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Zhao C, Viana A, Ma Y, Capasso R. High Tongue Position is a Risk Factor for Upper Airway Concentric Collapse in Obstructive Sleep Apnea: Observation Through Sleep Endoscopy. Nat Sci Sleep 2020; 12:767-774. [PMID: 33117012 PMCID: PMC7585274 DOI: 10.2147/nss.s273129] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 09/14/2020] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Identification of upper airway (UA) obstruction based on pharyngeal factors is important for obstructive sleep apnea (OSA) evaluation. This study is to assess the association between UA collapse characteristics and Friedman tongue position (FTP) in patients with OSA through drug-induced sleep endoscopy (DISE). PATIENTS AND METHODS Retrospective study in individuals with OSA who were intolerant to continuous positive airway pressure (CPAP) treatment, submitted to DISE between June 1, 2013, and July 31, 2017. All subjects were classified as having an FTP grade of I to IV, and the velum, oropharynx, tongue base, epiglottis (VOTE) classification was used to analyze the DISE findings. UA collapse characteristics by DISE and FTP grading were compared between groups. The associations between specific DISE findings and FTP were analyzed. RESULTS In total, 205 patients were assessed. A positive and significant correlation was identified between the presence of retropalatal complete concentric collapse (CCC) and FTP grade, according to the following distributions: I, 17.4%; II, 22.9%; III, 33.7%; and IV, 48.7% (P = 0.014). A logistic regression model revealed that CCC was associated with FTP grade IV. After adjusting for age, sex, body mass index (BMI), and tonsil size (TS), the grade IV individuals had a 4.4-fold higher risk of having CCC than grade I individuals (P = 0.026). Multiple collapse sites and palatopharyngeal or combined (palatopharyngeal and hypopharyngeal) collapse were more prevalent in grade IV individuals. CONCLUSION OSA patients intolerant to CPAP have a strong positive correlation between the FTP grade and presence of retropalatal CCC. FTP grade IV is an independent risk factor for velum-CCC, controlling for sex, age, BMI, and TS grade.
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Affiliation(s)
- Chen Zhao
- Department of Otorhinolaryngology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning, People's Republic of China.,Division of Sleep Surgery, Department of Otolaryngology- Head & Neck Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Alonço Viana
- Division of Sleep Surgery, Department of Otolaryngology- Head & Neck Surgery, Stanford University Medical Center, Stanford, CA, USA.,Graduate Program of Neurology, Rio de Janeiro State Federal University (UNIRIO), Rio de Janeiro, Brazil.,Department of Otorhinolaryngology, Marcílio Dias Naval Hospital, Rio de Janeiro, Brazil
| | - Yifei Ma
- Department of Otolaryngology- Head & Neck Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Robson Capasso
- Division of Sleep Surgery, Department of Otolaryngology- Head & Neck Surgery, Stanford University Medical Center, Stanford, CA, USA
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Kljajić Z, Roje Ž, Bečić K, Čapkun V, Vilović K, Ivanišević P, Marušić E. Formula for the prediction of apnea / hypopnea index in children with obstructive sleep apnea without polysomnography according to the clinical parameters: Is it reliable? Int J Pediatr Otorhinolaryngol 2017; 100:168-173. [PMID: 28802366 DOI: 10.1016/j.ijporl.2017.06.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 06/19/2017] [Accepted: 06/29/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE OF THE STUDY The aim of the study was to propose "the risk formula" for obstructive sleep apnea in children according to the general and local clinical parameters and findings relevant for obstructive sleep apnea (OSA) severity. The unmet need for this formula arises from the economic burden of polysomnography (device, staff, training, special sleep centers, etc) as the golden standard for the diagnostics. MATERIALS AND METHODS USED The study was performed from January 2013 until January 2016 in the Sleep Center, Department for Neuroscience, School of Medicine of the University of Split, Department of Pediatrics, University Hospital Split, Croatia and ENT Dept. University Hospital in Split, Croatia. Inclusion criteria were: age > two years, AHI >1 diagnosed by polysomnography. Exclusion criteria were: chronic lung disease, active tonsillitis/pharyngitis at the time of the physical exam and syndromes that affect breathing. All polysomnograms were scored by a qualified sleep technologist and interpreted by two board certified sleep physicians independently. Age, sex, BMI, Mallampati score, tonsillar size and adenoids size were recorded. All statistical calculations were performed using SPSS 20. RESULTS In total 60 children were included in the study. The median of age was 5 years (range 2-9). There were 19 (32%) girls and 41 (68%) boys. Of all evaluated predictors, there were statistically significant differences in the values of AHI among children with different modified Mallampati score (χ2 = 28.2; p < 0.001), different size of tonsils (χ2 = 25.3; p < 0.001) and different size of adenoids (z = 2.7; p = 0,006) in univariate regression analysis. Strong positive association of AHI with modified Mallampati score (standardized B = 0.51; partial correlation = 0.542, r = 0.631) was found, as well as positive correlation of AHI with tonsillar size (standardized B = 0.246; partial correlation = 0.295,R = 0.489) in the multivariate forward stepwise regression analysis. CONCLUSION Even though we are aware that PSG is the gold standard for diagnostics of SDB there is a significant financial burden for this diagnostic procedure. That is why there is a necessity for establishing good clinical standards and possible formula for OSA severity evaluation. We propose formula which includes Mallampati score and tonsillar size for OSA -risk calculation in order to perform early therapeutic intervention thereby reducing the risk of long-term negative consequences. We recommend this formula as the screening formula in circumstances where PSG is not available, in cases when the "waiting list" is too long or when a child can not cooperate to perform it. In developing countries like Croatia on time intervention with reduced procedure-associated costs is of the utmost importance.
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Affiliation(s)
- Zlatko Kljajić
- University Department of ENT, University Hospital Center Split, Spinčićeva 1, Split, Croatia
| | - Željka Roje
- Private ENT Practice dr. Željka Roje, Kranjčevićeva 45, Split, Croatia
| | - Kristijan Bečić
- School of Medicine, University of Split, Šoltanska 2, Split, Croatia.
| | - Vesna Čapkun
- Department of Nuclear Medicine, University Hospital Center Split, Spinčićeva 1, Split, Croatia
| | - K Vilović
- Department of Pathology, University Hospital Center Split, Spinčićeva 1, Split, Croatia
| | - Petar Ivanišević
- University Department of ENT, University Hospital Center Split, Spinčićeva 1, Split, Croatia
| | - Eugenija Marušić
- Department of Pediatrics, University Hospital Center Split, Spinčićeva 1, Split, Croatia
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Su MS, Zhang HL, Cai XH, Lin Y, Liu PN, Zhang YB, Hu WZ, Li CC, Xiao YF. Obesity in children with different risk factors for obstructive sleep apnea: a community-based study. Eur J Pediatr 2016; 175:211-20. [PMID: 26316318 DOI: 10.1007/s00431-015-2613-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 07/03/2015] [Accepted: 08/03/2015] [Indexed: 10/23/2022]
Abstract
UNLABELLED This study investigated the association between obesity and obstructive sleep apnea (OSA) in preschool and school-age children. Parents of obese and randomly chosen normal weight children completed a questionnaire on sleep-related symptoms, demography, family, and medical history. All subjects were invited to undergo polysomnography (PSG). OSA cases were defined as obstructive apnea hypopnea index (OAHI) ≥1. A total of 5930 children were studied with 9.5% obese (11.9% boys/6.1% girls), 205/2680 preschool and 360/3250 school children. There were 1030 children (535 obese/495 normal weight) who underwent PSG. OSA was higher in obese children and obese school children had higher OAHI, arousal index, and shorter total sleep time. However, there was no positive correlation between OSA and body mass index (BMI). The main risk factors for OSA in preschool children were adenotonsillar hypertrophy and recurrent respiratory tract infection. The main cause for OSA in school children was a history of parental snoring and obesity. Mallampati scores and sleep-related symptoms were found to be associated with OSA in both preschool and school children. CONCLUSION We demonstrated differential risk factors for OSA in obese children, which suggest that a different mechanism may be involved in OSA development in preschool and school-age children. WHAT IS KNOWN Various risk factors have been reported in obese children with OSA owing to the different age and different study design. Obese children have a higher prevalence and severity of obstructive sleep apnea (OSA). OSA risk factors in obese children are affected by different ages and study designs. WHAT IS NEW A differential prevalence and risk factors for obese preschool and school-age children with OSA has been demonstrated.
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Affiliation(s)
- Miao-Shang Su
- Department of Pediatrics, The 2nd Affiliated Hospital of Medical College of Xi'an Jiaotong University, Xi'an, Shanxi Province, People's Republic of China. .,Department of Pediatrics, The 2nd Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, People's Republic of China.
| | - Hai-Lin Zhang
- Department of Pediatrics, The 2nd Affiliated Hospital of Medical College of Xi'an Jiaotong University, Xi'an, Shanxi Province, People's Republic of China. .,Department of Pediatrics, The 2nd Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, People's Republic of China.
| | - Xiao-Hong Cai
- Department of Pediatrics, The 2nd Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, People's Republic of China.
| | - Ying Lin
- Department of Public Health, Center for Disease Control and Prevention in Wenzhou, Zhejiang, People's Republic of China.
| | - Pei-Ning Liu
- Department of Pediatrics, The 2nd Affiliated Hospital of Medical College of Xi'an Jiaotong University, Xi'an, Shanxi Province, People's Republic of China. .,Department of Pediatrics, The 2nd Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, People's Republic of China.
| | - Yuan-Bo Zhang
- Department of Pediatrics, The 2nd Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, People's Republic of China.
| | - Wen-Zhen Hu
- Department of Pediatrics, The 2nd Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, People's Republic of China.
| | - Chang-Chong Li
- Department of Pediatrics, The 2nd Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, People's Republic of China.
| | - Yan-Feng Xiao
- Department of Pediatrics, The 2nd Affiliated Hospital of Medical College of Xi'an Jiaotong University, Xi'an, Shanxi Province, People's Republic of China.
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Oliveira MCS, Tufik S, Haddad FLM, Santos-Silva R, Gregório LC, Bittencourt L. Systematic Evaluation of the Upper Airway in a Sample Population: Factors Associated with Obstructive Sleep Apnea Syndrome. Otolaryngol Head Neck Surg 2015; 153:663-70. [PMID: 25820578 DOI: 10.1177/0194599815577598] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 02/24/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To investigate the anatomy of the upper airway (UA) of a representative sample of the adult population of São Paulo city, Brazil, and to identify factors associated with the presence of obstructive sleep apnea syndrome (OSAS), as confirmed using full-night polysomnography (PSG). STUDY DESIGN Cross-sectional study. SETTING Population-based sample. METHODS A 3-stage sampling procedure was used to proportionally recruit adult residents of São Paulo city according to gender, age, and socioeconomic status. A complete evaluation was performed, including a systematic evaluation of the UA prior to conducting PSG. RESULTS Nine-hundred ninety-three (90.2%) of the participants were seen by an ear, nose, and throat (ENT) specialist. Individuals who were diagnosed with OSAS (32.9%) presented a higher frequency of nasal symptoms and structural abnormalities (both nasal and oropharyngeal) compared with those without OSAS. No anatomical differences were observed in the facial skeleton. An abnormal nasal structure visible via anterior rhinoscopy was the only UA factor predicting OSAS after adjustments for the other common OSAS risk factors (male sex, aging, obesity, and increased neck circumference). CONCLUSION This is the first study in which a systematic evaluation of the UA was followed by a sleep study in a population-based sample. In a sample of the general population that had not previously been screened for OSAS, having an abnormal nasal structure was found to be a risk factor for OSAS, in conjunction with other well-established clinical and demographic factors, such as male gender, increased age, increased neck circumference, and body mass index.
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Affiliation(s)
| | - Sergio Tufik
- Disciplina de Medicina e Biologia do Sono-Departamento de Psicobiologia, Universidade Federal de São Paulo, Brazil
| | - Fernanda Louise Martinho Haddad
- Departamento de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Universidade Federal de São Paulo, Brazil Disciplina de Medicina e Biologia do Sono-Departamento de Psicobiologia, Universidade Federal de São Paulo, Brazil
| | - Rogerio Santos-Silva
- Disciplina de Medicina e Biologia do Sono-Departamento de Psicobiologia, Universidade Federal de São Paulo, Brazil
| | - Luis Carlos Gregório
- Departamento de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Universidade Federal de São Paulo, Brazil
| | - Lia Bittencourt
- Disciplina de Medicina e Biologia do Sono-Departamento de Psicobiologia, Universidade Federal de São Paulo, Brazil
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Certal V, Camacho M, Winck JC, Capasso R, Azevedo I, Costa-Pereira A. Unattended sleep studies in pediatric OSA: A systematic review and meta-analysis. Laryngoscope 2014; 125:255-62. [DOI: 10.1002/lary.24662] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 03/03/2014] [Indexed: 11/07/2022]
Affiliation(s)
- Victor Certal
- Department of Otorhinolaryngology; University of Porto; Porto Portugal
- Sleep Surgery Division, Department of Otolaryngology-Head and Neck Surgery; Stanford University School of Medicine; Stanford California U.S.A
| | - Macario Camacho
- Sleep Surgery Division, Department of Otolaryngology-Head and Neck Surgery; Stanford University School of Medicine; Stanford California U.S.A
| | - João C. Winck
- Department of Pulmonology; Faculty of Medicine, University of Porto; Porto Portugal
| | - Robson Capasso
- Sleep Surgery Division, Department of Otolaryngology-Head and Neck Surgery; Stanford University School of Medicine; Stanford California U.S.A
| | - Inês Azevedo
- Department of Pediatrics; Faculty of Medicine, University of Porto; Porto Portugal
| | - Altamiro Costa-Pereira
- Hospital Sao Sebastiao, Sta Maria da Feira, and Center for Research in Health Technologies and Information Systems; University of Porto; Porto Portugal
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Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea. Anesthesiology 2014; 120:268-86. [DOI: 10.1097/aln.0000000000000053] [Citation(s) in RCA: 470] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
The American Society of Anesthesiologists Committee on Standards and Practice Parameters and the Task Force on Perioperative Management of Obstructive Sleep Apnea presents an updated report of the Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea.
Supplemental Digital Content is available in the text.
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Papuzinski Aguayo C, Martínez Lomakin F, Cardemil Morales F. Adenotonsillectomy for childhood sleep apnea: CAT. Medwave 2013. [DOI: 10.5867/medwave.2013.10.5825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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8
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Physical predictors for moderate to severe obstructive sleep apnea in snoring patients. Sleep Breath 2013; 18:151-8. [DOI: 10.1007/s11325-013-0863-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 04/24/2013] [Accepted: 05/08/2013] [Indexed: 10/26/2022]
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9
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Friedman M, Hamilton C, Samuelson CG, Lundgren ME, Pott T. Diagnostic Value of the Friedman Tongue Position and Mallampati Classification for Obstructive Sleep Apnea. Otolaryngol Head Neck Surg 2013; 148:540-7. [DOI: 10.1177/0194599812473413] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To assess the association between the Mallampati classification and Friedman tongue position for obstructive sleep apnea severity as determined by apnea-hypopnea index and to determine which method is most closely correlated with prediction of obstructive sleep apnea severity. Data Sources English-language searches of PubMed, MedLine, and the Cochrane database. Reference sections of identified studies were examined for additional articles. Review Methods Databases through December 2011 were searched, combined with review of relevant article bibliographies, and assessed by 4 reviewers. Systematic review and random-effects meta-analysis of studies evaluating tongue position and obstructive sleep apnea severity were performed. Outcomes were reported as correlations. Results Ten studies met inclusion criteria and had data for pooling (2513 patients). Friedman tongue position and Mallampati classification were significantly associated with obstructive sleep apnea severity, with a correlation of 0.351 (0.094-0.564, P = .008). Analysis of the correlation of tongue position with obstructive sleep apnea severity reveals correlations of 0.184 (0.052, 0.310, P = .006) and 0.388 (0.049, 0.646, P = .026) for the Mallampati classification and Friedman tongue position, respectively. Publication bias does not yield a significant Egger regression intercept; however, 4 imputed values to the right of the mean were found using Duval and Tweedie’s trim-and-fill method, yielding an overall correlation of 0.498 (confidence interval = 0.474-0.521). Conclusion The Mallampati classification and Friedman tongue position assessment techniques are significantly correlated with predicting obstructive sleep apnea severity. Publication bias does not significantly affect our results. The strength of this correlation is higher for Friedman tongue position, although 95% confidence intervals for the respective correlation coefficients overlap.
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Affiliation(s)
- Michael Friedman
- Rush University Medical Center, Chicago, Illinois, USA
- Advanced Center for Specialty Care, Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA
| | - Craig Hamilton
- Advanced Center for Specialty Care, Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA
| | - Christian G. Samuelson
- Advanced Center for Specialty Care, Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA
| | - Mary E. Lundgren
- Advanced Center for Specialty Care, Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA
| | - Thomas Pott
- Advanced Center for Specialty Care, Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA
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Serum, urine, and breath-related biomarkers in the diagnosis of obstructive sleep apnea in children. Curr Opin Pulm Med 2012; 18:561-7. [DOI: 10.1097/mcp.0b013e328358be2d] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Certal V, Catumbela E, Winck JC, Azevedo I, Teixeira-Pinto A, Costa-Pereira A. Clinical assessment of pediatric obstructive sleep apnea: A systematic review and meta-analysis. Laryngoscope 2012; 122:2105-14. [DOI: 10.1002/lary.23465] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 05/04/2012] [Indexed: 11/07/2022]
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Samson P, Casey KR, Knepler J, Panos RJ. Clinical characteristics, comorbidities, and response to treatment of veterans with obstructive sleep apnea, Cincinnati Veterans Affairs Medical Center, 2005-2007. Prev Chronic Dis 2012; 9:E46. [PMID: 22280961 PMCID: PMC3337849 DOI: 10.5888/pcd9.110117] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Introduction Obstructive sleep apnea (OSA) is a common disorder that is associated with significant morbidity. Veterans may be at an elevated risk for OSA because of increased prevalence of factors associated with the development and progression of OSA. The objective of this study was to determine the clinical characteristics, comorbidities, polysomnographic findings, and response to treatment of veterans with OSA. Methods We performed a retrospective chart review of 596 patients undergoing polysomnography at the Cincinnati Veterans Affairs Medical Center from February 2005 through December 2007. We assessed potential correlations of clinical data with polysomnography findings and response to treatment. Results Polysomnography demonstrated OSA in 76% of patients; 30% had mild OSA, 23% moderate OSA, and 47% severe OSA. Increasing body mass index, neck circumference, Epworth Sleepiness Scale score, hypertension, congestive heart failure, and type 2 diabetes correlated with increasing OSA severity. Positive airway pressure treatment was initiated in 81% of veterans with OSA, but only 59% reported good adherence to this treatment method. Of the patients reporting good adherence, a greater proportion of those with severe OSA (27%) than with mild or moderate disease (0%-12%) reported an excellent response to treatment. Conclusion The prevalence of metabolic and cardiovascular comorbidities increased with increasing OSA severity. Only 59% of treated patients reported good adherence to treatment with positive airway pressure, and response to treatment correlated with OSA severity.
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Affiliation(s)
- Pamela Samson
- Cincinnati Veterans Affairs Medical Center, Cincinnati, OH 45220, USA
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Abstract
The clinical syndrome of obstructive sleep apnea (OSAS) in children is a distinct, yet somewhat overlapping disorder with the condition that occurs in adults, such that the clinical manifestations, polysomnographic findings, diagnostic criteria and treatment approaches need to be considered in an age-specific manner. Childhood OSAS has now become widely recognized as a frequent disorder and as a major public health problem. Pediatric OSAS, particularly when obesity is concurrently present, is associated with substantial end-organ morbidities and increased healthcare utilization. Although adenotonsillectomy (T&A) remains the first line of treatment, evidence in recent years suggests that the outcomes of this surgical procedure may not be as favorable as expected, such that post-T&A polysomnographic evaluation may be needed, especially in high-risk patient groups. In addition, incorporation of nonsurgical approaches for milder forms of the disorder and for residual OSAS after T&A is now being investigated.
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Affiliation(s)
- Riva Tauman
- Sleep Disorders Center, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv 64239, Israel.
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Dayyat E, Kheirandish-Gozal L, Sans Capdevila O, Maarafeya MMA, Gozal D. Obstructive sleep apnea in children: relative contributions of body mass index and adenotonsillar hypertrophy. Chest 2009; 136:137-144. [PMID: 19225059 PMCID: PMC2716713 DOI: 10.1378/chest.08-2568] [Citation(s) in RCA: 165] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2008] [Accepted: 01/16/2009] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The obesity epidemic has prompted remarkable changes in the proportion of obese children who are referred for habitual snoring. However, the contribution of obesity to adenotonsillar hypertrophy remains undefined. METHODS In our study, 206 nonobese habitually snoring children with polysomnographically diagnosed obstructive sleep apnea (OSA) were matched for age, gender, ethnicity, and obstructive apnea-hypopnea index (OAHI) to 206 obese children. Size estimates of tonsils and adenoids, and Mallampati class scores were obtained, and allowed for the assessment of potential relationships between anatomic factors and obesity in pediatric OSA. RESULTS The mean OAHI for the two groups was approximately 10.0 episodes/h total sleep time. There was a modest association between adenotonsillar size and OAHI in nonobese children (r = 0.22; p < 0.001) but not in obese children. The mean (+/- SEM) adenotonsillar size was larger in nonobese children (3.85 +/- 0.16 vs 3.01 +/- 0.14, respectively; p < 0.0001), and conversely Mallampati class scores were significantly higher in obese children (p < 0.0001). CONCLUSION The magnitude of adenotonsillar hypertrophy required for any given magnitude of OAHI is more likely to be smaller in obese children compared to nonobese children. Increased Mallampati scores in obese children suggest that soft-tissue changes and potentially fat deposition in the upper airway may play a significant role in the global differences in tonsillar and adenoidal size among obese and nonobese children with OSA.
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Affiliation(s)
- Ehab Dayyat
- Division of Pediatric Sleep Medicine, Department of Pediatrics, University of Louisville, Louisville, KY
| | - Leila Kheirandish-Gozal
- Division of Pediatric Sleep Medicine, Department of Pediatrics, University of Louisville, Louisville, KY
| | - Oscar Sans Capdevila
- Division of Pediatric Sleep Medicine, Department of Pediatrics, University of Louisville, Louisville, KY
| | - Muna M A Maarafeya
- Department of Pediatrics, Division of Pediatric Pulmonology, Hamad Medical Corporation, Doha, Qatar
| | - David Gozal
- Division of Pediatric Sleep Medicine, Department of Pediatrics, University of Louisville, Louisville, KY.
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Loredo JS, Berry C, Nelesen RA, Dimsdale JE. Prediction of continuous positive airway pressure in obstructive sleep apnea. Sleep Breath 2007; 11:45-51. [PMID: 17089145 DOI: 10.1007/s11325-006-0082-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Continuous positive airway pressure (CPAP) prediction formulas can potentially simplify the treatment of obstructive sleep apnea (OSA). However, they can be difficult to derive and validate. We tested a statistical method to derive and validate a CPAP prediction formula using the same sample population. Seventy-six OSA patients underwent polysomnography and CPAP titration. Anthropometric measures, sleep parameters, and the Epworth sleepiness scale (ESS) were evaluated as predictors. All subsets regression was used to determine the optimum number of variables in the model. The Bayes information criterion was used to find the best-fit model. The model was then evaluated by a tenfold cross-validation procedure. Subjects were obese (BMI 31.3 +/- 5.4) and had significant daytime somnolence (ESS 11.9 +/- 5). Mean respiratory disturbance index (RDI) was 53.5 +/- 31.3. The ESS was not predictive of titrated CPAP. The best-fit model included three variables (CPAP(pred) = 30.8 + RDI x 0.03 - nadir saturation x 0.05 - mean saturation x 0.2). This model explained 67% of the variance. Our data and the literature suggest that a combination of two to three factors is predictive of titrated CPAP: RDI, oxyhemoglobin saturation, and obesity. Except for RDI, the specific factors vary in each population. A CPAP prediction formula that explains a high proportion of the titrated CPAP variance can be easily derived from parameters measured during the diagnostic work-up of OSA patients using a unique statistical model that allows derivation and validation of the formula in the same test population.
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Affiliation(s)
- José S Loredo
- Department of Medicine, University of California, San Diego, CA 92103-0804, USA.
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Dayyat E, Kheirandish-Gozal L, Gozal D. Childhood Obstructive Sleep Apnea: One or Two Distinct Disease Entities? Sleep Med Clin 2007; 2:433-444. [PMID: 18769509 DOI: 10.1016/j.jsmc.2007.05.004] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The spectrum of sleep disordered breathing (SDB) encompasses habitual snoring at the low end of severity all the way to frank obstructive sleep apnea (OSA), with upper airway resistance syndrome (UARS) and obstructive alveolar hypoventilation being considered as less severe variants of this condition. SDB occurs in children of all ages, from neonates to adolescents, and is characterized by repeated events of increased upper airway resistance as well as with either partial or complete upper airway obstruction during sleep, all of which may result in disruption of normal gas exchange and sleep integrity [1]. SDB was initially described over a century ago [2] and was then rediscovered in children by Guilleminault in 1976 [3]. However, this complex and relatively prevalent disorder is only now being recognized as a major public health problem. During the initial years since the seminal paper by Guilleminault et al [3], it became apparent that the classic clinical syndrome of OSA in children markedly differed from the OSA seen in adults, in particular with respect to gender distribution, clinical manifestations, polysomnographic findings, and treatment approaches [4,5]. However in more recent years, the epidemic of obesity that affects the pediatric population all over the world has led, in our opinion, to the emergence of a phenotypic variant of OSA in children that closely resembles that of adults with the disease. In this paper, we will review the pathophysiological mechanisms of OSA in children, delineate the clinical manifestations associated with the disease, and provide arguments for our novel and hopefully useful proposition that aims to define 2 types of OSA in children. For the sake of convenience, and in analogy with type I and type II diabetes, we propose to divide pediatric OSA as types I and II.
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Affiliation(s)
- Ehab Dayyat
- Division of Pediatric Sleep Medicine, Department of Pediatrics, University of Louisville, Louisville, KY 40202
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Svensson M, Holmstrom M, Broman JE, Lindberg E. Can anatomical and functional features in the upper airways predict sleep apnea? A population-based study in females. Acta Otolaryngol 2006; 126:613-20. [PMID: 16720446 DOI: 10.1080/00016480500468984] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
CONCLUSION The importance of clinical findings in the nose and throat, including fiberoptic endoscopy during the Muller maneuver, in predicting sleep apnea is greater in normal-weight than in overweight women. OBJECTIVES The aim of this study was to identify clinical features that could predict sleep apnea in women. METHOD From 6817 women who previously answered a questionnaire concerning snoring habits, 230 women who reported habitual snoring and 170 women from the whole cohort went through a full-night polysomnography. A nose and throat examination including fiber endoscopic evaluation of the upper airways during the Muller maneuver was performed in a random selection of 132 women aged 20-70 years. RESULTS Sleep apnea was defined as an apnea-hypopnea index of > or = 10. The influence of clinical features on the prevalence of sleep apnea varied between normal-weight and overweight women. A low soft palate, retrognathia, the uvula touching the posterior pharyngeal wall in the supine position, and a 75% or more collapse at the soft palate during the Muller maneuver were all significant predictors of sleep apnea in women with a body mass index (BMI) < 25 kg/m2 but not in overweight women.
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Affiliation(s)
- Malin Svensson
- Department of Surgical Sciences, Otolaryngology and Head- and Neck Surgery, Uppsala University, Uppsala, Sweden.
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Gozal D, Kheirandish L. Oxidant stress and inflammation in the snoring child: confluent pathways to upper airway pathogenesis and end-organ morbidity. Sleep Med Rev 2006; 10:83-96. [PMID: 16495092 DOI: 10.1016/j.smrv.2005.07.005] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Snoring in children is increasingly being recognized as a highly prevalent condition, and indicates the presence of heightened upper airway resistance during sleep. In this paper, we present evidence to support the hypothesis that local inflammatory processes within the upper airway contribute to the pathophysiology of adenotonsillar hypertrophy and altered reflexes potentially leading to increased propensity for upper airway obstruction during sleep. Furthermore, the cumulative evidence supporting multiorgan morbidity for sleep-disordered breathing (SDB) is reviewed, and a unified hypothesis of a triple risk model proposing oxidative-inflammatory mechanisms as mediating the morbid consequences of SDB is presented. This hypothetical working model incorporates both dose-dependent disease severity components, as well as environmental and genetic elements of susceptibility.
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Affiliation(s)
- David Gozal
- Division of Pediatric Sleep Medicine, Department of Pediatrics, Kosair Children's Hospital Research Institute, University of Louisville, 570 S. Preston Street, Suite 321, Louisville, KY 40202, USA.
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Carrasco Llatas M, Dalmau Galofre J, López Martínez R, Fernández Martínez S. Evaluación clínica del paciente con roncopatía. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2005; 56:309-16. [PMID: 16240921 DOI: 10.1016/s0001-6519(05)78621-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Sleep disordered breathing patients usually undergo an ENT clinical examination before any therapeutic decision is taker. This clinical examination should be predictive about the occurrence of OSAS, reproductible and should determine the sites of obstruction in the upper airways. We have evaluated the clinical ENT examination and compared it with the bibliography in order to standardize it. MATERIALS AND METHODS We have done the same clinical ENT examination to 181 patients. 127 had a standar polysomnography. RESULTS The patient's mean age was 49.6 years, the mean BMI was 29.3 kg/m2. 92.7% had an abnormal palate, 4.5% a tonsilar hipertrophy, 66.5% high Modified Mallampati scores, 60.8% were clasiffied as Fujita IIb type and 39.2% had nasal obstruction. CONCLUSIONS Upper airway examination is important for the assessment of chronic snoring patients. Most of them have anatomical alterations that can be represented in visual scales to make it more reproductible. The obstruction area does not predict the severity of OSAS.
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D'Andrea LA. Diagnostic studies in the assessment of pediatric sleep-disordered breathing: techniques and indications. Pediatr Clin North Am 2004; 51:169-86. [PMID: 15008588 DOI: 10.1016/s0031-3955(03)00182-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
In summary, SDB is a common condition in children that can have serious complications if left undiagnosed and untreated. OSA is the most commonly recognized form of SDB in children. The history and physical have limitations in their capacity to determine which children have SDB. Abbreviated or screening techniques, such as audio- or videotaping, oximetry studies, nap studies, or home studies, tend to be helpful if the results are positive but have a poor predictive value if the results are negative. Overnight polysomnography is the gold standard for the diagnosis of SDB in children. It is important that children are studied in laboratories that have expertise with children. Often, children with SDB have associated nonrespiratory or behavioral sleep disorders that also must be evaluated and addressed.
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Affiliation(s)
- Lynn A D'Andrea
- Department of Pediatrics, University Michigan Health System, L2221 Women's Hospital, Box 0212, 1500 East Medical Center Drive, Ann Arbor, MI 48109-0212, USA.
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Unal M, Oztürk L, Kanik A. The role of oxygen saturation measurement and body mass index in distinguishing between non-apnoeic snorers and patients with obstructive sleep apnoea syndrome. CLINICAL OTOLARYNGOLOGY AND ALLIED SCIENCES 2002; 27:344-6. [PMID: 12383294 DOI: 10.1046/j.1365-2273.2002.00592.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The aim of this study was to examine the role of oxygen saturation (SaO2) measurement in identifying apnoeic snorers from non-apnoeic snorers and in the assessment of the severity of obstructive sleep apnoea. Ninety-two patients with clinically suspected obstructive sleep apnoea syndrome (OSAS) were assessed, using overnight polysomnography. The patients were classified as follows: 14 patients were non-apnoeic snorers, 27 patients had mild OSAS, 31 patients had moderate OSAS and 20 patients had severe OSAS. Minimum SaO2 level, mean SaO2, time below 85% of SaO2, the ratio between the time SaO2 and total sleep time and body mass index (BMI) were assessed retrospectively. There was a statistically significant difference between the non-apnoeic group and OSAS patients in Min SaO2 (P = 0.03). Patients who had Min SaO2 above 85% could be evaluated as non-apnoeic snorers; however, SaO2 and BMI were not found to be useful in the assessment of the severity of OSAS.
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Affiliation(s)
- M Unal
- University of Mersin, School of Medicine, Department of Otorhinolaryngology, Mersin, Turkey.
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