The role of polysomnography in diagnosing and treating obstructive sleep apnea in pediatric patients.

Obstructive sleep apnea in children is associated with serious neurocognitive and cardiovascular morbidity, systemic inflammation, and increased health care use, yet remains underdiagnosed. Although the prevalence of obstructive sleep apnea is 1-3% in the pediatric population, the prevalence of primary snoring (PS) is estimated to be 3-12%. The challenge for pediatricians is to differentiate PS from obstructive sleep apnea in a cost-effective, reliable, and accurate manner before recommending invasive or intrusive therapies, such as surgery or continuous positive airway pressure. The validity of polysomnography as the gold standard for diagnosing obstructive sleep apnea has been challenged, primarily related to concerns that abnormalities on polysomnography do not correlate well with adverse outcomes, that those abnormalities have statistical more than clinical significance, and that performing polysomnograms on all children who snore is a practical impossibility. The aim of this article is to review the clinical utility of diagnostic tests other than polysomnography to diagnose obstructive sleep apnea, to highlight the limitations and strengths of polysomnography, to underscore the threshold levels of abnormalities detected on polysomnography that correlate with morbidity, and to discuss what the practical implications are for treatment.

[1]  R. Chervin,et al.  Pediatric sleep questionnaire: prediction of sleep apnea and outcomes. , 2007, Archives of otolaryngology--head & neck surgery.

[2]  L. Kheirandish-Gozal,et al.  Adipokines in children with sleep disordered breathing. , 2007, Sleep.

[3]  P. Lévy,et al.  Comparison of esophageal pressure with pulse transit time as a measure of respiratory effort for scoring obstructive nonapneic respiratory events. , 2000, American journal of respiratory and critical care medicine.

[4]  M. Schechter,et al.  Technical report: diagnosis and management of childhood obstructive sleep apnea syndrome. , 2002, Pediatrics.

[5]  Wiley Interscience,et al.  Reference values for sleep‐related respiratory variables in asymptomatic European children and adolescents , 2007, Pediatric pulmonology.

[6]  M. Mahowald,et al.  Postoperative respiratory compromise in children with obstructive sleep apnea syndrome: can it be anticipated? , 1994, Pediatrics.

[7]  Drew Dawson,et al.  Behavior and Neurocognitive Performance in Children Aged 5-10 Years Who Snore Compared to Controls , 2000, Journal of clinical and experimental neuropsychology.

[8]  R. Chervin,et al.  Polysomnography in Children Scheduled for Adenotonsillectomy , 2004, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[9]  J. Farber,et al.  Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. , 2002, Pediatrics.

[10]  David Gozal,et al.  Neurobehavioral implications of habitual snoring in children. , 2004, Pediatrics.

[11]  J. Kohyama,et al.  Blood pressure in sleep disordered breathing , 2003, Archives of disease in childhood.

[12]  S. Jones.  Activity-Adjusted 24-Hour Ambulatory Blood Pressure and Cardiac Remodeling in Children with Sleep Disordered Breathing , 2009 .

[13]  R. Chervin,et al.  Pediatric sleep questionnaire (PSQ): validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problems. , 2000, Sleep medicine.

[14]  P. Enright,et al.  Feasibility of using unattended polysomnography in children for research--report of the Tucson Children's Assessment of Sleep Apnea study (TuCASA). , 2001, Sleep.

[15]  E. Katz,et al.  Pulse Transit Time as a Measure of Arousal and Respiratory Effort in Children with Sleep-Disordered Breathing , 2003, Pediatric Research.

[16]  C. Hunt,et al.  Radiologic evaluation of adenoids and tonsils in children with obstructive sleep apnea: Plain films and fluoroscopy , 1983, Pediatric Radiology.

[17]  J. Pépin,et al.  A critical review of peripheral arterial tone and pulse transit time as indirect diagnostic methods for detecting sleep disordered breathing and characterizing sleep structure , 2009, Current opinion in pulmonary medicine.

[18]  R. Dahl,et al.  Preliminary evidence of behavioral and cognitive sequelae of obstructive sleep apnea in children. , 2002, Sleep medicine.

[19]  J. Stradling,et al.  Use of pulse transit time as a measure of inspiratory effort in patients with obstructive sleep apnoea. , 1995, The European respiratory journal.

[20]  S. Daniels,et al.  Left ventricular hypertrophy and abnormal ventricular geometry in children and adolescents with obstructive sleep apnea. , 2002, American journal of respiratory and critical care medicine.

[21]  C. Marcus,et al.  Comparison of nap and overnight polysomnography in children , 1992, Pediatric pulmonology.

[22]  G. Owen,et al.  Comment on metabolic balance studies as a method of estimating body composition of infants. With special consideration of nitrogen balance studies. , 1962, Pediatrics.

[23]  C. Marcus,et al.  Daytime Sleepiness and Hyperactivity in Children With Suspected Sleep-Disordered Breathing , 2004, Pediatrics.

[24]  Schechter.  Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome : Technical report : diagnosis and management of childhood obstructive sleep apnea syndrome , 2002 .

[25]  J. Stradling,et al.  Effect of adenotonsillectomy on nocturnal hypoxaemia, sleep disturbance, and symptoms in snoring children , 1990, The Lancet.

[26]  D. Gozal,et al.  Circulating vascular endothelial growth factor levels in patients with obstructive sleep apnea. , 2002, Sleep.

[27]  K. Gourgoulianis,et al.  Morning levels of C-reactive protein in children with obstructive sleep-disordered breathing. , 2005, American journal of respiratory and critical care medicine.

[28]  David W Roberson,et al.  Pulse transit time as a screening test for pediatric sleep-related breathing disorders. , 2007, Archives of otolaryngology--head & neck surgery.

[29]  C. Marcus,et al.  Sleep architecture and respiratory disturbances in children with obstructive sleep apnea. , 2000, American journal of respiratory and critical care medicine.

[30]  Debra E Weese-Mayer,et al.  Sleep-disordered breathing symptoms are associated with poorer cognitive function in 5-year-old children. , 2004, The Journal of pediatrics.

[31]  L. Kheirandish-Gozal,et al.  Systemic inflammation in non-obese children with obstructive sleep apnea. , 2008, Sleep medicine.

[32]  S. Redline,et al.  Identification of sleep-disordered breathing in children: variation with event definition. , 2002, Sleep.

[33]  S. Kihara,et al.  Association of Hypoadiponectinemia With Coronary Artery Disease in Men , 2003, Arteriosclerosis, thrombosis, and vascular biology.

[34]  W. T. McNicholas,et al.  Sleep apnoea as an independent risk factor for cardiovascular disease: current evidence, basic mechanisms and research priorities , 2006, European Respiratory Journal.

[35]  T. Campbell,et al.  Clinical assessment of pediatric obstructive sleep apnea. , 2004, Pediatrics.

[36]  R. Naclerio,et al.  Respiratory compromise after adenotonsillectomy in children with obstructive sleep apnea. , 1992, Archives of otolaryngology--head & neck surgery.

[37]  D. Gozal,et al.  Plasma C-reactive protein levels among children with sleep-disordered breathing. , 2004, Pediatrics.

[38]  C. Hunt,et al.  A diagnostic approach to suspected obstructive sleep apnea in children. , 1984, The Journal of pediatrics.

[39]  P. Ridker,et al.  Inflammatory bio‐markers and cardiovascular risk prediction , 2002, Journal of internal medicine.

[40]  C. Marcus,et al.  Polysomnographic values in children 2–9 years old: Additional data and review of the literature , 2005, Pediatric pulmonology.

[41]  H. So,et al.  C‐reactive protein in children with obstructive sleep apnea and the effects of treatment , 2008, Pediatric pulmonology.

[42]  C. Lamm,et al.  Evaluation of home audiotapes as an abbreviated test for obstructive sleep apnea syndrome (OSAS) in children , 1999, Pediatric pulmonology.

[43]  C. Marcus,et al.  Inability of clinical history to distinguish primary snoring from obstructive sleep apnea syndrome in children. , 1995, Chest.

[44]  J. Owens.  Neurocognitive and behavioral impact of sleep disordered breathing in children , 2009, Pediatric pulmonology.

[45]  M. Mograss,et al.  Home testing for pediatric obstructive sleep apnea syndrome secondary to adenotonsillar hypertrophy , 1995, Pediatric pulmonology.

[46]  R. Chervin,et al.  Cost-Utility of Three Approaches to the Diagnosis of Sleep Apnea: Polysomnography, Home Testing, and Empirical Therapy , 1999, Annals of Internal Medicine.

[47]  L. Kheirandish-Gozal,et al.  New approaches to the diagnosis of sleep-disordered breathing in children. , 2010, Sleep medicine.

[48]  L. Brooks,et al.  Adenotonsillectomy for treatment of obstructive sleep apnea in children. , 1995, Archives of otolaryngology--head & neck surgery.

[49]  E. Katz,et al.  Can History and Physical Examination Reliably Diagnose Pediatric Obstructive Sleep Apnea/Hypopnea Syndrome? A Systematic Review of the Literature , 2004, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[50]  R. Brouillette,et al.  Differences in pulse oximetry technology can affect detection of sleep-disorderd breathing in children. , 2002, Anesthesia and analgesia.

[51]  Robert C. Wang,et al.  Accuracy of Clinical Evaluation in Pediatric Obstructive Sleep Apnea , 1998, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[52]  Mark J. Ramos,et al.  Prevalence of Diagnosed Sleep Disorders in Pediatric Primary Care Practices , 2010, Pediatrics.

[53]  NoriyukiOuchi,et al.  Association of Hypoadiponectinemia With Coronary Artery Disease in Men , 2003 .

[54]  D. Gozal,et al.  Polysomnographic Characteristics in Normal Preschool and Early School-Aged Children , 2006, Pediatrics.

[55]  Sonia Caprio,et al.  Obesity and the metabolic syndrome in children and adolescents. , 2004, The New England journal of medicine.

[56]  J. Shults,et al.  Differences in overnight polysomnography scores using the adult and pediatric criteria for respiratory events in adolescents. , 2010, Sleep.

[57]  Haim Reuveni,et al.  A Cost-Effectiveness Analysis of Alternative At-Home or In-Laboratory Technologies for the Diagnosis of Obstructive Sleep Apnea Syndrome , 2001, Medical decision making : an international journal of the Society for Medical Decision Making.

[58]  Y. Pamula,et al.  Reduced neurocognition in children who snore , 2004, Pediatric pulmonology.

[59]  Sidney C. Smith,et al.  MARKERS OF INFLAMMATION AND CARDIOVASCULAR DISEASE: APPLICATION TO CLINICAL AND PUBLIC HEALTH PRACTICE: A STATEMENT FOR HEALTHCARE PROFESSIONALS FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION AND THE AMERICAN HEART ASSOCIATION , 2003 .

[60]  A. Chesson,et al.  The American Academy of Sleep Medicine (AASM) Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications , 2007 .

[61]  S. Redline,et al.  Increased Behavioral Morbidity in School-Aged Children With Sleep-Disordered Breathing , 2004, Pediatrics.

[62]  Y. Sivan,et al.  Screening obstructive sleep apnoea syndrome by home videotape recording in children. , 1996, The European respiratory journal.

[63]  D. Beebe,et al.  Neuropsychological effects of pediatric obstructive sleep apnea , 2004, Journal of the International Neuropsychological Society.

[64]  J. Foo,et al.  Pulse transit time in paediatric respiratory sleep studies. , 2007, Medical engineering & physics.

[65]  D. Gozal.  Sleep-disordered breathing and school performance in children. , 1998, Pediatrics.

[66]  C. Marcus,et al.  Obstructive hypopneas in children and adolescents: normal values. , 2003, American journal of respiratory and critical care medicine.

[67]  H. Trang,et al.  Sleep desaturation: Comparison of two oximeters , 2004, Pediatric pulmonology.

[68]  Gabriel G. Haddad,et al.  Standards and indications for cardiopulmonary sleep studies in children. American Thoracic Society. , 1996, American journal of respiratory and critical care medicine.

[69]  K. Waters,et al.  Nocturnal Pulse Oximetry as an Abbreviated Testing Modality for Pediatric Obstructive Sleep Apnea , 2000 .

[70]  W. Flemons,et al.  Comparison of home oximetry monitoring with laboratory polysomnography in children. , 2003, Chest.

[71]  J. Olson,et al.  Polysomnographic and clinical findings in children with obstructive sleep apnea. , 1992, Archives of otolaryngology--head & neck surgery.

[72]  S. Quan,et al.  Clinical outcomes associated with sleep-disordered breathing in Caucasian and Hispanic children--the Tucson Children's Assessment of Sleep Apnea study (TuCASA). , 2003, Sleep.

[73]  D. Greenblatt,et al.  The International Classification of Sleep Disorders , 1992 .

[74]  A. Messner,et al.  Evaluation of obstructive sleep apnea by polysomnography prior to pediatric adenotonsillectomy. , 1999, Archives of otolaryngology--head & neck surgery.

[75]  D. Ng,et al.  Twenty-four-hour ambulatory BP in snoring children with obstructive sleep apnea syndrome. , 2006, Chest.

[76]  S. Redline,et al.  Cardiorespiratory sleep studies in children: Establishment of normative data and polysomnographic predictors of morbidity , 1999 .

[77]  Thomas F Campbell,et al.  Child behavior and quality of life before and after tonsillectomy and adenoidectomy. , 2002, Archives of otolaryngology--head & neck surgery.

[78]  R. Tracy,et al.  Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults. The Bogalusa Heart Study. , 1998, The New England journal of medicine.

[79]  H. Reuveni,et al.  Obstructive sleep apnea syndrome: the diagnostic strategy dilemma. , 2004, The Israel Medical Association journal : IMAJ.

[80]  R. Chervin,et al.  Subjective sleepiness and polysomnographic correlates in children scheduled for adenotonsillectomy vs other surgical care. , 2006, Sleep.

[81]  David Gozal,et al.  Neurobehavioral correlates of sleep‐disordered breathing in children , 2004, Journal of sleep research.

[82]  S. Redline,et al.  Variation of C-Reactive Protein Levels in Adolescents: Association With Sleep-Disordered Breathing and Sleep Duration , 2005, Circulation.

[83]  C. Rosen.  Clinical features of obstructive sleep apnea hypoventilation syndrome in otherwise healthy children , 1999, Pediatric pulmonology.

[84]  T. Gislason,et al.  Snoring, apneic episodes, and nocturnal hypoxemia among children 6 months to 6 years old. An epidemiologic study of lower limit of prevalence. , 1995, Chest.

[85]  C L Marcus,et al.  Normal polysomnographic values for children and adolescents. , 1992, The American review of respiratory disease.

[86]  M. Yao,et al.  Diagnostic studies in obstructive sleep apnea. , 2007, Otolaryngologic clinics of North America.

[87]  Haim Reuveni,et al.  Health care services utilization in children with obstructive sleep apnea syndrome. , 2002, Pediatrics.

[88]  C. Marcus,et al.  Polysomnographic values in children undergoing puberty: pediatric vs. adult respiratory rules in adolescents. , 2008, Sleep.

[89]  R. Brouillette,et al.  Diagnostic techniques for obstructive sleep apnoea: is polysomnography necessary? , 2002, Paediatric respiratory reviews.

[90]  K. Flegal,et al.  Prevalence of overweight and obesity in the United States, 1999-2004. , 2006, JAMA.

[91]  Yakov Sivan,et al.  Normal polysomnographic respiratory values in children and adolescents. , 2004, Chest.

[92]  C. Chu,et al.  ADHERENCE TO ACCP GUIDELINE IMPROVES OUTCOMES IN COMPLICATED PARAPNEUMONIC EFFUSION AND EMPYEMA THORACIS , 2006 .

[93]  A. Tal,et al.  Inflammation and Sleep Disordered Breathing in Children: A State‐of‐the‐Art Review , 2008, Pediatric pulmonology.

[94]  Haim Reuveni,et al.  Adenotonsillectomy in children with obstructive sleep apnea syndrome reduces health care utilization. , 2004, Pediatrics.

[95]  T. Laitinen,et al.  Pediatric Metabolic Syndrome Predicts Adulthood Metabolic Syndrome, Subclinical Atherosclerosis, and Type 2 Diabetes Mellitus but Is No Better Than Body Mass Index Alone: The Bogalusa Heart Study and the Cardiovascular Risk in Young Finns Study , 2010, Circulation.

[96]  S. Redline,et al.  Risk factors for sleep-disordered breathing in children. Associations with obesity, race, and respiratory problems. , 1999, American journal of respiratory and critical care medicine.

[97]  C. Marcus,et al.  Blood pressure in children with obstructive sleep apnea. , 1998, American journal of respiratory and critical care medicine.

[98]  C. Tam,et al.  Inflammatory measures in children with obstructive sleep apnoea , 2006, Journal of paediatrics and child health.

[99]  M. Erkinjuntti,et al.  Radiological parameters of the bony nasopharynx and the adenotonsillar size compared with sleep apnea episodes in children. , 1987, International journal of pediatric otorhinolaryngology.

[100]  L. Ferini-Strambi,et al.  Respiratory monitoring by means of an unattended device in children with suspected uncomplicated obstructive sleep apnea: a validation study. , 2003, Chest.

[101]  Leila Kheirandish-Gozal,et al.  Two-dimensional differential in-gel electrophoresis proteomic approaches reveal urine candidate biomarkers in pediatric obstructive sleep apnea. , 2009, American journal of respiratory and critical care medicine.

[102]  R. Yellon.  Is polysomnography required prior to tonsillectomy and adenoidectomy for diagnosis of obstructive sleep apnea versus mild sleep disordered breathing in children? , 2010, The Laryngoscope.

[103]  E. Katz,et al.  Pediatric obstructive sleep apnea syndrome. , 2010, Clinics in chest medicine.

[104]  S. D. Davidson Ward,et al.  Should children with suspected obstructive sleep apnea syndrome and normal nap sleep studies have overnight sleep studies? , 2000, Chest.

[105]  Andrew P Bradley,et al.  Use of pulse transit time to distinguish respiratory events from tidal breathing in sleeping children. , 2005, Chest.

[106]  J. Stradling,et al.  Snoring, sleep disturbance, and behaviour in 4-5 year olds. , 1993, Archives of disease in childhood.

[107]  L. D. Grošelj,et al.  CT comparison of primary snoring and obstructive sleep apnea syndrome: role of pharyngeal narrowing ratio and soft palate-tongue contact in awake patient , 2009, European Archives of Oto-Rhino-Laryngology.

[108]  L. Kheirandish-Gozal,et al.  Plasma C-reactive protein in nonobese children with obstructive sleep apnea before and after adenotonsillectomy. , 2006, Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine.

[109]  D. Rapoport,et al.  Clinical Diagnosis of Pediatric Obstructive Sleep Apnea Validated by Polysomnography , 1994, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[110]  S. Devaraj,et al.  C-Reactive Protein: Risk Marker or Mediator in Atherothrombosis? , 2004, Hypertension.

[111]  D. Beebe.  Neurobehavioral morbidity associated with disordered breathing during sleep in children: a comprehensive review. , 2006, Sleep.

[112]  D. Gozal,et al.  Plasma adhesion molecules in children with sleep-disordered breathing. , 2006, Chest.

[113]  A. Tal,et al.  Ventricular dysfunction in children with obstructive sleep apnea: Radionuclide assessment , 1988, Pediatric pulmonology.