Pediatric Down Syndrome Upper Airway Stimulation: Patient Selection and Post-Implantation Optimization

OBJECTIVE

The Food and Drug Administration recently approved upper airway stimulation (UAS) for children with Down Syndrome and persistent obstructive sleep apnea who meet certain inclusion and exclusion criteria. Although there is a robust experience with this therapy in the adult population, established protocols used in adults are not directly transferrable to a complex pediatric population. This review aims to combine the protocols from several institutions for patient selection and postimplantation optimization, including a protocol for Drug-Induced Sleep Endoscopy in children with Down Syndrome, preactivation threshold measurements, device titration, and follow-up sleep studies.

STUDY DESIGN

Expert panel development of best Practice algorithm.

SETTING

Multi-institutional investigator review.

METHODS

An expert panel was assembled of pediatric otolaryngologists with extensive experience in hypoglossal nerve stimulation in children with Down Syndrome. Thirty statements were created during an initial drafting session. A modified Delphi method was used assess consensus among the panel.

RESULTS

After 2 rounds of Delphi surveys, 29 statements met criteria for consensus. One statement did not meet consensus. The statements were grouped into several categories to facilitate presentation.

CONCLUSIONS

A standardized approach to UAS for children with Down Syndrome must take into account the unique challenges inherent to treating a complex pediatric population with a high rate of sensory processing disorders. This expert panel has met consensus on several statements that will guide clinicians as this novel therapy is adopted.

Safety and efficacy of lingual tonsillectomy in multilevel airway surgery for pediatric obstructive sleep apnea

STUDY OBJECTIVES

Prior studies have demonstrated the efficacy of lingual tonsillectomy in treating pediatric obstructive sleep apnea. The goal of this study is to describe the postoperative outcomes following lingual tonsillectomy as a part of drug-induced sleep endoscopy-directed multilevel sleep surgery.

METHODS

A retrospective review was performed for pediatric patients with obstructive sleep apnea who underwent lingual tonsillectomy as a part of drug-induced sleep endoscopy-directed sleep surgery. Data collected included age, sex assigned at birth, body mass index z-score, polysomnography results, past medical and surgical history, and postoperative outcomes.

RESULTS

A total of 174 patients were included in the study with a mean age of 8.29 ± 3.49 years (range 1.89-15.62) and mean preoperative apnea-hypopnea index of 7.88 ± 13.42 (range 1.10-123.40). Complications occurred in 26 patients (14.9%) including 14 patients (8.0%) requiring emergency department visit or readmission and 12 patients (6.9%) experiencing postoperative bleeding. Asthma (P = .033) and developmental delay (P = .016) correlated with postoperative complications. For patients with preoperative and postoperative polysomnography data (n = 145; 83.3%), there was significant improvement (P < .001) in apnea-hypopnea index with a mean postoperative apnea-hypopnea index of 4.02 ± 7.81 (range 0.00-54.46). Surgical failure, defined as postoperative apnea-hypopnea index ≥ 5, was identified in 25 patients (17.2%). Surgical failure was associated with body mass index z-score > 2 (P = .025) and Trisomy 21 (P = .005).

CONCLUSIONS

This study highlights the promising surgical success rate of drug-induced sleep endoscopy-directed lingual tonsillectomy in multilevel sleep surgery (82.8%) and infrequent complications including postoperative bleeding (6.9%) and readmission (2.3%).

CITATION

Williamson A, Morrow VR, Carr MM, Coutras SW. Safety and efficacy of lingual tonsillectomy in multilevel airway surgery for pediatric obstructive sleep apnea. J Clin Sleep Med. 2024;20(2):189-199.

Clinical Application of Pediatric Sleep Endoscopy: An International Survey

OBJECTIVES

To investigate through an international survey the actual clinical application of drug-induced sleep endoscopy (DISE) in pediatric patients with obstructive sleep apnea (OSA) and to clarify the use, application, clinical indications, and protocol of pediatric DISE.

METHODS

A specific survey about pediatric DISE was initially developed by five international otolaryngologists with expertise in pediatric sleep apnea and drug-induced sleep endoscopy and was later spread to experts in the field of sleep apnea, members of different OSA-related associations.

RESULTS

A total of 101 participants who answered all the survey questions were considered in the study. Sixty-four sleep apnea experts, equivalent to 63.4% of interviewed experts, declared they would perform DISE in pediatric OSA patients. A total of 81.9% of responders agreed to consider the DISE as the first diagnostic step in children with persistent OSA after adenotonsillectomy surgery, whereas 55.4% disagreed with performing DISE at the same time of scheduled adenotonsillectomy surgery to identify other possible sites of collapse. In the case of young patients with residual OSA and only pharyngeal collapse during DISE, 51.8% of experts agreed with performing a velopharyngeal surgery. In this case, 27.7% disagreed and 21.4% were neutral.

CONCLUSION

Pediatric DISE is internationally considered to be a safe and effective procedure for identifying sites of obstruction and collapse after adenotonsillectomy in children with residual OSA. This is also useful in cases of patients with craniofacial malformations, small tonsils, laryngomalacia or Down syndrome to identify the actual site(s) of collapse. Despite this evidence, our survey highlighted that pediatric DISE is not used in different sleep centers.

A commentary on broader use of preoperative polysomnography in pediatric patients with obstructive sleep apnea

Obstructive sleep apnea (OSA), characterized by repeated episodes of prolonged airway obstruction during sleep, is a common condition in pediatric patients ages 2 to 6. Polysomnography (PSG) testing can be used to assess the severity of OSA or obstructive sleep-disordered breathing prior to adenotonsillectomy. The article "Characteristics and Frequency of Children With Severe Obstructive Sleep Apnea Undergoing Elective Polysomnography" by Bains et al. notes the variability in guidelines regarding indication for PSG amongst professional societies, making it difficult for physicians to determine which patients require PSG. The purpose of this commentary is to emphasize and elaborate on the potential benefit for preoperative PSG in all patients considering adenotonsillectomy as presented by the aforementioned article. With broader use of preoperative PSG, providers would have a more accurate assessment of OSA severity and to aid in surgical decision-making and postoperative planning.

Racial Disparity in Residual Sleep Apnea After Adenotonsillectomy

OBJECTIVE

Black children have a higher risk of residual obstructive sleep apnea after adenotonsillectomy than non-Black children. We analyzed Childhood Adenotonsillectomy Trial data to better understand this disparity. We hypothesized that (1) child-level factors, such as asthma, smoke exposure, obesity, sleep duration, and (2) socioeconomic factors, such as maternal education, maternal health, and neighborhood disadvantage, may confound, modify, or mediate the association between Black race and residual obstructive sleep apnea after adenotonsillectomy.

STUDY DESIGN

Secondary analysis of a randomized controlled trial.

SETTING

Seven tertiary care centers.

METHODS

We included two hundred and twenty-four 5-to-9-year-olds with mild-to-moderate obstructive sleep apnea who underwent adenotonsillectomy. The outcome was residual obstructive sleep apnea 6 months after surgery. Data were analyzed with logistic regression and mediation analysis.

RESULTS

Of 224 included children, 54% were Black. Compared with non-Black children, Black children had 2.7 times greater odds of residual sleep apnea (95% confidence interval [CI]: 1.2, 6.1; p = .01), adjusted for age, sex, and baseline Apnea Hypopnea Index. There was significant effect modification by obesity. Among obese children, there was no association between Black race and outcome. However, nonobese Black children were 4.9 times as likely to have residual sleep apnea than non-Black children (95% CI: 1.2, 20.0; p < 0.01). There was no significant mediation by any of the child-level or socioeconomic factors tested.

CONCLUSION

There was substantial effect modification by obesity on the association between Black race and residual sleep apnea after adenotonsillectomy for mild-to-moderate sleep apnea. Black race was associated with poorer outcome among nonobese but not obese children.

Use of Polysomnography and CPAP in Children Who Received Adenotonsillectomy, US 2004 to 2018

OBJECTIVES

1) To determine the prevalence polysomnogram (PSG) and continuous positive airway pressure (CPAP) therapy use in children who received adenotonsillectomy (AT) for sleep symptoms. 2) To identify health care disparities in these regards.

STUDY DESIGN

Retrospective database analysis.

METHODS

This study used data from Optum (Health Services Innovation Company) to identify 92,490 children who received AT for sleep symptoms between 2004 and 2018. Prevalence of preoperative PSG and postoperative PSG and CPAP were described. Clinical and demographic characteristics were compared between children who had preoperative PSG and those who did not. Characteristics of children with trisomy 21 (T21) were compared to assess PSG and CPAP use in a high-risk cohort. Predictive modeling was used to identify patient characteristics associated with postoperative PSG and CPAP use.

RESULTS

Preoperative PSG was obtained in 5.5% of children overall and 33.2% of children with T21. Male sex, obesity, other medical comorbidities, non-White race/ethnicity, and higher parent education were associated with preoperative PSG. Fewer than 3% of children received postoperative PSGs and approximately 3% went on to receive CPAP therapy postoperatively. Multiple logistic regression showed that age at surgery, male sex, obesity, other medical comorbidities, non-White race/ethnicity, and higher parent education were associated with postoperative PSG and CPAP use.

CONCLUSIONS AND RELEVANCE

This study described the prevalence pre-AT PSG use and post-AT PSG and CPAP use for persistent symptoms and identified sleep health care disparities in these regards. These results show that increased, equitable access to PSG is needed in children, particularly in the workup and treatment persistent symptoms after AT.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:184-188, 2023.

Lower respiratory tract infections in early life are associated with obstructive sleep apnea diagnosis during childhood in a large birth cohort

STUDY OBJECTIVES

Several birth cohorts have defined the pivotal role of early lower respiratory tract infections (LRTI) in the inception of pediatric respiratory conditions. However, the association between early LRTI and the development of obstructive sleep apnea (OSA) in children has not been established.

METHODS

To investigate whether early LRTIs increase the risk of pediatric OSA, we analyzed clinical data in children followed during the first 5 years in the Boston Birth Cohort (n = 3114). Kaplan-Meier survival estimates and Cox proportional hazards models adjusted by pertinent covariates were used to evaluate the risk of OSA by the age of 5 years between children with LRTI during the first 2 years of life in comparison to those without LRTI during this period.

RESULTS

Early life LRTI increased the risk of pediatric OSA independently of other pertinent covariates and risk factors (hazard ratio, 1.53; 95% CI, 1.15 to 2.05). Importantly, the association between LRTI and pediatric OSA was limited to LRTIs occurring during the first 2 years of life. Complementarily to this finding, we observed that children who had severe respiratory syncytial virus bronchiolitis during infancy had two times higher odds of OSA at 5 years in comparison with children without this exposure (odds ratio, 2.09; 95% CI, 1.12 to 3.88).

CONCLUSIONS

Children with severe LRTIs in early life have significantly increased risk of developing OSA during the first 5 years of life. Our results offer a new paradigm for investigating novel mechanisms and interventions targeting the early pathogenesis of OSA in the pediatric population.

Early Atherosclerotic Inflammatory Pathways in Children with Obstructive Sleep Apnea

OBJECTIVE

To evaluate structural and functional carotid changes and inflammatory profiles in children with obstructive sleep apnea (OSA) and healthy controls.

STUDY DESIGN

Patients with OSA and matched controls (ages 5-13 years) were recruited. Proinflammatory cytokines and acute phase reactants were measured at 6:00 p.m. Common carotid artery measures were determined using ultrasound. Confirmatory factor analysis was used to determine subgroups of cytokines and their effects on carotid measures.

RESULTS

Ninety-six patients participated (53 healthy controls, 43 patients with OSA). OSA was associated with increased proinflammatory cytokines (cluster of differentiation-40 ligand [CD40-L], interleukin [IL]-6, and IL-8) and high sensitivity C-reactive protein (P < .05 for all). One cytokine subgroup (IL-6 and IL-8) was negatively associated with markers of carotid function, indicating reduced arterial distensibility and increased stiffness (P < .05 for 3 ultrasound measures); and tumor necrosis factor-α had an opposing effect on carotid function compared with this cytokine subgroup (P < .05 for 2 ultrasound measures). Linear regression demonstrated significant associations between and tumor necrosis factor- α and 2 measures of carotid function (P < .05 for each). Children with OSA did not have functional or structural carotid changes compared with controls.

CONCLUSION

OSA was not directly associated with structural and functional carotid changes but was associated with upregulation of key proinflammatory cytokines (sCD40-L, IL-6, and IL-8). Together, IL-6 and IL-8 were associated with changes in carotid function. Longitudinal studies are needed to demonstrate that the inflammatory milieu observed in our population is a precursor of atherosclerosis in children.

Successful treatment of a child with Schwartz-Jampel syndrome using rapid maxillary expansion and CPAP

STUDY OBJECTIVES

We reported an 8-year-old male patient with Schwartz-Jampel syndrome, severe obstructive sleep apnea, constricted maxilla and moderate tonsillar hypertrophy. The syndrome is characterized by myotonia, skeletal dysplasia, and facial dysmorphism.

METHODS

CPAP was initially prescribed, but he was not able to tolerate due to a high pressure setting. Rapid maxillary expansion alone reduced AHI to 10.4 events/h.

RESULTS

When combined with CPAP, AHI is further reduced to 2.4 events/h. The patient has a better compliance with CPAP following rapid maxillary expansion therapy as the pressure setting decreased.

CONCLUSIONS

This is the first report utilizing a combination of rapid maxillary expansion and CPAP therapy to successfully treat severe pediatric OSA.

Supplemental Oxygen for Treatment of Infants With Obstructive Sleep Apnea

STUDY OBJECTIVES

Supplemental oxygen has been shown to decrease the frequency of obstructive respiratory events during sleep, but may result in alveolar hypoventilation. Limited information exists on the effect of supplemental oxygen on sleep and respiratory events in infants with obstructive sleep apnea (OSA).

METHODS

We conducted a retrospective study of infants with OSA who had sleep studies performed from 2007-2012. All infants underwent a room air diagnostic sleep study (RA-PSG), followed by a sleep study while breathing supplemental oxygen via nasal cannula (O₂-PSG) on a separate night. Infants with split-night studies or with inadequate sleep time were excluded.

RESULTS

Fifty-nine infants met criteria for entry into analysis. The mean age of infants at the time of RA-PSG was 13.0 ± 11.7 weeks and at O₂-PSG was 15.4 ± 13.0 weeks. The obstructive AHI decreased from 19.7 ± 13.0 during RA-PSG to 10.6 ± 11.7 during O₂-PSG (P < .001). The duration of longest obstructive apnea increased from 11.0 ± 4.2 seconds to 13.4 ± 7.4 seconds (P = .01). The lowest saturation associated with obstructive apneas increased from 80.7 ± 6.8% to 90.0 ± 6.7% (P < .001). Carbon dioxide data showed no difference in ventilation after supplemental oxygen administration. There was no significant change in the spontaneous arousal index, however, the percentage of respiratory events associated with arousal increased from 20.7 ± 11.1% to 35.7 ± 19.7% (P < .001).

CONCLUSIONS

Infants with OSA who received supplemental oxygen had a significant decrease in the frequency of obstructive respiratory events and improved oxygenation without adverse effect on alveolar ventilation. These data suggest that supplemental oxygen may be an effective treatment for infants with OSA who are not good candidates for continuous positive airway pressure or surgery.

CITATION

Brockbank J, Astudillo CL, Che D, Tanphaichitr A, Huang G, Tomko J, Simakajornboon N. Supplemental oxygen for treatment of infants with obstructive sleep apnea. J Clin Sleep Med. 2019;15(8):1115-1123.

Irreversible metabolic abnormalities following chronic upper airway loading

STUDY OBJECTIVES

Treatment of obstructive sleep apnea increases obesity risk by an unclear mechanism. Here, we explored the effects of upper airway obstruction and its removal on respiratory homeostasis, energy expenditure, and feeding hormones during the sleep/wake cycle from weaning to adulthood.

METHODS

The tracheas of 22-day-old rats were narrowed, and obstruction removal was performed on post-surgery day 14. Energy expenditure, ventilation, and hormone-regulated feeding were analyzed during 49 days before and after obstruction.

RESULTS

Energy expenditure increased and body temperature decreased in upper airway obstruction and was only partially recovered in obstruction removal despite normalization of airway resistance. Increased energy expenditure was associated with upregulation of ventilation. Decreased body temperature was associated with decreased brown adipose tissue uncoupling protein 1 level, suppressed energy expenditure response to norepinephrine, and decreased leptin level. Upper airway obstructed animals added less body weight, in spite of an increase in food intake, due to elevated hypothalamic orexin and neuropeptide Y and plasma ghrelin. Animals who underwent obstruction removal fed more due to an increase in hypothalamic neuropeptide Y and plasma ghrelin.

CONCLUSIONS

The need to maintain respiratory homeostasis is associated with persistent abnormal energy metabolism and hormonal regulation of feeding. Surgical treatment per se may not be sufficient to correct energy homeostasis, and endocrine regulation of feeding may have a larger effect on weight change.

Plasma Extracellular Vesicles in Children with OSA Disrupt Blood-Brain Barrier Integrity and Endothelial Cell Wound Healing in Vitro

Pediatric obstructive sleep apnea (P-OSA) is associated with neurocognitive deficits and endothelial dysfunction, suggesting the possibility that disruption of the blood-brain barrier (BBB) may underlie these morbidities. Extracellular vesicles (EVs), which include exosomes, are small particles involved in cell-cell communications via different mechanisms and could play a role in OSA-associated end-organ injury. To examine the roles of EVs in BBB dysfunction, we recruited three groups of children: (a) absence of OSA or cognitive deficits (CL, n = 6), (b) OSA but no evidence of cognitive deficits (OSA-NC(-), n = 12), and (c) OSA with evidence of neurocognitive deficits (OSA-NC(+), n = 12). All children were age-, gender-, ethnicity-, and BMI-z-score-matched, and those with OSA were also apnea-hypopnea index (AHI)-matched. Plasma EVs were characterized, quantified, and applied on multiple endothelial cell types (HCAEC, HIAEC, human HMVEC-D, HMVEC-C, HMVEC-L, and hCMEC/D3) while measuring monolayer barrier integrity and wound-healing responses. EVs from OSA children induced significant declines in hCMEC/D3 transendothelial impedance compared to CL (p < 0.001), and such changes were greater in NC(+) compared to NC(-) (p < 0.01). The effects of EVs from each group on wound healing for HCAEC, HIAEC, HMVED-d, and hCMEC/D3 cells were similar, but exhibited significant differences across the three groups, with evidence of disrupted wound healing in P-OSA. However, wound healing in HMVEC-C was only affected by NC(+) (p < 0.01 vs. NC(-) or controls (CO). Furthermore, no significant differences emerged in HMVEC-L cell wound healing across all three groups. We conclude that circulating plasma EVs in P-OSA disrupt the integrity of the BBB and exert adverse effects on endothelial wound healing, particularly among OSA-NC(+) children, while also exhibiting endothelial cell type selectivity. Thus, circulating EVs cargo may play important roles in the emergence of end-organ morbidity in pediatric OSA.

Admission Criteria for Children With Obstructive Sleep Apnea After Adenotonsillectomy: Considerations for Cost

STUDY OBJECTIVES

Postoperative respiratory complications (PRCs) are common among children with obstructive sleep apnea (OSA) after adenotonsillectomy. We analyzed postoperative admission guidelines to determine which optimally balanced patient safety and cost.

METHODS

Retrospective study of children aged 12 years or younger undergoing adenotonsillectomy for OSA after polysomnography at a tertiary academic care center over 2 years. Demographics, medical History, and hospital course were collected. Advanced Excel modeling was used to assess the number of children with PRCs identified with guideline admission criteria and to validate the significance of these findings in our patient population with logistic regression.

RESULTS

Six hundred thirty children were included; 116 had documented PRCs. Children with PRCs were younger (P = .024) and more frequently male (P = .012). There were no significant differences in race (P = .411) or obesity (P = .265). More children with PRCs had an apnea-hypopnea index (AHI) > 24 events/h (P < .001). Following guidelines from the American Academy of Pediatrics, American Academy of Otolaryngology - Head and Neck Surgery, and Nationwide Children's Hospital, 82%, 87%, and 99% of children with PRCs would be identified, costing $535,962, $647,165, and $1,053,694 for admission, respectively. Using a non-validated, forced model to refine predictors described in published guidelines, our model would have identified 95% of children with one or more PRCs, with a moderate cost.

CONCLUSIONS

Current admission guidelines attempt to identify children with OSA at high risk for PRCs after adenotonsillectomy; however, none consider the economic cost to the health care system. We present a comparison of the number of patients identified with PRCs after adenotonsillectomy and the cost of expected admissions using currently published guidelines.

COMMENTARY

A commentary on this article appears in this issue on page 1371.

Anthropometric and Dental Measurements in Children with Obstructive Sleep Apnea

STUDY OBJECTIVES

A number of authors have shown that children with OSA are more likely to have certain physical characteristics than healthy controls. With this in mind, our objectives were to collect normative baseline data and determine if there was a significant difference in anthropometric and dental measurements between children with OSA and age-matched nonsnoring controls.

METHODS

Children 2 to 12 y of age, in whom OSA was diagnosed by overnight polysomnography, were recruited to our experimental group. Age-matched nonsnoring controls were screened for signs of sleep-disordered breathing. Anthropometric measurements, including waist, neck, and hip circumferences, and waist-hip and neck-waist ratios, were obtained on all study participants preoperatively. Dental casts were acquired to determine intertooth distances and palatal height.

RESULTS

Sixty-one children (42 with OSA [69%] and 19 controls [31%]) with a mean age of 4.7 y participated in the study. Waist and hip circumferences were significantly larger in children with OSA (p = 0.001 and 0.001, respectively). However, there was no difference in neck circumference and waist-hip ratios between the two groups. Neck-waist ratio in children with OSA was significantly smaller than in controls (p = 0.001). Intertooth distance for the first (p < 0.0001) and second deciduous (p = 0.0002) and first permanent molars (p = 0.022) were significantly narrowed in children with OSA; however, no difference was seen in palatal height between groups. Body mass index was similar between groups (p = 0.76).

CONCLUSIONS

Anthropometric and dental measurements were significantly different in children with OSA compared to nonsnorers. Future studies with a large sample size may allow us to determine if these measurements can be used by clinicians to identify children at risk for OSA.

COMMENTARY

A commentary on this article appears in this issue on page 1213.

Two-year-old with post-surgical hypoglossal nerve injury and obstructive sleep apnea

BACKGROUND

Airway patency in both children and adults depends on the tonic and phasic activation of muscles of the tongue and pharynx supplied by the hypoglossal nerve arising at the medullary level.

METHODS/PATIENT

We report a case of a 2-year-old who after resection of fourth ventricle anaplastic ependymoma developed severe sleep disordered breathing and tongue fasciculation.

RESULTS

Polysomnography showed severe obstructive sleep apnea with oxygen desaturation to 33%. Magnetic resonance imaging of the brain showed post-surgical effacement of the dorsal lateral medulla.

CONCLUSIONS

We postulate that damage to the hypoglossal nerve at the level of the medulla contributed to the patient's severe obstructive sleep apnea. Patient was treated with tracheostomy.