Abstract
Continuous positive airway pressure (CPAP) is considered first-line treatment in the management of pediatric patients without a surgically correctible cause of obstruction who have confirmed moderate-to-severe obstructive sleep apnea (OSA). The evidence supports its reduction on patient morbidity and positive influence on neurobehavioral outcome. Unfortunately, in clinical practice, many patients either refuse CPAP or cannot tolerate it. An update on alternative approaches to CPAP for the management of OSA is discussed in this review, supported by the findings of systematic reviews and recent clinical studies. Alternative approaches to CPAP and adenotonsillectomy for the management of OSA include weight management, positional therapy, pharmacotherapy, high-flow nasal cannula, and the use of orthodontic procedures, such as rapid maxillary expansion and mandibular advancement devices. Surgical procedures for the management of OSA include tongue-base reduction surgery, uvulopalatopharyngoplasty, lingual tonsillectomy, supraglottoplasty, tracheostomy, and hypoglossal nerve stimulation. It is expected that this review will provide an update on the evidence available regarding alternative treatment approaches to CPAP for clinicians who manage patients with pediatric OSA in daily clinical practice.
Highlights
Obstructive sleep apnea (OSA) is characterized by intermittent partial or complete upper airway closure during sleep, associated with increased respiratory effort, sleep fragmentation, and/or gas exchange abnormalities [1]
Evidence-based guidelines support the use of Continuous positive airway pressure (CPAP) as an effective first-line treatment of OSA in children without adenotonsillar hypertrophy; this is complicated by low tolerance or refusal of treatment
This review illustrates several practical ideas for clinical practice: (1) weight management through exercise and dietary advice for patients who are overweight with OSA can reduce symptoms and morbidity; (2) treatment of underlying metabolic causes of weight gain; (3) surgical treatments if targeted properly, even for patients with severe OSA who are overweight; (4) identifying level of obstruction through the use of drug-induced sleep endoscopy (DISE) and choosing appropriate adjuvant surgery or orthodontic procedures for longlasting treatment effect; and (5) emerging treatments such as oxygen therapy through high-flow nasal cannula (HFNC) and pharmacotherapy which are still awaiting further support through clinical trials and long-term follow-up studies of adverse effects
Summary
Obstructive sleep apnea (OSA) is characterized by intermittent partial or complete upper airway closure during sleep, associated with increased respiratory effort, sleep fragmentation, and/or gas exchange abnormalities [1]. The aim of this review is to examine non-CPAP options for the management of OSA These include weight loss, positional therapy, pharmacotherapy, and the use of orthodontic procedures, including rapid maxillary expansion (RME) and mandibular advancement devices (MADs). Interventions for children with OSA are determined by a variety of parameters on a caseby-case basis, including age, severity of symptoms, presence of complex abnormalities or conditions (such as obesity, craniofacial deformities, malocclusion, neuromuscular disorders, Down’s syndrome, and Prader-Willi syndrome) and treatment thereof, degree of residual disease following treatment, and accepted practices in patients’ respective countries [12, 13]. This review is not intended to provide recommendations for clinical practice but to examine the evidence for possible treatments in the pediatric patient population, and in particular, to provide an update on the evidence to support alternative treatment approaches to adenotonsillectomy and CPAP for clinicians who manage patients with OSA
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