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Thavagnanam S, Cheong SY, Chinna K, Nathan AM, de Bruyne JA. Pre-operative parameters do not reliably identify post-operative respiratory risk in children undergoing adenotonsillectomy. J Paediatr Child Health 2018; 54:530-534. [PMID: 29168911 DOI: 10.1111/jpc.13789] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 09/09/2017] [Accepted: 09/16/2017] [Indexed: 11/28/2022]
Abstract
AIM Adenotonsillectomy is performed in children with recurrent tonsillitis or obstructive sleep apnoea. Children at risk of post-operative respiratory complications are recommended to be monitored in paediatric intensive care unit (PICU). The aim of the study is to review the risk factors for post-operative complications and admissions to PICU. METHODS A review of medical records of children who underwent adenotonsillectomy between January 2011 and December 2014 was performed. Association between demographic variables and post-operative complications were examined using chi-square and Mann-Whitney tests. RESULTS A total of 214 children were identified, and of these, 19 (8.8%) experienced post-operative complications. Six children (2.8%) had respiratory complications: hypoxaemia in four and laryngospasm requiring reintubation in a further two. Both of the latter patients were extubated upon arrival to PICU and required no escalation of therapy. A total of 13 (6.1%) children had non-respiratory complications: 8 (3.7%) had infection and 5 (2.3%) had haemorrhage. A total of 26 (12.1%) children were electively admitted to PICU and mean stay was 19.5 (SD ± 13) h. No association between demographic characteristics, comorbid conditions or polysomnographic parameters and post-operative complications were noted. A total of 194 (90.7%) children stayed only one night in hospital (median 1 day, range 1-5 days). CONCLUSION The previously identified risk factors and criteria for PICU admission need revision, and new recommendations are necessary.
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Affiliation(s)
- Surendran Thavagnanam
- Department of Paediatrics, University of Malaya, Kuala Lumpur, Malaysia.,University Malaya Paediatric and Child Health Research Group, University of Malaya, Kuala Lumpur, Malaysia
| | - Saou Y Cheong
- Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Karuthan Chinna
- Department of Social and Preventive Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Anna M Nathan
- Department of Paediatrics, University of Malaya, Kuala Lumpur, Malaysia.,University Malaya Paediatric and Child Health Research Group, University of Malaya, Kuala Lumpur, Malaysia
| | - Jessie A de Bruyne
- Department of Paediatrics, University of Malaya, Kuala Lumpur, Malaysia.,University Malaya Paediatric and Child Health Research Group, University of Malaya, Kuala Lumpur, Malaysia
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Saur JS, Brietzke SE. Response to Letter to the Editor regarding article titled "Polysomnography results versus clinical factors to predict postoperative respiratory complications following pediatric adenotonsillectomy". Int J Pediatr Otorhinolaryngol 2018; 105:189-190. [PMID: 29273274 DOI: 10.1016/j.ijporl.2017.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 12/04/2017] [Indexed: 10/18/2022]
Affiliation(s)
- John S Saur
- Walter Reed National Military Medical Center, Bethesda, MD 20889, United States
| | - Scott E Brietzke
- Joe DiMaggio Children's Hospital at Memorial, Hollywood, FL 33021, United States; Walter Reed National Military Medical Center, Bethesda, MD 20889, United States.
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Saur JS, Brietzke SE. Polysomnography results versus clinical factors to predict post-operative respiratory complications following pediatric adenotonsillectomy. Int J Pediatr Otorhinolaryngol 2017; 98:136-142. [PMID: 28583490 DOI: 10.1016/j.ijporl.2017.05.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 05/06/2017] [Accepted: 05/08/2017] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Systematically review the published literature comparing the presence of clinical features (age, BMI, co-morbidities, etc.) versus polysomnogram (PSG) results in the prediction of major post-operative respiratory complications following pediatric adenotonsillectomy (T/A) for the treatment of Obstructive Sleep Apnea Syndrome (OSAS). METHODS A systematic review of the PUBMED and EMBASE databases was performed to identify studies containing both clinical and PSG data predicting major post-operative respiratory complications following T/A. Inclusion criteria included English language and extractable data. Major respiratory complications were defined as events that required significant intervention (intubation, CPAP,etc.) and/or altered patient disposition. Random effect modeling was performed and study quality was assessed using the Newcastle-Ottawa Scale. RESULTS Twenty-two studies met the inclusion criteria with a median sample size of 157 (range 26-1735) and published between 1992 and 2015. The most common study design was a case series. Most studies included multiple patients at high risk for respiratory complications (Syndromic, obese, etc.). The summary estimate of the major respiratory complication rate following T/A was only 5.8% (95% CI = 4.2-7.4%, p < 0.001, I2 = 99%). For studies with extractable data, 102 of 112 patients (91.1%) with a post-operative respiratory complication had a clearly identifiable clinical risk factor, the remainder (8.9%) had only moderate or severe OSAS on PSG and no other predictor. CONCLUSION The major respiratory complication rate following pediatric T/A for OSAS is low even amongst series of high risk patients. The majority of the published literature report that readily identified clinical factors predict the large majority of post-operative respiratory complications following T/A.
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Affiliation(s)
- John S Saur
- Walter Reed National Military Medical Center, USA
| | - Scott E Brietzke
- Walter Reed National Military Medical Center, USA; Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, USA.
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Pringle MB, Natesh BG, Buchanan EM. National UK survey on the assessment and surgical management of suspected paediatric obstructive sleep apnoea syndrome. Int J Pediatr Otorhinolaryngol 2013; 77:1689-96. [PMID: 24001617 DOI: 10.1016/j.ijporl.2013.07.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Revised: 07/27/2013] [Accepted: 07/29/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Controversy exists amongst ENT surgeons as to the best way to manage a non-syndromal and otherwise healthy child with suspected OSAS. In 2002, The American Association of Paediatricians stated that the gold standard is a full polysomnography (PSG) for all children with suspected OSA and the revised version in 2012 repeated that requirement but recognized that facilities are not always available. In 2009 a UK Multidisciplinary Consensus Statement disagreed and reserved a full PSG for younger and syndromal or complicated children. We undertook a survey of UK ENT surgeons before and after the UK Consensus Statement to identify common practice with regards to diagnosis and management of suspected paediatric obstructive sleep apnoea syndrome in the UK. METHOD A questionnaire based on the management of a typical clinical case was sent to 542 ENT consultants in 2005 and repeated in 2011. RESULTS Less than 2% used PSG in assessing the child presented in our case study in both surveys. About 70% of respondents indicated that they would proceed with management of the child with no form of sleep study at all and this clinical practice has not changed after UK Multidisciplinary Consensus Statement. The majority would treat a child with possible OSAS and no co-morbidities with adenotonsillectomy as an inpatient. DISCUSSION The availability of paediatric PSG is very limited and because of a lack of normative data, uncertainty about interpretation of abnormal results, the recognition that even moderate snoring without sleep apnoea has detrimental neuro-cognitive effects and the fact that adenotonsillectomy is a very effective treatment for paediatric OSA we felt that a pragmatic and safe approach was to treat selected patients as if they had a positive PSG with appropriate anaesthetic technique and post operative care and monitoring.
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Clinical and Polysomnographic Correlation in Sleep-related Breathing Disorders in Children. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2013. [DOI: 10.1016/j.otoeng.2013.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Esteller E, Santos P, Segarra F, Estivill E, Lopez R, Matiñó E, Ademà JM. Clinical and polysomnographic correlation in sleep-related breathing disorders in children. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2012; 64:108-14. [PMID: 23141633 DOI: 10.1016/j.otorri.2012.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 07/30/2012] [Accepted: 08/03/2012] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Although polysomnography is the gold standard test for sleep-disordered breathing in children, there is controversy about its indication in all cases. Among the arguments both for and against is the lack of correlation between objective values and the symptoms. OBJECTIVE To evaluate the correlation between clinical data and apnea-hypopnoea index (AHI) in our work environment. MATERIAL AND METHODS We compared the preoperative clinical symptoms and AHI statistically in 170 children with sleep-disordered breathing who underwent polysomnography. We also analysed the correlation to postoperative level, with a subgroup of 80 children who underwent adenotonsillectomy with 1 year of polysomnography follow-up. RESULTS Before surgery, only the degree of tonsillar hypertrophy was statistically significant correlated with AHI. At post-operative follow-up, evidence of correlation between AHI and apnoea was observed: 38.1% of children improved in the group with persistence and 66.7% in the disease resolution group (P=.023). In addition, the correlations showed the level of improvement of snoring, as assessed by visual analogue scale. The mean was 5 points lower in the persistent group and 6.1 lower in the disease resolution group (P=.047). CONCLUSION Despite the limitations in the correlation between clinical data and polysomnography, especially in preoperative results, polysomnography remains the gold standard diagnostic tool. Efforts should be made to obtain objective parameters that provide higher levels of correlation.
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Affiliation(s)
- Eduard Esteller
- Servicio de Otorrinolaringología, Hospital General de Catalunya, San Cugat del Vallès, Barcelona, Spain.
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Kim JK, Lee JH, Lee SH, Hong SC, Cho JH. Effects of sleep-disordered breathing on physical traits, school performance, and behavior of Korean elementary school students in the upper grade levels. Ann Otol Rhinol Laryngol 2012; 121:348-54. [PMID: 22724282 DOI: 10.1177/000348941212100511] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES We investigated the physical traits, school performance, and behavior of Korean children with sleep-disordered breathing (SDB). METHODS We recruited 679 students from an elementary school in Seoul, Korea. We used a survey to collect information on the absence or presence of SDB at both the child's preschool age and his or her current age and on the degree of behavioral disturbance. Physical traits and examination scores were also analyzed. We divided the children into 4 groups: non-SDB group, past SDB group, recent SDB group, and continuous SDB group. Comparisons between these four groups were conducted. RESULTS Sixty-one students were excluded because of incomplete information. The current body mass index was significantly higher in the past (19.7 +/- 3.6), recent (21.2 +/- 3.6), and continuous SDB groups (20.7 +/- 3.9) than in the non-SDB group (18.8 +/- 3.2), but only for male students (p < 0.001). The examination scores were not different among the four groups, but the behavioral disturbance scores were much higher in the past, recent, and continuous SDB groups than in the non-SDB group for both genders. CONCLUSIONS Among these Korean elementary school students in the upper grade levels, the presence of current or past SDB appeared to influence the current body mass index in boys and the presence of behavioral disturbances in both genders. However, SDB was not associated with school performance.
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Affiliation(s)
- Jin Kook Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Konkuk University, Seoul, Korea
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Lee PC, Hwang B, Soong WJ, Meng CCL. The specific characteristics in children with obstructive sleep apnea and cor pulmonale. ScientificWorldJournal 2012; 2012:757283. [PMID: 22645449 PMCID: PMC3356724 DOI: 10.1100/2012/757283] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2011] [Accepted: 01/19/2012] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The prevalence of obstructive sleep apnea (OSA) in the pediatric population is currently estimated at 1-2% of all children. The purpose of this study was to investigate the clinical and hemodynamic characteristics in pediatric patients with cor pulmonale and OSA. METHODS Thirty children with the diagnosis of OSA were included. These patients consisted of 26 male and 4 female children with a mean age of 7 ± 4 years old. Five of those children were found to be associated with cor pulmonale, and 25 had OSA but without cor pulmonale. RESULTS The arousal index was much higher in children with OSA and cor pulmonale. The children with OSA and cor pulmonale had much lower mean and minimal oxygen saturation and a higher incidence of bradycardia events. All 5 patients with OSA and cor pulmonale underwent an adenotonsillectomy, and the pulmonary arterial pressure dropped significantly after the surgery. CONCLUSION This study demonstrated that the OSA pediatric patients with cor pulmonale had the different clinical manifestations and hemodynamic characteristics from those without cor pulmonale. The adenotonsillectomy had excellent results in both the OSA pediatric patients with and without cor pulmonale.
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Affiliation(s)
- Pi-Chang Lee
- Division of Pediatric Cardiology, Departments of Pediatrics, National Yang-Ming University and Taipei Veterans General Hospital, No 201 Sec 2, Shih-Pai Road, Taipei 112, Taiwan. pichang
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Kim JK, Lee JH, Lee SH, Hong SC, Cho JH. School Performance and Behavior of Korean Elementary School Students with Sleep-Disordered Breathing. Ann Otol Rhinol Laryngol 2011; 120:268-72. [DOI: 10.1177/000348941112000409] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: It is known that children with sleep-disordered breathing (SDB) often have accompanying growth retardation and learning and behavior disabilities. However, these results are based mainly on studies of children from European and North American countries. The objective of this study was to investigate the school performance and behavior of Korean children with SDB. Methods: We enrolled 302 third-grade elementary students from an elementary school in Seoul. A survey was conducted, using information from the children's parents for the diagnosis of SDB. The children's height, weight, midterm examination scores, and behavioral disturbances were analyzed. Results: Overall, 299 parents returned the survey. Of the 299 students, 29 (9.7%) were considered to have SDB. They showed no difference from the control in terms of body mass index. The mean examination score was higher in the control group than in the SDB group. However, there was a statistical difference only in social science. The prevalences of students who were inattentive (58.6% versus 23.7%) and lacking in self-control (44.8% versus 14.1%) were significantly higher among students with SDB. Conclusions: SDB is not closely associated with poor school performance among Korean elementary students. However, behavioral disturbance is more frequent among the students with SDB than in those without.
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Wise MS, Nichols CD, Grigg-Damberger MM, Marcus CL, Witmans MB, Kirk VG, D'Andrea LA, Hoban TF. Executive summary of respiratory indications for polysomnography in children: an evidence-based review. Sleep 2011; 34:389-98AW. [PMID: 21359088 PMCID: PMC3041716 DOI: 10.1093/sleep/34.3.389] [Citation(s) in RCA: 120] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE This comprehensive, evidence-based review provides a systematic analysis of the literature regarding the validity, reliability, and clinical utility of polysomnography for characterizing breathing during sleep in children. Findings serve as the foundation of practice parameters regarding respiratory indications for polysomnography in children. METHODS A task force of content experts performed a systematic review of the relevant literature and graded the evidence using a standardized grading system. Two hundred forty-three evidentiary papers were reviewed, summarized, and graded. The analysis addressed the operating characteristics of polysomnography as a diagnostic procedure in children and identified strengths and limitations of polysomnography for evaluation of respiratory function during sleep. RESULTS The analysis documents strong face validity and content validity, moderately strong convergent validity when comparing respiratory findings with a variety of relevant independent measures, moderate-to-strong test-retest validity, and limited data supporting discriminant validity for characterizing breathing during sleep in children. The analysis documents moderate-to-strong test-retest reliability and interscorer reliability based on limited data. The data indicate particularly strong clinical utility in children with suspected sleep related breathing disorders and obesity, evolving metabolic syndrome, neurological, neurodevelopmental, or genetic disorders, and children with craniofacial syndromes. Specific consideration was given to clinical utility of polysomnography prior to adenotonsillectomy (AT) for confirmation of obstructive sleep apnea syndrome. The most relevant findings include: (1) recognition that clinical history and examination are often poor predictors of respiratory polygraphic findings, (2) preoperative polysomnography is helpful in predicting risk for perioperative complications, and (3) preoperative polysomnography is often helpful in predicting persistence of obstructive sleep apnea syndrome in patients after AT. No prospective studies were identified that address whether clinical outcome following AT for treatment of obstructive sleep apnea is improved in association with routine performance of polysomnography before surgery in otherwise healthy children. A small group of papers confirm the clinical utility of polysomnography for initiation and titration of positive airway pressure support. CONCLUSIONS Pediatric polysomnography shows validity, reliability, and clinical utility that is commensurate with most other routinely employed diagnostic clinical tools or procedures. Findings indicate that the "gold standard" for diagnosis of sleep related breathing disorders in children is not polysomnography alone, but rather the skillful integration of clinical and polygraphic findings by a knowledgeable sleep specialist. Future developments will provide more sophisticated methods for data collection and analysis, but integration of polysomnographic findings with the clinical evaluation will represent the fundamental diagnostic challenge for the sleep specialist.
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Affiliation(s)
- Merrill S Wise
- Methodist Healthcare Sleep Disorders Center, Memphis, TN, USA
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Aurora RN, Zak RS, Karippot A, Lamm CI, Morgenthaler TI, Auerbach SH, Bista SR, Casey KR, Chowdhuri S, Kristo DA, Ramar K. Practice parameters for the respiratory indications for polysomnography in children. Sleep 2011; 34:379-88. [PMID: 21359087 PMCID: PMC3041715 DOI: 10.1093/sleep/34.3.379] [Citation(s) in RCA: 243] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND 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. METHODS 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) CONCLUSIONS 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.
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Esteller Moré E, Segarra Isern F, Huerta Zumel P, Enrique Gonzalez A, Matiñó Soler E, Manel Ademà Alcover J. Efectividad clínica y polisomnográfica de la adenamigdalectomía en el tratamiento de los trastornos respiratorios del sueño en los niños. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2008. [DOI: 10.1016/s0001-6519(08)75551-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Esteller Moré E, Segarra Isern F, Huerta Zumel P, Enrique González A, Matiñó Soler E, Ademà Alcover JM. Clinical Efficacy and Polysomnography of Adenotonsillectomy in the Treatment of Sleep-Related Respiratory Disorders in Children. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/s2173-5735(08)70248-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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