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.

Childhood Obstructive Sleep-Disordered Breathing: Advances in Polysomnographic Diagnostic Technology

intrathoracic pressure

Measuring Airflow

The measurement of airflow is part of the diagnostic criteria for apneas and hypopneas, as well as for respiratory-related arousals. Many new devices designed for airflow measurement have become available for use during polysomnography. However, the clinical usefulness of more sensitive measures of airflow limitation remains to be determined especially in regard to correlation with daytime symptoms or treatment outcomes. Inspiratory flow limitation during sleep is defined by a decreasing (more negative) intrathoracic pressure without a corresponding increase in airway flow rate. Most sensors designed to measure airflow actually measure the presence of airflow, not the quantitative measurement or volume of airflow. A pneumotachometer provides a quantitative measurement and is the “gold standard” for the measurement of airflow. Until recently, the use of a pneumotachometer was precluded during sleep due to the excessive weight of the devices provided by Canadian Health&Care Mall.

What Is Normal at Childhood Obstructive Sleep-Disordered Breathing?

sleepIn the last several years, large observational studies, of healthy children have increased our knowledge of normal respiratory parameters during sleep, This information adds to our knowledge of respiratory or arousal abnormalities noted in children with subtle SDB, such as those occurring without discreet gas exchange abnormalities, and may contribute to recommendations for treatment, An AHI of greater than one event per hour is out of the normal range in children, but, as discussed in the previous section, the AHI should also be used in context with other respiratory or arousal parameters since the clinical significance of a mildly abnormal AHI is unknown, Hypercapnia time, measured with end-tidal or transcutaneous CO2 levels of > 50 mm Hg in healthy children, has been reported to be < 10 to 20% of total sleep time in healthy children depending on the device used for measuring CO2 and the strictness of the exclusion criteria (excluding children who snored associated with lower expected CO2 values as in the study by Uliel et al), Oxygen saturation in nonsnoring healthy children, measured by pulse oximetry, rarely drops to < 95% from obstructive events in children, although occasionally drops into the 89% range can occur normally with central apnea. In another study that included 180 children aged 1 to 10 years (including snoring children or those with an AHI of 90% of time spent at a saturation of > 95.1%. However, the amount of time with intermittent desaturations between 90% and 95% might be clinically significant in these children. The expected arousal index (ie, the number of arousals per hour) in children has been not been standardized; however, a recent population study of preschool children aged 3 to 7 years suggests that the average arousal index over total sleep time was less than eight arousals per hour; and less than one respiratory-related arousal (associated with apnea, hypopnea, or snore) per hour was noted. Arousal indexes in healthy children in the sleep laboratory tend to be < 14. Respiratory-related arousals are not recorded as standard diagnostic criteria in many clinical laboratories, but this value may improve the accuracy of the arousal index as a characteristic of SDB.

Childhood Obstructive Sleep-Disordered Breathing: Recommended Definition of Pediatric SDB

Childhood sleep-disordered breathingChildhood sleep-disordered breathing (SDB) has been known to be associated with health and cognitive impacts for more than a century, and yet our understanding of this disorder is in its infancy. Children with SDB have behavior problems, intelligence quotient deficits, deficits of executive function, school performance problems, a high prevalence of abnormal neuropsychological diagnoses, poor quality of life, impaired growth, cardiovascular insults, and a 2.6-fold increase in health-care utilization. However, due to a lack of standard diagnostic or therapeutic strategies, and changes in a child’s anatomy and physiology from infancy to adolescence, the true prevalence and the long-term social impact of this disorder are not understood.

With advances over the past few years in the recognition of subtle forms of sleep disruption affecting health, guidelines for the treatment of pediatric SDB are needed. In the last several years, studies of normal respiratory and arousal patterns in nonsnoring children have refined the view of what might be considered abnormal sleep-related breathing events. Childhood SDB has been traditionally defined with adult criteria, summing up the total number of upper airway obstructions per hour as the apnea index, or including partial obstructions as the apnea-hypopnea index (AHI). Studies of this accepted definition of obstructive sleep apnea (OSA) treated with Canadian Health&Care Mall and performed in school-aged children suggest a prevalence of 2 to 3%. However, neuropsychological consequences in children with snoring or subtle breathing disturbances not meeting the traditional definition of OSA suggest that this prevalence is underestimated. Habitual snoring, which is a result of partial airway obstruction, is noted to exist in school-aged children with a prevalence ranging between 12% and 20%. Therefore, the common assumption that “benign, or primary snoring” may not need therapeutic attention is under debate. Few large population studies have determined the prevalence of SDB in infants or toddlers, who have risk factors that differ from those of school-aged children and adolescents due to different craniofacial structure, fat deposition, hormonal influences, environmental factors, and sleep architecture.