- Email: [email protected]
Childhood OSA Syndrome
goal in the real world remains a key challenge that physicians caring for patients with OSA need to focus on to optimize long-term health outcomes in these patients.
References 1. Schwartz AR, Patil SP, Laffan AM, Polotsky V, Schneider H, Smith PL. Obesity and obstructive sleep apnea: pathogenic mechanisms and therapeutic approaches. Proc Am Thorac Soc. 2008;5(2): 185-192. 2. Young T, Peppard PE, Taheri S. Excess weight and sleep-disordered breathing. J Appl Physiol (1985). 2005;99(4):1592-1599. 3. Drager LF, Brunoni AR, Jenner R, Lorenzi-Filho G, Benseñor IM, Lotufo PA. Effects of CPAP on body weight in patients with obstructive sleep apnoea: a meta-analysis of randomised trials. Thorax. 2015;70(3):258-264. 4. Quan SF, Budhiraja R, Clarke DP, et al. Impact of treatment with continuous positive airway pressure (CPAP) on weight in obstructive sleep apnea. J Clin Sleep Med. 2013;9(10):989-993. 5. Johansson K, Neovius M, Lagerros YT, et al. Effect of a very low energy diet on moderate and severe obstructive sleep apnoea in obese men: a randomised controlled trial. BMJ. 2009; 339:b4609. 6. Tuomilehto HP, Seppä JM, Partinen MM, et al; Kuopio Sleep Apnea Group. Lifestyle intervention with weight reduction: first-line treatment in mild obstructive sleep apnea. Am J Respir Crit Care Med. 2009;179(4):320-327. 7. Foster GD, Borradaile KE, Sanders MH, et al; Sleep AHEAD Research Group of Look AHEAD Research Group. A randomized study on the effect of weight loss on obstructive sleep apnea among obese patients with type 2 diabetes: the Sleep AHEAD study. Arch Intern Med. 2009;169(17):1619-1626. 8. Ng SSS, Chan RSM, Woo J, et al. A randomized controlled study to examine the effect of a lifestyle modification program in OSA. Chest. 2015;148(5):1193-1203. 9. Fernandez-Mendoza J, Vgontzas AN, Kritikou I, Calhoun SL, Liao D, Bixler EO. Natural history of excessive daytime sleepiness: role of obesity, weight loss, depression, and sleep propensity. Sleep. 2015; 38(3):351-360. 10. Chirinos JA, Gurubhagavatula I, Teff K, et al. CPAP, weight loss, or both for obstructive sleep apnea. N Engl J Med. 2014;370(24): 2265-2275. 11. Aurora RN, Collop NA, Jacobowitz O, Thomas SM, Quan SF, Aronsky AJ. Quality measures for the care of adult patients with obstructive sleep apnea. J Clin Sleep Med. 2015;11(3):357-383.
Childhood OSA Syndrome Patience for Your Patients Is a Virtue Ian Nathanson, MD, FCCP
(PSG), neuropsychologic testing, and symptom scoring using widely accepted questionnaires before being randomly assigned to either an early adenotonsillectomy (AT) group or a watchful waiting group. The protocol called for repeat PSG, neuropsychologic testing, and symptom scoring 7 months later. Of the 397 children who completed CHAT, PSGs normalized in 79% of the AT group and 46% of the watchful waiting group. Symptom scores also improved following AT, but neuropsychologic testing showed no significant improvement in attention or executive function. These findings raised important questions for clinicians about the indications of AT in a child with OSAS. Chervin et al1 present a detailed look at the children who did not have AT. Few would argue about recommending AT for severe or moderate OSAS in the presence of large tonsils,3 but deciding what to do with children with modest changes on PSG or symptom scores consistent with OSAS is less certain. The position of the American Academy of Otolaryngology—Head and Neck Surgery can be found on its website: “The gold standard for the diagnosis and quantification of OSA is full-night polysomnography, or sleep study. However, polysomnography is expensive, time-consuming, and often unavailable. Consequently, most otolaryngologists will perform an adenotonsillectomy (T&A) based on a strong clinical history and parental observation in a child with chronically enlarged adenoids and tonsils.”4 The findings of Chervin et al1 challenge this approach. Of the 194 children who completed the watchful waiting period, none had severe OSAS as defined by apnea/hypopnea index (AHI) ⱖ 30/min or oxygen saturation measured by pulse oximetry , 90% for ⱖ 2% of total sleep time. Rather, this group had a mild to moderate OSAS with a mean AHI of 6.7 ⫾ 5.6 (range, 1.1-29.3). This represents the most vexatious group, because the best management approach is not clear-cut. Following completion of a 7-month watchful waiting period, 42% of the children showed spontaneous PSG resolution of OSAS compared with only 15% who showed significant improvement of the symptom scores and 12% who showed resolution of both PSGs and improvement in symptom scores. This
Maitland, FL
In this issue of CHEST (see page 1204), Chervin et al1 provide important information that should influence how we treat young children who have OSA syndrome (OSAS). The reported data came from the Childhood Adenotonsillectomy Trial (CHAT), a multicenter research project that included 464 children 5 to 9 years of age who had OSAS.2 Each child underwent polysomnography
journal.publications.chestnet.org
AFFILIATIONS: From Section Editor, Guidelines and Consensus Statements for CHEST. CONFLICT OF INTEREST: None declared. CORRESPONDENCE TO: Ian Nathanson, MD, FCCP, 838 Lake Catherine Ct, Maitland, FL 32751; e-mail: [email protected] © 2015 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.15-1041
1129
disparity suggests that we should use symptom scores instead of PSGs to decide how to proceed. Recent data reported by Rosen et al5 indicate that despite these disparities in the level of improvement, neither PSGs nor symptom scores can serve as the sole source of data. Adding to this, Chervin et al1 noted that spontaneous resolution of OSA without AT was associated with non-black race, smaller waist circumference, smaller neck circumference, wider oropharyngeal spaces, and lower BMI. Although AT is a relatively safe procedure, complications do occur, and we must not be cavalier about recommending this to children with mild OSAS. Furthermore, AT does not always resolve the OSAS.2 Certainly, no one wants to return to the days when upward of 60% of children had tonsillectomies (primarily for infection),6 but AT remains one of the most common surgical procedures. Data from the National Survey of Ambulatory Surgery showed that in 2006 there were about 530,000 tonsillectomies (with or without adenoidectomy) and 132,000 adenoidectomies alone in children younger than 15 years.7 Sleep-disordered breathing was listed as the primary indication in 69.5% of cases before the age of 6 years and 59.2% of cases at 7 to 12 years. The incidence of these surgeries was not significantly different between Medicaid and non-Medicaid insurance coverage. There was, however, significant variability between regions of the United States and levels of urbanization.8 Further proof of lack of standardization was reported by Mahant et al,9 who found wide variability in adherence by children’s hospitals to clinical practice guidelines published by the American Academy of Otolaryngology— Head and Neck Surgery.10 This group also found that 7.8% of 139,715 children required a revisit to the hospital or ED within 30 days of their tonsillectomy, mostly for bleeding and dehydration.9 Even relatively safe surgical procedures can have complications, and the financial impact associated with professional fees, facility fees, medications, and parental lost time at work is substantial. This makes it imperative that
1130 Editorials
we better understand who requires surgery and who does not. There is encouraging evidence to suggest that empirical use of antiinflammatory agents may be effective to treat mild to moderate OSAS.11,12 Now, the report by Chervin et al1 further supports that surgery may not be the treatment of choice for children who have a low symptom burden, little snoring, low AHI, and no central obesity. As we learn more about who is affected by this disorder new treatments will likely emerge, but in the meantime we can feel comfortable that watchful waiting can be an appropriate strategy.
References 1. Chervin RD, Ellenberg SS, Hou X, et al. Prognosis for spontaneous resolution of OSA in children. Chest. 2015;148(5):1204-1213. 2. Marcus CL, Moore RH, Rosen CL, et al; Childhood Adenotonsillectomy Trial (CHAT). A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med. 2013;368(25):2366-2376. 3. Mitchell RB. Adenotonsillectomy for obstructive sleep apnea in children: outcome evaluated by pre- and postoperative polysomnography. Laryngoscope. 2007;117(10):1844-1854. 4. Tonsillectomy facts in the US: from ENT doctors. http://www. entnet.org/content/tonsillectomy-facts-us-ent-doctors. Accessed April 27, 2015. 5. Rosen CL, Wang R, Taylor HG, et al. Utility of symptoms to predict treatment outcomes in obstructive sleep apnea syndrome. Pediatrics. 2015;135(3):e662-e671. 6. Goodman DC, Challener GJ. Tonsillectomy: a procedure in search of evidence. J Pediatr. 2012;160(5):716-718. 7. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory Surgery in the United States, 2006. Revised. Hyattsville, MD: National Center for Health Statistics; 2009. National Health Statistics Report No. 11. 8. Boss EF, Marsteller JA, Simon AE. Outpatient tonsillectomy in children: demographic and geographic variation in the United States, 2006. J Pediatr. 2012;160(5):814-819. 9. Mahant S, Keren R, Localio R, et al; Pediatric Research in Inpatient Settings (PRIS) Network. Variation in quality of tonsillectomy perioperative care and revisit rates in children’s hospitals. Pediatrics. 2014;133(2):280-288. 10. Baugh RF, Archer SM, Mitchell RB, et al; American Academy of Otolaryngology-Head and Neck Surgery Foundation. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg. 2011;144(suppl 1):S1-S30. 11. Kheirandish-Gozal L, Bhattacharjee R, Bandla HP, Gozal D. Antiinflammatory therapy outcomes for mild OSA in children. Chest. 2014;146(1):88-95. 12. Kuhle S, Urschitz MS. Anti-inflammatory medications for obstructive sleep apnea in children. Cochrane Database Syst Rev 2011;(1):CD007074.
[
148#5 CHEST NOVEMBER 2015
]
References 1. Schwartz AR, Patil SP, Laffan AM, Polotsky V, Schneider H, Smith PL. Obesity and obstructive sleep apnea: pathogenic mechanisms and therapeutic approaches. Proc Am Thorac Soc. 2008;5(2): 185-192. 2. Young T, Peppard PE, Taheri S. Excess weight and sleep-disordered breathing. J Appl Physiol (1985). 2005;99(4):1592-1599. 3. Drager LF, Brunoni AR, Jenner R, Lorenzi-Filho G, Benseñor IM, Lotufo PA. Effects of CPAP on body weight in patients with obstructive sleep apnoea: a meta-analysis of randomised trials. Thorax. 2015;70(3):258-264. 4. Quan SF, Budhiraja R, Clarke DP, et al. Impact of treatment with continuous positive airway pressure (CPAP) on weight in obstructive sleep apnea. J Clin Sleep Med. 2013;9(10):989-993. 5. Johansson K, Neovius M, Lagerros YT, et al. Effect of a very low energy diet on moderate and severe obstructive sleep apnoea in obese men: a randomised controlled trial. BMJ. 2009; 339:b4609. 6. Tuomilehto HP, Seppä JM, Partinen MM, et al; Kuopio Sleep Apnea Group. Lifestyle intervention with weight reduction: first-line treatment in mild obstructive sleep apnea. Am J Respir Crit Care Med. 2009;179(4):320-327. 7. Foster GD, Borradaile KE, Sanders MH, et al; Sleep AHEAD Research Group of Look AHEAD Research Group. A randomized study on the effect of weight loss on obstructive sleep apnea among obese patients with type 2 diabetes: the Sleep AHEAD study. Arch Intern Med. 2009;169(17):1619-1626. 8. Ng SSS, Chan RSM, Woo J, et al. A randomized controlled study to examine the effect of a lifestyle modification program in OSA. Chest. 2015;148(5):1193-1203. 9. Fernandez-Mendoza J, Vgontzas AN, Kritikou I, Calhoun SL, Liao D, Bixler EO. Natural history of excessive daytime sleepiness: role of obesity, weight loss, depression, and sleep propensity. Sleep. 2015; 38(3):351-360. 10. Chirinos JA, Gurubhagavatula I, Teff K, et al. CPAP, weight loss, or both for obstructive sleep apnea. N Engl J Med. 2014;370(24): 2265-2275. 11. Aurora RN, Collop NA, Jacobowitz O, Thomas SM, Quan SF, Aronsky AJ. Quality measures for the care of adult patients with obstructive sleep apnea. J Clin Sleep Med. 2015;11(3):357-383.
Childhood OSA Syndrome Patience for Your Patients Is a Virtue Ian Nathanson, MD, FCCP
(PSG), neuropsychologic testing, and symptom scoring using widely accepted questionnaires before being randomly assigned to either an early adenotonsillectomy (AT) group or a watchful waiting group. The protocol called for repeat PSG, neuropsychologic testing, and symptom scoring 7 months later. Of the 397 children who completed CHAT, PSGs normalized in 79% of the AT group and 46% of the watchful waiting group. Symptom scores also improved following AT, but neuropsychologic testing showed no significant improvement in attention or executive function. These findings raised important questions for clinicians about the indications of AT in a child with OSAS. Chervin et al1 present a detailed look at the children who did not have AT. Few would argue about recommending AT for severe or moderate OSAS in the presence of large tonsils,3 but deciding what to do with children with modest changes on PSG or symptom scores consistent with OSAS is less certain. The position of the American Academy of Otolaryngology—Head and Neck Surgery can be found on its website: “The gold standard for the diagnosis and quantification of OSA is full-night polysomnography, or sleep study. However, polysomnography is expensive, time-consuming, and often unavailable. Consequently, most otolaryngologists will perform an adenotonsillectomy (T&A) based on a strong clinical history and parental observation in a child with chronically enlarged adenoids and tonsils.”4 The findings of Chervin et al1 challenge this approach. Of the 194 children who completed the watchful waiting period, none had severe OSAS as defined by apnea/hypopnea index (AHI) ⱖ 30/min or oxygen saturation measured by pulse oximetry , 90% for ⱖ 2% of total sleep time. Rather, this group had a mild to moderate OSAS with a mean AHI of 6.7 ⫾ 5.6 (range, 1.1-29.3). This represents the most vexatious group, because the best management approach is not clear-cut. Following completion of a 7-month watchful waiting period, 42% of the children showed spontaneous PSG resolution of OSAS compared with only 15% who showed significant improvement of the symptom scores and 12% who showed resolution of both PSGs and improvement in symptom scores. This
Maitland, FL
In this issue of CHEST (see page 1204), Chervin et al1 provide important information that should influence how we treat young children who have OSA syndrome (OSAS). The reported data came from the Childhood Adenotonsillectomy Trial (CHAT), a multicenter research project that included 464 children 5 to 9 years of age who had OSAS.2 Each child underwent polysomnography
journal.publications.chestnet.org
AFFILIATIONS: From Section Editor, Guidelines and Consensus Statements for CHEST. CONFLICT OF INTEREST: None declared. CORRESPONDENCE TO: Ian Nathanson, MD, FCCP, 838 Lake Catherine Ct, Maitland, FL 32751; e-mail: [email protected] © 2015 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.15-1041
1129
disparity suggests that we should use symptom scores instead of PSGs to decide how to proceed. Recent data reported by Rosen et al5 indicate that despite these disparities in the level of improvement, neither PSGs nor symptom scores can serve as the sole source of data. Adding to this, Chervin et al1 noted that spontaneous resolution of OSA without AT was associated with non-black race, smaller waist circumference, smaller neck circumference, wider oropharyngeal spaces, and lower BMI. Although AT is a relatively safe procedure, complications do occur, and we must not be cavalier about recommending this to children with mild OSAS. Furthermore, AT does not always resolve the OSAS.2 Certainly, no one wants to return to the days when upward of 60% of children had tonsillectomies (primarily for infection),6 but AT remains one of the most common surgical procedures. Data from the National Survey of Ambulatory Surgery showed that in 2006 there were about 530,000 tonsillectomies (with or without adenoidectomy) and 132,000 adenoidectomies alone in children younger than 15 years.7 Sleep-disordered breathing was listed as the primary indication in 69.5% of cases before the age of 6 years and 59.2% of cases at 7 to 12 years. The incidence of these surgeries was not significantly different between Medicaid and non-Medicaid insurance coverage. There was, however, significant variability between regions of the United States and levels of urbanization.8 Further proof of lack of standardization was reported by Mahant et al,9 who found wide variability in adherence by children’s hospitals to clinical practice guidelines published by the American Academy of Otolaryngology— Head and Neck Surgery.10 This group also found that 7.8% of 139,715 children required a revisit to the hospital or ED within 30 days of their tonsillectomy, mostly for bleeding and dehydration.9 Even relatively safe surgical procedures can have complications, and the financial impact associated with professional fees, facility fees, medications, and parental lost time at work is substantial. This makes it imperative that
1130 Editorials
we better understand who requires surgery and who does not. There is encouraging evidence to suggest that empirical use of antiinflammatory agents may be effective to treat mild to moderate OSAS.11,12 Now, the report by Chervin et al1 further supports that surgery may not be the treatment of choice for children who have a low symptom burden, little snoring, low AHI, and no central obesity. As we learn more about who is affected by this disorder new treatments will likely emerge, but in the meantime we can feel comfortable that watchful waiting can be an appropriate strategy.
References 1. Chervin RD, Ellenberg SS, Hou X, et al. Prognosis for spontaneous resolution of OSA in children. Chest. 2015;148(5):1204-1213. 2. Marcus CL, Moore RH, Rosen CL, et al; Childhood Adenotonsillectomy Trial (CHAT). A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med. 2013;368(25):2366-2376. 3. Mitchell RB. Adenotonsillectomy for obstructive sleep apnea in children: outcome evaluated by pre- and postoperative polysomnography. Laryngoscope. 2007;117(10):1844-1854. 4. Tonsillectomy facts in the US: from ENT doctors. http://www. entnet.org/content/tonsillectomy-facts-us-ent-doctors. Accessed April 27, 2015. 5. Rosen CL, Wang R, Taylor HG, et al. Utility of symptoms to predict treatment outcomes in obstructive sleep apnea syndrome. Pediatrics. 2015;135(3):e662-e671. 6. Goodman DC, Challener GJ. Tonsillectomy: a procedure in search of evidence. J Pediatr. 2012;160(5):716-718. 7. Cullen KA, Hall MJ, Golosinskiy A. Ambulatory Surgery in the United States, 2006. Revised. Hyattsville, MD: National Center for Health Statistics; 2009. National Health Statistics Report No. 11. 8. Boss EF, Marsteller JA, Simon AE. Outpatient tonsillectomy in children: demographic and geographic variation in the United States, 2006. J Pediatr. 2012;160(5):814-819. 9. Mahant S, Keren R, Localio R, et al; Pediatric Research in Inpatient Settings (PRIS) Network. Variation in quality of tonsillectomy perioperative care and revisit rates in children’s hospitals. Pediatrics. 2014;133(2):280-288. 10. Baugh RF, Archer SM, Mitchell RB, et al; American Academy of Otolaryngology-Head and Neck Surgery Foundation. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg. 2011;144(suppl 1):S1-S30. 11. Kheirandish-Gozal L, Bhattacharjee R, Bandla HP, Gozal D. Antiinflammatory therapy outcomes for mild OSA in children. Chest. 2014;146(1):88-95. 12. Kuhle S, Urschitz MS. Anti-inflammatory medications for obstructive sleep apnea in children. Cochrane Database Syst Rev 2011;(1):CD007074.
[
148#5 CHEST NOVEMBER 2015
]