Obstructive Sleep Apnea in Children and Adolescents and the Risk of Major Adverse Cardiovascular Events: A Nationwide Cohort Study in Taiwan

A Comprehensive Review of Pediatric Obstructive Sleep Apnea: From Assessment to Intervention

Pediatric obstructive sleep apnea (OSA) is a prevalent sleep disorder characterized by upper airway obstruction during sleep, leading to oxygen desaturation and sleep disruptions. This comprehensive review examines the epidemiology, pathophysiology, clinical manifestations, diagnostic approaches, consequences, management strategies, challenges, and future directions of pediatric OSA. Prevalence rates vary globally, with notable associations found between OSA and obesity. The review explores the anatomical and neuromuscular factors contributing to airway obstruction, emphasizing the importance of timely identification and intervention to mitigate long-term health implications. Diagnostic tools such as polysomnography (PSG) are essential, although challenges in accessibility exist. Pediatric OSA is linked to various health issues, including cardiovascular complications, metabolic disturbances, and neurocognitive impairments. Treatment options range from surgical interventions like adenotonsillectomy to non-pharmacological therapies and pharmacotherapy. Challenges in diagnosis and treatment warrant research into innovative diagnostic approaches and refining clinical prediction rules. Addressing these areas will enhance clinical management and outcomes for children with OSA.

Global longitudinal strain and the risk of major adverse cardiac events in post-myocardial infarction patients: A retrospective cohort study

BACKGROUND

This study evaluates the relationship between global longitudinal strain (GLS) and late major adverse cardiovascular events (MACEs) in patients after acute myocardial infarction (AMI).

METHODS

Data of newly diagnosed AMI patients between March 2010 and July 2014 were retrospectively evaluated. The patients underwent serial echocardiography at admission and at third and sixth months post-admission. We calculated GLS by averaging the strain from all myocardial segments using speckle-tracking echocardiography (STE). We used multivariate Cox regression analysis and receiver operating characteristic (ROC) curve analyses to assess the relationship between GLS at admission and late MACEs.

RESULTS

Eighty-nine newly diagnosed AMI patients were enrolled. The average age at diagnosis was 61 ± 12.5 years, and approximately 89.9% of the patients were men. The average level of GLS was -17.5 ± 3.9%. The overall prevalence of MACEs was 23.6% (21/89), compared with 44% (11/25) in the group with GLS≥-15% and 17.9% (5/28) in the group with GLS<-20%. GLS was positively linked with MACEs in the fully adjusted Cox proportional hazard model (hazard ratio [HR], 1.19; 95% confidence interval [CI], 1.04-1.37; P=0.014) after adjusting potential confounders. The ROC curve analysis for one year MACEs between GLS at admission, with the most significant area under the curve(AUC) 78.1% (95% CI, 63.8% - 92.6%).

CONCLUSIONS

Myocardial dysfunction, characterized by impaired GLS, is often observed in AMI patients, and a decrease in GLS levels at admission were associated with an increased risk of long-term MACEs in post-myocardial infarction patients.

Cardiovascular Burden of Narcolepsy Disease (CV-BOND): a real-world evidence study

STUDY OBJECTIVES

Narcolepsy is associated with cardiovascular risk factors; however, the risk of new-onset cardiovascular events in this population is unknown. This real-world study evaluated the excess risk of new-onset cardiovascular events in U.S. adults with narcolepsy.

METHODS

A retrospective cohort study using IBM MarketScan administrative claims data (2014-2019) was conducted. A narcolepsy cohort, comprising adults (≥18 years) with at least two outpatient claims containing a narcolepsy diagnosis, of which at least one was non-diagnostic, was matched to a non-narcolepsy control cohort (1:3) based on cohort entry date, age, sex, geographic region, and insurance type. The relative risk of new-onset cardiovascular events was estimated using a multivariable Cox proportional hazards model to compute adjusted hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

The narcolepsy and matched non-narcolepsy control cohorts included 12 816 and 38 441 individuals, respectively. At baseline, cohort demographics were generally similar; however, patients with narcolepsy had more comorbidities. In adjusted analyses, the risk of new-onset cardiovascular events was higher in the narcolepsy cohort compared with the control cohort: any stroke (HR [95% CI], 1.71 [1.24, 2.34]); heart failure (1.35 [1.03, 1.76]); ischemic stroke (1.67 [1.19, 2.34]); major adverse cardiac event (1.45 [1.20, 1.74]); grouped instances of stroke, atrial fibrillation, or edema (1.48 [1.25, 1.74]); and cardiovascular disease (1.30 [1.08, 1.56]).

CONCLUSION

Individuals with narcolepsy are at increased risk of new-onset cardiovascular events compared with individuals without narcolepsy. Physicians should consider cardiovascular risk in patients with narcolepsy when weighing treatment options.

Impact of obstructive sleep apnea in cardiovascular risk in the pediatric population: A systematic review

While the association of obstructive sleep apnea (OSA) with an increased cardiovascular risk (CVR) in the adult population is well known, there is insufficient evidence to affirm something similar in the pediatric population. On the other hand, adenotonsillectomy has been shown to be an effective treatment. Our objective was to evaluate the association of sleep respiratory disorders in children with increased CVR and the impact of adenotonsillectomy in the literature. To this aim, a literature search was conducted, between 2002 to the present. After carrying out a systematic review, the following results were provided: thoracic echocardiography after surgery found improvements in terms of cardiac function and structure; blood pressure (BP) measurement, verified a tendency to higher BP values in the OSA pediatric population, which improved after surgery; different biomarkers of CVR, were increased in OSA patients and improved after treatment and finally; some studies found endothelial dysfunction in pediatric OSA, a measurement of vascular system function, was reversible with adenotonsillectomy. Increases in BP parameters, biological markers related to CVR and alterations in cardiac function structure, have been reported in pediatric patients with OSA. At least, some of these parameters would be reversible after adenotonsillectomy, reflecting a possible reduction in CVR.

Retrospective Analysis of the Airway Space Changes in Dentofacial Deformity after Two-Jaw Orthognathic Surgery Using Cone Beam Computed Tomography

Orthognathic surgery is used to modify anomalies in maxillomandibular position; this process can significantly affect the anatomy of the airway and cause functional changes. This study aims to define the impact of mandibular maxillary movement on the airway of subjects with dentofacial deformity. A retrospective study was conducted on subjects with Angle class II (CII group) and Angle class III (CIII group) dentofacial deformities. The subjects were treated via bimaxillary surgery; for all of them, planning was performed with software and 3D printing. Cone beam computed tomography (CBCT) was obtained 21 days before surgery and 6 months after surgery and was used for planning and follow-up with the same conditions and equipment. Was used the superimposition technique to obtain the maximum and minimum airway areas and total airway volume. The data were analyzed with the Shapiro-Wilk test and Student's t-test, while Spearman's test was used to correlate the variables, considering a value of p < 0.05. Thus, 76 subjects aged 18 to 55 years (32.38 ± 10.91) were included: 46 subjects were in CII group, treated with a maxillo-mandibular advancement, and 30 subjects were in the CIII group, treated with a maxillary advancement and a mandibular setback. In the CII group, a maxillary advancement of +2.45 mm (±0.88) and a mandibular advancement of +4.25 mm (±1.25) were observed, with a significant increase in all the airway records. In the CIII group, a maxillary advancement of +3.42 mm (±1.25) and a mandibular setback of -3.62 mm (±1.18) were noted, with no significant changes in the variables measured for the airway (p > 0.05). It may be concluded that maxillo-mandibular advancement is an effective procedure to augment the airway area and volume in the CII group. On the other hand, in subjects with mandibular prognathism and Angle class III operated with the maxillary advancement and mandibular setback lower than 4 mm, it is possible to not reduce the areas and volume in the airway.

Paediatric sleep apnea event prediction using nasal air pressure and machine learning

Sleep-disordered breathing is an important health issue for children. The objective of this study was to develop a machine learning classifier model for the identification of sleep apnea events taken exclusively from nasal air pressure measurements acquired during overnight polysomnography for paediatric patients. A secondary objective of this study was to differentiate site of obstruction exclusively from hypopnea event data using the model. Computer vision classifiers were developed via transfer learning to either normal breathing while asleep, obstructive hypopnea, obstructive apnea or central apnea. A separate model was trained to identify site of obstruction as either adeno-tonsillar or tongue base. In addition, a survey of board-certified and board-eligible sleep physicians was completed to compare clinician versus model classification performance of sleep events, and indicated very good performance of our model relative to human raters. The nasal air pressure sample database available for modelling comprised 417 normal, 266 obstructive hypopnea, 122 obstructive apnea and 131 central apnea events derived from 28 paediatric patients. The four-way classifier achieved a mean prediction accuracy of 70.0% (95% confidence interval [67.1-72.9]). Clinician raters correctly identified sleep events from nasal air pressure tracings 53.8% of the time, whereas the local model was 77.5% accurate. The site of obstruction classifier achieved a mean prediction accuracy of 75.0% (95% confidence interval [68.7-81.3]). Machine learning applied to nasal air pressure tracings is feasible and may exceed the diagnostic performance of expert clinicians. Nasal air pressure tracings of obstructive hypopneas may "encode" information regarding the site of obstruction, which may only be discernable by machine learning.

Diagnosis and Treatment of Sleep Apnea in Children: A Future Perspective Is Needed

Obstructive sleep apnea (OSA) in children is a prevalent, but still, today, underdiagnosed illness, which consists of repetitive episodes of upper airway obstruction during sleep with important repercussions for sleep quality. OSA has relevant consequences in the pediatric population, mainly in the metabolic, cardiovascular (CV), and neurological spheres. However, contrary to adults, advances in diagnostic and therapeutic management have been scarce in the last few years despite the increasing scientific evidence of the deleterious consequences of pediatric OSA. The problem of underdiagnosis and the lack of response to treatment in some groups make an update to the management of OSA in children necessary. Probably, the heterogeneity of OSA is not well represented by the classical clinical presentation and severity parameters (apnea/hypopnea index (AHI)), and new strategies are required. A specific and consensus definition should be established. Additionally, the role of simplified methods in the diagnosis algorithm should be considered. Finally, the search for new biomarkers for risk stratification is needed in this population. In conclusion, new paradigms based on personalized medicine should be implemented in this population.

Effect of Preoperative Weight Status and Disease Presentation on Postoperative Elevated Blood Pressure After Childhood Adenotonsillectomy

OBJECTIVE

To investigate the risk factors of postoperative elevated blood pressure (BP) in children with childhood obstructive sleep apnea syndrome (OSAS) after adenotonsillectomy (AT).

STUDY DESIGN

Case series with planned data collection.

SETTING

Tertiary referral center.

METHODS

Two hundred forty-five consecutive children (180 boys and 65 girls, median age 6.6 years) with polysomnography-diagnosed OSAS who underwent AT between January 2010 and August 2019. Clinical, polysomnographic, and evening BP data were assessed preoperatively and postoperatively (≥3 months after AT). Changes in the variables before and after AT and between individuals with and without hypertension were compared.

RESULTS

Postoperatively, the median (interquartile range) apnea-hypopnea index significantly decreased from 10.4 (5.3-22.6) to 2.2 (1.0-3.8) events/h. In addition, the mean (standard deviation) evening diastolic BP z-score significantly decreased from 0.7 (0.94) to 0.5 (0.81) in the overall cohort, and both systolic (2.1 [0.94]-1.0 [1.31]) and diastolic BP z-scores (1.6 [0.98]-0.7 [0.85]) significantly decreased in the preoperative elevated BP subgroup. Multivariate logistic regression analysis showed that preoperative obesity (adjusted odds ratio = 4.36, 95% confidence interval = 2.24-8.49) and mean peripheral oxygen saturation <95% during sleep (adjusted odds ratio = 2.73, 95% confidence interval = 1.29-5.79) were independently associated with postoperative elevated BP.

CONCLUSION

Preoperative obesity and mean peripheral oxygen saturation <95% during sleep were significantly associated with postoperative elevated BP in the children with OSAS, further indicating the importance of careful BP monitoring in this subgroup despite AT treatment.

Efficacy of obstructive sleep apnea treatment by antileukotriene receptor and surgery therapy in children with adenotonsillar hypertrophy: A descriptive and cohort study

Background

Prevalence of obstructive sleep apnea (OSA) in children with adenotonsillar hypertrophy is high and related to the occlusion of the upper airway. The main treatments of OSA in these children is adenotonsillectomy. However, this intervention is an invasive method with a various success rate. Thus, the indications of tonsillectomy remain debatable and non-invasive treatment is still a potential choice in these patients.

Methods

It was a cross-sectional and interventional study. This study included children aged from 2 to 12 years-old who were diagnosed with OSA by respiratory polygraphy and had tonsillar hypertrophy with/without adenoid hypertrophy. All main data including age, gender, height, weight, body mass index (BMI), clinical symptoms, and medical history were recorded for analysis. Physical examination and endoscopy were done to evaluate the size of tonsillar and adenoid hypertrophy by using Brodsky and Likert classifications, respectively. The severity of OSA was done by using the classification of AHI severity for children.

Results

There were 114 patients (2–12 years old) with a mean age of 5.5 ± 2.1 years included in the present study. The main reasons for consultations were snoring (96.7%), a pause of breathing (57.1%), an effort to breathe (36.8%), unrefreshing sleep (32%), doziness (28.2%), and hyperactivity (26.3%). There were 36% of subjects with tonsillar hypertrophy grade 1–2, 48.2% with grade 3, and 15.8% with grade 4 (Brodsky classification); among them, there were 46.5% of subjects with grades 1–2 of adenoid hypertrophy, 45.6% with grade 3, and 7.0% with grade 4 (Likert classification). The mean AHI was 12.6 ± 11.2 event/h. There was a significant correlation between the mean AHI and the level of tonsillar and adenoid hypertrophy severity (r = 0.7601 and r = 0.7903; p &lt; 0.05 and p &lt; 0.05, respectively). The improvement of clinical symptoms of study subjects was found in both groups treated with ALR (antileukotriene receptor) or ST (surgery therapy). The symptoms related to OSA at night including snoring, struggle to breathe, sleeping with the mouth open, and stopping breathing during sleep were significantly improved after treatment with ATR and with ST (p &lt; 0.001 and p = 0.001, respectively). The mean AHI was significantly reduced in comparison with before treatment in study subjects treated with ALR (0.9 ± 1.0 vs. 3.9 ± 2.7 events/h; p = 0.001) or with ST (3.5 ± 1.4 vs. 23.4 ± 13.1 events/h; p &lt; 0.001).

Conclusion

The treatment of OSA due to adeno-tonsillar hypertrophy with ALR for moderate OSA or surgery for severe OSA might reduce the symptoms related to OSA at night and during the day.

Office Blood Pressure Monitoring in Children with Obesity and Obstructive Sleep Apnea

OBJECTIVE

To investigate the relative contributions of obesity and obstructive sleep apnea (OSA) to unfavorable blood pressure in children.

STUDY DESIGN

Children aged 3-18 years with OSA-related symptoms were recruited. All children underwent office blood pressure (BP) monitoring and full-night polysomnography. Obesity was defined as a body mass index ≥95th percentile. OSA severity was divided into primary snoring (apnea-hypopnea index [AHI] <1), mild OSA (5> AHI ≥1), and moderate to severe OSA (AHI ≥5). Age- and sex-adjusted logistic regression analysis was performed to determine the associations among OSA, obesity, and elevated BP.

RESULTS

This cross-sectional study enrolled 1689 children (66% boys), with a mean age of 7.9 years. Compared with children with primary snoring, children with moderate to severe OSA had significantly higher systolic BP (108.1 mmHg vs 105.6 mmHg), diastolic BP (75.0 mmHg vs 70.4 mmHg), systolic BP percentile (75.0 vs 70.4), and diastolic BP percentile (74.0 vs 69.2). The rate of unfavorable BP (ie, elevated BP or hypertension level BP) also was significantly higher in children with more severe OSA. Children with obesity had higher BP and BP percentile. Logistic regression analysis revealed that children with obesity and moderate to severe OSA have a 3-fold greater risk of unfavorable BP compared with children without obesity and primary snoring.

CONCLUSIONS

We identified a 3-fold greater risk of unfavorable BP in children with obesity and moderate to severe OSA.

24-Hour Ambulatory Blood Pressure Variability in Children with Obstructive Sleep Apnea

OBJECTIVE

To evaluate blood pressure (BP) variability in 24-hour ambulatory BP monitoring in children with obstructive sleep apnea (OSA).

STUDY DESIGN

Case series study.

METHODS

Children aged 4 to 16 years with clinical symptoms were recruited in a tertiary medical center. Overnight polysomnography and 24-hour recordings of ambulatory BP were performed for each child. The severity of OSA was classified as primary snoring (apnea-hypopnea index [AHI] < 1), mild OSA (1 ≤ AHI < 5), moderate OSA (10 > AHI ≥ 5), and severe OSA (AHI ≥ 10). The standard deviation of mean BP was used as an indicator of BP variability.

RESULTS

A total of 550 children were included (mean age: 7.6 years; 70% were boys; 20% were obese). Compared with the children with primary snoring, children with severe OSA exhibited significantly higher nighttime systolic BP (108.0 vs. 100.5 mmHg, P < .001), nighttime diastolic BP (58.9 vs 55.6 mmHg, P = .002), nighttime mean arterial pressure (75.3 vs. 70.5 mmHg, P < .001), nighttime systolic BP load (40.5% vs. 25.0%, P < .001), nighttime diastolic BP load (25.3% vs. 12.9%, P < .001), and nighttime systolic BP variability (11.4 vs. 9.6, P = .001). Multiple linear regression analyses revealed an independent association between AHI and nighttime systolic BP variability (regression coefficient = 0.31, 95% CI = 0.06-0.56, P = .015) after adjustment for age, gender, adiposity, and hypertensive status.

CONCLUSIONS

OSA in children is associated with increased BP and BP variability.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:2126-2132, 2021.

Effect of Adenotonsillectomy on Cardiac Function in Children Age 5-13 Years With Obstructive Sleep Apnea

Changes in left ventricular structure and function have been previously described in children with obstructive sleep apnea (OSA). We aimed to determine if these structural and functional cardiac changes are reversible after treatment of OSA with adenotonsillectomy. Children aged 5 to 13 years with OSA and matched healthy controls were recruited. Adenotonsillectomy occurred within 1 month after diagnosis. Echocardiography and polysomnography were repeated postoperatively. Linear mixed models were fitted to echocardiography measures at baseline and follow-up to assess the effect of OSA on cardiac structure and function. These adjusted for age, gender, race, body mass index, systolic, and diastolic blood pressure. The study sample included 373 children, 199 with OSA and 174 healthy controls. In the control group, 114 children completed the study and 112 completed the study in the OSA group. Children with OSA had reduced diastolic function, lower systolic function, and greater left ventricular mass index at baseline compared with healthy controls (all p < 0.05). Measures of active relaxation, elastic recoil and lengthening of the left ventricle impacted overall diastolic function; each of these worsened with increasing OSA severity. Postoperatively, diastolic function improved in children with OSA compared with controls. There were not significant changes in LV mass index or geometry. In conclusion, children with OSA have impaired left ventricular relaxation during diastole indicating early stage diastolic dysfunction. Adenotonsillectomy for OSA signficantly improved diastolic function. Left ventricular remodeling did not change with improvement of OSA.

Increased risk of major depressive disorder in sleep apnea patients in Taiwan

The association between sleep apnea (SA) and depression had been reported in a few previous studies. However, whether SA increases the risk of major depressive disorder (MDD) has not been studied comprehensively in a large-scale study. We performed this population-based cohort study to assess the association between SA and MDD. We identified adult patients having SA from the Taiwan National Health Insurance Research Database and excluded those having MDD before SA diagnosis. Thirty control subjects were randomly selected to match to each SA patient by age and sex. Totally, 10,259 SA patients were matched to 102,590 control subjects. The incidence rate and cumulative incidence of MDD were significantly higher in SA patients than in the control subjects (both p < 0.0001). Multivariable Cox regression analysis showed that SA remained an independent risk factor for incident MDD after adjusting for age, sex, residency, income level, and comorbidities (hazard ratio = 2.9 [95% CI 2.8–3.1], p < 0.0001). In summary, SA patients have an increased risk to develop MDD. Physicians caring for SA patients must pay attention to their psychosocial health status.

The cardiovascular risk in paediatrics: the paradigm of the obstructive sleep apnoea syndrome

BACKGROUND

Obstructive sleep apnoea syndrome (OSAS) describes a spectrum of abnormal breathing patterns during sleep characterised by snoring, increased upper airway resistance and pharyngeal collapsibility, with alteration of normal oxygenation and ventilation. Intermittent desaturations during sleep have multi-organ implications. Adults with OSAS have an increased risk of developing a dysfunctional endothelium that is characterised by greater adherence of inflammatory mediators to endothelial cells and hypercoagulability. There is increasing evidence to show that risk factors for comorbid cardiovascular disease (CVD) can develop during childhood and adolescence and are likely to continue over time. Risk factors for CVD include both modifiable factors and factors that cannot be changed.

MATERIALS AND METHODS

Using the MEDLINE^® electronic database, we reviewed the scientific literature for published studies evaluating the association between sleep-disordered breathing and cardiovascular damage in children.

RESULTS

In this review, we show the role of blood markers in demonstrating the inflammation caused by intermitted oxygen desaturations during sleep in both healthy and obese children. Several instrumental techniques, in addition to serum biomarkers, can be used to assess vascular endothelial damage and its deterioration in the form of a pre-atherosclerotic condition. The confirmation of their role as markers of inflammation and vascular damage is supported by normalisation after resolution or improvement of the sleep-disordered breathing with surgery.

DISCUSSION

Great attention should be given to this condition in infants and children as it will significantly affect their present and future well-being as they grow into adulthood. Healthcare professionals, especially paediatricians, should be trained to recognise the signs and symptoms of the disease in order to send children forward for specialist care in centres dealing with sleep-disordered breathing.

Obstructive sleep apnea syndrome and neuropsychological function in pediatric stroke

OBJECTIVES

To assess the prevalence of obstructive sleep apnea syndrome (OSAS) in children with arterial ischemic stroke (AIS) and to evaluate its association with neuropsychological outcomes.

METHODS

We conducted a cross-sectional study of sleep health and neuropsychological outcome in children with AIS. A consecutive cohort of children attending a stroke clinic were assessed using a standardized pediatric sleep questionnaire (PSQ) and standardized measures of pediatric stroke outcome and intellectual, executive and adaptive function. High risk for OSAS was defined as PSQ score ≥0.33.

RESULTS

Overall, 102 children were included (55% males, median age: 9 years [interquartile-range [IQR]: 6-14]). The prevalence of OSAS in children with AIS was significantly higher compared to published normative prevalence rate (25.5% vs 5%, p < 0.001). Children with OSAS were more likely to have infarcts affecting both the anterior and posterior circulation (37.5% vs 9.5%, p = 0.021). In addition, children with OSAS had significantly higher median Pediatric Stroke Outcome Measure (PSOM) scores (2 [IQR: 0-2] vs 1 [IQR: 1-3.5], p = 0.01) and were more likely to be prescribed concomitant medications affecting sleep architecture (50% vs 22.4%, p = 0.007). OSAS was associated with significantly lower scores on intellectual, memory, cognitive, behavioral, attention, executive and adaptive function scales. The association between PSQ and intellectual ability and working memory remained statistically significant upon controlling for potential confounding factors including stroke related characteristics (neurologic impairment and arterial territory).

CONCLUSIONS

The prevalence of OSAS in children with AIS compared to healthy controls is significantly elevated and is associated with poor neuropsychological outcomes. We highlight the importance of regular screening for OSAS - a modifiable risk factor - in children with AIS. The specific risk factors for OSAS and the potential benefits of therapeutic interventions in this patient population warrant further investigation.

Stimulants associated with reduced risk of hospitalization for motor vehicle accident injury in patients with obstructive sleep apnea-a nationwide cohort study

Background

The risk of injury directly related to hospitalization for motor vehicle accidents (MVAs) in the obstructive sleep apnea (OSA) patients has not been thoroughly understood. Our study aimed to examine the association between the OSA and the hospitalization for an MVA injury.

Methods

This retrospective cohort study used Taiwan’s National Health Insurance Research Database (NHIRD) between 2000 and 2015. The OSA patients aged ≥20 years by age, sex, and index-year matched by non-OSA controls were enrolled (1:3). We used the Cox proportional regression model to evaluate the association between the OSA and the hospitalization for an MVA injury.

Results

The incidence rate of hospitalization for an MVA injury was higher in the OSA cohort (N = 3025) when compared with the non-OSA controls (N = 9075), as 575.3 and 372.0 per 100,000 person-years, respectively (p < 0.001). The Kaplan-Meier analysis showed that the OSA cohort had a significantly higher incidence of hospitalization for the MVA injury (log-rank test, p < 0.001). After adjusting for the covariates, the risk of hospitalization for the MVA injury among the OSA was significantly higher (hazard ratio [HR] =2.18; 95% confidence interval [CI] = 1.79–2.64; p < 0.001). Stimulants usage was associated with a nearly 20% decrease in the risk of an overall hospitalization for an MVA injury in the OSA patients.

Conclusions

This study provides evidence that patients with OSA are at a two-fold higher risk of developing hospitalization for an MVA injury, and the usage of modafinil and methylphenidate was associated with a lower risk of an overall hospitalization for the MVA injury.

[Obstructive sleep disordered breathing and orthodontics: primum non nocere]

Obstructive sleep apnoea syndrome is a widespread and under-diagnosed condition, making it a major public health and safety issue. The objective of this article was to clarify some of the evidence-based elements of therapeutic decision-making and the information provided to the patient and family on the benefit-cost-security ratio of several of his therapeutic options. Published data on the effectiveness of oral appliances and functional orthopaedic appliances for obstructive sleep apnea (OSA) in children, the durability of their effects, the therapeutic possibilities of maxillary or bimaxillary expansion, and the interrelationships between permanent teeth extractions and obstructive sleep disordered breathing, were researched and analyzed. Based on available evidence, in growing patients with Class II malocclusion, treatment with functional orthopedic devices can increase the volume of the pharyngeal airway and thus hopefully reduce the risk of developing OSA. An improvement in the apnea-hypopnea index and lower oxygen saturation was observed in children treated with rapid maxillary expansion. Permanent teeth extractions prescribed for the treatment of teeth crowding in an orthodontic age patient do not result in any significant change in the upper airway. The role of the orthodontist in the multidisciplinary team in the screening and management of Obstructive Sleep Disordered Breathing (OSDB) is essential. By combining clinical experience with published data on various therapeutic approaches, the orthodontist helps the patient to benefit from better adapted care and a more sustainable outcome, while taking into account his or her preferences.

[The contribution of orofacial myofunctional reeducation to the treatment of obstructive sleep apnoea syndrome (OSA): a systematic review of the literature]

Obstructive sleep apnoea syndrome (OSA) is a widespread and under-diagnosed condition, making it a major public health and safety problem. Orofacial myofunctional reeducation (OMR) has been shown to be effective in the multidisciplinary treatment of OSA in children, adolescents and adults and is prescribed at several stages of OSA management. The main objective of this systematic literature review was to evaluate the effectiveness of active or passive orofacial myofunctional reeducation (OMR) in the treatment of obstructive sleep apnoea syndrome in children, adolescents and adults. The systematic literature review was undertaken from the three electronic databases: Medline (via PubMed), Cochrane Library, Web of Science Core Collection, and supplemented by a limited grey literature search (Google Scholar) in order to identify the studies evaluating the effectiveness of the OMR on OSA. The primary outcome of interest was a decrease in the Apnea-Hypopnea Index (AHI) of at least five episodes per hour compared to the baseline state. Secondary outcomes were an improvement in subjective sleep quality, sleep quality measured by night polysomnography and subjectively measured quality of life. Only ten studies met all the inclusion criteria. Eight were randomized controlled clinical trials, one was a prospective cohort study and another was a retrospective cohort study. Six studies were devoted to adult OSA and four to pediatric OSA. All included studies were assessed as "low risk of bias" based on the 12 bias risk criteria of the Cochrane Back Review Group. Based on the available evidence, RMO allows a significant reduction in AHI, up to 90.6% in children and up to 92.06% in adults. It significantly reduces the intensity and frequency of snoring, helps reduce daytime sleepiness, limits the recurrence of OSA symptoms after adenoamygdalectomy in children and improves adherence to PPC therapy. Passive RMO, with the assistance provided to the patient by wearing a custom orthosis, increases adherence to reeducation, significantly improves snoring intensity, AHI and significantly increases the upper airway. Published data show that orofacial myofunctional rééducation is effective in the multidisciplinary treatment of OSA in children, adolescents and adults and should be widely prescribed at several stages of OSA management. Passive RMO, with the pearl mandibular advancement orthosis designed by Michèle Hervy-Auboiron, helps to compensate for the frequent non-compliance observed during active RMO treatments.