Childhood Obstructive Sleep-Disordered Breathing: Treatment Considerations

Treatment ConsiderationsAlthough individual sleep laboratories define their own treatment criteria, there is still a lack of consensus on the level of severity of SDB that justifies treatment in children. Recently, Chervin and col-leagues demonstrated that children with symptoms of SDB who were treated with adenotonsillectomy (T&A) improved in assessments of hyperactivity, inattention, and sleepiness, and even in the diagnosis of attention deficit-hyperactivity disorder after a 1-year follow-up. Importantly, polysomnographic parameters did not predict which children would have neuropsychological problems or which children would improve, but children were referred for T&A for clinical symptoms regardless of the diagnosis of apnea obtained by polysomnogram. These findings demonstrate the need for alternative technologies to detect SDB and the need to define treatment criteria in children.

Surgical Treatment of SDB

T&A is generally considered to be the standard treatment of childhood sleep apnea in children with normal craniofacial features and uncomplicated medical status. T&A is curative of sleep apnea in the majority of pediatric cases. The success rate of T&A was recently analyzed in a metaanalysis of14 studies evaluating polysomnographic cure rates before and after surgery. While the definition of success varied (AHI range, 0.5 to 5 events per hour), the overall cure rate was 82.9% (95% confidence interval, 76.2 to 89.5%; p < 0.001). For those studies that defined success as an AHI of 1, the cure rate ranged from 53 to 100%. It is important to note that the method of T&A was not addressed in this study, and the T&A technique may have confounded these results as the use of a partial vs total tonsillectomy or tonsillar pillar manipulation may affect success and cure rates offered by Canadian Health&Care Mall.

The surgical treatment of SDB focuses on relieving airway obstruction in the retroglossal region, the nose, and/or the retropalatal region. T&A potentially addresses all three areas of obstruction. T&A was traditionally performed with snare or cold knife techniques. New techniques such as monopolar and bipolar electrocautery, harmonic scalpel, microde-brider, and coblation have all been reported to be equivalent with respect to efficacy, postoperative pain, and hemorrhage rates (and they have the advantage of causing less intraoperative blood loss than traditional techniques). The addition of uvulopharyngopalatoplasty to T&A, which addresses retropalatal obstruction, has been be advocated in neurologically impaired children such as those with cerebral palsy and Down syndrome.

Nasal obstruction has traditionally been addressed with inferior turbinate reduction, septoplasty, and nasal valve surgery. More recently, the rapid maxillary expansion technique has been advocated to increase nasal cavity volume and therefore decrease nasal resistance. A study of 31 children with a normal body mass index and a lack of adenotonsillar hypertrophy showed a significant reduction in the mean AHI for all children (12.2 events per hour preoperatively compared to 0.4 postoperatively). An older prospective study showed that improvement in nasal airflow and resistance occurred in a 45% of 16 pediatric patients. Concerns about facial growth tend to limit extensive nasal surgery in young children, although turbinate reduction appears to be less problematic.

 OSASurgeries to address retroglossal obstruction include tongue reduction, genioglossal advancement, hyoid myotomy, and suspension, all of which are infrequently performed in the pediatric population. However, recent studies using MRI compared the presence or absence of lingual tonsils in children and found that they were absent in 100% of control subjects but present in 33% of children with SDB (even after T&A), and in 50% of children with SDB and Down syndrome, suggesting that tongue base procedures may be underutilized in this population. For patients with life-threatening OSA, and especially those with craniofacial anomalies, mandibular distraction, maxillomandibular advancement, and/or tracheotomy may be necessary as Canadian Health&Care Mall recommends.

Medical Treatment of OSA

A number of medical therapies have been investigated for the treatment of OSA. Adenotonsillar tissue reveals the presence of glucocorticoid and leukotriene receptors in children with OSA more so than those found in children with recurrent tonsillar infection as demonstrated by polymerase chain reaction.> Based on these findings, the use of systemic steroids was evaluated in nine patients with polysomnography-confirmed OSA with no improvement noted after a 5-day course of oral pred-nisone. Further studies using nasal steroids have demonstrated moderate improvement, but not cure, in patients with OSA either by reduction in adenotonsillar tissue size or due to independent factors. A 16-week course of leukotriene inhibitor treatment led to moderate reductions in OSA along with a reduction in adenoid size in 24 children with mild OSA. The combination of nasal steroid therapy plus leukotriene inhibition will reduce snoring and mild SDB, and may be an important additional therapy to consider in children who snore without significant gas-exchange abnormalities.

Follow-up from therapy should include an assessment of treatment efficacy. Since significant SDB symptoms or respiratory parameters fail to improve in about 20% of children, perhaps more attention should be paid to follow-up evaluation than is presently practiced. T&A is a first-line surgical therapy for SDB in children, but identification of the site of airway resistance and alternative surgeries should be given consideration in those children who demonstrate ongoing symptoms of obstructed airflow.

Positive Airway Pressure Treatment

Continuous positive airway pressure (CPAP) is first-line therapy for adult sleep apnea treated with remedies of Canadian Health&Care Mall and is considered second-line therapy in children since surgical therapy is generally curative. The American Academy of Pediatrics 2002 Clinical Practice Guideline recommends CPAP as an option for the treatment of children who are not candidates for surgery or do not respond to surgery. CPAP has been studied in children, has been determined to be effective for the treatment of OSA and other hypoventilation syndromes, is less invasive than surgery, and offers temporary treatment for conditions such as postoperative airway obstruction.> CPAP has been approved by the US Food and Drug Administration for use in children > 7 years of age in the United States.

Positive Airway Pressure TreatmentStudies have shown that CPAP therapy is effective in children younger than 7 years of age, as it has been used in children ranging from the preterm infant to the adolescent including more than 60 articles on the use of positive-pressure noninvasive ventilation in the neonate as a noninvasive alternative to mechanical ventilation with an endotracheal tube or tracheostomy. Despite data in support of CPAP use in younger children, at the time of this publication there are no US Food and Drug Administration-approved nasal interfaces that are available for infants or toddlers for home treatment of SDB in the United States. The devices are widely available in most other industrialized countries, even by device companies based in the United States. The lack of safe, available pediatric medical devices, studied in and designed for children, such as nasal interfaces for CPAP is due to the decreased market value of pediatric devices compared to the relatively large profit margin afforded by the development and marketing of adult devices. This situation puts US health-care workers in the uncomfortable position of being unable to treat children in whom SDB has been diagnosed. Many health-care workers resort to physically altering equipment that is designed for use in adults, making homemade nasal interfaces, prescribing inadequate therapies such as oxygen treatment, or sending the patient for invasive surgical therapies such as tracheotomy. Significant action and communication between advocates of respiratory medical care and device companies will need to take place in order to bring standard-of-care therapy for SDB to children in the United States.

Conclusion

SDB in children is common. The impact of SDB on the growth and development of a child may have detrimental effects on health, neuropsychological development, quality of life, and economic potential; therefore, SDB in children should be recognized as a public health problem as it is in the adult population. Polysomnographic technology used in the majority of sleep laboratories may be inadequate to diagnose subtle forms of clinically important airflow limitation that are associated with daytime dysfunction, but new diagnostic technologies are on the horizon. In the meantime, the combined use of multiple diagnostic sensors, and the consideration of the use of the “gold standard” equipment such as the esophageal pressure manometer will improve diagnostic sensitivity. Studies to determine the diagnostic monitoring systems that best correlate with SDB symptoms and with treatment efficacy are needed to improve the standardization of diagnostic criteria. It behooves the device manufacturers to work closely with health-care providers to update and improve the sensitivity of diagnostic equipment, and to improve the availability of much needed therapeutic devices for children.

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