Inflammatory Factors: Nonobese Pediatric Obstructive Sleep Apnea and Adenotonsillectomy

Evaluation of Serum/Plasma Levels of Interleukins (IL-6, IL-12, IL-17, IL-18, and IL-23) in Adults and Children with Obstructive Sleep Apnea: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis

Obstructive sleep apnea (OSA) is a chronic inflammatory disease characterized by partial or complete upper airway obstruction during sleep. We aimed to evaluate serum/plasma levels of several cytokines (interleukin [IL]-6, IL-12, IL-17, IL-18, and IL-23) in a systematic review meta-analysis in both adults and children with OSA compared with controls. We conducted a comprehensive search of 4 digital databases (PubMed, Web of Science, Scopus, and Cochrane Library) up until October 19, 2023, without any limitations. For our meta-analysis, we used Review Manager, version 5.3, and displayed the data as the standardized mean difference (SMD) and 95% confidence interval (CI) to assess the correlation between cytokine levels and OSA. We utilized Comprehensive Meta-Analysis version 3.0 software to conduct bias analyses, meta-regression, and sensitivity analyses. From 1881 records, 84 articles were included in the systematic review and meta-analysis. In adults, the pooled SMDs for IL-6 level were 0.79 (P value < 0.00001), for IL-17 level were 0.74 (P value = 0.14), and for IL-18 level were 0.43 (P value = 0.00002). In children, the pooled SMD for IL-6 was 1.10 (P value < 0.00001), for IL-12 was 0.47 (P value = 0.10), for IL-17 was 2.21 (a P value = 0.24), for IL-18 was 0.19 (P value = 0.07), and for IL-23 was 2.46 (P value < 0.0001). The subgroup analysis showed that the ethnicity, mean body mass index, and mean apnea-hypopnea index for IL-6 levels in adults and the ethnicity for IL-6 levels in children were effective factors in the pooled SMD. The findings of the trial sequential analysis revealed that adequate evidence has been obtained. The analysis of IL levels in adults and children with OSA compared with those without OSA revealed significant differences. In adults, IL-6 and IL-18 levels were significantly higher in the OSA group, while in children, only IL-6 and IL-23 levels were significantly elevated.

Efficacy of adenotonsillectomy on pediatric obstructive sleep apnea and related outcomes: A narrative review of current evidence

This review summarizes the current evidence in systematic reviews, meta-analysis and randomized controlled trials regarding adenotonsillectomy outcomes in pediatric obstructive sleep apnea (OSA). Adenotonsillectomy is effective in treating OSA in children without co-morbidities, despite postoperative residual OSA remained in roughly half of these children. For children with comorbidities such as Down syndrome, Prader-Willi syndrome, sickle cell disease, or cerebral palsy, adenotonsillectomy is less effective and associated with more postoperative complications than that in children without comorbidities. For other OSA-related outcomes, evidence from meta-analyses and randomized controlled trials confirm adenotonsillectomy results in improvement of subjective OSA-related outcomes (e.g. symptoms, behaviors, and quality of life), but the results in objective OSA-related outcomes (e.g. cardiometabolic parameters or neurocognitive functions) are inconsistent. Future studies should focus on randomized controlled trials comparing objective OSA-related outcomes and the long-term effects of adenotonsillectomy in children with OSA.

Association of Tumor Necrosis Factor-Alpha, Interleukin-1β, Interleukin-8, and Interferon-γ with Obstructive Sleep Apnea in Both Children and Adults: A Meta-Analysis of 102 Articles

Background: Cytokines may have a significant impact on sleep regulation. In this meta-analysis, we present the serum/plasma levels of tumor necrosis factor-alpha (TNF-α), interleukin (IL)-8, IL-1β, and interferon-gamma (IFN-γ) in both children and adults with obstructive sleep apnea (OSA) in comparison to controls. Methods: Four electronic databases were systematically searched (PubMed, Web of Science, Scopus, and Cochrane Library) through 19 October 2023, without any restrictions on language, date, age, and sex. We used Review Manager version 5.3 to perform meta-analysis and presented the data as standardized mean difference (SMD) and 95% confidence interval (CI) values to evaluate the relationships between the levels of cytokines and OSA. Results: A total of 102 articles (150 independent studies) were included in the meta-analysis. The pooled SMDs in adults were 1.42 (95%CI: 1.11, 1.73; p < 0.00001), 0.85 (95%CI: 0.40, 1.31; p = 0.0002), 0.69 (95%CI: 0.22, 1.16; p = 0.004), and 0.39 (95%CI: -0.37, 1.16; p = 0.31) for TNF-α, IL-8, IL-1β, and IFN-γ, respectively. The pooled SMDs in children were 0.84 (95%CI: 0.35, 1.33; p = 0.0008), 0.60 (95%CI: 0.46, 0.74; p < 0.00001), 0.25 (95%CI: -0.44, 0.93; p = 0.49), and 3.70 (95%CI: 0.75, 6.65; p = 0.01) for TNF-α, IL-8, IL-1β, and IFN-γ, respectively. Conclusions: The levels of proinflammatory cytokines of TNF-α, IL-8, and IL-1β in adults, and TNF-α, IL-8, and IFN-γ in children with OSA, are significantly higher than those in controls.

Interleukin-10 is not associated with obstructive sleep apnea hypopnea syndrome: A meta-analysis and meta-regression

BACKGROUND

This study was conducted to explore the potential relationship between interleukin-10 (IL-10) and obstructive sleep apnea hypopnea syndrome (OSAHS).

METHODS

All the related research articles published before October 2022 were retrieved through the online database (EMBASE, VIP, Wan Fang, Web of Science, PubMed, and CNKI). Stata 11.0 software was used to calculate the standard mean difference (SMD) of the continuous variable and 95% confidence interval (CI). Expression profiles GSE38792 and GSE135917 were acquired from Gene Expression Omnibus (GEO) database, respectively. The expression of IL-10 mRNA in subcutaneous adipose tissue and visceral adipose tissue of OSAHS patients and healthy subjects was extracted by R software to verify the difference in IL-10 between the 2 groups.

RESULTS

The IL-10 level in the plasma of people with and without OSAHS (STD Mean Difference (SMD) = -0.68, 95% CI = -1.58 to 0.21, I2 = 94.3%, P = .136) was the same. There was also no difference in IL-10 levels in serum between people with and without OSAHS (SMD = -0.12, 95% CI = -0.55 to 0.32, I2 = 94.4%, P = .591). In addition, the subjects were divided into different subgroups for meta-analysis according to race, body mass index, age, study type, and disease severity. Based on the outcomes, no notable difference was observed in the plasma/serum IL-10 level between the OSAHS subgroups and the control group. The results of bioinformatics analysis indicated that there was no significant difference in the expression of IL-10 mRNA in subcutaneous adipose tissue and visceral adipose tissue between patients with OSAHS and those in the control group.

CONCLUSION

The current meta-analysis highlighted that IL-10 levels between patients with OSAHS and healthy people had no difference.

Adipocytokines in obstructive sleep apnea: A systematic review and meta-analysis

BACKGROUND AND AIM

Adipocytokines play an important role in obstructive sleep apnea (OSA) by mediating inflammatory responses. Previous studies have reported that OSA is related to a change in the serum levels of adipocytokines; however, the results are still controversial. This meta-analysis aimed to assess the relationship between OSA and circulating level of adipocytokines in adults and children.

METHODS

A comprehensive search was conducted in databases of Medline/PubMed and Scopus for pertinent articles published since their inception to July 2022. Weighted mean differences (WMDs) and 95% confidence intervals (CIs) were used to assess the strength of the relationship between the concentrations of adipocytokines with OSA.

RESULTS

In the overall analysis, contrary to IL-10, which showed a significant reduction, IL-1β, IL-4, IL-8, IL-17, and IFN- gamma showed higher levels in OSA patients in comparison with control groups (p <0.05). For adults, IL-1β, IL-8, IL-17, IL-18, vaspin, visfatin, and chemerin were linked to a greater serum levels in patients with OSA, while, IL-5 and IL-10 were detected significantly lower in adults with OSA in comparison with healthy adults (p <0.05). In children with OSA, the serum levels of IL-4, IL-8, IL-12, IL-17, IL-23, and IFN-gamma were significantly higher than healthy children (p <0.05).

CONCLUSION

The levels of inflammatory markers were found to be higher in OSA patients compared with control individuals, suggesting that adipocytokines may contribute to the pathology of OSA.

Causal analysis between altered levels of interleukins and obstructive sleep apnea

Background

Inflammation proteins including interleukins (ILs) have been reported to be related to obstructive sleep apnea (OSA). The aims of this study were to estimate the levels for several key interleukins in OSA and the causal effects between them.

Method

Weighted mean difference (WMD) was used to compare the expression differences of interleukins between OSA and control, and the changed levels during OSA treatments in the meta-analysis section. A two-sample Mendelian randomization (MR) was used to estimate the causal directions and effect sizes between OSA risks and interleukins. The inverse-variance weighting (IVW) was used as the primary method followed by several other MR methods including MR Egger, Weighted median, and MR-Robust Adjusted Profile Score as sensitivity analysis.

Results

Nine different interleukins—IL-1β, IL-2, IL-4, IL-6, IL-8, IL-12, IL-17, IL-18, and IL-23—were elevated in OSA compared with control to varying degrees, ranging from 0.82 to 100.14 pg/ml, and one interleukin, IL-10, was decreased by 0.77 pg/ml. Increased IL-1β, IL-6, and IL-8 rather than IL-10 can be reduced in OSA by effective treatments. Further, the MR analysis of the IVW method showed that there was no significant evidence to support the causal relationships between OSA and the nine interleukins—IL-1β, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-17, and IL-18. Among them, the causal effect of OSA on IL-5 was almost significant [estimate: 0.267 (−0.030, 0.564), p = 0.078]. These results were consistent in the sensitivity analysis.

Conclusions

Although IL-1β, IL-2, IL-4, IL-6, IL-8, IL-12, IL-17, IL-18, and IL-23 were increasing and IL-10 was reducing in OSA, no significant causal relationships were observed between them by MR analysis. Further research is needed to test the causality of OSA risk on elevated IL-5 level.

Assessment of sleep-disordered breathing in pediatric otitis media with effusion

BACKGROUND

Given the role of adenoid in the pathogenesis of otitis media with effusion (OME) and sleep-disordered breathing (SDB), the present study aimed to investigate the sleep quality and the impact of adenoidectomy on improvement of sleep symptoms in children with OME.

METHODS

Children with SDB or OME, aged 3-12 years, were prospectively enrolled before undergoing adenoidectomy in a tertiary medical center. The symptom severity of obstructive sleep apnea syndrome (OSAS) was evaluated by OSA-18 questionnaire on the day before and 6 months after surgery.

RESULTS

In total, 79 pediatric patients including 50 children with SDB and 29 children with OME were enrolled. The mean total OSA-18 score was 56.5 ± 15.1 and ten (34.5%) children experienced moderate to severe symptoms of OSAS as indicated by OSA-18 score ≥ 60 in OME group. After surgery, patients in both SDB and OME groups experienced improvement (both p < 0.001) and presented no difference in the scores of OSA-18. The proportional change in OSA-18 scores after surgery was related to pre-operative OSA-18 scores and BMI in OME patients (r_s = 0.400 and 0.542, p = 0.047 and 0.008), and to pre-operative OSA-18 scores in patients with SDB (r_s = 0.393, p = 0.008).

CONCLUSION

Children with OME experienced significant symptoms of OSAS and associated impairment of quality of life. Adenoidectomy is effective in the improvement of sleep symptoms in these patients. Comprehensive assessment of sleep breathing as planning surgery for OME children is suggested.

Much Ado about Sleep: Current Concepts on Mechanisms and Predisposition to Pediatric Obstructive Sleep Apnea

Obstructive Sleep Apnea (OSA) is a form of sleep-disordered breathing characterized by upper airway collapse during sleep resulting in recurring arousals and desaturations. However, many aspects of this syndrome in children remain unclear. Understanding underlying pathogenic mechanisms of OSA is critical for the development of therapeutic strategies. In this article, we review current concepts surrounding the mechanism, pathogenesis, and predisposing factors of pediatric OSA. Specifically, we discuss the biomechanical properties of the upper airway that contribute to its primary role in OSA pathogenesis and examine the anatomical and neuromuscular factors that predispose to upper airway narrowing and collapsibility.

Paediatrics: how to manage obstructive sleep apnoea syndrome

Obstructive sleep apnoea syndrome (OSAS) is defined as the intermittent reduction or cessation of airflow due to partial or complete obstruction of the upper airway during sleep. Paediatric OSAS has specific contributing factors, presenting symptoms and management strategies in various age groups. Untreated OSAS can lead to detrimental effects on neurocognitive development and cardiovascular and metabolic functions of a growing child. In the past decade, practice guidelines have been developed to guide the evaluation and management of OSAS. This article provides a narrative review on the current diagnostic and treatment options for paediatric OSAS. Alternative diagnostic tools other than the standard polysomnography are discussed. Adenotonsillectomy is considered the first-line therapy yet it is not suitable for treatment of all OSAS cases. Nocturnal non-invasive positive airway pressure ventilation is effective and could be the priority treatment for patients with complex comorbidities, residual OSAS post-adenotonsillectomy or obesity. However, intolerance and non-adherence are major challenges of positive airway pressure therapy especially in young children. There is increasing evidence for watchful waiting and other gentler alternative treatment options in mild OSAS. The role of anti-inflammatory drugs as the primary or adjunctive treatment is discussed. Other treatment options, including weight reduction, orthodontic procedures and myofunctional therapy, are indicated for selected patients. Nevertheless, the successful management of paediatric OSAS often requires a multidisciplinary team approach.

Obstructive sleep apnea increases heart rhythm disorders and worsens subsequent outcomes in elderly patients with subacute myocardial infarction

OBJECTIVE

Obstructive sleep apnea (OSA) is a potential cardiovascular risk. We aimed to investigate the association of OSA with heart rhythm disorders and prognosis in elderly patients with new-onset acute myocardial infarction (AMI).

METHODS

We prospectively enrolled 252 AMI elderly patients (mean age, 68.5 ± 6.9 years) who were undergoing revascularization and completed a sleep study during their hospitalization. All subjects were categorized into non-OSA (apnea–hypopnea index (AHI) < 15, n = 130) and OSA (AHI ≥ 15, n = 122) groups based on the AHI. The changes in the autonomic nervous system, incidence of arrhythmia during nocturnal sleep, and major adverse cardiovascular and cerebrovascular events (MACCEs) were compared between the groups.

RESULTS

The mean AHI value in all AMI patients was 22.8 ± 10.9. OSA patients showed higher levels of body mass index and peak high-sensitivity C-reactive protein and lower levels of minimum nocturnal oxygen saturation (MinSaO₂), as well as greater proportion of multivessel coronary artery disease (all P < 0.05). The OSA group also showed significant increases in heart rate variability and heart rate turbulence onset (both P < 0.05) and higher incidence of arrhythmia (including sinus, atrial, and ventricular in origin). At a median follow-up of 6 months (mean 0.8–1.6 years), OSA (AHI ≥ 15) combined with hypoxia (MinSaO ₂ ≤ 80%) was independently associated with the incidence of MACCEs (hazard ratio [HR]: 4.536; 95% confidence interval [CI]: 1.461−14.084,P = 0.009) after adjusting for traditional risk factors.

CONCLUSIONS

OSA and OSA-induced hypoxia may correlate with the severity of myocardial infarction, increase the occurrence of heart rhythm disorders in elderly subacute MI patients, and worsen their short-term poor outcomes.

Idiopathic Sudden Sensorineural Hearing Loss in Patients with Obstructive Sleep Apnea

PURPOSE

Obstructive sleep apnea (OSA) is characterized by recurring hypoxic-apneic events during sleep, and labyrinthine vascular compromise is a pathophysiologic hallmark of idiopathic sudden sensorineural hearing loss (ISSNHL). Some reports have discussed the relationship between OSA and hearing impairment; however, few have examined hearing prognosis in OSA and patients without OSA with ISSNHL. We aimed to investigate clinical manifestations of ISSNHL in patients with OSA, including severity of hearing loss and response to treatment.

PATIENTS AND METHODS

A case-control study was conducted by extracting data from the sleep center and cochlea center databases of the Chang Gung Memorial Hospital. A retrospective chart review was performed to include confirmed adult OSA patients diagnosed with unilateral ISSNHL. Age and sex-matched patients without OSA with ISSNHL were enrolled as controls. Pure-tone average (PTA) thresholds were measured at specific frequencies. Changes in PTA before and after standard treatment with oral prednisolone (1mg/kg/day for 5 days, then tapered) and between participants with OSA and without OSA were compared. Standard treatment was given to all ISSNHL patients.

RESULTS

Twenty-eight out of 8500 (0.33%) OSA patients experienced subsequent ISSNHL in 9 years. Patients with OSA (n=28) had poorer high-frequency perception in the unaffected ear than the patients without OSA (n=120), although the difference was not significant. Hearing in the affected ear among patients with OSA was comparable to that patients without OSA at individual frequencies and average, suggesting no difference in hearing loss in the affected ear between the two groups. In terms of high-frequencies (4000 and 8000 Hz) perception, patients with OSA had significantly poorer responses to steroid treatment than patients without OSA.

CONCLUSION

ISSNHL may be one of the auditory complications associated with OSA. Patients with OSA had poorer prednisolone related hearing improvement in high frequencies than patients without OSA. Despite study limitations, OSA-related hypoxia and snoring noise is hazardous to hearing and standard treatments with CPAP is suggested in OSA patients for both holistic and auditory health.