Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children: a multicenter retrospective study

Am J Respir Crit Care Med. 2010 Sep 1;182(5):676-83. Epub 2010 May 6.

Bhattacharjee R, Kheirandish-Gozal L, Spruyt K, Mitchell RB, Promchiarak J, Simakajornboon N, Kaditis AG, Splaingard D,Splaingard M, Brooks LJ, Marcus CL, Sin S, Arens R, Verhulst SL, Gozal D.

Department of Pediatrics, University of Chicago, Comer Children's Hospital, 5721 S. Maryland Avenue, Chicago, IL 60637, USA.

Abstract

RATIONALE: The overall efficacy of adenotonsillectomy (AT) in treatment of obstructive sleep apnea syndrome (OSAS) in children is unknown. Although success rates are likely lower than previously estimated, factors that promote incomplete resolution of OSAS after AT remain undefined.

OBJECTIVES: To quantify the effect of demographic and clinical confounders known to impact the success of AT in treating OSAS.

METHODS: A multicenter collaborative retrospective review of all nocturnal polysomnograms performed both preoperatively and postoperatively on otherwise healthy children undergoing AT for the diagnosis of OSAS was conducted at six pediatric sleep centers in the United States and two in Europe. Multivariate generalized linear modeling was used to assess contributions of specific demographic factors on the post-AT obstructive apnea-hypopnea index (AHI).

MEASUREMENTS AND MAIN RESULTS: Data from 578 children (mean age, 6.9 +/- 3.8 yr) were analyzed, of which approximately 50% of included children were obese. AT resulted in a significant AHI reduction from 18.2 +/- 21.4 to 4.1 +/- 6.4/hour total sleep time (P < 0.001). Of the 578 children, only 157 (27.2%) had complete resolution of OSAS (i.e., post-AT AHI <1/h total sleep time). Age and body mass index z-score emerged as the two principal factors contributing to post-AT AHI (P < 0.001), with modest contributions by the presence of asthma and magnitude of pre-AT AHI (P < 0.05) among nonobese children.

CONCLUSIONS: AT leads to significant improvements in indices of sleep-disordered breathing in children. However, residual disease is present in a large proportion of children after AT, particularly among older (>7 yr) or obese children. In addition, the presence of severe OSAS in nonobese children or of chronic asthma warrants post-AT nocturnal polysomnography, in view of the higher risk for residual OSAS.

Effects of mandibular retropositioning, with or without maxillary advancement, on the oro-naso-pharyngeal airway and development of sleep-related breathing disorders.

J Oral Maxillofac Surg. 2010 Oct;68(10):2431-6. Epub 2010 Jul 21.

Demetriades N, Chang DJ, Laskarides C, Papageorge M.

Department of Oral and Maxillofacial Surgery, Tufts University School of Dental Medicine, Boston, MA 02111, USA. neophytos.demetriades@tufts.edu

Abstract

PURPOSE: Literature suggests that patients without pre-existing sleep-related breathing disorders who undergo orthognathic surgery for treatment of facial asymmetry may experience changes in their oropharyngeal airway. Mandibular retropositioning can compromise the posterior airway space, alter the physiologic airflow through the upper airway, and predispose patients to development of obstructive sleep apnea syndrome (OSAS).

PATIENTS AND METHODS: This study was a retrospective cohort analysis of 26 patients who underwent mandibular retropositioning with or without maxillary advancement within the past 5 years at Tufts University School of Dental Medicine. Pre- and postoperative lateral cephalometric radiographs were analyzed with digital DOLPHIN software (Dolphin Imaging, Chatsworth, CA) for evidence of changes to the posterior airway dimension. In addition, patients were evaluated postoperatively with SNAP polysomnography (model 4/6; SNAP Laboratories, Wheeling, IL) for evidence of OSAS.

RESULTS: Results indicated that mandibular retropositioning greater than or equal to 5 mm decreased the posterior airway space below 11 mm (30.75%, P = .03) and showed evidence of soft palate elongation greater than 32 mm (15.39%, P = .037) in a significant number of patients. However, as determined by cephalometric analysis, mandibular retropositioning greater than or equal to 5 mm in combination with maxillary advancement had no significant effect on the posterior airway space or soft palate.

CONCLUSION: Postoperative SNAP polysomnography showed higher incidence of mild to moderate OSAS in patients who underwent mandibular retropositioning greater than or equal to 5 mm (69.25%) compared with patients who underwent mandibular retropositioning in combination with maxillary advancement (38.46%, P = .039).

Copyright © 2010 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.

Diagnostic accuracy of split-night polysomnograms.

J Clin Sleep Med. 2010 Aug 15;6(4):357-62.

Khawaja IS, Olson EJ, van der Walt C, Bukartyk J, Somers V, Dierkhising R, Morgenthaler TI.

Center for Sleep Medicine, Mayo Clinic, Rochester, MN 55905, USA.

Abstract

STUDY OBJECTIVES: American Academy of Sleep Medicine (AASM) practice parameters indicate that split-night polysomnograms (SN-PSG) may be performed when the apnea hypopnea index (AHI) is > or = 20 to 40, depending on clinical factors. The aim of this study was to determine the diagnostic accuracy of SN-PSG, including at the lower range of AHIs.

METHODS: We reviewed 114 consecutive full-night PSGs (FN-PSG) performed at our center between August 2006 and November 2008 on subjects enrolled in studies in which obstructive sleep apnea (OSA) was the sleep disorder of interest. We compared the AHI from the first 2 hours (2 hr-AHI) and 3 hours (3 hr-AHI) of sleep with the "gold standard" AHI from FN-PSG (FN-AHI), considering OSA present if FN-AHI > or = 5.

RESULTS: The 2 hr-AHI and 3 hr-AHI correlated strongly with the FN-AHI (concordance correlation coefficient [CCC] = 0.93 and 0.97, respectively). After adjusting for percentage of sleep in stage REM sleep and in supine position, the correlation of 2 hr- and 3 hr-AHI with FN-AHI remained strong (0.92 and 0.96, respectively). The area under the receiver operating curves (AUC) for 2 hr-AHI and 3 hr-AHI using FN-AHI > or = 5 were 0.93 and 0.95, respectively.

CONCLUSIONS: The AHI derived from the first 2 or 3 hours of sleep is of sufficient diagnostic accuracy to rule-in OSA at an AHI threshold of 5 in patients suspected of having OSA. This study suggests that the current recommended threshold for split-night studies (AHI > or = 20 to 40) may be revised to a lower number, allowing for more efficient use of resources.

Snoring and obstructive sleep apnea.

Med Clin North Am. 2010 Sep;94(5):1047-55.

Ulualp SO.

Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9035, USA. seckin.ulualp@utsouthwestern.edu

Abstract

Obstructive sleep apnea (OSA) may be associated with myriad clinical consequences such as increased risk of systemic hypertension, coronary vascular disease, congestive heart failure, cerebrovascular disease, glucose intolerance, impotence, obesity, pulmonary hypertension, gastroesophageal reflux, and impaired concentration. Nonetheless, OSA remains undiagnosed in 82% of men and 93% of women with the condition. Early identification and treatment of OSA provides significant relief for individuals, prevents complications of OSA, and reduces overall health care costs. Better understanding of the pathogenesis, risk factors, diagnosis, and treatment of OSA has the potential to improve early recognition of OSA and prevention of adverse effects on the individual and society.

Prader-Willi syndrome: sorting out the relationships between obesity, hypersomnia, and sleep apnea

Current Opinion in Pulmonary Medicine:

November 2010 - Volume 16 - Issue 6 - p 568–573

Bruni, Oliviero

doi: 10.1097/MCP.0b013e32833ef547

Sleep and respiratory neurobiology: Edited by Lee K. Brown

Purpose of review: Although several studies in the last years have evaluated obesity, obstructive sleep apnea (OSAS), and excessive daytime sleepiness (EDS) in patients with Prader–Willi syndrome (PWS), their pathophysiologies and interactions and the role of treatment with growth hormone are not completely understood. The present review analyzes the contributing role of obesity, OSAS, and sleep structure abnormalities in determining the EDS and the role of specific treatment in improving the clinical outcome.

Recent findings: The studies on sleep structure of PWS patients show abnormalities of rapid eye movement (REM) sleep and a decrease in non-REM sleep instability, corroborating the hypothesis of the presence of a primary disorder of vigilance and the similarities with obstructive sleep apnea. These sleep alterations might also be linked to the action of mediators of inflammation (i.e. adiponectin or cytokines) determined by obesity. Obesity and hypothalamic dysfunction could be responsible for the primary abnormalities of ventilation during sleep that, in turn, might contribute to EDS. Although EDS seems to resemble narcolepsy, PWS patients do not present the other typical symptoms of narcolepsy.

Summary: The most consistent hypothesis for linking the three different symptoms of PWS is a primary central hypothalamic dysfunction. Further research is needed to evaluate the contribution of the upper airway resistance syndrome in the pathogenesis of EDS, the role of the alterations of sleep microstructure, the relationships between PWS and narcoleptic phenotype, the involvement of orexin/hypocretin, and the effects of drugs acting on REM sleep and/or wakefulness.

Electrical stimulation of the hypoglossal nerve in the treatment of obstructive sleep apnea

Sleep Medicine Reviews , 

Eric J. Kezirian, An Boudewyns, David W. Eisele, Alan R. Schwartz, Philip L. Smith, Paul H. Van de Heyning, Wilfried A. De Backer

Volume 14, Issue 5, Pages 299-305 (October 2010)

Upper airway occlusion in obstructive sleep apnea has been attributed to a decline in pharyngeal neuromuscular activity occurring in a structurally narrowed airway. 

Surgical treatment focuses on the correction of anatomic abnormalities, but there is a potential role for activation of the upper airway musculature, especially with stimulation of the hypoglossal nerve and genioglossus muscle. 

We present evidence from research on upper airway neuromuscular electrical stimulation in animals and humans. We also present results from eight obstructive sleep apnea patients with a fully implanted system for hypoglossal nerve stimulation, demonstrating an improvement in upper airway collapsibility and obstructive sleep apnea severity. 

Future research, including optimization of device features and stimulation parameters as well as patient selection, is necessary to make hypoglossal nerve stimulation a viable alternative to positive airway pressure therapy and upper airway surgical procedures.

Bacterial communication encourages chronic, resistant ear infections

Bacterial communication encourages chronic, resistant ear infections

Intoxicating fragrance: Jasmine as valium substitute

Intoxicating fragrance: Jasmine as valium substitute

New link between pollution, temperature and sleep-disordered breathing

New link between pollution, temperature and sleep-disordered breathing

Anadolu Kardiyol Derg. 2010 Apr;10(2):168-75. doi: 10.5152/akd.2010.044.




Cardiovascular consequences of sleep apnea: II-Cardiovascular mechanisms.

Turgut Celen Y, Peker Y.



Department of Neurology and Rehabilitation Medicine, Skaraborg Hospital, Skövde, Sweden.



Abstract

Obstructive sleep apnea (OSA) is a common disorder with serious cardiovascular consequences. The pathogenesis in this context is likely to be multifactorial process including large negative swings in intrathoracic pressure, intermittent hypoxemia and hypercapnia, increased sympathetic nervous system activity, vascular endothelial dysfunction, oxidative stress, systemic inflammation, excessive platelet activation as well as metabolic dysregulation. Although there is scientific support for a considerable impact of OSA on vascular structure and function, it is likely that development of cardiovascular diseases is determined by multiple genotypic and phenotypic factors. The current article focuses on the available research evidence addressing the cardiovascular mechanisms in this context.

Surgical options for the treatment of obstructive sleep apnea.

Med Clin North Am. 2010 May;94(3):479-515.

Holty JE, Guilleminault C.
Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, VA Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA 94304, USA. jholty@stanford.edu



Abstract

Obstructive sleep apnea (OSA) is a prevalent condition characterized by repetitive airway obstruction during sleep with associated increased morbidity and mortality. Although CPAP is the preferred treatment, poor compliance is common. Patients intolerant of conventional OSA medical treatment may benefit from surgical therapy to alleviate pharyngeal obstruction. Case series suggest that maxillomandibular advancement has the highest surgical efficacy (86%) and cure rate (43%). Soft palate surgical techniques are less successful, with uvulopalatopharyngoplasty having an OSA surgical success rate of 50% and cure rate of 16%. Further research is needed to more thoroughly assess clinical outcomes (eg, quality of life, morbidity), better identify key preoperative patient and clinical characteristics that predict success, and confirm long-term effectiveness of surgical modalities to treat OSA.

Clinical characteristics and outcomes of patients with obstructive sleep apnoea requiring intensive care.

Anaesth Intensive Care. 2010 May;38(3):506-12.


Hang LW, Chen W, Liang SJ, Lin YC, Tu CY, Chen HJ, Chiu KL.

Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan.



Abstract

We reviewed the clinical characteristics, required intervention and short- and long-term outcomes in obstructive sleep apnoea (OSA) patients requiring intensive care. A retrospective, single-centre, observational cohort study was undertaken in a multidisciplinary teaching medical and surgical intensive care unit. Adult patients with OSA (apnoea-hypopnoea index of 5 or higher) requiring intensive care from January 2000 to January 2005 were included. Thirty-seven OSA patients (age: 58 +/- 14 years, male:female 27:10) were admitted due to respiratory (n=12, 32%), cerebrovascular (n=8, 22%), cardiovascular (n=16, 43%) and infectious events (n=1, 2.7%). Comparing the clinical features, polysomnographic data and outcome among these groups, we found that OSA patients admitted due to respiratory events had significantly higher Acute Physiology and Chronic Health Evaluation II scores, lower arterial blood gas pH, higher PaCO2, a higher incidence of respiratory failure (92%) and required non-invasive ventilation after extubation (73%), and higher intensive care unit readmission rates than patients admitted due to cerebrovascular events and cardiovascular events (P < 0.05). No difference was found in the in-hospital and long-term mortality rate. The most common reason for intensive care unit admission in critically ill OSA patients was a cardiovascular event, followed by respiratory and cerebrovascular events. The baseline polysomnographic data of the OSA patients were not correlated with their clinical features and outcomes in the intensive care unit. A more complicated clinical course and higher intensive care unit readmission rate were encountered in OSA patients admitted due to respiratory events. Further studies would be required to evaluate the efficacy of non-invasive ventilation for facilitation of extubation in OSA patients presenting with hypercapnic respiratory failure.

Cardiovascular consequences of obese and nonobese obstructive sleep apnea.

Med Clin North Am. 2010 May;94(3):465-78.


Ramar K, Caples SM.
Division of Pulmonary, Sleep and Critical Care Medicine, Center for Sleep Medicine, Mayo Clinic, 200 First Street South West, Rochester, MN 55901, USA. ramar.kannan@mayo.edu



Abstract

Current evidence suggests a role for obstructive sleep apnea (OSA) in the development of cardiovascular disorders. However, obesity is an active confounder in this relationship. OSA and obesity share similar pathophysiologic mechanisms potentially leading to cardiovascular disorders. Presence of OSA in obese patients may further contribute to adverse cardiovascular outcomes when compared with each condition in isolation. In this review the authors explore the complex relationship between OSA and obesity (and nonobese subjects) in the development of cardiovascular disorders.

Pharmacological treatment of obstructive sleep apnea with a combination of pseudoephedrine and domperidone.

J Clin Sleep Med. 2010 Apr 15;6(2):117-23.
Larrain A, Kapur VK, Gooley TA, Pope CE 2nd.
Clinica Servet, Santiago, Chile.



Comment in: J Clin Sleep Med. 2010 Apr 15;6(2):124-6.



Abstract

OBJECTIVES: To determine the effect of the drug combination domperidone and pseudoephedrine on nocturnal oximetry measurements and daytime sleepiness in patients with obstructive sleep apnea.
METHODS: We recruited patients with severe snoring and apneic episodes willing to undergo repeated nocturnal oximetry testing. Following baseline clinical history, Epworth Sleepiness Scale administration, and home overnight nocturnal oximetry, patients were started on weight-adjusted doses of domperidone and pseudoephedrine. Follow-up oximetry studies were performed at the patient's convenience. On the final visit, a repeat clinical history, Epworth score, and oximetry were obtained.
RESULTS: Seventeen of 23 patients noted disappearance of snoring and apneic episodes. Another 2 patients reported improvement in snoring and no apneic episodes. All but one patient had a decrease in Epworth scores (mean decrease 9.4 (95% CI, 6.8-12.1, p < 0.0001). Mean oxygen saturation (2.5; 95% Cl, 0.66-4.41, p = 0.008), percent time with oxygen saturation < 90% (14.8; 95% CI, 24.4 to 5.2, p = 0.003), and the 4% oxygen desaturation index (18.2; 95% CI, 27.3 to 9.1, p < 0.0001) improved significantly. No adverse effects of treatment were noted.
CONCLUSIONS: The combination of domperidone and pseudoephedrine improved self reported snoring and sleepiness, and may have improved apneic episodes and sleep-related nocturnal oxygen desaturation in patients with obstructive sleep apnea provided the proportion of time spent asleep did not diminish. This drug combination warrants further study as a treatment for obstructive sleep apnea.

:Citation: Larrain A; Kapur VK; Gooley TA; Pope CE. Pharmacological treatment of obstructive sleep apnea with a combination of pseudoephedrine and domperidone.

Chronic cough and obstructive sleep apnea in a community-based pulmonary practice

Cough 2010, 6:2doi:10.1186/1745-9974-6-2

Krishna M Sundar , Sarah E Daly , Michael J Pearce and William T Alward

Published:	15 April 2010

Abstract (provisional)

Background

Recent reports suggest an association between unexplained chronic cough and obstructive sleep apnea (OSA). Current guidelines provide an empiric integrative approach to the management of chronic cough, particularly for etiologies of gastroesophageal reflux (GERD), upper airway cough syndrome (UACS) and cough variant asthma (CVA) but do not provide any recommendations regarding testing for OSA. This study was done to evaluate the prevalence of OSA in patients referred for chronic cough and examine the impact of treating OSA in resolution of chronic cough.

Methods

A retrospective review of chronic cough patients seen over a four-year period in a community-based pulmonary practice was done. Patients with abnormal chest radiographs, abnormal pulmonary function tests, history of known parenchymal lung disease, and inadequate followup were excluded. Clinical data, treatments provided and degree of resolution of cough was evaluated based on chart review. Specifically, diagnostic testing for OSA and impact of management of OSA on chronic cough was assessed.

Results

75 patients with isolated chronic cough were identified. 44/75 had single etiologies for cough (GERD 37%, UACS 12%, CVA 8%). 31/75 had multiple etiologies for their chronic cough (GERD-UACS 31%, GERD-CVA 5%, UACS-CVA 3%, GERD-UACS-CVA 3%). 31% patients underwent further diagnostic testing to evaluate for UACS, GERD and CVA. Specific testing for OSA was carried out in 38/75 (51%) patients and 33/75 (44%) were found to have obstructive sleep apnea. 93% of the patients that had interventions to optimize their sleep-disordered breathing had improvement in their cough.

Conclusions

OSA is a common finding in patients with chronic cough, even when another cause of cough has been identified. CPAP therapy in combination with other specific therapy for cough leads to a reduction in cough severity. Sleep apnea evaluation and therapy needs to considered early during the management of chronic cough and as a part of the diagnostic workup for chronic cough.

Dentofacial characteristics as indicator of obstructive sleep apnoea-hypopnoea syndrome in patients with severe obesity

Obesity Reviews
Diagnostic in Obesity and Complications
M. E. S. Maciel Santos 1 , J. R. Laureano Filho 1 , J. M. Campos 2 and E. M. Ferraz 2
  1 Department of Oral and Maxillofacial Surgery, Dentistry College of Pernambuco, University of Pernambuco, Camaragibe, 2 Division of General Surgery and Obesity Surgery, University Hospital of the Federal University of Pernambuco, Recife, PE, Brazil
Correspondence to Dr JR Laureano Filho, Dentistry College of Pernambuco, University of Pernambuco, Av. Gal. Newton Cavalcanti, 1650, Tabatinga, Camaragibe, Pernambuco, Brazil, CEP 54753-220. E-mail: laureano@pq.cnpq.br
Copyright Journal compilation © 2010 International Association for the Study of Obesity

ABSTRACT

Obstructive sleep apnoea-hypopnoea syndrome (OSAHS) is a complex disease with a multifactor aetiology. OSAHS is strongly associated with obesity, but there are many other clinical risk factors, such as the dentofacial characteristics of hard and soft tissues, hyoid bone position, neck circumference, upper airway spaces and nasal respiration. A descriptive cross-sectional study was carried out involving 13 patients (one man and 12 women) with severe obesity in order to evaluate specific physical dentofacial characteristics through a cephalometric examination. Cephalometry was analysed using 29 measurements of the hard and soft tissues of the craniofacial structures and dimensions of the upper airways. The demographic data revealed a mean body mass index of 48 ± 6.26 kg m−2 and cervical circumference of 43 ± 3.69 cm. No patient exhibited important facial asymmetry and facial types 1 (normal) and 3 (mandible forward) were the most prevalent. Septal deviation was observed in 46% of patients. The most prevalent modified Mallampati index score was between 3 and 4, while grade 1 was the most prevalent tonsillar hypertrophy index score (46%). Cephalometry revealed angular and linear measurements with normally acceptable values for the hard tissues. Obese patients seem to have a normal craniofacial structure and the risk of developing OSAHS is especially related to obesity.

Received 2 November 2009; revised 18 December 2009; accepted 22 December 2009