Residual Obstructive Sleep Apnea Syndrome Research Articles

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.

Adenotonsillectomy: the good, the bad and the unknown.

Adenotonsillar hypertrophy is the most common pathogenetic contributor to obstructive sleep apnea syndrome (OSAS) in childhood, and adenotonsillectomy is the standard initial treatment. Here, we summarize the most recent evidence on the efficacy and complications of adenotonsillectomy and explore knowledge gaps in clinical management. Favorable adenotonsillectomy effects have been reported in children with very severe OSAS [apnea-hypopnea index (AHI) &gt;20 episodes/h] and extremely severe OSAS (AHI &gt;100 episodes/h), without postoperative mortality, need for endotracheal intubation, prolonged hospital stay or re-admission after hospital discharge. However, the risk of residual OSAS after adenotonsillectomy, which may reach 30-60%, has not been thoroughly established. Behavior, OSAS-related symptoms and quality of life improve postoperatively even in children with AHI 1-5 episodes/h. Natural history of enuresis resolution is accelerated postadenotonsillectomy and office-based systemic blood pressure is decreased in OSAS and hypertension. However, which children younger than 2 years should undergo adenotonsillectomy instead of adenoidectomy only to prevent recurrence of OSAS symptoms and revision surgery remains unclear. Adenotonsillectomy in children with Prader-Willi syndrome is frequently accompanied by postoperative residual OSAS while complications are not uncommon. In the last 2 years, several studies have provided evidence supporting the efficacy and safety of adenotonsillectomy as treatment intervention for otherwise healthy children with OSAS.

Positive Airway Pressure Therapy for Pediatric Obstructive Sleep Apnea.

Pediatric obstructive sleep apnea syndrome (OSAS) is a disorder of breathing during sleep, characterized by intermittent or prolonged upper airway obstruction that can disrupt normal ventilation and/or sleep patterns. It can affect an estimated 2–4% of children worldwide. Untreated OSAS can have far reaching consequences on a child’s health, including low mood and concentration as well as metabolic derangements and pulmonary vascular disease. Most children are treated with surgical intervention (e.g., first-line therapy, adenotonsillectomy); however, for those for whom surgery is not indicated or desired, or for those with postoperative residual OSAS, positive airway pressure (PAP) therapy is often employed. PAP therapy can be used to relieve upper airway obstruction as well as aid in ventilation. PAP therapy is effective in treatment of OSAS in children and adults, although with pediatric patients, additional considerations and limitations exist. Active management and care for various considerations important to pediatric patients with OSAS can allow PAP to be an effective and safe therapy in this population.

0896 Nutritional Status Improves Following The Implementation Of Positive Airway Pressure For The Treatment Of Obstructive Sleep Apnea In Youth With Down Syndrome

Abstract Introduction In typically developing youth, increases in body mass index (BMI) and rates of obesity accompany treatment of obstructive sleep apnea syndrome (OSAS) with adenotonsillectomy regardless of baseline BMI and OSAS severity. Residual OSAS following adenotonsillectomy and overweight/obesity are common in Down syndrome (DS). We sought to examine the impact of positive airway pressure (PAP) on BMIZ in youth with DS and OSAS. Methods Baseline, 6, and 12 month height/length and weight as well as pre-PAP PSG data were abstracted from the Children’s Hospital of Philadelphia Sleep Center for patients with DS and OSAS initiated on PAP between 01/01/2014-07/11/01/2017 (N=73; Median age=6.6y IQR: 3.6-12.1; 52% White, 29% Black; 42% Male). BMIZ was calculated. Longitudinal mixed effects models adjusted for adherence from 0-6 months, baseline BMIZ, and baseline SpO2 nadir were used to evaluate change in BMIZ at months 6 and 12 and the impact of baseline BMIZ on trajectories. Results OAHI (median; IQR) at initiation was 15.9 (8.1-28.9) events/hour, SpO2 nadir was 83% (77-88), and BMIZ was 1.50 (0.94-2.34). No differences in BMIZ at 6 and 12 months compared to baseline BMIZ were found (p&amp;gt;0.2 for both). Baseline BMIZ was associated with BMIZ at 6- and 12 months (β-coefficient=0.99; p&amp;lt;0.0001); the increase in BMIZ at 12 mo (β-coefficient= 0.49, p=0.001) was offset with decreasing BMIZ (12mo*baseline BMIZ β-coefficient= -0.3; p&amp;lt;0.0001); such that lower BMIZ was associated with increases in BMIZ while higher BMIZ was associated with decreases in BMIZ. Conclusion Initiation of PAP has a beneficial impact on nutritional status in youth with DS and OSAS. In youth who are at the lower end of BMIZ, BMIZ increases to a healthier status following the initiation of PAP, and in youth who are at the higher side of BMIZ, BMIZ decreases to a healthier status. Prospective studies are needed to elaborate on these associations. Support None

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.

Drug-induced sedation endoscopy in children

Few data are available about the pattern of upper airway (UA) obstruction in children <2years with obstructive sleep apnea syndrome (OSAS). Also, the role of adenoidectomy versus adenotonsillectomy (AT) is poorly defined in this age group. We performed drug-induced sedation endoscopy(DISE) in young OSAS children to investigate the pattern of UA obstruction and the value of DISE in therapeutic decision making. Retrospective analysis of ≤2-year-old children undergoing DISE-directed UA surgery. OSAS severity and the treatment outcomes were documented by polysomnography. Data are available for 28 patients, age 1.5years (1.3-1.8), BMI-z score 0.5 (-0.7to1.3) with severe OSAS, obstructive apnea/hypopnea index (oAHI) 13.8/hr (7.5-28.3). All but 3 had (>50%) obstruction at the level of the adenoids, and all but 5 had (>50%) tonsillar obstruction. DISE-directed treatment consisted of adenoidectomy (n = 4), tonsillectomy (n = 1), and AT (n = 23). There was a significant improvement in respiratory parameters. Twenty children (71.4%) had a postoperative oAHI <2/hr. None had palatal or tongue base obstruction. Five children had a circumferential UA narrowing (hypotonia), 2 of them had residual OSAS. DISE showed a collapse of the epiglottis in 6 and late-onset laryngomalacia in 4. These findings did not affect surgical outcome. Adenotonsillar hypertrophy is the major cause of UA obstruction, and DISE-directed UA surgery was curative in 71,4% of children ≤2years. We suggest that DISE may be helpful in surgical decision making. Circumferential UA narrowing may result in less favorable surgical outcomes.

Application of desaturation index in post-surgery follow-up in children with obstructive sleep apnea syndrome.

Adenotonsillectomy is recommended for children who need surgery for obstructive sleep apnea syndrome (OSAS). Overnight, polysomnography (PSG) is suggested for post-surgery follow-up, but this diagnostic technique is time consuming and inconvenient. Desaturation index (DI) has been reported as a good tool for predicting both the presence and severity of OSAS in children. The purpose of this study was to determine the usefulness of the DI for post-surgery follow-up of children with OSAS. This retrospective study enrolled 42 children, aged 3-12years, who were snorers diagnosed with OSAS by overnight PSG and who underwent an adenotonsillectomy. Pre- and postoperative PSG parameters, nocturnal pulse oximetry data, and modified Epworth sleepiness scale scores were assessed. Previously determined cut-off DI values (2.05, 3.50, and 4.15 for mild, moderate, and severe OSAS, respectively) were used to predict residual OSAS. Of the 42 children, obvious improvements were observed in apnea-hypopnea index (AHI, decreased 45.5%), arousal index (decreased 30.5%), DI (decreased 40.4%), and snore index (decreased 100.3%) compared with the preoperative measurements. Among these objective PSG measures, DI had the strongest correlation with AHI both pre- and post-surgeries (r=0.947 and r=0.954, respectively; p all <0.001). The DI change, before and after surgery, also had the strongest positive correlation to the AHI change (r=0.482 and p=0.001). Using the previously determined DI cut-off values to predict postoperative residual OSAS, there was a good positive predictive value (92.6%) for mild residual OSAS and a good negative predictive value for moderate and severe residual OSAS (85.2 and 89.7%, respectively). These findings suggest that DI, as determined using a nocturnal pulse oximeter, may be an alternative tool for postoperative evaluation and follow-up of children with OSAS.

Intracapsular and Extracapsular Tonsillectomy and Adenoidectomy in Pediatric Obstructive Sleep Apnea.

Limited information exists regarding clinical outcomes of children undergoing extracapsular tonsillectomy and adenoidectomy (ETA) or intracapsular tonsillectomy and adenoidectomy (ITA) for treatment of obstructive sleep apnea syndrome (OSAS). To quantify polysomnography (PSG) and clinical outcomes of ETA and ITA in children with OSAS and to assess the contribution of comorbid conditions of asthma and obesity. Retrospective cohort study using medical records at a tertiary pediatrics inner-city hospital. Medical records from 89 children who underwent ETA or ITA between October 1, 2008, and December 31, 2013, were analyzed. The dates of our analysis were January 6, 2014, to April 11, 2014. Inclusion criteria required no evidence of craniofacial or neurological disorders, confirmation of OSAS by PSG within the 2 years before surgery, and a second PSG within the 2 years after surgery. Each child underwent ETA or ITA after being evaluated by a pediatric otolaryngologist and obtaining written parental informed consent. Main primary outcomes were derived from PSG. Secondary outcomes included treatment failure, defined as residual OSAS with an obstructive apnea-hypopnea index of at least 5 events per hour. Comparisons were made between and within groups. Logistic regression was used to identify factors associated with treatment failure. Fifty-two children underwent ETA, and 37 children underwent ITA. Children in the ETA group were older (7.5 vs 5.2 years, P = .001) and more obese (60% [31 of 52] vs 30% [11 of 37], P = .004). However, both groups had similar severity of OSAS, with median preoperative obstructive apnea-hypopnea indexes of 17.0 in the ETA group and 24.1 in the ITA group (P = .21), and similar prevalences of asthma (38% [20 of 52] vs 38% [14 of 37]). After surgery, significant improvement was noted on PSG in both groups, with no differences in any clinical outcomes. There was no association between procedure type, age, or body mass index z score and treatment failure. However, in a subset of patients with asthma and obesity, ITA was associated with residual OSAS (odds ratio, 16.5; 95% CI, 1.1-250.2; P = .04). Both ETA and ITA are effective modalities to treat OSAS, with comparable surgical outcomes on short-term follow-up. However, when comorbid diagnoses of both asthma and obesity exist, OSAS is likely to be refractory to treatment with ITA compared with ETA.

Tonsillectomy – Orthodontics: Which sequences in children?

The most common cause of childhood obstructive sleep apnea syndrome (OSAS) is adenotonsillar hypertrophy. Aside from nocturnal symptoms, children with OSAS may present with lower school performance, behavioral disorder, cardiovascular complications and failure to thrive. First-line treatment is adenotonsillectomy; however, residual OSAS on postoperative polygraphy is reported in 20% to 40% of cases. In well-selected cases, orthodontic treatment can play an important role in the management of light to moderate childhood OSAS or residual OSAS after surgery, using growth activators or oral mandibular advancement appliances, rapid maxillary expansion and orofacial rehabilitation. Nevertheless, clinical studies with a high level of evidence of efficacy are lacking. To illustrate therapeutic sequences that may include an orthodontic phase, we present clinical cases encountered in our multidisciplinary outpatients clinic.

Drug-induced sedation endoscopy in pediatric obstructive sleep apnea syndrome

AimTo describe the pattern of upper airway (UA) obstruction during drug-induced sedation endoscopy (DISE) and to evaluate the outcome of DISE-directed treatment. MethodsProspective study of DISE in surgically naive obstructive sleep apnea syndrome (OSAS) children without syndromic comorbidity or craniofacial abnormalities. Treatment was individually tailored according to UA findings during DISE and polysomnographic data. Reported values are median (lower–upper quartile). ResultsThirty-seven children aged 4.1 years (2.1–6.0), with body mass index z-score 0.3 (−0.9 to 0.9), and obstructive apnea–hypopnea index (oAHI) 9.0/h (6.1–19.3) were included. Adenotonsillar obstruction was found in 33 cases (89%) as an isolated entity or as part of a multi-level obstruction. These children were treated with adenotonsillectomy (n = 28), adenoidectomy (n = 3), or tonsillectomy (n = 2). The remaining four patients received non-surgical treatment. Pre-postoperative polysomnographic data in 22 patients showed a significant improvement in oAHI from 8.6/h (6.7–20.7) to 1.0/h (0.6–2.0) (P = 0.001). Only two of these 22 children had residual OSAS (oAHI ≥ 5/h), indicating a success rate of 91%. ConclusionsBased on UA findings during DISE, a non-surgical treatment was proposed for 11% of children. A 91% success rate was obtained in those treated with (adeno)tonsillectomy. These data suggest that DISE may be helpful to identify patients most likely to benefit from UA surgery.

Effect of Obesity and Medical Comorbidities on Outcomes After Adjunct Surgery for Obstructive Sleep Apnea in Cases of Adenotonsillectomy Failure

To evaluate the effect of body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) and medical comorbidities on outcomes after lingual tonsillectomy and supraglottoplasty performed for obstructive sleep apnea syndrome (OSAS) caused by lingual tonsillar hypertrophy and occult laryngomalacia. Retrospective case review series Academic tertiary referral center Children with persistent OSAS after adenotonsillectomy who underwent surgery to correct obstruction at the level of the lingual tonsils and/or supraglottis identified on sleep endoscopy. All children underwent lingual tonsillectomy, supraglottoplasty, or both. Change in polysomnographic parameters, including apnea-hypopnea index (AHI), number of nighttime apneas, and lowest oxygen saturation level. We analyzed the medical records of 84 children with persistent OSAS after adenotonsillectomy who underwent either lingual tonsillectomy (n = 68), supraglottoplasty (n = 24) or both (n = 8). Compared with children with lingual tonsillar hypertrophy, children with occult laryngomalacia were younger, had lower BMI, and were more likely to have a medical comorbidity. Overall, both operations significantly improved the AHI; however, children with comorbidities had significantly higher postoperative AHIs after supraglottoplasty than those without, and overweight children had significantly higher postoperative AHIs after lingual tonsillectomy than those of normal weight. The BMI z-score and age had direct, though weak, correlations with postoperative AHI among all children undergoing either technique of adjunct airway surgery. Lingual tonsillar hypertrophy and occult laryngomalacia are 2 important causes of residual OSAS after adenotonsillectomy. However, they tend to affect distinct populations of children, and though appropriate surgical correction can improve AHI, cure rates are significantly worse for overweight children undergoing lingual tonsillectomy and for children with medical comorbidities undergoing supraglottoplasty.

Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome

This technical report describes the procedures involved in developing recommendations on the management of childhood obstructive sleep apnea syndrome (OSAS). The literature from 1999 through 2011 was evaluated. A total of 3166 titles were reviewed, of which 350 provided relevant data. Most articles were level II through IV. The prevalence of OSAS ranged from 0% to 5.7%, with obesity being an independent risk factor. OSAS was associated with cardiovascular, growth, and neurobehavioral abnormalities and possibly inflammation. Most diagnostic screening tests had low sensitivity and specificity. Treatment of OSAS resulted in improvements in behavior and attention and likely improvement in cognitive abilities. Primary treatment is adenotonsillectomy (AT). Data were insufficient to recommend specific surgical techniques; however, children undergoing partial tonsillectomy should be monitored for possible recurrence of OSAS. Although OSAS improved postoperatively, the proportion of patients who had residual OSAS ranged from 13% to 29% in low-risk populations to 73% when obese children were included and stricter polysomnographic criteria were used. Nevertheless, OSAS may improve after AT even in obese children, thus supporting surgery as a reasonable initial treatment. A significant number of obese patients required intubation or continuous positive airway pressure (CPAP) postoperatively, which reinforces the need for inpatient observation. CPAP was effective in the treatment of OSAS, but adherence is a major barrier. For this reason, CPAP is not recommended as first-line therapy for OSAS when AT is an option. Intranasal steroids may ameliorate mild OSAS, but follow-up is needed. Data were insufficient to recommend rapid maxillary expansion.

Supraglottoplasty for Occult Laryngomalacia to Improve Obstructive Sleep Apnea Syndrome

To evaluate the polysomnographic outcomes after supraglottoplasty (SGP) performed for obstructive sleep apnea syndrome (OSAS) associated with occult laryngomalacia. Retrospective case series with medical chart review. Tertiary pediatric medical center. Twenty-two patients aged 2 to 17 years met the inclusion criteria of polysomnography-proven OSAS and occult laryngomalacia seen on flexible fiber-optic sleep endoscopy. Infants with congenital laryngomalacia were excluded. Carbon dioxide laser SGP was performed either alone or in conjunction with other operations for OSAS. Preoperative and postoperative nocturnal polysomnographic data were paired and analyzed statistically. Supraglottoplasty for occult laryngomalacia resulted in statistically significant reduction in the apnea-hypopnea index (AHI) (from 15.4 to 5.4) (P <.001). Subgroup analysis of children who underwent either SGP alone or in combination with other interventions showed comparable reductions in AHI. Medical comorbidities were associated with worsened postoperative outcomes, although still significantly improved compared with baseline. Overall, 91% of children had an improvement in AHI, and 64% had only mild or no residual OSAS after SGP. Supraglottoplasty is an effective technique for the treatment of OSAS associated with occult laryngomalacia.

Witnessed apnoeas in a 6-yr-old boy: a brain teaser

A 6-yr-old boy was admitted to our paediatric sleep lab because of witnessed apnoeas by his parents. There were no difficulties falling asleep, nocturnal awakenings nor excessive daytime sleepiness or tiredness. He was a boy of nonconsanguine parents with normal developmental milestones. His past medical history included snoring which disappeared after adenotonsillectomy at the age of 4 yrs, asthma and allergic rhinitis for which he was on salmeterol and fluticason, cetirizine and mometason. He was also seen 6 months prior to admission because of headache after physical effort without vomiting. Blood pressure, EEG, dilated fundus examination and renal workup were all normal. A brain MRI was also performed in another hospital of which we had a written report stating that it was normal. The complaints of headache spontaneously resolved over the next months. Familial history was negative for sleep, respiratory, neurological and other relevant medical disorders. Clinical and neurological examination was normal. Length was on the 25th percentile and weight on the 50th percentile. His body mass index was 16.5 kg·m−2. A single-night, full polysomnography was performed to rule out residual obstructive sleep apnea syndrome after adenotonsillectomy (fig. 1). Figure 1 Polysomnography results. ### Question 1: Which respiratory abnormality does figure 1 show? ### Answer 1: The tracing shows the presence …

Obstructive hypopnea and gastroesophageal reflux as factors associated with residual obstructive sleep apnea syndrome

Objective The mechanism of persisting obstructive sleep apnea (OSA) after adenotonsillectomy is not fully explained. The purpose of this study was to evaluate factors associated with residual OSA. The primary outcome measures were metabolic tests and polysomnographic respiratory indices in children with residual disease compared with children who were diagnosed with OSA but were untreated. Secondary outcome measures were acid gastroesophageal reflux indices recorded parallel to the sleep study. Methods In the one-year study consecutive series of patients with sleep disordered breathing hospitalized in a tertiary pediatric center were evaluated. Following the study protocol a sleep interview, physical examination, metabolic blood tests (serum leptin and the homeostasis model assessment index for insulin resistance, HOMA-IR) and an overnight polysomnography with pH-metry recording were performed. Children diagnosed with OSA were analyzed in two groups: I – residual OSA (after surgery), II – non-residual OSA (newly diagnosed). Logistic regression analysis was applied to obtain significant risk factors for prediction of OSA. Results Fifty-seven children (mean age ± SE, 6.9 ± 0.5 years; 66.7% boys) met the inclusion criteria and were enrolled in the study as residual ( n = 19) or non-residual OSA ( n = 38). The groups differed significantly in mean oxygen saturation, SpO 2 (94.3% vs. 96.2%; p = 0.018 respectively), in the Apnea Hypopnea Index, (20.6/h vs. 9.1/h; p < 0.03), the number of respiratory arousals with desaturation (2.2/h vs. 0.8/h; p < 0.03); mean intraluminal esophageal pH (5.36 vs. 5.86; p = 0.007) and the Reflux Index (9.61% vs. 4.35%; p = 0.003). The groups did not differ in total sleep time, tonsil size, BMI z-score and blood metabolic indices. Logistic regression analysis showed that residual OSA was significantly predicted by two polygraphic findings: the obstructive hypopnea index (OR 1.15; 95% CI 1.02–1.28; p = 0.014) and by the Reflux Index (OR 1.01; 95% CI 1.00–1.34; p = 0.042). Conclusions 1. Obstructive hypopneas, rather than obstructive apneas, persist after adenotonsillar surgery resulting in residual OSA. 2. Children with residual OSA are at higher risk of acid gastroesophageal reflux and should be evaluated for gastroesophageal reflux disease.

Practice parameters for the respiratory indications for polysomnography in children.

There has been marked expansion in the literature and practice of pediatric sleep medicine; however, no recent evidence-based practice parameters have been reported. These practice parameters are the first of 2 papers that assess indications for polysomnography in children. This paper addresses indications for polysomnography in children with suspected sleep related breathing disorders. These recommendations were reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine. A systematic review of the literature was performed, and the American Academy of Neurology grading system was used to assess the quality of evidence. RECOMMENDATIONS FOR PSG USE: 1. Polysomnography in children should be performed and interpreted in accordance with the recommendations of the AASM Manual for the Scoring of Sleep and Associated Events. (Standard) 2. Polysomnography is indicated when the clinical assessment suggests the diagnosis of obstructive sleep apnea syndrome (OSAS) in children. (Standard) 3. Children with mild OSAS preoperatively should have clinical evaluation following adenotonsillectomy to assess for residual symptoms. If there are residual symptoms of OSAS, polysomnography should be performed. (Standard) 4. Polysomnography is indicated following adenotonsillectomy to assess for residual OSAS in children with preoperative evidence for moderate to severe OSAS, obesity, craniofacial anomalies that obstruct the upper airway, and neurologic disorders (e.g., Down syndrome, Prader-Willi syndrome, and myelomeningocele). (Standard) 5. Polysomnography is indicated for positive airway pressure (PAP) titration in children with obstructive sleep apnea syndrome. (Standard) 6. Polysomnography is indicated when the clinical assessment suggests the diagnosis of congenital central alveolar hypoventilation syndrome or sleep related hypoventilation due to neuromuscular disorders or chest wall deformities. It is indicated in selected cases of primary sleep apnea of infancy. (Guideline) 7. Polysomnography is indicated when there is clinical evidence of a sleep related breathing disorder in infants who have experienced an apparent life-threatening event (ALTE). (Guideline) 8. Polysomnography is indicated in children being considered for adenotonsillectomy to treat obstructive sleep apnea syndrome. (Guideline) 9. Follow-up PSG in children on chronic PAP support is indicated to determine whether pressure requirements have changed as a result of the child's growth and development, if symptoms recur while on PAP, or if additional or alternate treatment is instituted. (Guideline) 10. Polysomnography is indicated after treatment of children for OSAS with rapid maxillary expansion to assess for the level of residual disease and to determine whether additional treatment is necessary. (Option) 11. Children with OSAS treated with an oral appliance should have clinical follow-up and polysomnography to assess response to treatment. (Option) 12. Polysomnography is indicated for noninvasive positive pressure ventilation (NIPPV) titration in children with other sleep related breathing disorders. (Option) 13. Children treated with mechanical ventilation may benefit from periodic evaluation with polysomnography to adjust ventilator settings. (Option) 14. Children treated with tracheostomy for sleep related breathing disorders benefit from polysomnography as part of the evaluation prior to decannulation. These children should be followed clinically after decannulation to assess for recurrence of symptoms of sleep related breathing disorders. (Option) 15. Polysomnography is indicated in the following respiratory disorders only if there is a clinical suspicion for an accompanying sleep related breathing disorder: chronic asthma, cystic fibrosis, pulmonary hypertension, bronchopulmonary dysplasia, or chest wall abnormality such as kyphoscoliosis. (Option) RECOMMENDATIONS AGAINST PSG USE: 16. Nap (abbreviated) polysomnography is not recommended for the evaluation of obstructive sleep apnea syndrome in children. (Option) 17. Children considered for treatment with supplemental oxygen do not routinely require polysomnography for management of oxygen therapy. (Option) Current evidence in the field of pediatric sleep medicine indicates that PSG has clinical utility in the diagnosis and management of sleep related breathing disorders. The accurate diagnosis of SRBD in the pediatric population is best accomplished by integration of polysomnographic findings with clinical evaluation.

Adenotonsillectomy Outcomes in Treatment of Obstructive Sleep Apnea in Children

The overall efficacy of adenotonsillectomy (AT) in treatment of obstructive sleep apnea syndrome (OSAS) in children is unknown. Although success rates are likely lower than previously estimated, factors that promote incomplete resolution of OSAS after AT remain undefined. To quantify the effect of demographic and clinical confounders known to impact the success of AT in treating OSAS. A multicenter collaborative retrospective review of all nocturnal polysomnograms performed both preoperatively and postoperatively on otherwise healthy children undergoing AT for the diagnosis of OSAS was conducted at six pediatric sleep centers in the United States and two in Europe. Multivariate generalized linear modeling was used to assess contributions of specific demographic factors on the post-AT obstructive apnea-hypopnea index (AHI). Data from 578 children (mean age, 6.9 +/- 3.8 yr) were analyzed, of which approximately 50% of included children were obese. AT resulted in a significant AHI reduction from 18.2 +/- 21.4 to 4.1 +/- 6.4/hour total sleep time (P < 0.001). Of the 578 children, only 157 (27.2%) had complete resolution of OSAS (i.e., post-AT AHI <1/h total sleep time). Age and body mass index z-score emerged as the two principal factors contributing to post-AT AHI (P < 0.001), with modest contributions by the presence of asthma and magnitude of pre-AT AHI (P < 0.05) among nonobese children. AT leads to significant improvements in indices of sleep-disordered breathing in children. However, residual disease is present in a large proportion of children after AT, particularly among older (>7 yr) or obese children. In addition, the presence of severe OSAS in nonobese children or of chronic asthma warrants post-AT nocturnal polysomnography, in view of the higher risk for residual OSAS.

Adenotonsillectomy for Obstructive Sleep Apnea in Obese Children

To assess the efficacy of adenotonsillar surgery on respiratory sleep parameters and avoiding continuous positive airway pressure (CPAP) treatment in morbidly obese children with obstructive sleep apnea syndrome (OSAS). Retrospective. Tertiary referral institution. Children aged 2 to 18 years, with a body mass index (BMI) at or higher than the 95th percentile (adjusted for age and sex), undergoing adenotonsillar surgery for OSAS. Adenotonsillectomy. Preoperative and postoperative respiratory disturbance index, oxygen saturation nadir, overall severity of OSAS (mild, moderate, or severe) and candidacy for CPAP treatment were assessed and compared. Variables such as age, severity of disease, adenotonsillar size, and BMI z scores were compared between responders and nonresponders to surgical treatment. A total of 19 patients with full preoperative and postoperative data for evaluation were identified. The median (SD) age was 78 months (53.3 months). The median (SD) BMI z score was 2.84 (0.94). Eighteen patients (95%) had OSAS preoperatively to warrant CPAP treatment. Surgery reduced the overall median (SD) respiratory disturbance index from 20.7 (24.5) to 7.3 (14.9) (P<.001) and improved the median (SD) oxygen saturation nadir from 77.5% (16.3%) to 88.5 (13.1%) (P<.01). A total of 7 patients (37%) were cured by surgery. Ten patients (53%) had postoperative disease of sufficient severity to require CPAP. Surgery obviated the need for further treatment in only 8 (44%) of the 18 patients with preoperative disease warranting CPAP. No differences were identified between responders and nonresponders to surgical treatment. Adenotonsillar surgery improves sleep respiratory parameters in morbidly obese children with OSAS. Most patients have residual OSAS requiring further treatment.