Sleep-disordered breathing (SDB) refers to a collection of ventilatory disorders characterized by recurrent partial or complete cessation of breathing resulting in multitude of night and day time symptoms (1). Sleep disordered breathing can be considered as a spectrum of breathing disorders ranging from benign snoring to obstructive sleep apnea (OSA) depending on the varying degree of airway obstruction. Primary snoring is the early stage where the patients present without any daytime symptoms or evidence of obstruction. Upper airway resistance syndrome (UARS) follows next when the symptoms begin to appear during the day or night with increase in the upper airway resistance. When the upper airway resistance is significant enough to produce hypoxemia or hypercarbia without evidence of complete airway obstruction, it is called as obstructive hypopnea. OSA is the most severe form of SDB with evidence of intermittent or complete airway obstruction with or without symptoms of SDB (2,3) and snoring is on the other benign end of the spectrum.
OSA in children is a disorder with significant comorbidity that causes poor sleep quality (4,5). There is evidence in the literature to support that treatment of OSA improves sleep quality (6). OSA in children is strongly associated with a range of complications including but not limited to the immediate perioperative period (7,8) and long-term behavioral problems like neurocognitive dysfunction, hyperactivity, inattentive behaviors (9-11). OSA is also associated with a variety of medical conditions like obesity, increased blood pressure, diabetes, changes in cardiovascular geometry (12,13) and increased mortality (14,15).
Prevalence of pediatric OSA varied between 1–5% depending on the population and age group studied and the prevalence of habitual snoring up to 27.5% depending on the study and definition used (16,17). The prevalence is significantly higher in obese children, patients with down syndrome, cerebral palsy, prematurity and craniofacial abnormalities. The prevalence is reported to be four to five-fold higher in obese children (18). Based on PSG in a large cohort of patients with down syndrome, the prevalence of OSA is reported to be 66% (19).
Short term and long-term complications
Short term complications: OSA independently increases the risk of perioperative respiratory adverse events including hypoxemia, prolonged oxygen supplementation, laryngospasm, pulmonary edema, need for noninvasive ventilatory support like positive airway pressure (BiPAP/CPAP), prolonged mechanical ventilation, reintubation, unanticipated inpatient and critical care unit admission among many others (8,20-22)
Long term complications: OSA is a multisystem disorder resulting in cardiovascular, neurological and metabolic complications in the long-term. Neuropsychological sequel of OSA include cognitive deficits, behavioral abnormalities, increased day time sleepiness, hyperactivity and/or attention deficit hyperactivity disorder (ADHD), depression and poor quality of life (9,10,23-25). Cardiovascular complications include ventricular hypertrophy (right, left, biventricular), pulmonary hypertension, Cor-pulmonale, elevated blood pressure, autonomic instability (13,26-28). OSA also has been shown to affect growth, decrease in serum insulin-like growth factor (IGF) and associated with metabolic syndrome (29-31).
Early diagnosis and treatment of pediatric OSA is important to minimize the risk of development of the above-mentioned complications. Treatment of OSA in children is primarily surgical mainly by tonsillectomy and adenoidectomy. Additional treatment is usually reserved for syndromic children and includes changes in facial architecture to improve risk of obstruction. Adenotonsillectomy has shown to improve the long-term outcomes in cardiovascular, cognitive, neuropsychological and quality of life measures in multiple studies (32-35).
Genotypes and phenotypes of OSA
The case for genetic basis of OSA has been made since more than four decades ago (36). There has been a number of clinical and epidemiological studies providing compelling evidence for familial clustering and probable genetic factors in the expression of OSA (37). In the Cleveland Clinic family study, the prevalence of OSA in the first-degree relatives of OSA patients ranged from 22% to 84%. It also showed that first degree relatives of OSA patients had a higher relative risk for OSA even after controlled for body mass index (BMI) (38,39). Several studies also have showed that OSA occur more commonly in African Americans which suggests the role of genetic components (38,40). Relatives of OSA patients have been shown to have similar craniofacial structures like narrow upper airways, retroposed maxilla, longer soft palate and high arched hard palate which may contribute to the familial tendency (41,42). Although multiple studies have shown strong familial tendency for sleep disordered breathing, conclusive evidence of a single genetic foci which can predict the occurrence of OSA is still elusive. Many gene association studies focusing on different genetic locations including apolipoprotein E4 (ApoE4), tumor necrosis factor (TNF) and angiotensin converting enzyme (ACE) so far have yielded mixed results (43-46). Fatal familial insomnia with mutation on the PRNP gene and Familial advanced sleep phase syndrome with mutation in the human PER2 gene have been identified as sleep disorders with definite genetic basis (39,47,48). Given that OSA has several risk factors and different phenotypic expressions, looking for a single genetic focus to identify the OSA is not rational. Also, whether these genetic associations are causal or byproduct of OSA related complications is still remains to be determined.
Earlier studies of pediatric SDB suggested that the clinical signs and symptoms, presentation and pathophysiology of pediatric OSA was markedly different than the adult OSA. It is due to the fact that the pediatric OSA was caused by adeno-tonsillar hypertrophy rather than fatty infiltration of the soft tissues. However, with recent epidemic increase in the incidence of childhood obesity, more than 50% habitual snoring has been attributed to childhood obesity thus presenting with the similar pathophysiology of adult OSA (49). In many of these patients, OSA may still be persistent even after successful adenotonsillectomy which necessitates a different approach to treatment of OSA in obese children (50). Pediatric OSA phenotypes have been categorized into two subtypes: type 1 being primarily due to lymphadenoid hypertrophy without obesity and type 2 being primarily caused by obesity with minimal lymphadenoid hypertrophy mimicking the adult variant of OSA (49).
OSA and Inflammation
Elevated levels of inflammatory markers like CRP, IL-6, IFN-γ and TNF-α and decreased levels of anti-inflammatory cytokine IL-10 has been reported in non-obese pediatric patients with OSA and noted to return to baseline after treatment of OSA with adeno-tonsillectomy (51,52). Obesity itself is currently considered as a proinflammatory state (53,54) and the presence of OSA in addition to obesity exacerbates the chronic low-grade inflammatory state. Obese OSA children have higher levels of plasminogen activator inhibitor 1 and monocyte chemoattractant protein which activate the inflammatory pathways (55). Microarray analysis of RNA derived from peripheral leukocytes showed the presence of altered expression of gene clusters in pediatric OSA patients and majority of the altered gene clusters were involved in the activation of inflammatory pathways (56). The elevated levels of proinflammatory cytokines is not uniformly present in all the OSA patients suggests that environmental and genetic factors may play a role in the inflammatory process (57,58). OSA patients with high level of inflammatory markers found to have higher DNA methylation of inflammatory related genes when compared with OSA patients without high level of inflammatory markers (59). These epigenetic changes may explain some of the phenotypic variations and the assessment of the DNA methylation of specific genes may help predict the pro-inflammatory risk of individual patients in the future.
SDB in special population
Children with syndromes are at high risk for post tonsillectomy complications. Overnight admissions are recommended in otherwise healthy children with down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, mucopolysaccharidoses, Prader-Willi syndrome, Achondroplasia, obesity and other conditions at a higher risk for OSA. There are numerous reviews on this topic particularly obesity and down syndrome are well studied. We provide more details regarding Pierre Robin syndrome and 22q11 syndromes.
Pierre Robin syndrome/sequence
Pierre Robin syndrome results from genetic anomalies at chromosomes 2, 11, or 17. It is frequently referred to as a sequence consisting of constellation of problems characterized by micrognathia, large posteriorly placed tongue (glossoptosis) which frequently results in airway obstruction. Uncorrected OSA leads to recurrent hypoxia, right heart failure, failure to thrive, feeding difficulties, and developmental impairment. PSG is indicated to assess the degree of airway obstruction and a multidisciplinary team is necessary to care for these children. Management includes positioning to side or prone to avoid airway obstruction, nasopharyngeal airway, or surgical interventions. Mandibular distraction is the most commonly performed procedure.
Prevalence of OSA in infants with Pierre Robin syndrome is as high as 85% (60). Children with Pierre Robin at risk for persistent OSA (1 out of 4 children) between the ages of 1 and 18 years particularly if they require respiratory support soon after birth (61). Infants treated with prone positioning alone are not as likely to develop persistent airway obstruction later in life (61). Significant reductions in apnea-hypopnea index (AHI) was seen in 9 out of the 45 evaluated children who underwent mandibular osteogenesis as evidenced by PSG (62). The severity of OSA did not decrease with increasing age as seen in non-Pierre Robin syndromic patients (62). A meta-analysis of 7 studies with 90 patients has shown the benefit of tongue-lip adhesion and tongue repositioning procedures in improving PSG parameters. Tongue-lip adhesion reduced the mean AHI by 50% and tongue repositioning reduced it by 62.6% (63).
22q11 deletion syndrome and OSA
22q11 deletion is the most common microdeletion syndrome and results in variables phenotypes including DiGeorge syndrome. Children present with a range of symptoms and signs and cardiac involvement is very common. Structural anomalies and retrognathia results in an increased probability of obstructive breathing. The prevalence of OSA is as high as 58% in one retrospective review of children (64). The risk of OSA may be reduced with adenotonsillectomy (64). children with 22q11 often required surgical treatment of velopharyngeal insufficiency which is characterized by poor palatal elevation and muscular hypotonia with an intact palate. With the repair of velopharyngeal insufficiency and surgical obstruction to the velopharynx, these children are predisposed to increased risk of OSA post-surgery (65). Monitoring of OSA is recommended and families should be counselled for post-operative CPAP or surgery (64,65).
SDB and secondhand (SHS) exposure
Secondhand smoke (SHS) exposure occurs in most parts of the world and most notably in Asian countries. Of the one billion children younger than 15 years studied from 21 countries, SHS exposure in home occurred in more than half of these children. Out of the countries studied, most exposures were reported from China, India, Bangladesh, Indonesia and the Philippines (66). Exposure to SHS has been associated with myriad of problems in children including exacerbation of asthma, respiratory infections, increased perioperative respiratory adverse events. A limited number of studies have shown that patients exposed to SHS have an increased risk of SDB. A systematic review on the association of SHS and SDB showed a significant association, albeit most studies were focused on snoring as the primary outcome (67). Few studies have explored the relation of SHS and OSA. A multicenter showed that both exposure to environmental tobacco smoke and African American race are associated with a 20% increase in AHI (68). Strategies to help reduce SHS exposure may be beneficial in reducing OSA severity.
Screening for SDB
Current literature suggests that the clinical symptoms are unable to identify patients with clinically significant SDB (69). PSG is the gold standard for diagnosis of OSA. However, only 10% of the children with SDB undergo PSG testing for diagnosis preoperatively due to limited availability, cost and lack of adequate time to undergo the testing prior to surgery. Multiple questionnaires including the ASA checklist, OSA-18, Clinical Assessment Score (CAS-15) and pediatric sleep questionnaire (PSQ) among many other have been developed to screen pediatric patients at high risk for OSA. We performed a systematic review and found there were more than 15 different modes of diagnostic modalities for pediatric OSA screening of which most of them were questionnaires (70).
The American Society of Anesthesiologists (ASA) Task Force on Perioperative Management of Patients with OSA has recommended a checklist (ASA checklist) as a routine screening tool for OSA in surgical patients (71) which contains 14 questions for pediatric patients. The ASA checklist in adult patients over 18 years of age undergoing surgery is shown to be fairly sensitive and predict higher risk for postoperative complications (72,73). PSQ consists of 22 questionnaires (Yes/No/Unknown) and a score of >/= 8 is positive for OSA. It has been validated in research setting but may not be reliable to assess the OSA risk at individual patient level (74). However, it may be a better tool in assessing the neurobehavioral morbidity and its response to adenotonsillectomy as a follow up tool (75). Tait et al. developed a short version of PSQ, STBUR that did not correlate with PSG indices but shown to be predictive of pediatric respiratory adverse events (PRAE) (76). Similarly, PSQ was unable to predict the OSA in severely obese adolescent patients (77). A short 6 questionnaire version adapted from PSQ was shown to correlate with PSG in predicting postoperative oxygen requirement (78). Raman et al. developed another short 6 questionnaire version adapted from PSQ with good predictive utility for moderate to severe OSA (79). External validation of these short questionnaires is currently limited. In the childhood adenotonsillectomy trial (CHAT) with more than 450 pediatric patients, both ASA checklist and PSQ failed to demonstrate good reliability in predicting the presence or severity of OSA (80,81). OSA-18 questionnaire and child health questionnaire have been reported to better assess the impact of OSA on the child’s overall quality of life and multiple studies have utilized either questionnaire to show sustainable improvement in the quality of life after adenotonsillectomy (82,83). CAS-15 is another questionnaire which has been reported to have correctly diagnose 72% patients referred for PSG in an office-based setting (84). With any questionnaires, the answers to the questions can be very subjective, inherently biased by under- and over-reporting of the symptoms and we are yet to find a screening questionnaire that is able to predict the diagnosis or the severity of OSA reliably and consistently (81).
Portable devices with either single channel monitoring such as nocturnal pulse-oximetry readings, nasal airflow or multichannel monitoring devices combining various data have been used in addition to the questionnaires to predict the risk of OSA as a cheaper alternative to the in-laboratory PSG testing. This is described further in the ambulatory sleep apnea testing part of this article.
Anthropometric measures such as neck circumference has been well documented as OSA predictors in adults. With increasing incidence of childhood obesity, these measures may become more relevant in pediatric patients as well. In one study, neck circumference-height (NHR) ratio was shown to predict SDB in pediatric patients (85). Sagittal abdominal diameter has been shown to correlate with AHI and oxygen nadir of PSG in severely obese adolescent patients (77). In one study, adding anthropometric measures such as neck circumference and BMI did not significantly improve the predictive validity of the pediatric OSA screening questionnaire (79).
Serum biomarkers such as C-reactive protein (CRP) and IGF-1, genetic susceptibility of apolipoprotein E (ApoE) allele and epigenetic modifications of increased DNA methylation of inflammatory genes all have been studied to associate OSA with inflammation and resulting neurocognitive dysfunction and to predict the risk OSA (52,59,86,87). These markers are currently in the very early stages of research and further studies are needed before they can be incorporated into clinical practice (88).
Diagnosis of SDB
Diagnosis of SDB in pediatric patients can be challenging due to wide variety of presenting symptoms including snoring, behavioral and cognitive defects, nocturnal enuresis, headaches, poor school performance and cardiovascular symptoms. A high degree of suspicion and thorough history and physical examination focused on craniofacial anatomy and adeno-tonsillar examination is necessary prior to referring the patients with high degree of suspicion for OSA to a formal sleep study. However, demographics, clinical history, physical examination findings including tonsil size, and caregiver reports from questionnaires does not seem to predict the severity of OSA (80,89,90). So overnight in-laboratory PSG is still considered to be the gold standard diagnostic test for SDB.
The indications for PSG are outlined in Table 1. PSG measures a number of parameters including electroencephalography; electrooculography; electromyography; electrocardiography; and nasal airflow, respiratory effort, and oxygen saturation. The PSG report usually contains the AHI which is the total number of episodes of apnea and hypopnea per hour of sleep, oxygen saturation nadir, peak and average end tidal carbon-dioxide level and respiratory disturbances index (RDI). Apnea is defined as a decrease in flow of 90% or more for two breaths or more. Hypopnea is defined as a decrease in flow 50% or more coupled with a 4% decrease in oxygen saturation, decrease in the heart rate or electroencephalographic evidence of arousal. The severity of OSA is calculated by the AHI. ASA Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea defines OSA severity of pediatric patients based on AHI as mild (AHI 1–5), moderate (AHI 6–10) and severe (AHI >10) (71). The criteria for measuring the severity of OSA varies widely based on the laboratory and the ASA task force advises that the laboratory’s assessment of severity should take precedence over the actual number of AHI in the report (93).
Ambulatory sleep apnea testing
As mentioned earlier, it is not realistic to get an overnight PSG in every child who is suspected to have SDB due to multiple factors including but not limited to scarcity of resources, socio-economic factors, cost, prolonged wait time etc. Alternatives to the full attended nocturnal PSG have been explored including single channel devices such as nocturnal oximetry, nasal airflow, nasal pressure variations, electrocardiogram for heart rate variability and multichannel devices which include three or more of the parameters.
Nocturnal pulse-oximetry trend graph alone as a single channel monitoring device has yielded mixed results. In one study it was shown to have 97% positive predictive value in children above the age of 12 months with suspected OSA and offer a possible cheaper alternative to PSG testing in patients with adeno-tonsillar hypertrophy (94,95). Patients with significant desaturations on overnight pulse-oximetry can be prioritized for adenotonsillectomy without waiting for PSG testing where PSG testing is limited availability. It is shown to correlate with increased risk of PRAE which might help plan the perioperative care in these patients (96,97). However, other studies contradict the predictive value of pulse-oximetry alone for the diagnosis of OSA (98).
Adding additional data like nasal airflow and respiratory rate to the pulse-oximetry can increase the sensitivity of the diagnosis. Many commercially available multichannel recording devices include The ApneaLink Plus (ResMed Corporation, Poway, CA, USA), eXim Apnea Polygraph (Bitmed, SIBEL Group), Embletta® Gold™III (Embla, Broomfield, CO, USA) among others. The ApneaLink Plus is a portable multichannel screening device that records nasal airflow by nasal pressure transducer, respiratory effort, pulse rate, and hemoglobin saturation by pulse oximetry. In a small study of 25 severely obese pediatric patients, the ApneaLink autoscore correlated well with the Obstructive Apnea-Hypopnea Index (OAHI) score (99). This has been validated to reliably identify SDB in children older than 10 years (100). The multichannel recording devices have a better success rate of acquiring data and correlating with PSG when the initial setup was performed by a technician or a nurse when compared to caregiver setup (101-103). In pediatric patients, age might also be a factor in determining the success of the ambulatory PSG with good correlation with attended PSG has been found in children with age 6 or older versus higher discordance in younger children (104). According to the American Academy of Sleep Medicine (AASM) guidelines, portable monitors may be used as an alternative to in-laboratory PSG in patients with high pre-test probability of having moderate to severe sleep apnea. However, they are not appropriate for screening asymptomatic patients, patients with comorbid conditions or central sleep apnea (105,106).
Drug induced sleep endoscopy (DISE)
Majority of the children with OSA will improve with adeno-tonsillectomy. However, about 10–20% of patients with persistent OSA after adenotonsillectomy will need additional studies (107). DISE is the endoscopic evaluation of the airway under a drug induced state of sleep without any airway support to mimic the airway collapse under natural sleep to localize the level of obstruction to plan for further surgical interventions (108,109). Various anesthetic agents including propofol, ketamine, dexmedetomidine, remifentanil, benzodiazepines and combination of these agents have been used with varying degrees of success for DISE (110,111). In our personal experience, Ketamine bolus 1 mg/kg with dexmedetomidine bolus 2 mcg/kg over 10 min followed by 2 mcg/kg infusion provides the optimal condition and best successful completion rate for the DISE study (109).
Ciné magnetic resonance imaging (MRI) sleep study
Ciné MRI sleep study is another airway evaluation tool for persistent sleep apnea post tonsillectomy to locate the level and magnitude of airway collapsibility and obstruction (112,113). Anesthetic concerns remain the same as the DISE study to mimic natural sleep and maintain natural airway without airway adjuncts. Reviewing the PSG report to determine the nadir SpO2 will help guide the anesthesiologist when to intervene with airway support. Dexmedetomidine is shown to provide ideal conditions for the Cine MRI sleep studies (114).
Treatment of SDB
Pharyngeal obstruction is caused by faster growth of pharyngeal lymphoid tissue as compared to facial bones between the ages of 2 and 6 contributing to OSA. Hence, adenotonsillectomy is the first line treatment for pediatric OSA and relieves symptoms in 80% of cases (115).
The most recent clinical practice guidelines in children having tonsillectomy for OSA and infectious causes was released in 2019 by American Academy of Otolaryngology-Head and Neck Surgery (91). This is an update of the previous guidelines released in 2011 (116). There are guidelines published on OSA by the American Academy of Pediatrics and the AASM that may differ from this guideline (16,92).
We are providing a summary of the updated guidelines published in 2019 (Table 2). The 2019 guidelines provide recommendations on the perioperative management of children aged 1 to 18 years undergoing tonsillectomy. The guidelines exclude children with neuromuscular disease, diabetes mellitus, chronic cardiopulmonary disease, congenital head and neck anomalies, coagulopathies or immune deficiency pathologies. The guidelines recommend detailed history of associated comorbidities in children with SDB. PSG is recommended for the following children with SDB: <2 years of age, obesity, down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, mucopolysaccharidoses, uncertainty in the need for tonsillectomy, and discordance between physical examination and reported SDB severity. The important take away points for anesthesia management includes administration of a single dose of intraoperative dexamethasone, and ibuprofen or acetaminophen or both for analgesia.
The updated guidelines recommend against routine antibiotic use and administering codeine or codeine containing medications in children less than 12 years of age (Table 2). Our practice is not to use codeine or codeine containing medications and they should not be prescribed to any child undergoing tonsillectomy due to varied metabolism of codeine by CYP2D6 (14,117,118). FDA received reports of 24 deaths related to use of codeine of which 21 was in children <12 years of age. In 2013, FDA issued a black box warning concerning the use of codeine in tonsillectomy. Although most opioids undergo metabolism with CYP2D6, oxycodone is minimally metabolized and at this moment appears to be a relatively safe to be used as an analgesic (91).
Education on assessing and managing pain should be provided to families. Emphasis should be provided to both pharmacologic and non-pharmacologic modes of treatment for post-operative pain. Intraoperative single dose dexamethasone is an important component of multimodal treatment. Although there are concerns for postoperative bleeding, this has not been shown in most studies. The beneficial effects of dexamethasone are its anti-inflammatory effect, reduces swelling and pain. The commonly indicated dose is 0.5 mg/kg (dose range =0.15 to 1.0 mg/kg) with a maximum dose based on local hospital protocols with a range of 8 to 25 mg (119).
Tonsillectomy for OSA carries a high risk for perioperative respiratory adverse events. Although most children are operated are outpatients, in patient overnight monitoring is indicated in children <3 years old or those who have severe OSA measured by an AHI >/= 10 events/hour or oxygen saturation nadir <80% or both. It is also prudent to admit any obese child for overnight monitoring if quantification of SDB severity with PSG has not been obtained prior to surgery. These criteria are based on expert consensus due to lack of data on the threshold for severe OSA for PSG predictive of complications or appropriate age (91). A follow up for postoperative complications should be performed. Admission to intensive care unit is indicated if the AHI is >30 or there is underlying comorbidity with difficult airway or based on local hospital policies.
The updated 2019 tonsillectomy guidelines emphasize the administration of acetaminophen or ibuprofen or both based on efficacy from systematic review and randomized controlled trials. The goal is to potentially avoid the use of opioids. Although there are theoretical concerns of bleeding with the use of ibuprofen it has been found to be safe after tonsillectomy. The use of ketorolac is controversial and most physicians elect not to use it with tonsillectomy. Acetaminophen is recommended in an age dependent dosage with a maximum of 75 mg/kg or 4,000 mg in 24 hours whichever is lower. Although effect site concentrations can be achieved with either oral, rectal or intravenous routes, it is the authors preference to use routine intravenous acetaminophen for tonsillectomies (120). This is because with postoperative use children often have difficulty swallowing and the preemptive analgesic effect is absent. Intraoperative use could also reduce the use of opioids. Rectal administration is not favored due to requirement of high loading dose which significantly limits subsequent doses. Preoperative oral acetaminophen use is not followed due to risk of inadvertent medication error with intraoperative intravenous formulation (121). The 2019 guidelines emphasize the use of education materials and brochures to promote the routine use of acetaminophen and ibuprofen and avoid the routine use of opioids.
The CHAT study which was the first randomized controlled trail to compare watchful waiting to tonsillectomy reported that the overall success rate for OSA (AHI <2 events/hour) in children having tonsillectomy was 79%. The risk factors for persistent OSA were age greater than 7 years, obesity, asthma, certain ethnicities, and increased baseline OSA (AHI >4.7 events/hour) (107,122). The CHAT study also found improvements in standard measures of quality of life, sleep and behavior (122).
In children who underwent adenotonsillectomy, resolution of OSA was less likely in children with obesity and higher AHI at baseline. Children with severe OSA and significant comorbidities or syndromes were excluded from this study. The resolution rate was 39 percent in patients with severe obesity or severe OSA, compared with 74 percent in uncomplicated patients (123).
The surgical technique can be either intracapsular or extracapsular with each has its advantages. Intracapsular tonsillectomy was associated with shorter duration of postoperative pain and faster return to normal life compared with traditional extracapsular tonsillectomy (124-126). Meta-analyses have shown that symptom recurrence was more common among children undergoing intracapsular tonsillectomy compared to extracapsular tonsillectomy as revealed in these meta-analyses (125,126). A practice pattern survey of US Otolaryngologists showed that 73% performed complete extracapsular tonsillectomy for a surgical indication of SDB (127). Follow up evaluations of post-surgical patients for resolution of symptoms is important as those with persistent symptoms require a repeat PSG. In children with risk factors for persistent disease, a PSG is recommended even in the absence of symptoms suggestive of SDB (16).
Uvulopalatopharyngoplasty is a surgical procedure performed to open airway spaces by reducing soft tissues contributing to airway obstruction. It has been used in cerebral palsy, down syndrome and other disorders where abnormal airway tone contributes to OSA. The surgical procedure strengthens the hypotonic pharyngeal musculature (128,129). Increasingly variants of this surgical procedure are performed where in only part of the soft tissue debulking is done. Expansion of lateral pharyngoplasty can benefit children with pharyngeal wall collapse. Supraglottoplasty is typically considered in infants with laryngomalacia and OSA (130,131).
Tongue debulking is occasionally used in patients with significant macroglossia related to syndromes such as Beckwith-Wiedemann syndrome and trisomy 21. They are generally avoided because of the highly vascular nature of the tongue but offer a solution in persistent OSA after adenotonsillectomy in patients who have an identified obstruction at the level of the base of the tongue (132). Newer techniques such as partial midline glossectomy and tongue suspension are evolving as surgical options (133).
Facial bone distraction
Maxillary expansion is an option in patients who are pre pubertal and have a narrow palate and persistent OSA with minimal adenotonsillar tissue. It may be used in combination with adenotonsillectomy in patients who have both conditions (134,135). Mandibular distraction is performed in children with Pierre Robin syndrome and other micrognathic conditions to relieve airway obstruction. The distraction devices are being placed internally eliminating the need for external pins (136).
Hypoglossal nerve stimulation
Hypoglossal nerve stimulation is a treatment modality that has been used to alleviate airway obstruction due to tongue malposition by applying low-voltage electric pulses to the hypoglossal nerve in synchronization with diaphragmatic excursion, activating the muscles that move the tongue forward (137,138).
Tracheotomy may be a first line therapy in the rare instance of contraindications for other surgeries along with presence of failure to thrive. Tracheotomy could be a last resort in multimodality treatment failed significant OSA (139).
Non-surgical treatment options
There are various non-surgical treatment options available to treat or reduce the severity of OSA.
Weight Loss can lead to a marginal (5–10%) improvement in AHI in children with SDB. Weight loss could also happen as a surgical outcome, since improved quality after surgery could lead to weight loss. Weight loss is frequently recommended as a part of SDB treatment particularly when there is underlying obesity even when surgery is an option (140,141).
Positive airway pressure
CPAP and BiPAP while useful as surgery sparing noninvasive treatment modalities in SDB have their limitations in being less useful in younger children due to compliance. They are invaluable in management of residual sleep apnea after surgery in the immediate postoperative period. Standard precautions are followed for indications and contraindications like at risk of aspiration (142).
The use of pharmacotherapy in the treatment of pediatric OSA is summarized in a review (143). Medications that have been evaluated are intranasal steroids and leukotriene receptor antagonists (e.g., Montelukast). In milder cases montelukast along with inhaled steroids might be useful in reducing tissue inflammation and treatment of postoperative residual OSA (144,145).
Pediatric SDB is a spectrum and OSA is the most severe variant with a prevalence of up to 4% or higher in children. There are numerous challenges with screening and diagnosis which leaves high number of undiagnosed OSA. The approach to a child with suspected or confirmed OSA presenting for perioperative care is summarized. The recently published guidelines on tonsillectomy by American Academy of Otolaryngology is endorsed by various other societies. The guidelines provide a comprehensive view of perioperative management of a child with sleep disordered breathing presenting to an anesthesiologist and otolaryngologist for perioperative management.
Conflicts of Interest: The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
- Grime C, Tan HL. Sleep Disordered Breathing in Children. Indian J Pediatr 2015;82:945-55. [Crossref] [PubMed]
- Lerman J. A disquisition on sleep-disordered breathing in children. Paediatr Anaesth 2009;19 Suppl 1:100-8. [Crossref] [PubMed]
- Carroll JL. Obstructive sleep-disordered breathing in children: new controversies, new directions. Clin Chest Med 2003;24:261-82. [Crossref] [PubMed]
- Durdik P, Sujanska A, Suroviakova S, et al. Sleep Architecture in Children With Common Phenotype of Obstructive Sleep Apnea. J Clin Sleep Med 2018;14:9-14. [Crossref] [PubMed]
- Vlahandonis A, Nixon GM, Davey MJ, et al. A four year follow-up of sleep and respiratory measures in elementary school-aged children with sleep disordered breathing. Sleep Med 2013;14:440-8. [Crossref] [PubMed]
- Loredo JS, Ancoli-Israel S, Kim EJ, et al. Effect of continuous positive airway pressure versus supplemental oxygen on sleep quality in obstructive sleep apnea: a placebo-CPAP-controlled study. Sleep 2006;29:564-71. [Crossref] [PubMed]
- Gupta RM, Parvizi J, Hanssen AD, et al. Postoperative complications in patients with obstructive sleep apnea syndrome undergoing hip or knee replacement: a case-control study. Mayo Clin Proc 2001;76:897-905. [Crossref] [PubMed]
- Sabers C, Plevak DJ, Schroeder DR, et al. The diagnosis of obstructive sleep apnea as a risk factor for unanticipated admissions in outpatient surgery. Anesth Analg 2003;96:1328-35. [Crossref] [PubMed]
- Chervin RD, Dillon JE, Bassetti C, et al. Symptoms of sleep disorders, inattention, and hyperactivity in children. Sleep 1997;20:1185-92. [Crossref] [PubMed]
- O'Brien LM, Mervis CB, Holbrook CR, et al. Neurobehavioral correlates of sleep-disordered breathing in children. J Sleep Res 2004;13:165-72. [Crossref] [PubMed]
- Montgomery-Downs HE, Jones VF, Molfese VJ, et al. Snoring in preschoolers: associations with sleepiness, ethnicity, and learning. Clin Pediatr (Phila) 2003;42:719-26. [Crossref] [PubMed]
- Enright PL, Goodwin JL, Sherrill DL, et al. Blood pressure elevation associated with sleep-related breathing disorder in a community sample of white and Hispanic children: the Tucson Children's Assessment of Sleep Apnea study. Arch Pediatr Adolesc Med 2003;157:901-4. [Crossref] [PubMed]
- Amin RS, Kimball TR, Bean JA, et al. Left ventricular hypertrophy and abnormal ventricular geometry in children and adolescents with obstructive sleep apnea. Am J Respir Crit Care Med 2002;165:1395-9. [Crossref] [PubMed]
- Subramanyam R, Chidambaran V, Ding L, et al. Anesthesia- and opioids-related malpractice claims following tonsillectomy in USA: LexisNexis claims database 1984-2012. Paediatr Anaesth 2014;24:412-20. [Crossref] [PubMed]
- Coté CJ, Posner KL, Domino KB. Death or neurologic injury after tonsillectomy in children with a focus on obstructive sleep apnea: houston, we have a problem! Anesth Analg 2014;118:1276-83. [Crossref] [PubMed]
- Marcus CL, Brooks LJ, Draper KA, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2012;130:e714-55. [Crossref] [PubMed]
- Lumeng JC, Chervin RD. Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc 2008;5:242-52. [Crossref] [PubMed]
- Bin-Hasan S, Katz S, Nuget Z, et al. Prevalence of obstructive sleep apnea among obese toddlers and preschool children. Sleep Breath 2018;22:511-5. [Crossref] [PubMed]
- Maris M, Verhulst S, Wojciechowski M, et al. Prevalence of Obstructive Sleep Apnea in Children with Down Syndrome. Sleep 2016;39:699-704. [Crossref] [PubMed]
- Hill CA, Litvak A, Canapari C, et al. A pilot study to identify pre- and peri-operative risk factors for airway complications following adenotonsillectomy for treatment of severe pediatric OSA. Int J Pediatr Otorhinolaryngol 2011;75:1385-90. [Crossref] [PubMed]
- Jaryszak EM, Shah RK, Vanison CC, et al. Polysomnographic variables predictive of adverse respiratory events after pediatric adenotonsillectomy. Arch Otolaryngol Head Neck Surg 2011;137:15-8. [Crossref] [PubMed]
- Sanders JC, King MA, Mitchell RB, et al. Perioperative complications of adenotonsillectomy in children with obstructive sleep apnea syndrome. Anesth Analg 2006;103:1115-21. [Crossref] [PubMed]
- Kennedy JD, Blunden S, Hirte C, et al. Reduced neurocognition in children who snore. Pediatr Pulmonol 2004;37:330-7. [Crossref] [PubMed]
- Mulvaney SA, Goodwin JL, Morgan WJ, et al. Behavior problems associated with sleep disordered breathing in school-aged children--the Tucson children's assessment of sleep apnea study. J Pediatr Psychol. 2006;31:322-30. [Crossref] [PubMed]
- O'Brien LM, Mervis CB, Holbrook CR, Bruner JL, Klaus CJ, Rutherford J, et al. Neurobehavioral implications of habitual snoring in children. Pediatrics. 2004;114:44-9. [Crossref] [PubMed]
- O'Brien LM, Gozal D. Autonomic dysfunction in children with sleep-disordered breathing. Sleep 2005;28:747-52. [Crossref] [PubMed]
- Duman D, Naiboglu B, Esen HS, et al. Impaired right ventricular function in adenotonsillar hypertrophy. Int J Cardiovasc Imaging 2008;24:261-7. [Crossref] [PubMed]
- Enright PL, Goodwin JL, Sherrill DL, et al. Blood pressure elevation associated with sleep-related breathing disorder in a community sample of white and Hispanic children: the Tucson Children's Assessment of Sleep Apnea study. Arch Pediatr Adolesc Med 2003;157:901-4. [Crossref] [PubMed]
- Nieminen P, Löppönen T, Tolonen U, et al. Growth and biochemical markers of growth in children with snoring and obstructive sleep apnea. Pediatrics 2002;109:e55. [Crossref] [PubMed]
- Bonuck KA, Freeman K, Henderson J. Growth and growth biomarker changes after adenotonsillectomy: systematic review and meta-analysis. Arch Dis Child 2009;94:83-91. [Crossref] [PubMed]
- Castaneda A, Jauregui-Maldonado E, Ratnani I, et al. Correlation between metabolic syndrome and sleep apnea. World J Diabetes 2018;9:66-71. [Crossref] [PubMed]
- Chervin RD, Ruzicka DL, Giordani BJ, et al. Sleep-disordered breathing, behavior, and cognition in children before and after adenotonsillectomy. Pediatrics 2006;117:e769-78. [Crossref] [PubMed]
- Friedman BC, Hendeles-Amitai A, Kozminsky E, et al. Adenotonsillectomy improves neurocognitive function in children with obstructive sleep apnea syndrome. Sleep 2003;26:999-1005. [Crossref] [PubMed]
- Colen TY, Seidman C, Weedon J, et al. Effect of intracapsular tonsillectomy on quality of life for children with obstructive sleep-disordered breathing. Arch Otolaryngol Head Neck Surg 2008;134:124-7. [Crossref] [PubMed]
- Ugur MB, Dogan SM, Sogut A, et al. Effect of adenoidectomy and/or tonsillectomy on cardiac functions in children with obstructive sleep apnea. ORL J Otorhinolaryngol Relat Spec 2008;70:202-8. [Crossref] [PubMed]
- Strohl KP, Saunders NA, Feldman NT, et al. Obstructive sleep apnea in family members. N Engl J Med 1978;299:969-73. [Crossref] [PubMed]
- Redline S, Tishler PV. The genetics of sleep apnea. Sleep Med Rev 2000;4:583-602. [Crossref] [PubMed]
- Redline S, Tishler PV, Tosteson TD, et al. The familial aggregation of obstructive sleep apnea. Am J Respir Crit Care Med 1995;151:682-7. [Crossref] [PubMed]
- Parish JM. Genetic and immunologic aspects of sleep and sleep disorders. Chest 2013;143:1489-99. [Crossref] [PubMed]
- Rosen CL, Larkin EK, Kirchner HL, et al. Prevalence and risk factors for sleep-disordered breathing in 8- to 11-year-old children: association with race and prematurity. J Pediatr 2003;142:383-9. [Crossref] [PubMed]
- Mathur R, Douglas NJ. Family studies in patients with the sleep apnea-hypopnea syndrome. Ann Intern Med 1995;122:174-8. [Crossref] [PubMed]
- Guilleminault C, Partinen M, Hollman K, et al. Familial aggregates in obstructive sleep apnea syndrome. Chest 1995;107:1545-51. [Crossref] [PubMed]
- Varvarigou V, Dahabreh IJ, Malhotra A, et al. A review of genetic association studies of obstructive sleep apnea: field synopsis and meta-analysis. Sleep 2011;34:1461-8. [Crossref] [PubMed]
- Riha RL, Brander P, Vennelle M, et al. Tumour necrosis factor-alpha (-308) gene polymorphism in obstructive sleep apnoea-hypopnoea syndrome. Eur Respir J 2005;26:673-8. [Crossref] [PubMed]
- Gottlieb DJ, DeStefano AL, Foley DJ, et al. APOE epsilon4 is associated with obstructive sleep apnea/hypopnea: the Sleep Heart Health Study. Neurology 2004;63:664-8. [Crossref] [PubMed]
- Thakre TP, Mamtani MR, Kulkarni H. Lack of association of the APOE epsilon 4 allele with the risk of obstructive sleep apnea: meta-analysis and meta-regression. Sleep 2009;32:1507-11. [Crossref] [PubMed]
- Cortelli P, Gambetti P, Montagna P, et al. Fatal familial insomnia: clinical features and molecular genetics. J Sleep Res 1999;8 Suppl 1:23-9. [Crossref] [PubMed]
- Toh KL, Jones CR, He Y, et al. An hPer2 phosphorylation site mutation in familial advanced sleep phase syndrome. Science 2001;291:1040-3. [Crossref] [PubMed]
- Dayyat E, Kheirandish-Gozal L, Gozal D. Childhood Obstructive Sleep Apnea: One or Two Distinct Disease Entities? Sleep Med Clin 2007;2:433-44. [Crossref] [PubMed]
- Tauman R, Gulliver TE, Krishna J, et al. Persistence of obstructive sleep apnea syndrome in children after adenotonsillectomy. J Pediatr 2006;149:803-8. [Crossref] [PubMed]
- Gozal D, Serpero LD, Sans Capdevila O, et al. Systemic inflammation in non-obese children with obstructive sleep apnea. Sleep Med 2008;9:254-9. [Crossref] [PubMed]
- Gozal D, Crabtree VM, Sans Capdevila O, et al. C-reactive protein, obstructive sleep apnea, and cognitive dysfunction in school-aged children. Am J Respir Crit Care Med 2007;176:188-93. [Crossref] [PubMed]
- Ford ES, Galuska DA, Gillespie C, et al. C-reactive protein and body mass index in children: findings from the Third National Health and Nutrition Examination Survey, 1988-1994. J Pediatr 2001;138:486-92. [Crossref] [PubMed]
- Visser M, Bouter LM, McQuillan GM, et al. Low-grade systemic inflammation in overweight children. Pediatrics 2001;107:E13. [Crossref] [PubMed]
- Gileles-Hillel A, Alonso-Álvarez ML, Kheirandish-Gozal L, et al. Inflammatory markers and obstructive sleep apnea in obese children: the NANOS study. Mediators Inflamm 2014;2014:605280. [Crossref] [PubMed]
- Khalyfa A, Capdevila OS, Buazza MO, et al. Genome-wide gene expression profiling in children with non-obese obstructive sleep apnea. Sleep Med 2009;10:75-86. [Crossref] [PubMed]
- Tam CS, Wong M, McBain R, et al. Inflammatory measures in children with obstructive sleep apnoea. J Paediatr Child Health 2006;42:277-82. [Crossref] [PubMed]
- Kaditis AG, Alexopoulos EI, Kalampouka E, et al. Morning levels of C-reactive protein in children with obstructive sleep-disordered breathing. Am J Respir Crit Care Med 2005;171:282-6. [Crossref] [PubMed]
- Kim J, Bhattacharjee R, Khalyfa A, et al. DNA methylation in inflammatory genes among children with obstructive sleep apnea. Am J Respir Crit Care Med 2012;185:330-8. [Crossref] [PubMed]
- Khayat A, Bin-Hassan S, Al-Saleh S. Polysomnographic findings in infants with Pierre Robin sequence. Ann Thorac Med 2017;12:25-9. [Crossref] [PubMed]
- van Lieshout MJS, Joosten KFM, Koudstaal MJ, et al. Management and outcomes of obstructive sleep apnea in children with Robin sequence, a cross-sectional study. Clin Oral Investig 2017;21:1971-8. [Crossref] [PubMed]
- Lee JJ, Thottam PJ, Ford MD, et al. Characteristics of sleep apnea in infants with Pierre-Robin sequence: Is there improvement with advancing age? Int J Pediatr Otorhinolaryngol 2015;79:2059-67. [Crossref] [PubMed]
- Camacho M, Noller MW, Zaghi S, et al. Tongue-lip adhesion and tongue repositioning for obstructive sleep apnoea in Pierre Robin sequence: A systematic review and meta-analysis. J Laryngol Otol 2017;131:378-83. [Crossref] [PubMed]
- Kennedy WP, Mudd PA, Maguire MA, et al. 22q11.2 Deletion syndrome and obstructive sleep apnea. Int J Pediatr Otorhinolaryngol 2014;78:1360-4. [Crossref] [PubMed]
- Crockett DJ, Goudy SL, Chinnadurai S, et al. Obstructive sleep apnea syndrome in children with 22q11.2 deletion syndrome after operative intervention for velopharyngeal insufficiency. Front Pediatr 2014;2:84. [Crossref] [PubMed]
- Mbulo L, Palipudi KM, Andes L, et al. Secondhand smoke exposure at home among one billion children in 21 countries: findings from the Global Adult Tobacco Survey (GATS). Tob Control 2016;25:e95-e100. [Crossref] [PubMed]
- Jara SM, Benke JR, Lin SY, et al. The association between secondhand smoke and sleep-disordered breathing in children: a systematic review. Laryngoscope 2015;125:241-7. [Crossref] [PubMed]
- Weinstock TG, Rosen CL, Marcus CL, et al. Predictors of obstructive sleep apnea severity in adenotonsillectomy candidates. Sleep 2014;37:261-9. [Crossref] [PubMed]
- Spruyt K, Gozal D. Screening of pediatric sleep-disordered breathing: a proposed unbiased discriminative set of questions using clinical severity scales. Chest 2012;142:1508-15. [Crossref] [PubMed]
- Arnez K JD, Mahmoud M, McClung H, et al. Systematic review of preoperative screening of obstructive sleep apnea and anesthesia outcomes. Soceity for Pedatric Anesthesia Abstract 2019;OS5-190.
- American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology 2014;120:268-86. [Crossref] [PubMed]
- Chung F, Yegneswaran B, Liao P, et al. Validation of the Berlin questionnaire and American Society of Anesthesiologists checklist as screening tools for obstructive sleep apnea in surgical patients. Anesthesiology 2008;108:822-30. [Crossref] [PubMed]
- Munish M, Sharma V, Yarussi KM, et al. The use of practice guidelines by the American Society of Anesthesiologists for the identification of surgical patients at high risk of sleep apnea. Chron Respir Dis 2012;9:221-30. [Crossref] [PubMed]
- Chervin RD, Hedger K, Dillon JE, et al. Pediatric sleep questionnaire (PSQ): validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problems. Sleep Medicine 2000;1:21-32. [Crossref] [PubMed]
- Chervin RD, Weatherly RA, Garetz SL, et al. Pediatric sleep questionnaire: prediction of sleep apnea and outcomes. Arch Otolaryngol Head Neck Surg 2007;133:216-22. [Crossref] [PubMed]
- Tait AR, Voepel-Lewis T, Christensen R, et al. The STBUR questionnaire for predicting perioperative respiratory adverse events in children at risk for sleep-disordered breathing. Paediatr Anaesth 2013;23:510-6. [Crossref] [PubMed]
- Ishman S, Heubi C, Jenkins T, et al. OSA screening with the pediatric sleep questionnaire for adolescents undergoing bariatric surgery in teen-LABS. Obesity (Silver Spring) 2016;24:2392-8. [Crossref] [PubMed]
- Kako H, Tripi J, Walia H, et al. Utility of screening questionnaire and polysomnography to predict postoperative outcomes in children. Int J Pediatr Otorhinolaryngol 2017;102:71-5. [Crossref] [PubMed]
- Raman VT, Splaingard M, Tumin D, et al. Utility of screening questionnaire, obesity, neck circumference, and sleep polysomnography to predict sleep-disordered breathing in children and adolescents. Paediatr Anaesth 2016;26:655-64. [Crossref] [PubMed]
- Mitchell RB, Garetz S, Moore RH, et al. The use of clinical parameters to predict obstructive sleep apnea syndrome severity in children: the Childhood Adenotonsillectomy (CHAT) study randomized clinical trial. JAMA Otolaryngol Head Neck Surg 2015;141:130-6. [Crossref] [PubMed]
- Scalzitti NJ, Sarber KM. Diagnosis and perioperative management in pediatric sleep-disordered breathing. Paediatr Anaesth 2018;28:940-6. [Crossref] [PubMed]
- Franco RA Jr, Rosenfeld RM, Rao M. First place--resident clinical science award 1999. Quality of life for children with obstructive sleep apnea. Otolaryngol Head Neck Surg 2000;123:9-16. [Crossref] [PubMed]
- Baldassari CM, Mitchell RB, Schubert C, et al. Pediatric obstructive sleep apnea and quality of life: a meta-analysis. Otolaryngol Head Neck Surg 2008;138:265-73. [Crossref] [PubMed]
- Goldstein NA, Stefanov DG, Graw-Panzer KD, et al. Validation of a clinical assessment score for pediatric sleep-disordered breathing. Laryngoscope 2012;122:2096-104. [Crossref] [PubMed]
- Ho AW, Moul DE, Krishna J. Neck Circumference-Height Ratio as a Predictor of Sleep Related Breathing Disorder in Children and Adults. J Clin Sleep Med 2016;12:311-7. [Crossref] [PubMed]
- Gozal D, Capdevila OS, Kheirandish-Gozal L, et al. APOE epsilon 4 allele, cognitive dysfunction, and obstructive sleep apnea in children. Neurology 2007;69:243-9. [Crossref] [PubMed]
- Gozal D, Sans Capdevila O, McLaughlin Crabtree V, et al. Plasma IGF-1 levels and cognitive dysfunction in children with obstructive sleep apnea. Sleep Med 2009;10:167-73. [Crossref] [PubMed]
- Gozal D. Serum, urine, and breath-related biomarkers in the diagnosis of obstructive sleep apnea in children: is it for real? Curr Opin Pulm Med 2012;18:561-7. [Crossref] [PubMed]
- Carroll JL, McColley SA, Marcus CL, et al. Inability of clinical history to distinguish primary snoring from obstructive sleep apnea syndrome in children. Chest 1995;108:610-8. [Crossref] [PubMed]
- Nolan J, Brietzke SE. Systematic review of pediatric tonsil size and polysomnogram-measured obstructive sleep apnea severity. Otolaryngol Head Neck Surg 2011;144:844-50. [Crossref] [PubMed]
- Mitchell RB, Archer SM, Ishman SL, et al. Clinical Practice Guideline: Tonsillectomy in Children (Update). Otolaryngol Head Neck Surg 2019;160:S1-42. [Crossref] [PubMed]
- Aurora RN, Zak RS, Karippot A, et al. Practice parameters for the respiratory indications for polysomnography in children. Sleep 2011;34:379-88. [Crossref] [PubMed]
- Patino M, Sadhasivam S, Mahmoud M. Obstructive sleep apnoea in children: perioperative considerations. Br J Anaesth 2013;111 Suppl 1:i83-95. [Crossref] [PubMed]
- Brouillette RT, Morielli A, Leimanis A, et al. Nocturnal pulse oximetry as an abbreviated testing modality for pediatric obstructive sleep apnea. Pediatrics 2000;105:405-12. [Crossref] [PubMed]
- Horwood L, Brouillette RT, McGregor CD, et al. Testing for pediatric obstructive sleep apnea when health care resources are rationed. JAMA Otolaryngol Head Neck Surg 2014;140:616-23. [Crossref] [PubMed]
- Nixon GM, Kermack AS, Davis GM, et al. Planning adenotonsillectomy in children with obstructive sleep apnea: the role of overnight oximetry. Pediatrics 2004;113:e19-25. [Crossref] [PubMed]
- Wilson K, Lakheeram I, Morielli A, et al. Can assessment for obstructive sleep apnea help predict postadenotonsillectomy respiratory complications? Anesthesiology 2002;96:313-22. [Crossref] [PubMed]
- Kirk VG, Bohn SG, Flemons WW, et al. Comparison of home oximetry monitoring with laboratory polysomnography in children. Chest 2003;124:1702-8. [Crossref] [PubMed]
- Lesser DJ, Haddad GG, Bush RA, et al. The utility of a portable recording device for screening of obstructive sleep apnea in obese adolescents. J Clin Sleep Med 2012;8:271-7. [PubMed]
- Stehling F, Keull J, Olivier M, et al. Validation of the screening tool ApneaLink. Sleep Med 2017;37:13-8. [Crossref] [PubMed]
- Brockmann PE, Perez JL, Moya A. Feasibility of unattended home polysomnography in children with sleep-disordered breathing. Int J Pediatr Otorhinolaryngol 2013;77:1960-4. [Crossref] [PubMed]
- Alonso-Álvarez ML, Terán-Santos J, Ordax Carbajo E, et al. Reliability of home respiratory polygraphy for the diagnosis of sleep apnea in children. Chest 2015;147:1020-8. [Crossref] [PubMed]
- Poels PJ, Schilder AG, van den Berg S, et al. Evaluation of a new device for home cardiorespiratory recording in children. Arch Otolaryngol Head Neck Surg 2003;129:1281-4. [Crossref] [PubMed]
- Scalzitti N, Hansen S, Maturo S, et al. Comparison of home sleep apnea testing versus laboratory polysomnography for the diagnosis of obstructive sleep apnea in children. Int J Pediatr Otorhinolaryngol 2017;100:44-51. [Crossref] [PubMed]
- Collop NA, Anderson WM, Boehlecke B, et al. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Portable Monitoring Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med 2007;3:737-47. [PubMed]
- Cooksey JA, Balachandran JS. Portable Monitoring for the Diagnosis of OSA. Chest 2016;149:1074-81. [Crossref] [PubMed]
- Bhattacharjee R, Kheirandish-Gozal L, Spruyt K, et al. Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children: a multicenter retrospective study. Am J Respir Crit Care Med 2010;182:676-83. [Crossref] [PubMed]
- Truong MT, Woo VG, Koltai PJ. Sleep endoscopy as a diagnostic tool in pediatric obstructive sleep apnea. Int J Pediatr Otorhinolaryngol 2012;76:722-7. [Crossref] [PubMed]
- Kandil A, Subramanyam R, Hossain MM, et al. Comparison of the combination of dexmedetomidine and ketamine to propofol or propofol/sevoflurane for drug-induced sleep endoscopy in children. Paediatr Anaesth 2016;26:742-51. [Crossref] [PubMed]
- Kuyrukluyıldız U, Binici O, Onk D, et al. Comparison of dexmedetomidine and propofol used for drug-induced sleep endoscopy in patients with obstructive sleep apnea syndrome. Int J Clin Exp Med 2015;8:5691-8. [PubMed]
- Cho JS, Soh S, Kim EJ, et al. Comparison of three sedation regimens for drug-induced sleep endoscopy. Sleep Breath 2015;19:711-7. [Crossref] [PubMed]
- Isaiah A, Kiss E, Olomu P, et al. Characterization of upper airway obstruction using cine MRI in children with residual obstructive sleep apnea after adenotonsillectomy. Sleep Med 2018;50:79-86. [Crossref] [PubMed]
- Clark C, Ulualp SO. Multimodality assessment of upper airway obstruction in children with persistent obstructive sleep apnea after adenotonsillectomy. Laryngoscope 2017;127:1224-30. [Crossref] [PubMed]
- Mahmoud M, Gunter J, Donnelly LF, et al. A comparison of dexmedetomidine with propofol for magnetic resonance imaging sleep studies in children. Anesth Analg 2009;109:745-53. [Crossref] [PubMed]
- Wolfensberger M, Haury JA, Linder T. Parent satisfaction 1 year after adenotonsillectomy of their children. Int J Pediatr Otorhinolaryngol 2000;56:199-205. [Crossref] [PubMed]
- Baugh RF, Archer SM, Mitchell RB, et al. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg 2011;144:S1-30. [Crossref] [PubMed]
- Subramanyam R, Varughese A, Willging JP, et al. Future of pediatric tonsillectomy and perioperative outcomes. Int J Pediatr Otorhinolaryngol 2013;77:194-9. [Crossref] [PubMed]
- Tobias JD, Green TP, Cote CJ, et al. Codeine: Time to Say "No". Pediatrics 2016;138:e20162396. [Crossref] [PubMed]
- Steward DL, Grisel J, Meinzen-Derr J. Steroids for improving recovery following tonsillectomy in children. Cochrane Database Syst Rev 2011.CD003997. [PubMed]
- Subramanyam R, Varughese A, Kurth CD, et al. Cost-effectiveness of intravenous acetaminophen for pediatric tonsillectomy. Paediatr Anaesth 2014;24:467-75. [Crossref] [PubMed]
- . Available online: http://wakeupsafe.org/wp-content/uploads/2018/10/acetaminophen_warning.pdfSafe WU.
- Marcus CL, Moore RH, Rosen CL, et al. A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med 2013;368:2366-76. [Crossref] [PubMed]
- Friedman M, Wilson M, Lin HC, et al. Updated systematic review of tonsillectomy and adenoidectomy for treatment of pediatric obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg 2009;140:800-8. [Crossref] [PubMed]
- Walton J, Ebner Y, Stewart MG, et al. Systematic review of randomized controlled trials comparing intracapsular tonsillectomy with total tonsillectomy in a pediatric population. Arch Otolaryngol Head Neck Surg 2012;138:243-9. [Crossref] [PubMed]
- Kim JS, Kwon SH, Lee EJ, et al. Can Intracapsular Tonsillectomy Be an Alternative to Classical Tonsillectomy? A Meta-analysis. Otolaryngol Head Neck Surg 2017;157:178-89. [Crossref] [PubMed]
- Zhang LY, Zhong L, David M, et al. Tonsillectomy or tonsillotomy? A systematic review for paediatric sleep-disordered breathing. Int J Pediatr Otorhinolaryngol 2017;103:41-50. [Crossref] [PubMed]
- Walner DL, Parker NP, Miller RP. Past and present instrument use in pediatric adenotonsillectomy. Otolaryngol Head Neck Surg 2007;137:49-53. [Crossref] [PubMed]
- Kosko JR, Derkay CS. Uvulopalatopharyngoplasty: treatment of obstructive sleep apnea in neurologically impaired pediatric patients. Int J Pediatr Otorhinolaryngol 1995;32:241-6. [Crossref] [PubMed]
- Donaldson JD, Redmond WM. Surgical management of obstructive sleep apnea in children with Down syndrome. J Otolaryngol 1988;17:398-403. [PubMed]
- Zafereo ME, Taylor RJ, Pereira KD. Supraglottoplasty for laryngomalacia with obstructive sleep apnea. Laryngoscope 2008;118:1873-7. [Crossref] [PubMed]
- Lee CF, Hsu WC, Lee CH, et al. Treatment outcomes of supraglottoplasty for pediatric obstructive sleep apnea: A meta-analysis. Int J Pediatr Otorhinolaryngol 2016;87:18-27. [Crossref] [PubMed]
- Ishman SL, Chang KW, Kennedy AA. Techniques for evaluation and management of tongue-base obstruction in pediatric obstructive sleep apnea. Curr Opin Otolaryngol Head Neck Surg 2018;26:409-16. [Crossref] [PubMed]
- Manickam PV, Shott SR, Boss EF, et al. Systematic review of site of obstruction identification and non-CPAP treatment options for children with persistent pediatric obstructive sleep apnea. Laryngoscope 2016;126:491-500. [Crossref] [PubMed]
- Guilleminault C, Monteyrol PJ, Huynh NT, et al. Adeno-tonsillectomy and rapid maxillary distraction in pre-pubertal children, a pilot study. Sleep Breath 2011;15:173-7. [Crossref] [PubMed]
- Pirelli P, Saponara M, Guilleminault C. Rapid maxillary expansion in children with obstructive sleep apnea syndrome. Sleep 2004;27:761-6. [Crossref] [PubMed]
- Abramson ZR, Susarla SM, Lawler ME, et al. Effects of mandibular distraction osteogenesis on three-dimensional airway anatomy in children with congenital micrognathia. J Oral Maxillofac Surg 2013;71:90-7. [Crossref] [PubMed]
- Hong SO, Chen YF, Jung J, et al. Hypoglossal nerve stimulation for treatment of obstructive sleep apnea (OSA): a primer for oral and maxillofacial surgeons. Maxillofac Plast Reconstr Surg 2017;39:27. [Crossref] [PubMed]
- Diercks GR, Wentland C, Keamy D, et al. Hypoglossal Nerve Stimulation in Adolescents With Down Syndrome and Obstructive Sleep Apnea. JAMA Otolaryngol Head Neck Surg 2018;144:37-42. [PubMed]
- Conway WA, Victor LD, Magilligan DJ, et al. Adverse effects of tracheostomy for sleep apnea. JAMA 1981;246:347-50. [Crossref] [PubMed]
- Verhulst SL, Franckx H, Van Gaal L, et al. The effect of weight loss on sleep-disordered breathing in obese teenagers. Obesity (Silver Spring) 2009;17:1178-83. [PubMed]
- Cespedes EM, Hu FB, Redline S, et al. Chronic insufficient sleep and diet quality: Contributors to childhood obesity. Obesity (Silver Spring) 2016;24:184-90. [Crossref] [PubMed]
- Friedman O, Chidekel A, Lawless ST, et al. Postoperative bilevel positive airway pressure ventilation after tonsillectomy and adenoidectomy in children--a preliminary report. Int J Pediatr Otorhinolaryngol 1999;51:177-80. [Crossref] [PubMed]
- Tapia IE, Marcus CL. Newer treatment modalities for pediatric obstructive sleep apnea. Paediatr Respir Rev 2013;14:199-203. [Crossref] [PubMed]
- Kheirandish L, Goldbart AD, Gozal D. Intranasal steroids and oral leukotriene modifier therapy in residual sleep-disordered breathing after tonsillectomy and adenoidectomy in children. Pediatrics 2006;117:e61-6. [Crossref] [PubMed]
- Kheirandish-Gozal L, Gozal D. Intranasal budesonide treatment for children with mild obstructive sleep apnea syndrome. Pediatrics 2008;122:e149-55. [Crossref] [PubMed]
Cite this article as: Narayanasamy S, Kidambi SS, Mahmoud M, Subramanyam R. Pediatric sleep disordered breathing: a narrative review. Pediatr Med 2019;2:52.