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Polytarchou A, Moudaki A, Van de Perck E, Boudewyns A, Kaditis AG, Verhulst S, Ersu R. An update on diagnosis and management of obstructive sleep apnoea in the first 2 years of life. Eur Respir Rev 2024; 33:230121. [PMID: 38296343 PMCID: PMC10828842 DOI: 10.1183/16000617.0121-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 12/05/2023] [Indexed: 02/03/2024] Open
Abstract
The aim of this review is to summarise evidence that became available after publication of the 2017 European Respiratory Society statement on the diagnosis and management of obstructive sleep apnoea syndrome (OSAS) in 1- to 23-month-old children. The definition of OSAS in the first 2 years of life should probably differ from that applied in children older than 2 years. An obstructive apnoea-hypopnoea index >5 events·h-1 may be normal in neonates, as obstructive and central sleep apnoeas decline in frequency during infancy in otherwise healthy children and those with symptoms of upper airway obstruction. A combination of dynamic and fixed upper airway obstruction is commonly observed in this age group, and drug-induced sleep endoscopy may be useful in selecting the most appropriate surgical intervention. Adenotonsillectomy can improve nocturnal breathing in infants and young toddlers with OSAS, and isolated adenoidectomy can be efficacious particularly in children under 12 months of age. Laryngomalacia is a common cause of OSAS in young children and supraglottoplasty can provide improvement in children with moderate-to-severe upper airway obstruction. Children who are not candidates for surgery or have persistent OSAS post-operatively can be treated with positive airway pressure (PAP). High-flow nasal cannula may be offered to young children with persistent OSAS following surgery, as a bridge until definitive therapy or if they are PAP intolerant. In conclusion, management of OSAS in the first 2 years of life is unique and requires consideration of comorbidities and clinical presentation along with PSG results for treatment decisions, and a multidisciplinary approach to treatment with medical and otolaryngology teams.
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Affiliation(s)
- Anastasia Polytarchou
- Division of Pediatric Pulmonology, First Department of Pediatrics, National and Kapodistrian University of Athens School of Medicine and Agia Sofia Children's Hospital, Athens, Greece
- These authors contributed equally to this review article and share first authorship
| | - Angeliki Moudaki
- Division of Pediatric Pulmonology, First Department of Pediatrics, National and Kapodistrian University of Athens School of Medicine and Agia Sofia Children's Hospital, Athens, Greece
- These authors contributed equally to this review article and share first authorship
| | - Eli Van de Perck
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium
- Faculty of Medicine Translational Neurosciences, University of Antwerp, Antwerp, Belgium
- These authors contributed equally to this review article and share first authorship
| | - An Boudewyns
- Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Antwerp, Belgium
- Faculty of Medicine Translational Neurosciences, University of Antwerp, Antwerp, Belgium
| | - Athanasios G Kaditis
- Division of Pediatric Pulmonology, First Department of Pediatrics, National and Kapodistrian University of Athens School of Medicine and Agia Sofia Children's Hospital, Athens, Greece
| | - Stijn Verhulst
- Department of Pediatric Pulmonology and Sleep Medicine, Antwerp University Hospital, Antwerp, Belgium
- Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Antwerp, Belgium
| | - Refika Ersu
- Division of Respiratory Medicine, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
- University of Ottawa, Ottawa, ON, Canada
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Keserű F, Sipos Z, Farkas N, Hegyi P, Juhász MF, Jászai VA, Párniczky A, Benedek PE. The risk of postoperative respiratory complications following adenotonsillar surgery in children with or without obstructive sleep apnea: A systematic review and meta-analysis. Pediatr Pulmonol 2022; 57:2889-2902. [PMID: 36030550 DOI: 10.1002/ppul.26121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 08/11/2022] [Accepted: 08/14/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Obstructive sleep apnea (OSA) appears in 2%-5% of children, with first-line treatment being adenotonsillar (AT) surgery. Our aim was to examine the risk of postoperative respiratory complications (PoRCs) in non-OSA and the different OSA severity (mild, moderate, severe) groups. STUDY DESIGN We conducted a systematic review and meta-analysis of studies comparing PoRCs following AT surgery in children with and without OSA. METHODS Nineteen observational studies were identified with the same search key used in MEDLINE, Embase, and CENTRAL. The connection between PoRCs, the presence and severity of OSA, and additional comorbidities were examined. Odds ratios (OR) were calculated with 95% confidence intervals (CI). RESULTS We found that PoRCs appeared more frequently in moderate (p = 0.048, OR: 1.79, CI [1.004, 3.194]) and severe OSA (p = 0.002, OR: 4.06, CI [1.68, 9.81]) compared to non-OSA patients. No significant difference was detected in the appearance of major complications (p = 0.200, OR: 2.14, CI [0.67, 6.86]) comparing OSA and non-OSA populations. No significant difference was observed in comorbidities (p = 0.669, OR: 1.29, CI [0.40, 4.14]) or in the distribution of PoRCs (p = 0.904, OR: 0.94, CI [0.36, 2.45]) between the two groups. CONCLUSION Uniform guidelines and a revision of postoperative monitoring are called for as children with moderate and severe OSA are more likely to develop PoRCs following AT surgery based on our results, but no significant difference was found in mild OSA. Furthermore, the presence of OSA alone is not associated with an increased risk of developing major complications.
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Affiliation(s)
- Fanni Keserű
- Heim Pál National Paediatric Institute, Budapest, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Zoltán Sipos
- Medical School, Institute for Translational Medicine, Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Nelli Farkas
- Medical School, Institute for Translational Medicine, Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Medical School, Institute for Translational Medicine, Szentágothai Research Centre, University of Pécs, Pécs, Hungary.,Division of Pancreatic Diseases, Heart and Vascular Center, Centre for Translational Medicine, Semmelweis University, Budapest, Hungary.,First Department of Medicine, University of Szeged, Szeged, Hungary
| | - Márk Félix Juhász
- Heim Pál National Paediatric Institute, Budapest, Hungary.,Medical School, Institute for Translational Medicine, Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Viktória Adrienn Jászai
- Medical School, Institute for Translational Medicine, Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Andrea Párniczky
- Heim Pál National Paediatric Institute, Budapest, Hungary.,Medical School, Institute for Translational Medicine, Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Pálma Edina Benedek
- Heim Pál National Paediatric Institute, Budapest, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
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Friedman NR, Meier M, Tholen K, Crowder R, Hoefner-Notz R, Nguyen T, Derieg S, Campbell K, McLeod L. Tonsillectomy for Obstructive Sleep-Disordered Breathing: Should They Stay, or Could They Go? Laryngoscope 2022; 132:1675-1681. [PMID: 34672364 DOI: 10.1002/lary.29909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 10/05/2021] [Accepted: 10/12/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Children who do not require oxygen beyond 3 hours after surgery and pass a sleep room air challenge (SRAC) are safe for discharge regardless of polysomnogram (PSG) results or comorbidities. STUDY DESIGN Cross-sectional prospective study. METHODS All children observed overnight undergoing an adenotonsillectomy for obstructive sleep-disordered breathing were prospectively recruited. Demographic, clinical, and PSG characteristics were stratified by whether the patient had required oxygen beyond 3 hours postoperatively (prolonged oxygen requirement [POR]) and compared using t test, chi-squared test, or Fisher's exact test depending on distribution. Optimal cut points for predicting POR postsurgery were calculated using receiver operating characteristic curves. The primary analysis was performed on the full cohort via logistic regression using POR as the outcome. Significant characteristics were analyzed in a logistic regression model, with significance set at P < .05. RESULTS A total of 484 participants met the inclusion criteria. The mean age was 5.65 (standard deviation = 4.02) years. Overall, 365 (75%) did not have a POR or any other adverse respiratory event. In multivariable logistic regression, risk factors for POR were an asthma diagnosis (P < .001) and an awake SpO2 <96% (P = .005). The probability of a POR for those without asthma and a SpO2 ≥ 96% was 18% (95% confidence interval: 14-22). Age, obesity, and obstructive apnea/hypopnea index were not associated with POR. CONCLUSIONS In conclusion, all children in our study who are off oxygen within 3 hours of surgery and passed a SRAC were safe for discharge from a respiratory standpoint regardless of age, obesity status, asthma diagnosis, and obstructive apnea/hypopnea index. Additional investigations are necessary to confirm our findings. LEVEL OF EVIDENCE 3 Laryngoscope, 132:1675-1681, 2022.
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Affiliation(s)
- Norman R Friedman
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
- Division of Pediatric Otolaryngology, Children's Hospital Colorado, Aurora, Colorado, U.S.A
| | - Maxene Meier
- The Center for Research in Outcomes for Children's Surgery, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Kaitlyn Tholen
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
- Division of Pediatric Otolaryngology, Children's Hospital Colorado, Aurora, Colorado, U.S.A
| | - Renee Crowder
- University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Regina Hoefner-Notz
- Perioperative Services, Children's Hospital Colorado, Aurora, Colorado, U.S.A
| | - Thanh Nguyen
- Division of Pediatric Anesthesia, Children's Hospital Colorado, Aurora, Colorado, U.S.A
- Department of Anesthesiology, School of Medicine, University of Colorado, Aurora, Colorado, U.S.A
| | - Sarah Derieg
- Ambulatory Services, Children's Hospital Colorado, Aurora, Colorado, U.S.A
| | - Kristen Campbell
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Lisa McLeod
- Pediatric Center of Excellence, Global Product Development, Pfizer, Inc., New York, New York, U.S.A
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Polysomnography variables associated with postoperative respiratory issues in children <3 Years of age undergoing adenotonsillectomy for obstructive sleep apnea. Int J Pediatr Otorhinolaryngol 2020; 137:110215. [PMID: 32896341 DOI: 10.1016/j.ijporl.2020.110215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/18/2020] [Accepted: 06/18/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To determine the polysomnogram (PSG) variables associated with increased incidence of postoperative respiratory complications in children <3 years of age undergoing adenotonsillectomy (T&A) for the management of obstructive sleep apnea (OSA). METHODS Retrospective case series of children <3 years of age who underwent T&A for the management of OSA at a tertiary care children's hospital from 1/1/08-6/1/2018. Postoperative hospital courses were analyzed to determine if certain clinical or PSG variables might have predicted an increased rate of respiratory complications. RESULTS A total of 195 children <3 years of age with OSA on preoperative PSGs underwent T&A. The mean age of patients was 25.8 months (range 9-35 months). Seventeen patients (16.2%) had mild OSA, 35 (17.9%) had moderate, and 141 (72.3%) had severe OSA. Most patients (n = 155, 79.5%) required no respiratory intervention postoperatively. Those with severe OSA were more likely to require oxygen support (n = 25, 17.7%) when compared to those with mild-moderate OSA (n = 3, 5.6%). Patients admitted directly to the pediatric intensive care unit (PICU) from the sleep lab (n = 7) had a mean apnea-hypopnea index (AHI) of 63.6 events/hour (range 23-146/hr.), and a mean SpO2 nadir of 56.3% (range 46-68%). Four of these patients required CPAP after T&A. Of the 7 patients (3.6%) who required intubation after their procedure, only 1 did not have severe OSA, and 2 were intubated to manage post-obstructive pulmonary edema (POPE). Only 4 patients (4.2%) had unplanned PICU admissions. An AHI >12.7 events/hour, >18.5 obstructive apneas, and SpO2 nadir <72.5% were associated with a greater likelihood of requiring postoperative respiratory interventions. CONCLUSIONS Most children <3 years of age, even with severe OSA, had no respiratory issues postoperatively. Those with severe OSA and hypoxemia admitted directly from the sleep lab were more likely to require CPAP postoperatively. All but one patient who developed POPE or who required intubation had severe OSA with associated hypoxemia on their preoperative PSGs.
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Evans SS, Cho DY, Richman J, Kulbersh B. Revisiting age-related admission following tonsillectomy in the pediatric population. Laryngoscope 2019; 129:E389-E394. [PMID: 30644565 DOI: 10.1002/lary.27795] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 12/04/2018] [Accepted: 12/17/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS The objectives of this study were to examine patient outcomes using a 36-month age cutoff as a strict admission criterion following tonsillectomy, and review the safety and determine the plausibility of same-day discharge of children under 3 years old following tonsillectomy. STUDY DESIGN Retrospective chart review. METHODS A chart review of patients aged 24 to 42 months undergoing tonsillectomy over a 3-year period was conducted. Patients were stratified into <36 months and ≥ 36 months cohorts. Data collected included demographics, medical/sleep history, inpatient records, 30-day emergency department visits, and readmission data. Bivariate comparisons were made using χ2 and Wilcoxon tests for categorical and continuous variables. RESULTS Between July 2014 and July 2017, 427 patients aged 24 to 42 months underwent tonsillectomy at our institution. Thirty-day emergency department visit, readmission, and greater-than-expected length of stay rates were 3.0% versus 3.7% (P = .75), 1.0 versus 1.8% (P = .61), and 4.7% versus 4.5% (P = 1.00) between the younger and older cohorts, respectively, with no difference in complication rates identified based on age. CONCLUSIONS No significant difference in adverse outcomes was appreciated based on a cutoff of 36 months of age at a tertiary center over 3 years. There should continue to be ongoing studies addressing strict age-related admission criteria. LEVEL OF EVIDENCE 4 Laryngoscope, 129:E389-E394, 2019.
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Affiliation(s)
- Sean S Evans
- The Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Do Yeon Cho
- The Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Joshua Richman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Brian Kulbersh
- Pediatric Ear, Nose, and Throat Associates of Alabama, Children's Hospital of Alabama, Birmingham, Alabama, U.S.A
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Schwartz CM, Honsinger K, Fischer BA, Elmaraghy CA. Evaluation of the effect of pre-operative oral midazolam on post-operative oral fluid intake after tonsillectomy. Int J Pediatr Otorhinolaryngol 2018; 113:248-251. [PMID: 30173995 DOI: 10.1016/j.ijporl.2018.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/07/2018] [Accepted: 08/08/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION The objective of this study was to determine if pre-operative oral midazolam administration decreased postoperative oral fluid intake after tonsillectomy with or without adenoidectomy. METHODS A retrospective chart review identified 104 patients who were undergoing tonsillectomy with and without adenoidectomy who were not given midazolam preoperatively and 182 who were given midazolam preoperatively. Indications for tonsillectomy with or without adenoidectomy included obstructive sleep apnea, recurrent acute streptococcal pharyngotonsillitis, and, in selected cases, periodic fever with aphthous stomatitis, pharyngitis and adenopathy. All patients were evaluated in the pre-operative area by the attending anesthesiologist, who then determined whether or not he/she felt the patient would benefit from premedication with oral midazolam prior to surgery. Patients whom the attending anesthesiologist judged would benefit from midazolam were then given a 0.12-1.06 mg/kg dose (mean 0.35 mg/kg, STD 0.12), at the discretion of the anesthesiologist. Various methods were used to perform tonsillectomy, such as coblation and electrocautery, at the discretion of the otolaryngologist. Results were not stratified by surgical technique. Oral fluid intake was calculated by establishing the time of return to the floor from surgery and determining the documented oral fluid intake for the next 12 h. Oral fluid intake per kg per hour was then calculated. The amount of midazolam given was documented. RESULTS There was no significant difference in oral fluid intake by group when adjusting for age and weight, F(1, 282) = 0.383, p = 0.537. Also, there was no significant difference in ml/kg/hr by group when adjusting for age and weight, F(1, 282) = 2.813, p = 0.095. CONCLUSIONS There was no significant difference in oral fluid intake between the no midazolam and midazolam groups, indicating that clinicians can continue to use their judgement in administering midazolam to select anxious patients prior to tonsillectomy with or without adenoidectomy. Future work could include multi-center retrospective reviews or a randomized placebo-controlled trial to examine more carefully the effects of midazolam on postoperative oral fluid intake. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
| | - Kristen Honsinger
- Department of Otolaryngology, Cook Children's Health Care System, USA
| | - Beth A Fischer
- Center for Surgical Outcomes Research, Nationwide Children's Hospital, USA
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