Characteristics and surgical and clinical outcomes of severely obese children with obstructive sleep apnea

Surgical Management of Pediatric Obstructive Sleep Apnea Beyond Adenotonsillectomy: The Nose, Nasopharynx, and Palate

While adenotonsillectomy is the primary treatment of pediatric obstructive sleep apnea (OSA), persistent OSA after surgery is common and may be due to residual obstruction at the nose, nasopharynx, and/or palate. Comprehensive evaluation for persistent pediatric OSA ideally includes clinical examination (with or without awake nasal endosocpy) as well as drug-induced sleep endoscopy in order to accurately identify sources of residual obstruction. Depending on the site of obstruction, some of the surgical management options include submucous inferior turbinate resection, septoplasty, adenoidectomy, and expansion sphincter pharyngoplasty.

Assessment of obstructive sleep apnoea in children: What are the challenges we face?

There is an increasing demand for the assessment of sleep-disordered breathing in children of all ages to prevent the deleterious neurocognitive and behaviour consequences of the under-diagnosis and under-treatment of obstructive sleep apnoea [OSA]. OSA can be considered in three broad categories based on predominating contributory features: OSA type 1 [enlarged tonsils and adenoids], type II [Obesity] and type III [craniofacial abnormalities, syndromal, storage diseases and neuromuscular conditions]. The reality is that sleep questionnaires or calculations of body mass index in isolation are poorly predictive of OSA in individuals. Globally, the access to testing in tertiary referral centres is comprehensively overwhelmed by the demand and financial cost. This has prompted the need for better awareness and focussed history taking, matched with simpler tools with acceptable accuracy used in the setting of likely OSA. Consequently, we present key indications for polysomnography and present scalable, existing alternatives for assessment of OSA in the hospital or home setting, using polygraphy, oximetry or contactless sleep monitoring.

Sleep quality, sleep apnea, and metabolic health in children treated with adenotonsillectomy

PURPOSE

The aim of this study was to determine if cardiopulmonary coupling (CPC) calculated sleep quality (SQI) may predict changes in metabolic health in children treated with early adenotonsillectomy (eAT) for obstructive sleep apnea (OSA).

METHODS

Secondary analysis of the Childhood Adenotonsillectomy Trial (CHAT) was performed including children 5.0-9.9 years with OSA assigned to eAT. The cohort was stratified based on SQI and AHI to evaluate (1) response to eAT in children with high sleep quality (SQI ≥ 75) and mild-OSA, AHI < 5.0 (group1) and children with moderate-OSA AHI ≥ 5.0 or SQI < 75 (group2) at baseline and (2) effect of eAT therapy on metabolic health, GroupRemission (AHI < 1.0, SQI ≥ 75) compared to GroupResidual.

RESULTS

At baseline group2 (n=124) had higher average heart rate during sleep (AHRSleep), 87 vs. 81 beats/minute (p < 0.001) compared to group1 (n=72). After surgery, group2 on average had less increase in BMI z-score 0.13 vs. 0.27, (p = 0.025), improved their SQI + 2.06 compared to decline - 3.75 in group1, (p = 0.015), decreased AHRSleep-- 2.90 vs. - 0.34 (p = 0.025) and AHI - 5.00 vs. - 0.36 (p = 0.002). GroupRemission was younger 6.59 vs. 7.41; p < 0.001; with lower BMI z-score 0.90 vs. 1.34; p = 0.021; AHRSleep 80.60 vs. 83.50; p = 0.032; fasting insulin (µIU/ml) 7.54 vs. 12.58; p = 0.017 and glucose (mmol/L) 4.45 vs. 4.60; p = 0.049, with better lipid metabolism though not statistically significantly, low-density-lipoprotein 90.26 mg/dL vs. 97.94; p = 0.081 and cholesterol 154.66 mg/dL vs. 164.36; p = 0.076.

CONCLUSION

The results may indicate that children with mild-OSA and high-SQI may be less likely to benefit from eAT than children with moderate-OSA. To improve metabolic health, successfully treating both AHI and SQI is likely needed. CPC-calculated SQI may have a role to identify children less likely to benefit from eAT and to evaluate success of therapy.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00560859.

Adherence to Continuous Positive Airway Pressure Therapy in Pediatric Patients with Obstructive Sleep Apnea: A Meta-Analysis

Introduction

Obstructive sleep apnea (OSA) is a public health problem that affects children. Although continuous positive airway pressure (CPAP) therapy is effective, the CPAP adherence rate in children is varied. This study aimed to evaluate the CPAP adherence rate and factors associated with CPAP adherence in children with OSA using a systematic review.

Methods

The inclusion criteria were observational studies conducted in children with OSA and assessed adherence of CPAP using objective evaluation. The literature search was performed in four databases. Meta-analysis using fixed-effect model was conducted to combine results among included studies.

Results

In all, 34 studies that evaluated adherence rate and predictors of CPAP adherence in children with OSA were included, representing 21,737 patients with an average adherence rate of 46.56%. There were 11 calculations of factors predictive of CPAP adherence: age, sex, ethnicity, body mass index, obesity, income, sleep efficiency, the apnea-hypopnea index (AHI), severity of OSA, residual AHI, and lowest oxygen saturation level. Three different factors were linked to children with adherence and non-adherence to CPAP: age, body mass index, and AHI.

Conclusion

The CPAP adherence rate in children with OSA was 46.56%. Young age, low body mass index, and high AHI were associated with acceptable CPAP adherence in children with OSA.

Expert Consensus Statement: Management of Pediatric Persistent Obstructive Sleep Apnea After Adenotonsillectomy

OBJECTIVE

To develop an expert consensus statement regarding persistent pediatric obstructive sleep apnea (OSA) focused on quality improvement and clarification of controversies. Persistent OSA was defined as OSA after adenotonsillectomy or OSA after tonsillectomy when adenoids are not enlarged.

METHODS

An expert panel of clinicians, nominated by stakeholder organizations, used the published consensus statement methodology from the American Academy of Otolaryngology-Head and Neck Surgery to develop statements for a target population of children aged 2-18 years. A medical librarian systematically searched the literature used as a basis for the clinical statements. A modified Delphi method was used to distill expert opinion and compose statements that met a standardized definition of consensus. Duplicate statements were combined prior to the final Delphi survey.

RESULTS

After 3 iterative Delphi surveys, 34 statements met the criteria for consensus, while 18 statements did not. The clinical statements were grouped into 7 categories: general, patient assessment, management of patients with obesity, medical management, drug-induced sleep endoscopy, surgical management, and postoperative care.

CONCLUSION

The panel reached a consensus for 34 statements related to the assessment, management and postoperative care of children with persistent OSA. These statements can be used to establish care algorithms, improve clinical care, and identify areas that would benefit from future research.

Relationship between obstructive sleep apnea, insulin resistance, and metabolic syndrome: a nationwide population-based survey

We aimed to identify the association between obstructive sleep apnea (OSA), insulin resistance (IR), and metabolic syndrome (MetS) in a nationwide population-based sample. A total of 7,900 adults with information on the STOP-Bang score and MetS (3,341 men and 4,469 women) were identified from the dataset of the Korea National Health and Nutrition Examination Survey 2019-2020. The association between OSA, IR, MetS, and its components was estimated using complex sample logistic regression analysis with adjustments for age, body mass index, residence, smoking status, alcohol consumption, household income, education, and the presence of diabetes. Participants with a high OSA score were more likely to have IR (odds ratio [OR] 2.78, 95% confidence interval [CI] 1.96-3.95 in men and OR 2.64, 95% CI 0.55-12.80 in women), MetS (OR 6.05, 95% CI 4.23-8.69 in men and OR 4.20, 95% CI 1.23-15.70 in women), and components of MetS, compared to individuals with a low OSA score. Compared to premenopausal women, postmenopausal women had a more intense association between OSA and IR (OR 1.78, 95% CI 0.13-24.43 for premenopausal women and OR 3.64, 95% CI 0.60-22.28 for postmenopausal women) and MetS (OR 2.58, 95% CI 0.23-29.55 for premenopausal women and OR 5.36, 95% CI 1.42-20.21 for postmenopausal women). OSA was associated with abdominal obesity and hypertension in premenopausal women, while all components of MetS were associated with OSA in postmenopausal women. Further studies are necessary to elucidate the underlying mechanisms of these findings.

Adenotonsillectomy outcomes in obese adolescents with obstructive sleep apnea

STUDY OBJECTIVES

(1) To assess adenotonsillectomy (AT) outcomes in adolescents with obesity and with obstructive sleep apnea (OSA); (2) To identify clinical factors predicting OSA in adolescents following AT.

METHODS

Adolescents 12 to 18 years old with obesity who underwent AT for OSA were included. Subjects had pre-AT and post-AT polysomnogram. Nonobese adolescents with OSA that underwent AT were included as a comparison.

RESULTS

Seventy adolescents with obesity with a mean age of 14.2 years and a mean body mass index of 38.0 kg/m2 were included. Patients in the nonobese group (n = 32) were similar demographically to the obese group, with the exception of body mass index. The majority of adolescents with obesity (74%) had severe OSA (apnea-hypopnea index [AHI] ≥ 10 events/h) with a mean baseline AHI of 33.9 events/h (standard deviation 28.5). The obese and control groups experienced clinically meaningful improvements in AHI following AT, with median change scores of 18.3 (95% confidence interval -29.2, -11.2, P < .001) and 14.6 (95% confidence interval -25.5, -8.5, P < .001), respectively. In the adolescents with obesity, 48% had an AHI < 5 events/h on postoperative PSG. However, adolescents with obesity were 7 times more likely (odds ratio = 7.1, 95% confidence interval [2.24, 22.48], P = .001) to have moderate or severe persistent OSA (AHI > 5 events/h) after AT compared with patients who were not obese. The need for post-AT positive airway pressure therapy was significantly higher in adolescents with obesity, with 37.1% of participants requiring this therapy (odds ratio = 8.3, 95% confidence interval 1.8, 37.6, P < .001).

CONCLUSIONS

AT results in improvement in polysomnogram parameters in adolescents with obesity and OSA. However, patients with obesity are at high risk for persistent OSA. Future research should include prospective trials to compare outcomes between AT and positive airway pressure therapy for adolescents with obesity.

CITATION

Kearney TC, Vazifedan T, Baldassari CM. Adenotonsillectomy outcomes in obese adolescents with obstructive sleep apnea. J Clin Sleep Med. 2022;18(12):2855-2860.

Innovations in the Treatment of Pediatric Obstructive Sleep Apnea

Obstructive sleep apnea affects a large proportion of otherwise healthy children in the context of interactions between craniofacial elements, adenotonsillar hypertrophy and other anatomical factors, and neuromuscular reflexes of the upper airway. In light of the adverse consequences of sleep apnea, it is important not only to proceed with early diagnosis but also to implement adequate treatment that is guided by the pathophysiological determinants of the disease in each child. Here, we will describe the current standard of care approaches to the treatment of pediatric obstructive sleep apnea, and will also explore novel management strategies that should enable more personalized therapy in the near future.

Machine learning-based preoperative datamining can predict the therapeutic outcome of sleep surgery in OSA subjects

Increasing recognition of anatomical obstruction has resulted in a large variety of sleep surgeries to improve anatomic collapse of obstructive sleep apnea (OSA) and the prediction of whether sleep surgery will have successful outcome is very important. The aim of this study is to assess a machine learning-based clinical model that predict the success rate of sleep surgery in OSA subjects. The predicted success rate from machine learning and the predicted subjective surgical outcome from the physician were compared with the actual success rate in 163 male dominated-OSA subjects. Predicted success rate of sleep surgery from machine learning models based on sleep parameters and endoscopic findings of upper airway demonstrated higher accuracy than subjective predicted value of sleep surgeon. The gradient boosting model showed the best performance to predict the surgical success that is evaluated by pre- and post-operative polysomnography or home sleep apnea testing among the logistic regression and three machine learning models, and the accuracy of gradient boosting model (0.708) was significantly higher than logistic regression model (0.542). Our data demonstrate that the data mining-driven prediction such as gradient boosting exhibited higher accuracy for prediction of surgical outcome and we can provide accurate information on surgical outcomes before surgery to OSA subjects using machine learning models.

Tonsillectomy Outcomes for Children With Severe Obesity

OBJECTIVES/HYPOTHESIS

To determine the success of an adenotonsillectomy (T&A) in treating children with severe obesity utilizing a more accurate obesity scale.

STUDY DESIGN

Retrospective cohort.

METHODS

A retrospective cohort of children with obesity between 5 and 10 years of age who underwent a T&A at Children's Hospital of Colorado (CHCO) was used. This study also utilized publicly available data from the Childhood Adenotonsillectomy Trial (CHAT) study. The cohort was divided into three obesity classes using age- and sex-specific body mass index (BMI) expressed as a percentage of the 95th percentile (%BMIp95) and compared for operative success differences.

RESULTS

There were 132 patients included in our primary analysis, with obesity distribution as follows: Class 1 to 53 patients (40%), Class 2 to 45 patients (34%), and Class 3 to 34 patients (26%). Overall, 52 patients (35.9%) experienced a cure (obstructive apnea/hypopnea index [OAHI] <1), with 27 (52%) patients in Class 1 obesity, 18 (35%) in Class 2, and 7 (13%) in Class 3. Class 3 had a significantly lower obstructive sleep apnea cure rate compared with Class 1 patients (P = .013), but after adjusting for covariates, this difference was no longer present (P > .05). There was no significant difference in the preoperative to postoperative percent change in mean oxygen saturation (P = .82 CHCO, P = .43 CHAT), oxygen nadir (P = .20 CHCO, P = .49 CHAT), or OAHI (P = .12 CHCO, P = .26 CHAT) between the obesity classes.

CONCLUSION

After adjusting for covariates, children with Class 3 obesity are as likely to be cured with a T&A as those with Class 1 obesity. A T&A should be considered a first line treatment for all children with obesity.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Cardiovascular changes in children with obstructive sleep apnea and obesity after treatment with noninvasive ventilation

STUDY OBJECTIVES

Adults with obesity and obstructive sleep apnea (OSA) are at risk for cardiometabolic disease, and this risk likely extends to children with both conditions. Noninvasive ventilation (NIV; including continuous and bilevel positive airway pressure) is often used to treat OSA in children with obesity. The aim of this study was to examine the impact of NIV treatment on heart rate variability (HRV), as a marker of cardiovascular risk, in children with obesity and newly diagnosed OSA.

METHODS

A prospective multicenter cohort study was conducted in children with obesity prescribed NIV therapy for newly diagnosed moderate-severe OSA. Measurements of HRV were derived from polysomnography recordings at baseline and after 12 months of treatment. HRV parameters were examined by sleep stage, before and after arousal and oxygen desaturation events. HRV parameters were compared between time points using pair t tests as well as mixed model analysis.

RESULTS

Twelve children had appropriate data for analysis at baseline and 12 months. Heart rate decreased by 4.5 beats/min after NIV treatment, with no change in HRV parameters. HRV parameters differed by sleep stage and showed an increase in arousal-related sympathetic-parasympathetic balance after 12 months of NIV treatment. HRV parameters did not differ before and after oxygen desaturation events.

CONCLUSIONS

NIV for the treatment in children with obesity and OSA resulted in a small decrease in heart rate and an increase in arousal-related sympathetic-parasympathetic balance. These findings suggest small, potentially positive impacts of NIV on cardiovascular risk in children with concurrent obesity and OSA.

Improvement in BMI z-score following adenotonsillectomy in adolescents aged 12-18 years: a retrospective cohort study

BACKGROUND

Characteristics of obstructive sleep apnea (OSA) changes with age. Infants, toddlers and prepubertal children with OSA are usually underweight and may suffer from failure to thrive (FTT). Adenotonsillectomy (T&A) is the first line of treatment for OSA in childhood. In adults OSA is commonly associated with obesity and the metabolic syndrome. The change in body mass index (BMI) in adolescents with OSA following T&A was only sporadically studied. Thus, we peruse to examine the BMI z-score change following T&A in adolescents.

METHODS

Clalit Health Services is the largest health care organization in Israel with the largest patient registry (more than 50% of the population). Two hundred and forty two adolescents aged 12-18 who underwent T&A between 2006 and 2015 were identified in the Clalit registry and their characteristics including height and weight were retrieved. The BMI z-score of these adolescents at baseline (up to 3 months prior to T&A) and during the consecutive 3 years after T&A were analyzed and compared.

RESULTS

Changes in BMI Z-score were observed to all directions following T&A with overall small increase, not statistically significant (P = 0.26) from a median of 0.79 prior to T&A to a median of 0.835 after it. There was a minimal trend toward BMI z-score reduction in overweight children (n = 74) from 1.508 to 1.48 following T&A (p = NS), and in obese children (n = 33) from 2.288 to 2.000 (P = 0.06, 2 tailed). Interestingly thin individuals (n = 6) increased their BMI z-score following T&A from - 2.4 to - 0.59 (p = 0.046).

CONCLUSIONS

Adolescents show variable changes in their BMI z-score following T&A. In this aspect their BMI z-score change is closer to the change seen in adults treated for OSA and not that of young children. The changes observed show a trend toward normalization of the BMI z-score such that overweight children tend to decrease their BMI z-score while thin individuals tend to increase it.

Parental Perception of Weight Status for Adenotonsillectomy Patients

OBJECTIVE

Weight status can affect outcomes in pediatric adenotonsillectomy performed for obstructive sleep disordered breathing. Parents frequently underestimate their child's weight and are unaware weight status may affect adenotonsillectomy success. Accurate understanding of a child's weight status is important for shared decision making with the family and perioperative care. The purpose of this study is to analyze the accuracy of the parent's perception of their child's weight status.

METHODS

A retrospective analysis was performed of prospective data collected from families of children undergoing adenotonsillectomy from June 2018 through June 2019.

RESULTS

A total of 522 children met the inclusion criteria. Two hundred and thirty-two children were either overweight (n = 46, 9%) or obese (n = 186, 36%). Among parents of this cohort whose children were overweight or obese, 74 (32%) erroneously reported that their child was normal weight. For the 290 nonoverweight children, 99% of parents accurately reported weight status. After adjusting for ethnicity, race, BMI%, and sex, for every 1-year increase in age of the child, the odds of the parent correctly identifying their child as overweight increased by a factor of 1.18 (95% CI: 1.09, 1.27).

CONCLUSION

One-third of families with children who were overweight or obese undergoing adenotonsillectomy for obstructive sleep disordered breathing underestimated their child's weight. This study highlights the need to facilitate family understanding of weight status' potential impact on both obstructive sleep disordered breathing severity and adenotonsillectomy success, especially for younger children.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:2121-2125, 2021.

Pediatric Obstructive Sleep Apnea and Neurocognition

Pediatric obstructive sleep apnea affects a large number of children and has multiple end-organ sequelae. Although many of these have been demonstrated to be reversible, the effects on some of the organ systems, including the brain, have not shown easy reversibility. Progress in this area has been hampered by lack of a preclinical model to study the disease. Therefore, perioperative and sleep physicians are tasked with making a number of difficult decisions, including optimal surgical timing to prevent disease evolution, but also to keep the perioperative morbidity in a safe range for these patients.

Factors related to positive airway pressure therapy adherence in children with obesity and sleep-disordered breathing

STUDY OBJECTIVES

Positive airway pressure (PAP) is used to treat children with concurrent obesity and sleep-disordered breathing (SDB), but achieving adherence remains challenging. We aimed to identify factors associated with PAP adherence in a prospective cohort of children with obesity prescribed PAP for newly diagnosed SDB.

METHODS

A questionnaire to assess factors related to PAP adherence was administered to participants and their parent ≥12 months after enrollment. Adherence (PAP use ≥4 hours/night on >50% of nights) was measured with PAP machine downloads, diaries, and physician assessments. Questionnaire responses were compared between adherent/nonadherent participants and between children/parents. Age, total and obstructive apnea-hypopnea index (OAHI), lowest oxygen saturation, and highest carbon dioxide were compared between adherent/nonadherent children with univariate differences of medians, with 95% confidence intervals.

RESULTS

Fourteen children (median age: 14.3 years; 93% male; all with obstructive sleep apnea) were included. Eleven (79%) were adherent to PAP. SDB symptom improvement was reported in 9 of 14 children (64%); 8 of 14 children (57%) had positive experiences with PAP. Most children assumed an active role in PAP initiation and felt supported by the clinical team. Responses between adherent/nonadherent groups and between children/parents were similar. Oxygen saturation nadir (median difference between nonadherent and adherent groups: 8.9%; 95% confidence interval: 1.7, 16.1), but not age, apnea-hypopnea index, OAHI, or maximum carbon dioxide, was associated with PAP adherence.

CONCLUSIONS

Children with obesity-related SDB with lower nocturnal oxygen saturation nadir were more likely to adhere to PAP therapy. Ensuring adequate understanding of PAP therapy and medical team support are key factors in PAP success.

Evaluation and Management of Children with Obstructive Sleep Apnea Syndrome

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

Predictors of adherence to positive airway pressure therapy in children: a systematic review and meta-analysis

BACKGROUND

While positive airway pressure (PAP) is effective for treating sleep-disordered breathing (SDB) in children, adherence is poor. Studies evaluating predictors of PAP adherence have inconsistent findings, and no rigorous reviews have been conducted. This systematic review aims to summarize the literature on predictors of PAP therapy adherence in children.

METHODS

Studies evaluating baseline predictors of PAP therapy adherence in children (≤20 years) with SDB were included. We searched MEDLINE, Embase, CENTRAL, CINAHL, Clinicaltrials.gov, and the last four years of conference abstracts. Results were described narratively, with random-effects meta-analyses performed where feasible. Risk of bias and confidence in the evidence were assessed.

RESULTS

We identified 50 factors evaluated across 28 studies (21 full text articles, seven abstracts). The highest rates of PAP therapy adherence were most consistently found with female sex, younger age, Caucasian race, higher maternal education, greater baseline apnea-hypopnea index (AHI), and presence of developmental delay. Pooled estimates included odds ratios of 1.48 (95%CI: 0.75-2.93) favoring female sex, 1.26 (95%CI: 0.68-2.36) favoring Caucasian race, and a mean difference in AHI of 4.32 (95%CI: -0.61-9.26) events/hour between adherent and non-adherent groups. There was low quality evidence to suggest that psychosocial factors like health cognitions and family environment may predict adherence.

CONCLUSION

In this novel systematic review, we identified several factors associated with increased odds of PAP therapy adherence in children. These findings may help guide clinicians to identify and support children less likely to adhere to PAP therapy and should be considered when developing interventions to improve adherence.

Managing the Child with Persistent Sleep Apnea

Pediatric obstructive sleep apnea (OSA) affects 2% to 4% of American children, and is associated with metabolic, cardiovascular, and neurocognitive sequelae. The primary treatment for pediatric OSA is adenotonsillectomy. Children with obesity, craniofacial syndromes, and severe baseline OSA are at risk for persistent disease. Evaluation of persistent OSA should focus on identifying the causes of upper airway obstruction. Interventions should be tailored to address the patient's symptomatology, sites of obstruction, and preference for surgical versus medical management. Further research is needed to identify management protocols that result in improved outcomes for children with persistent OSA.

[Adolescent obstructive sleep apnoea syndrome: Characteristics and treatment]

Although the prevalence of the obstructive sleep apnoea syndrome (OSAS) is high in adolescents, studies pertaining to adolescent OSAS are less numerous than childhood studies. Cases of adolescent OSAS may consist of residual OSAS after adenotonsillectomy, but most often are de novo cases. Major pathophysiological factors are weight excess or even high-grade obesity, and the association of upper airway narrowing and tonsillar hypertrophy (pharyngeal, palatal or even lingual). ENT and systematic orthodontic assessments are the main points. In case of predisposing factors such as dental, occlusal or dento-facial abnormalities, a specific orthodontic treatment can be discussed. First line treatment is surgical adenotonsillectomy; surgical reduction of the lingual tonsils is seldom required. CPAP treatment may be indicated in the case of severe comorbidities (craniofacial malformations, neuromuscular diseases…) or in obese adolescents with severe residual OSAS. Treatment of adolescent OSAS has to be comprehensive and multidisciplinary, taking into account the specific treatments of obesity and abnormal sleep/wake rhythms.

Guidelines of the French Society of Otorhinolaryngology. Role of the ENT specialist in the diagnosis of childhood obstructive sleep apnea-hypopnea syndrome (OSAHS). Part 1: Interview and physical examination

OBJECTIVES

To present the 2017 Clinical Practice Guidelines of the French Society of Otorhinolaryngology concerning the role of the ENT specialist in the diagnosis of pediatric obstructive sleep apnea-hypopnea syndrome. This article focuses specifically on medical history and physical examination.

METHODS

A multidisciplinary work-group drew up a first version of the guidelines, graded according to level of evidence following the GRADE grading system. The final version was obtained by including the suggestions and comments from the editorial group.

RESULTS

At the end of the process, guidelines were established and graded regarding the following points: interview and analysis of the various interview scores recommended in the literature; clinical examination with awake upper-airway endoscopy; and indications for referral to non-ENT specialists.

Crowdsourcing the Citation Screening Process for Systematic Reviews: Validation Study

BACKGROUND

Systematic reviews (SRs) are often cited as the highest level of evidence available as they involve the identification and synthesis of published studies on a topic. Unfortunately, it is increasingly challenging for small teams to complete SR procedures in a reasonable time period, given the exponential rise in the volume of primary literature. Crowdsourcing has been postulated as a potential solution.

OBJECTIVE

The feasibility objective of this study was to determine whether a crowd would be willing to perform and complete abstract and full text screening. The validation objective was to assess the quality of the crowd's work, including retention of eligible citations (sensitivity) and work performed for the investigative team, defined as the percentage of citations excluded by the crowd.

METHODS

We performed a prospective study evaluating crowdsourcing essential components of an SR, including abstract screening, document retrieval, and full text assessment. Using CrowdScreenSR citation screening software, 2323 articles from 6 SRs were available to an online crowd. Citations excluded by less than or equal to 75% of the crowd were moved forward for full text assessment. For the validation component, performance of the crowd was compared with citation review through the accepted, gold standard, trained expert approach.

RESULTS

Of 312 potential crowd members, 117 (37.5%) commenced abstract screening and 71 (22.8%) completed the minimum requirement of 50 citation assessments. The majority of participants were undergraduate or medical students (192/312, 61.5%). The crowd screened 16,988 abstracts (median: 8 per citation; interquartile range [IQR] 7-8), and all citations achieved the minimum of 4 assessments after a median of 42 days (IQR 26-67). Crowd members retrieved 83.5% (774/927) of the articles that progressed to the full text phase. A total of 7604 full text assessments were completed (median: 7 per citation; IQR 3-11). Citations from all but 1 review achieved the minimum of 4 assessments after a median of 36 days (IQR 24-70), with 1 review remaining incomplete after 3 months. When complete crowd member agreement at both levels was required for exclusion, sensitivity was 100% (95% CI 97.9-100) and work performed was calculated at 68.3% (95% CI 66.4-70.1). Using the predefined alternative 75% exclusion threshold, sensitivity remained 100% and work performed increased to 72.9% (95% CI 71.0-74.6; P<.001). Finally, when a simple majority threshold was considered, sensitivity decreased marginally to 98.9% (95% CI 96.0-99.7; P=.25) and work performed increased substantially to 80.4% (95% CI 78.7-82.0; P<.001).

CONCLUSIONS

Crowdsourcing of citation screening for SRs is feasible and has reasonable sensitivity and specificity. By expediting the screening process, crowdsourcing could permit the investigative team to focus on more complex SR tasks. Future directions should focus on developing a user-friendly online platform that allows research teams to crowdsource their reviews.

Surgery for Obstructive Sleep Apnea in Obese Children: Literature Review and Meta-analysis

OBJECTIVES

Surgical intervention for obstructive sleep apnea (OSA) in overweight and obese children may not be as effective as it is in normal-weight children. The purpose of this study was to systematically review the effects of various surgical interventions for OSA in obese children and to meta-analyze the current data.

DATA SOURCES

PubMed, OVID, and Cochrane databases.

REVIEW METHODS

Databases were searched for studies examining adenotonsillectomy, uvulopalatopharyngoplasty, supraglottoplasty, or tongue base surgeries and combinations in obese children with OSA. Adenotonsillectomy was the only procedure with enough data for meta-analysis; polysomnographic data were extracted and analyzed using a random-effects model.

RESULTS

For adenotonsillectomy, 11 studies were included in the meta-analysis. Despite significant improvement in the apnea-hypopnea index (22.9 to 8.1 events/h, P < .001), respiratory disturbance index (24.8 to 10.4 events/h, P < .001), and oxygen saturation nadir (78.4% to 87.0%, P < .001), rates of persistent OSA ranged from 51% to 66%, depending on the outcome criterion used. There was evidence of limited effectiveness for surgical interventions to treat OSA in obese children using uvulopalatoplasty (12.5%) and tongue base surgery (74%-88%).

CONCLUSIONS

Surgical interventions for OSA in overweight and obese children are effective at reducing OSA but with higher rates of persistent OSA than reported for normal-weight children. However, the amount of reduction appears to vary by surgical procedure. More attention should be paid toward preoperative weight loss and patient selection, and parents should be provided with realistic postoperative expectations in this difficult-to-treat population.

The shifting relationship between weight and pediatric obstructive sleep apnea: A historical review

OBJECTIVES

For more than a century, pediatric obstructive sleep apnea (OSA) was associated with failure to thrive. However, that association has faded over the last few decades. A 21st century child with OSA is much more likely to be overweight than underweight. This raises the question: Has pediatric OSA changed over time, or has the rise of childhood obesity in the United States created a new, separate disease? This literature review explores the historical shift in the relationship between weight and OSA, and the associated changes in treatment.

RESULTS

We demonstrate a clear transition in the prevalence of failure to thrive and obesity in the OSA literature in the mid-2000s. What is less clear is whether these two clinical phenotypes should be considered two distinct diseases, or whether subtle differences in one set of pathophysiologic pathways-adenotonsillar hypertrophy, altered inflammation, and increased energy expenditure-can lead to divergent metabolic outcomes. More research is needed to fully elucidate the pathophysiology of OSA in children with obesity.

CONCLUSIONS

We may need new and different treatments for obesity-associated OSA as adenotonsillectomy-which is effective at reversing failure to thrive in OSA-is not as effective at treating OSA in children with obesity. One option is drug-induced sleep endoscopy, which could personalize and improve surgical treatment of OSA. There is some evidence that therapies used for OSA in adults (e.g., weight loss and positive airway pressure) are also helpful for overweight/obese children with OSA. Laryngoscope, 129:2414-2419, 2019.

Pediatric Pulmonology year in review 2015: Part 2

Pediatric Pulmonology covers a broad range of research and scholarly topics related to children's respiratory disorders. For updated perspectives on the rapidly expanding knowledge in our field, we will summarize the past year's publications in our major topic areas, as well as selected publications in these areas from the core clinical journal literature outside our own pages. The current review (Part 2) covers articles on sleep-disordered breathing. Pediatr Pulmonol. 2016;51:740-746. © 2016 Wiley Periodicals, Inc.