOOTS score with ≥ 4 "yes" responses, the sensitivity and specificity were 85.7% (95% confidence interval, 57.2-98.2) and 54.2% (95% confidence interval, 32.8-74.4), respectively, for identifying those with an LPSG obstructive apnea-hypopnea index ≥ 10 events/h.

CONCLUSIONS

Using HSAT, we clinically applied cutoff values to identify moderate to severe obstructive sleep apnea in typically developing children. The SHOOTS questionnaire may aid in identifying children at risk for obstructive sleep apnea and who are candidates for HSAT.

CITATION

Revana A, Vecchio J, Guffey D, Minard CG, Glaze DG. Clinical application of home sleep apnea testing in children: a prospective pilot study. J Clin Sleep Med. 2022;18(2):533-540.

Expression and clinical significance of IL-33 and its receptor ST2 in children with obstructive sleep apnea syndrome

BACKGROUND

Obstructive sleep apnea syndrome (OSAS) is characterized by a majority population of respiratory sleep disorders, which consists of simple snoring as well as increased upper airway resistance syndrome. Adenoid hypertrophy has been suggested as the main cause of OSAS in children. The role of interleukin-33 (IL-33) and its receptor suppressor of tumorigenicity 2 (ST2) in a variety of pediatric allergic diseases has been confirmed. We hypothesized that IL-33/ST2 path way might play a pivotal role in the pathogenesis of adenoid hypertrophy-associated OSAS in children.

METHODS

A total of 40 children undergoing adenoidectomy due to OSAS in the Otolaryngology of Tianjin Children's Hospital were selected as the study participants. The quantity of IL-33 and ST2 positive cells in adenoids was detected by immunohistochemical (IHC) streptavidin-peroxidase conjugate (SP) method.

RESULTS

The IL-33 positive cells were mainly distributed in the submucosa epithelium and vascular endothelium, and expressed in the nucleus and cytoplasm. Meanwhile, ST2 positive cells were primarily observed in the mucosa and expressed in the nucleus and cytoplasm, with a little expression of intercellular substance. There was a positive correlation between the proportion of adenoids in the posterior nostril diameter and the number of IL-33 positive cells. The expression of IL-33 in adenoids was positively correlated with the level of ST2 (r=0.809, P=0.000). The expression of IL-33 in adenoids was positively correlated with the level of eosinophil granulocyte (r=0.859, P=0.000). Moreover, the expression of ST2 in adenoids was positively correlated with the level of eosinophil granulocyte (r=0.814, P=0.000). The number of IL-33 positive cells was significantly higher in the moderate hypoxemia group than that in the mild hypoxemia group (P<0.05). There was no significant difference in the number of ST2 positive cells between the moderate hypoxemia group and mild hypoxemia group (P>0.05).

CONCLUSIONS

Both IL-33 and its receptor ST2 were expressed in adenoids of OSAS children. The severity of airway obstruction caused by adenoid hypertrophy was positively correlated with the expression of IL-33.

The Effect of Adenotonsillectomy on Children's Behavior and Cognitive Performance with Obstructive Sleep Apnea Syndrome: State of the Art

(1) Background: This systematic review was designed to analyze adenotonsillectomy’s role in treating behavioural disorders and sleep-related quality of life in pediatric OSAS. (2) Methods: Papers that report pre-operative and post-operative outcomes by using the Epworth sleepiness scale, OSA-18, NEPSY, Conners’ rating scale, BRIEF, PSQ-SRBD, PedsQL and CBCL. We performed a comprehensive review of English papers published during the last 20 years regarding behavioural disorders in OSAS patients and adenotonsillectomy. (3) Results: We included 11 studies reporting behavioral outcomes and sleep related quality of life after surgery. We investigated changes in behavior and cognitive outcomes after AT, and we found significant improvements of the scores post-AT in almost all studies. After comparing the AT group and control group, only one study had no difference that reached significance at one year post-AT. In another study, it did not show any significant improvement in terms of all behavioural and cognitive outcomes. The questionnaires on sleep-related quality of life after AT (PSQ-SRBD or ESS or OSA-18 or KOSA) may improve with positive changes in sleep parameters (AHI, ODI and SpO2). Furthermore, there is a significantly higher decrease in OSAS symptoms than the pre-AT baseline score. (4) Conclusion: Future studies should pay more attention to characterizing patient populations as well as rapid surgical treatments through existing criteria.

Characterization of the abnormal cortical effective connectivity in patients with sleep apnea hypopnea syndrome during sleep

BACKGROUND AND OBJECTIVES

Sleep apnea hypopnea syndrome (SAHS) is a prevalent sleep breathing disorder that can lead to brain damage and is also a risk factor for cognitive impairment and some common diseases. Studies on cortical effective connectivity (EC) during sleep may provide more direct and pathological information and shed new light on brain dysfunction due to SAHS. However, the EC is rarely explored in SAHS patients, especially during different sleep stages.

METHODS

To this end, six-channel EEG signals of 43 SAHS patients and 41 healthy participants were recorded by whole-night polysomnography (PSG). The symbolic transfer entropy (STE) was applied to measure the EC between cortical regions in different frequency bands. Posterior-anterior ratio (PA) was employed to evaluate the posterior-to-anterior pattern of information flow based on overall cortical EC. The statistical characteristics of the STE and PA and of the intra-individual normalized parameters (STE* and PA*) were served as different feature sets for classifying the severity of SAHS.

RESULTS

Although the patterns of STE across electrodes were similar, significant differences were found between the patient and the control groups. The variation trends across stages in the PA were also different in multiple frequency bands between groups. Important features extracted from the STE* and PA* were distributed in multiple rhythms, mainly in δ, α, and γ. The PA* feature set gave the best results, with accuracies of 98.8% and 83.3% for SAHS diagnosis (binary) and severity classification (four-way).

CONCLUSIONS

These results suggest that modifications in cortical EC were existed in SAHS patients during sleep, which may help characterize cortical abnormality in patients.

Impact of Snoring on Telomere Shortening in Adolescents with Atopic Diseases

Atopic diseases can impose a significant burden on children and adolescents. Telomere length is a cellular marker of aging reflecting the impact of cumulative stress exposure on individual health. Since elevated oxidative stress and inflammation burden induced by chronic atopy and snoring may impact telomere length, this study aimed to investigate whether snoring would moderate the relationship between atopic diseases and telomere length in early adolescence. We surveyed 354 adolescents and their parents. Parents reported the adolescents' history of atopic diseases, recent snoring history as well as other family sociodemographic characteristics. Buccal swab samples were also collected from the adolescents for telomere length determination. Independent and combined effects of atopic diseases and snoring on telomere length were examined. Among the surveyed adolescents, 174 were reported by parents to have atopic diseases (20 had asthma, 145 had allergic rhinitis, 53 had eczema, and 25 had food allergy). Shorter TL was found in participants with a history of snoring and atopic diseases (β = -0.34, p = 0.002) particularly for asthma (β = -0.21, p = 0.007) and allergic rhinitis (β = -0.22, p = 0.023). Our findings suggest that snoring in atopic patients has important implications for accelerated telomere shortening. Proper management of atopic symptoms at an early age is important for the alleviation of long-term health consequences at the cellular level.

Childhood Obesity and Respiratory Diseases: Which Link?

Prevalence of childhood obesity is progressively increasing, reaching worldwide levels of 5.6% in girls and of 7.8% in boys. Several evidences showed that obesity is a major preventable risk factor and disease modifier of some respiratory conditions such as asthma and Obstructive Sleep Apnea Syndrome (OSAS). Co-occurrence of asthma and obesity may be due to common pathogenetic factors including exposure to air pollutants and tobacco smoking, Western diet, and low Vitamin D levels. Lung growth and dysanapsis phenomenon in asthmatic obese children play a role in impaired respiratory function which appears to be different than in adults. Genes involved in both asthma and obesity have been identified, though a gene-by-environment interaction has not been properly investigated yet. The identification of modifiable environmental factors influencing gene expression through epigenetic mechanisms may change the natural history of both diseases. Another important pediatric respiratory condition associated with obesity is Sleep-Disordered Breathing (SDB), especially Obstructive Sleep Apnea Syndrome (OSAS). OSAS and obesity are linked by a bidirectional causality, where the effects of one affect the other. The factors most involved in the association between OSAS and obesity are oxidative stress, systemic inflammation, and gut microbiota. In OSAS pathogenesis, obesity's role appears to be mainly due to mechanical factors leading to an increase of respiratory work at night-time. However, a causal link between obesity-related inflammatory state and OSAS pathogenesis still needs to be properly confirmed. To prevent obesity and its complications, family education and precocious lifestyle changes are critical. A healthy diet may lead to an improved quality of life in obese children suffering from respiratory diseases. The present review aimed to investigate the links between obesity, asthma and OSAS, focusing on the available evidence and looking for future research fields.

The impact of childhood obstructive sleep apnea on speech and oral language development: a systematic review

PURPOSE

The purpose of this systematic review was to review and synthesize the current evidence on speech and language outcomes of children with Obstructive Sleep Apnea (OSA), or more broadly sleep-disordered breathing.

METHOD

A comprehensive literature search was conducted across 5 databases. Studies were selected based on the following criteria: 1) peer-reviewed research published between 2000 and 2020, 2) available in English or accessible non-English data, 3) children aged 2-13 years diagnosed with Sleep Disordered Breathing (SDB) or OSA, and 4) speech and language outcomes examined within research.

RESULTS

Studies were appraised using PEDro-P and the overall certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Six studies met the current review selection criteria: one paper examined speech outcomes and the remaining five examined receptive and expressive language outcomes. The overall quality of the body of evidence was rated as very low, with methodological weaknesses present in study designs and sample sizes.

CONCLUSION

Speech and language difficulties are common in children with OSA/SDB, in addition to neurocognitive and/or neurobehavioral issues. Further investigation of specific speech and language skills, which are compromised in this population, is needed to guide clinical practice and decision making, with particular involvement from speech-language pathologists.

Does Bilateral Gap Arthroplasty Increase the Severity of Obstructive Sleep Apnea in Patients With Temporomandibular Joint Ankylosis?

PURPOSE

Obstructive sleep apnea (OSA) is common in patients with bilateral temporomandibular joint ankylosis (TMJA). The purpose of this study was to compare the preoperative and postoperative apnea-hypopnea index (AHI) in patients with TMJA undergoing bilateral gap arthroplasty (BGA).

METHODS

The investigators implemented a prospective cohort study on patients with bilateral TMJA treated with BGA. The primary predictor variable was time (before and after BGA). The primary outcome variable was AHI and secondary outcome variable included posterior airway space, skeletal changes, Epworth sleepiness scale, minimum oxygen_, average oxygen saturation, and maximal incisal opening at preoperative time (T0), 1 month (T1), and at 6 months (T2). The statistical test used were Greenhouse-Geisser test, repeated measure ANOVA (1 way), followed by post hoc Bonferroni test. The P-value was taken significant when <0.05 at a confidence interval of 95%.

RESULTS

The study sample included 12 (m:f = 1:2) patients of bilateral TMJA with a mean age of 14.9 ± 4.8 years and mean follow-up of 6 months. Mean duration of ankylosis was 10.5 ± 6.9 years (median = 12). Trauma was the main etiological factor in 11 (91.7%) patients followed by infection in 1 (8.3%) patient. The mean increase in AHI was 8.6 (T0 to T1) with P-value = .002 and 23.4 (T1 to T2) and was statistically significant (P = .001). The mean decrease in posterior airway space was 4.5 ± 1.0 to 3.5 ± 0.5 (T0 to T2) and was statistically significant (P = .02). Mean difference in minimum oxygen was 6.8 (P-value = .015). Skeletal changes are consistent with clockwise rotation of the mandible and statistically significant changes in horizontal and vertical dimension. The mean change in average oxygen was statistically insignificant (P = 1.0).

CONCLUSIONS

The present study concludes that gap arthroplasty in patients with bilateral TMJA can lead to development or worsening of pre-existing mild to moderate OSA. Ramus-condyle reconstruction should be performed to prevent the retropositioning of mandible and worsening of OSA.

Sleep-disordered breathing among Saudi children seeking orthodontic treatment

Aims

The aim of this research is to assess the prevalence of sleep disordered breathing (SDB) and evaluate the risks and symptoms in children seeking orthodontic treatment in a Saudi dental center.

Settings and Design

It is a cross-sectional survey-based study.

Methods and Material

Pediatric sleep questionnaire (PSQ) was used to survey 285 children and adolescents aged 5 to 18 years old who are undergoing orthodontic screening in a Saudi Dental Center.

Statistical Analysis Used

PSQ scores were tested with multiple variables including gender, parents' education, academic performance using Mann-Whitney-U test. Correlation of study sample scores with age were calculated using the Spearman rank correlation coefficient (rho).

Results

In this study 136 (47.7%) of the participants were deemed to be high risk for developing SDB and 149 (52.3%) were low risk, males were significantly at higher risk compared to females (P ≤ 0.05). Participants with previous adenoidectomy surgery were more likely to be identified as high-risk for SDB (P-value = 0.000) as well as participants with a family history of snoring (P-value = 0.000).

Conclusions

Sleep disordered breathing was prevalent among Saudi children seeking orthodontic therapy, it is important to screen children and adolescents in dental pediatric and orthodontic clinics for SDB risk as this is a prevalent disorder among this population, early detection of SDB will improve patients' quality of life and prevent future complications associated to this disorder.

Nuclear factor kappa B activation in cardiomyocytes by serum of children with obstructive sleep apnea syndrome

Obstructive sleep apnea syndrome (OSA) is associated with cardiovascular morbidity in adults and children. NFκB activity is enhanced in circulating monocytes of adults with OSA, that decreases following positive pressure therapy. OSA children’s serum activates NFκB in a cell line. We hypothesized that OSA children’s serum can activate NFκB in cardiomyocytes (CM) and effect their viability. In order to explore the role played by NFκB in OSA cardiovascular pathophysiology, rat, mouse and human immortalized CM were exposed to human serum drawn from OSA children and matched controls. Increased expression of NFκB classical subunits p65/p50 as well as major morphological changes occurred in cardiomyocytes following OSA’s serum exposure. OSA children’s serum induced NFκB activity as measured by p65 nuclear translocation in immortalized human CM and rat cardiomyocytes as well as dense immunostaining of the nucleus. Trypan blue and XTT assays showed that OSA sera induced CM apoptosis. We conclude that NFκB is systemically activated in cardiomyocytes, who also demonstrate decreased viability and contractility following exposure to OSA serum. It supports the hypothesis NFκB plays a role in the evolution of cardiovascular morbidity in OSA. It may support the search for new therapeutic interventions controlling NFκB activation in OSA.

Behavioural disorders and parental stress in children suffering from obstructive sleep apnoea syndrome: a pre- and post-adenotonsillectomy confrontation

The primary goal of the present study was to compare breathing difficulties resulting from OSAS to possible cognitive-behavioural problems of the child linked to their parents’ emotional-relational aspects. There is strong evidence that sleep breathing disorders are associated with behavioural alterations, a tendency towards aggressiveness, weak school performance and a clear disorder in continuous and selective attention other than vigilance status. Not all patients suffering from OSA have cognitive and/or behavioural manifestations; furthermore, the degree of dysfunction that the patient may present does not seem to be associated with the seriousness of sleep breathing disorder (SBD). It is therefore likely that genetic susceptibility associated with particular environmental factors has a role in determining phenotypic manifestations which are unique for every single patient. Questionnaires were given to parents, one regarding executive functions and one regarding parental stress: Conners’ Rating Scale Revised; Parenting Stress Index. All parents of children who suffer from moderate to severe OSA, with a McGill score of 3 to 4 and with no exclusion criteria are included in the study; behavioural and parental stress evaluation was made during hospitalisation and at 6 months after adenotonsillectomy. The results show that resolving OSAS led to important improvements in the competence and behavioural attitudes of the patient, as well as in relational and management difficulties by parents. The identification of such indicators could represent a support to surgical programming, even in non-severe SBD. Future research will have the goal of identifying standardised risk indicators that can provide further indications for surgical treatment in children up to 5 years of age.

Outcome of drug induced sleep endoscopy directed surgery in paediatrics obstructive sleep apnoea: A systematic review

INTRODUCTION

Paediatrics obstructive sleep apnoea have been discussed to a great degree over the recent years and remains a conundrum till date. The advent of instrumentation has aided upper airway evaluation in determining the site and degree of upper airway collapse for targeted and effective surgical planning. The literature was reviewed to determine the outcome of Drug Induced Sleep Endoscopy (DISE) directed surgery in children with obstructive sleep apnoea.

MATERIAL AND METHODS

A literature search was conducted for the period from January 2000 to December 2019 by using a number of medical literature data bases including Scopus, PubMed and Embase. The following search words were used either individually or in combination: drug-induced sleep endoscopy, sleep endoscopy directed surgery, paediatrics sleep apnoea. The search was conducted over a month period (December 2019). Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Cochrane Handbook for Systematic Reviews of Interventions were followed when possible.

RESULTS

Seven clinical research articles were selected based on our objective and selection criteria. Seven studies were of level III evidence: retrospective, case-control and prospective series. Altogether, there were 996 patients with male predominance; 61%. Over 10% of patients (133 patients) were found to have comorbidities or were syndromic. The mean age of patient was 6 years and majority (87.6%) of our patients were found to be surgically naïve, that is, no previous surgical procedures were performed for OSA. Surgical decision was changed in 295 patients (30%) following DISE. Post intervention outcomes were objectively revealed in 4 studies. Most of our patients underwent a multilevel surgery based on DISE (86%). Complications were documented in 3 studies.

CONCLUSIONS

Analysis of the results indicated that DISE directed surgery was an effective, safe therapeutic approach to treating paediatrics obstructive sleep apnoea. DISE directed surgery has shown to have changed surgical management in most studies.

Drug-induced sleep endoscopy findings in surgically-naïve obese vs non-obese children

OBJECTIVE

To determine if drug-induced sleep endoscopy (DISE) findings are different in obese versus non-obese pediatric patients with obstructive sleep apnea (OSA) or sleep-disordered breathing (SDB).

METHODS

Prospective, observational cohort study from June 2017 to June 2018 at a tertiary academic pediatric medical center that included surgically-naïve children ages 2-12 with diagnoses of OSA or sleep-disordered breathing. Subjects with a known diagnosis of craniofacial syndromes, genetic disorders, prior adenoidectomy or tonsillectomy, or chronic tonsillitis as the indication for surgery were excluded. Two groups were assessed for patterns of obstruction based on DISE videos at each anatomic airway level using a previously published DISE scoring system. The groups included obese subjects (BMI ≥ 95th percentile) and non-obese controls (BMI <85th percentile). Each video was graded by two blinded, fellowship-trained Pediatric Otolaryngologists.

RESULTS

Fifty-one patients were included, 26 non-obese and 25 obese. Based on anatomic airway level, there was no statistically significant difference in airway obstruction at the velum (p = 0.134), adenoid (p = 0.592), lateral pharyngeal walls (p = 0.867), tongue base (p = 0.977), or supraglottis (p = 0.428) between obese and non-obese children.

CONCLUSION

Our prospective study did not associate severity of obstruction with obesity status based on anatomic airway levels. Further studies are needed to elucidate the etiology of the high rate of persistent obstructive sleep apnea in obese children.

Impact of adenotonsillectomy in children with severe obstructive sleep apnea: A systematic review

OBJECTIVES

To determine the impact of adenotonsillectomy for treatment of severe obstructive sleep apnea (OSA) in children without comorbidities.

METHODS

A systematic review was performed to identify studies regarding adenotonsillectomy for treatment of children with severe sleep apnea. Polysomnographic parameters were considered as metric of cure and the number of patients of persistent apnea was calculated. Quality of evidence was graded using OCEBM (Oxford Center for Evidence Based Medicine) and MINORS (Methodological Index for Nonrandomized Studies) scores.

RESULTS

The systematic review included nine studies. Five studies were prospective and four retrospectives. No one was controlled. The number of subjects with severe OSA included was 499 with a prevalence of male. The mean age varied from 4.3 to 8.2. The follow-up period ranges from 1 to 23 months. The criteria for considering severe OSA ranges from AHI or RDI ≥10 to ≥30. All the trials have found a statistically significant reduction of postoperative AHI or RDI values in patients who had undergone adenotonsillectomy for severe OSA. The AHI and RDI improving varied from 57.7% to 93.3%. All the studies documented persistent OSA after adenotonsillectomy. The number of residual OSA considering AHI≥5 varied from 30 to 55.5%, in case of AHI ≥1 from 60 to 90.6%.

CONCLUSION

To the best of our knowledge, this is the first review regarding the effectiveness of adenotonsillectomy for severe OSA in otherwise healthy children. Adenotonsillectomy is partially effective in the treatment of severe OSA in children without comorbidities. However, it reduces the severity of OSA determining a significant reduction of polysomnographic parameters. These results suggest a clinical and polysomnographic follow-up after surgery in order to manage the residual mild and moderate OSA.

The impact of positive airway pressure on midface growth: a literature review

INTRODUCTION

The treatment of obstructive sleep apnea with positive airway pressure in children is restricted due to concerns that it could affect maxilla growth over time.

OBJECTIVE

To undertake a systematic review of the literature about the long-term impact of using a positive airway pressure mask on the midface in growing individuals.

METHODS

The literature search was conducted in September 2019 using the keywords ("long-term" OR "long term" OR "side effects" OR longitudinal) AND (children OR child OR preschool OR adolescents OR adolescent OR infant OR infants) AND (craniofacial OR "mid-face" OR midface OR midfacial OR facial OR maxillary) AND ("airway pressure" OR ventilation) in the databases PubMed, Web of Science and Lilacs. The search included papers published in English, until September 2019, on the effects of positive airway pressure on midfacial growth.

RESULTS

The search strategy identified five studies: two case reports, two cross-sectional studies and one retrospective cohort study. All studies evaluated the long-term effects of a using a nasal mask on the midface in children and adolescents; four showed midface hypoplasia and one no showed difference post- treatment compared to a control.

CONCLUSION

Most of the studies demonstrated that long-term use of nasal positive airway pressure in childhood/adolescence is associated with midface hypoplasia.

Combined Surgical and Orthodontic Treatments in Children with OSA: A Systematic Review

Obstructive sleep apnea (OSA) is a sleeping breathing disorder. In children, adenotonsillar hypertrophy remains the main anatomical risk factor of OSA. The aim of this study was to assess the current scientific data and to systematically summarize the evidence for the efficiency of adenotonsillectomy (AT) and orthodontic treatment (i.e., rapid maxillary expansion (RME) and mandibular advancement (MA)) in the treatment of pediatric OSA. A literature search was conducted in several databases, including PubMed, Embase, Medline, Cochrane and LILACS up to 5th April 2020. The initial search yielded 509 articles, with 10 articles being identified as eligible after screening. AT and orthodontic treatment were more effective together than separately to cure OSA in pediatric patients. There was a greater decrease in apnea hypoapnea index (AHI) and respiratory disturbance index (RDI), and a major increase in the lowest oxygen saturation and the oxygen desaturation index (ODI) after undergoing both treatments. Nevertheless, the reappearance of OSA could occur several years after reporting adequate treatment. In order to avoid recurrence, myofunctional therapy (MT) could be recommended as a follow-up. However, further studies with good clinical evidence are required to confirm this finding.

How to interpret polysomnography

A 5-year-old child presents to a paediatric clinic with their parents because of concerns about snoring, which is loud, every night and associated with respiratory pauses. This has been present for 6 months. Can clinical evaluation diagnose sleep-disordered breathing in children or are further investigations required? Should further investigations include oximetry or polysomnography? If a polysomnogram is performed, how are the results interpreted? In this paper we describe the indications for polysomnography, outline the parameters measured and decode a clinical polysomnography report.

Treatment of Obstructive Sleep Apnea in Children: Handling the Unknown with Precision

Treatment approaches to pediatric obstructive sleep apnea (OSA) have remarkably evolved over the last two decades. From an a priori assumption that surgical removal of enlarged upper airway lymphadenoid tissues (T&A) was curative in the vast majority of patients as the recommended first-line treatment for pediatric OSA, residual respiratory abnormalities are frequent. Children likely to manifest persistent OSA after T&A include those with severe OSA, obese or older children, those with concurrent asthma or allergic rhinitis, children with predisposing oropharyngeal or maxillomandibular factors, and patients with underlying medical conditions. Furthermore, selection anti-inflammatory therapy or orthodontic interventions may be preferable in milder cases. The treatment options for residual OSA after T&A encompass a large spectrum of approaches, which may be complementary, and clearly require multidisciplinary cooperation. Among these, continuous positive airway pressure (CPAP), combined anti-inflammatory agents, rapid maxillary expansion, and myofunctional therapy are all part of the armamentarium, albeit with currently low-grade evidence supporting their efficacy. In this context, there is urgent need for prospective evidence that will readily identify the correct candidate for a specific intervention, and thus enable some degree of scientifically based precision in the current one approach fits all model of pediatric OSA medical care.

Telemonitor care helps CPAP compliance in patients with obstructive sleep apnea: a systemic review and meta-analysis of randomized controlled trials

Background:

This was a meta-analysis of continuous positive airway pressure (CPAP) compliance. We compared telemonitor (TM) care with usual care and supervised PAP titration (SPT) in the sleep unit with home auto-adjusting pressure titration (HAPT) in patients with obstructive sleep apnea (OSA).

Methods:

We searched PubMed, Web of Science, Scopus, and Medline for appropriate randomized controlled trials (RCTs) that compared TM care with usual care for patients with OSA. Review Manager 5.3 was used for all comparisons and analyses.

Results:

Our meta-analysis included 19 studies involving a total of 2464 patients with OSA; CPAP compliance was significantly higher in the TM care group [mean difference (MD) 0.68 h, 95% confidence interval (CI) 0.48–0.89 h, I² = 49%] compared with the usual care group. When we compared SPT and HAPT, two groups did not exhibit significantly different levels of CPAP compliance (MD −0.34 h, 95% CI −0.72–0.05 h, I² = 91%). Subgroup analysis comparing the SPT with HAPT in CPAP compliance was grouped by follow-up time (⩾3 months or <3 months). Once again, there were no between-group differences in either long-term (MD = 0.56 h, 95% CI = 1.39–0.26 h, I² = 91%), or short-term (MD = 0.34 h, 95% CI = 0.26–0.27 h, I² = 14%) follow up.

Conclusions:

TM care was associated with significantly greater CPAP compliance compared with usual care. Also, HAPT was not inferior to SPT for CPAP compliance.

Influence of β2 adrenergic receptor genotype on risk of nocturnal ventilation in patients with Duchenne muscular dystrophy

Duchenne muscular dystrophy (DMD) is a progressive neuromuscular disease resulting in severe respiratory derangements. As such, DMD patients are at a high risk of nocturnal hypoventilation, thereby requiring nocturnal ventilation (NV). To this end, NV is an important clinical milestone in the management of DMD. Emerging evidence suggests that ß₂ adrenergic receptors (ADRB2) may play a role in determining respiratory function, whereby more functional ADRB2 genotype variants (e.g., Gly16) are associated with improved pulmonary function and respiratory muscle strength. These findings suggest that the more functional ADRB2 genotype may help to preserve respiratory function in patients with DMD. The purpose of this study was to identify the influence of ADRB2 genotype on the risk of NV use in DMD. Data from the CINRG Duchenne Natural History Study including 175 DMD patients (3–25 yrs) were analyzed focusing on ADRB2 genotype variants. Time-to-event analyses were used to examine differences in the age at prescription of full-time NV use between genotypes. There were no differences between genotype groups in age, height, weight, corticosteroid use, proportion of ambulatory patients, or age at loss of ambulation. DMD patients expressing the Gly16 polymorphism had a significantly (P < 0.05) lower mean age at NV prescription compared with those patients expressing the Arg16 polymorphism (21.80 ± 0.59 yrs. vs 25.91 ± 1.31 yrs., respectively). In addition, a covariate-adjusted Cox model revealed that the Gly16 variant group possessed a 6.52-fold higher risk of full-time NV use at any given age compared with the Arg16 polymorphism group. These data suggest that genetic variations in the ADRB2 gene may influence the age at which DMD patients are first prescribed NV, whereby patients with the Gly16 polymorphism are more likely to require NV assistance at an earlier age than their Arg16 counterparts.

Ultrasonographic Evaluation of Upper Airway Structures in Children With Obstructive Sleep Apnea

Importance

Adenotonsillar hypertrophy is an important cause of obstructive sleep apnea (OSA) in children. However, residual OSA and abnormal polysomnographic findings have been reported in up to 75% of cases after adenotonsillectomy. Other anatomical and functional factors that influence upper airway structures, including the lateral pharyngeal wall, have rarely been studied in children with OSA.

Objective

To determine whether the upper airway structures can be evaluated using head and neck ultrasonography and if there is an association between the ultrasonographic measurements for these structures and severity of OSA seen on polysomnography in children.

Design, Setting, and Participants

Prospective, single-center, observational study of 82 children younger than 18 years with a diagnosis of sleep-disordered breathing (20 with primary snoring, 62 with OSA, as determined by the apnea-hypopnea index) and admitted to a tertiary teaching hospital for adenotonsillectomy.

Exposures

Ultrasonography and polysomnography.

Main Outcomes and Measures

Ultrasonographic measurements of upper airway structures.

Results

Of the 82 children studied, 62 (76%) were boys; mean (SD) age, 7.7 (6.2). There was no significant difference found in tonsillar dimensions or volume between the children with OSA and those with primary snoring. However, the mean (SD) total lateral pharyngeal wall and the total neck thicknesses at the retropalatal level were both greater in children with OSA than in those with primary snoring at rest (24.9 [4.4] mm vs 21.3 [2.6] mm; difference, 3.61 mm; 95% CI of difference, 1.48-5.74 mm for lateral pharyngeal wall; and 59.9 [14.4] mm vs 49.9 [11.2] mm; difference, 10.9 mm, 95% CI of difference, 3.8-17.9 mm for the total neck).

Conclusions and Relevance

Estimated tonsillar volume measured using ultrasonography had no relationship with the apnea-hypopnea index in childhood sleep-disordered breathing. However, the lateral pharyngeal wall was significantly thicker in children with OSA than in those with primary snoring at rest.

Risk Factors for Obstructive Sleep Apnea Syndrome in Children: State of the Art

The obstructive sleep apnea syndrome (OSAS) represents only part of a large group of pathologies of variable entity called respiratory sleep disorders (RSD) which include simple snoring and increased upper airway resistance syndrome (UARS). Although the etiopathogenesis of adult OSAS is well known, many aspects of this syndrome in children are still debated. Its prevalence is about 2% in children from 2 to 8 years of age, mostly related to the size of the upper airways adenoid tissue. Several risk factors linked to the development of OSAS are typical of the pediatric age. The object of this paper is to analyze the state of the art on this specific topic, discussing its implications in terms of diagnosis and management.

Relationship between Drug-Induced Sleep Endoscopy Findings, Tonsil Size, and Polysomnographic Outcomes of Adenotonsillectomy in Children

OBJECTIVE

(1) Determine the correlation of awake tonsil scores and preadenotonsillectomy (pre-AT) sleep endoscopy findings. (2) Assess the relationship between polysomnographic AT outcomes with awake tonsil scores and sleep endoscopy ratings of tonsil and adenoid obstruction.

STUDY DESIGN

Retrospective case series with chart review.

SETTING

Tertiary care children's hospital.

SUBJECTS AND METHODS

Children aged 1 to 18 years who underwent sleep endoscopy and AT from January 1, 2013, to August 30, 2016, were included. Pre-AT sleep endoscopy findings were scored with the Sleep Endoscopy Rating Scale. Awake tonsil scores and sleep endoscopy ratings were compared with Spearman correlation. Associations between changes in pre- and post-AT polysomnography parameters and (1) awake tonsil scoring and (2) sleep endoscopy scoring were assessed with 1-way analysis of variance and linear regression.

RESULTS

Participants included 36 children (mean ± SD age, 6.8 ± 4.3 years; 68% male, 44% obese). Awake tonsil scores and sleep endoscopy ratings were strongly correlated (R = 0.58, P = .003). Awake tonsil scores were not associated with changes in any polysomnography parameters after AT (all P > .05), while sleep endoscopy ratings of adenotonsillar obstruction were significantly associated (all P < .05, R² = 0.16-0.35). Patients with minimal adenotonsillar obstruction during sleep endoscopy had less improvement than those with partial or complete obstruction (mean obstructive apnea-hypopnea index change: -8.2 ± 11.5 vs -15.9 ± 14.3, and -46.8 ± 31.3, respectively; P < .001).

CONCLUSIONS

In children at risk for AT failure, assessment of dynamic collapse with sleep endoscopy may better predict the outcome of AT than awake tonsil size assessment, thus helping to inform surgical expectations.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of appropriately trained staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

Sleep disordered breathing in children - Diagnostic questionnaires, comparative analysis

STUDY OBJECTIVES

The purpose of this work is to present available questionnaires enabling diagnostic screening when obstructive sleep disordered breathing (SDB) in a child is suspected or its effects are observed and polysomnography is unavailable. These questionnaires are designed to facilitate further diagnostic process or even therapeutic decisions, aid in selecting the optimal one for the specified conditions of clinical practice, with the caveat that none of these represents a diagnostic equivalent to PSG.

METHODS

The questionnaires subjected to analysis: Pediatric Sleep Questionnaire (PSQ), Sleep Clinical Record (SCR), OSA-18 score (OSA-18), Brouilette score (BS), "I'm Sleepy" questionnaire (I'M SLEEPY), and "Sleeping Sleepless Sleepy Disturbed Rest" questionnaire (SSSDR). The comparative analysis of questionnaires included the following parameters: simplicity and time of administer; necessity to engage a physician or other trained individual; taking into account examination of the patient; type and scope of considered symptoms and consequences of obstructive SDB, sensitivity, specificity, recommendations of the guidelines.

RESULTS

Seven questionnaires were subjected to analysis with presentation of their similarities and differences. Six out of seven were evaluated as simple in administration. Time required to fulfill the questionnaires ranged between 1 and 60 min. Three of them involved a physician or a trained personnel. Physical examination was necessary in two out of seven questionnaires. Sensitivity was estimated in 5 of them and ranged between 59 and 96%. Specificity ranged between 46 and 72%.

CONCLUSIONS

Several questionnaires enabling quick, simple, and inexpensive screening for OSAS have been created. Four (of the seven analyzed) questionnaires may be useful in diagnosis of obstructive SDB in children - two follow current (2015) recommendations. However, there is a need for further work on optimizing such tools, particularly on improving their specificity.

Outcome of drug-induced sleep endoscopy-directed surgery for persistent obstructive sleep apnea after adenotonsillar surgery

PURPOSE

Drug-induced sleep endoscopy (DISE) is suitable for evaluating persistent obstructive sleep apnea syndrome (OSAS) after adenotonsillar surgery as a means to guide surgical intervention, yet few studies demonstrate its usefulness in resolving the syndrome. We describe our experience of DISE-directed surgery in children with persistent OSAS by analysing objective and subjective outcomes of this treatment.

METHODS

Prospective study of 20 otherwise healthy 2-12 year-old children with OSAS persisting after adenotonsillar surgery. All patients underwent DISE-directed surgery and were followed up clinically and with a polysomnogram at 12 ± 3 months.

RESULTS

All 20 children had an apnea-hypopnea index (AHI) score ≥1 (mean: 6.1 ± 4.9) and 75% had AHI>3 before surgery. We performed a total of 14 total tonsillectomies (70%), 7 with associated pharyngoplasties; 5 radiofrequency turbinate reductions (25%); 7 radiofrequency lingual tonsil reductions (35%); and 10 revision adenoidectomies (50%). No surgery-related complications were observed. AHI scores at follow-up were significantly lower than AHI scores before surgery (1.895 ± 1.11 vs 6.143 ± 4.88; p < 0.05) and, in 85% (n = 17) of patients, AHI was below 3. There was a significant reduction in the number of children with AHI>3 in follow-up at 12 ± 3 months (15%; n = 3) compared to before surgery (75%; n = 15) (p < 0.005).

CONCLUSION

DISE-directed surgery for otherwise healthy children with persistent OSAS is a useful and safe technique to decide a therapeutic strategy and to obtain good objective and subjective results regarding resolution of the syndrome.

A Cross-sectional Analysis of Pediatric Ambulatory Tonsillectomy Surgery in the United States

Objectives

To report nationwide estimates of ambulatory tonsillectomies performed in hospitals and ambulatory surgery centers in the United States.

Study Design

Cross-sectional survey.

Setting

National databases.

Subjects and Methods

We analyzed the 2010 National Hospital Ambulatory Medical Care Survey of hospitals and ambulatory surgery centers for pediatric patients undergoing tonsillectomy with or without adenoidectomy. We determined estimations of the number of procedures, demographics, and outcomes. A tonsillectomy cohort from the 2009 National Inpatient Sample served as a comparison group.

Results

In 2010, there were an estimated 339,000 (95% CI, 288,000-391,000) ambulatory tonsillectomies in the United States. The mean age was 7.8 years (SD, 5.1), and 71,000 (21.0%) were <3 years old. The male:female ratio was even (51% vs 49%). The racial makeup mirrored the US census (69% white, 18% Hispanic, and 12% black). Obstructive sleep-disordered breathing was reported in 48%. Perioperative events such as apnea, hypoxia, or bleeding occurred 7.8% of the time. Approximately 9% of patients could not be discharged home. When compared with cases of inpatient tonsillectomies, ambulatory cases comprised older patients (7.8 vs 5.9 years, P < .001) and were less likely to include obstructive sleep-disordered breathing (48% vs 77%, P < .001).

Conclusion

Tonsillectomy was one of the most common ambulatory surgical procedures in 2010 in the United States. The majority of patients were low risk, but some at higher risk were included (age ≤3 years and obstructive sleep apnea). The National Hospital Ambulatory Medical Care Survey estimates provide useful baseline data for future research on quality measures and outcomes.

Effects of an Adenotonsillectomy on the Cognitive and Behavioural Function of Children Who Snore: A naturalistic observational study

Objectives

This study aimed to evaluate cognitive and behavioural changes among 9-14-year-old Omani children with obstructive sleep apnoea (OSA) after an adenotonsillectomy (AT).

Methods

This naturalistic observational study was conducted at the Sultan Qaboos University Hospital, Muscat, Oman, between January 2012 and December 2014. Omani children with adenotonsillar hypertrophy (ATH) underwent overnight polysomnography and those with confirmed OSA were scheduled for an AT. Cognitive and behavioural evaluations were performed using standardised instruments at baseline prior to the procedure and three months afterwards.

Results

A total of 37 children were included in the study, of which 24 (65%) were male and 13 (35%) were female. The mean age of the males was 11.4 ± 1.9 years, while that of the females was 11.1 ± 1.5 years. Following the AT, there was a significant reduction of 56% in mean apnoea-hypopnoea index (AHI) score (2.36 ± 4.88 versus 5.37 ± 7.17; P <0.01). There was also a significant positive reduction in OSA indices, including oxygen desaturation index (78%), number of desaturations (68%) and number of obstructive apnoea incidents (74%; P <0.01 each). Significant improvements were noted in neurocognitive function, including attention/concentration (42%), verbal fluency (92%), learning/recall (38%), executive function (52%) and general intellectual ability (33%; P <0.01 each). There was a significant decrease of 21% in both mean inattention and hyperactivity scores (P <0.01 each).

Conclusion

These results demonstrate the effectiveness of an AT in improving cognitive function and attention deficit hyperactivity disorder-like symptoms among children with ATH-caused OSA. Such changes can be observed as early as three months after the procedure.