Tomasz Lis, *Lidia Zawadzka-Głos
Diagnosis and evaluation of a child suspected for obstructive sleep apnea: an overview
Diagnoza i ocena dziecka z podejrzeniem obturacyjnego bezdechu sennego: przegląd
Department of Pediatric Otolaryngology, Medical University of Warsaw, Poland
Head of Department: Associate Professor Lidia Zawadzka-Głos, MD, PhD
Streszczenie
Obturacyjny bezdech senny (OBS) jest często występującym zaburzeniem w populacji pediatrycznej, charakteryzującym się blokadą dróg oddechowych w trakcie snu, prowadzącym do wielu niekorzystnych efektów zdrowotnych. Te dotyczą przede wszystkim układu sercowo-naczyniowego, funkcji poznawczych i metabolizmu. Wczesna diagnoza OBS jest ważna, aby zapobiec poważnym negatywnym konsekwencjom zdrowotnym. W tej pracy przeglądowej zawarliśmy bieżącą wiedzę dotyczącą oceny dziecka z podejrzewanym OBS. Skupiliśmy się na możliwościach diagnostycznych, do których należą nadzorowane badania w laboratorium snu, z polisomnografią (PSG), pozostającą złotym standardem diagnostyki OBS u dzieci, oraz szeroko rozwijanymi domowymi badaniami bezdechu sennego (HSAT – home sleep apnea testing) należącymi do badań ambulatoryjnych. Kolejna przedstawiona kwestia dotyczy dostępnych technik ewaluacji. Do tych należą badanie podmiotowe i przedmiotowe oraz kwestionariusze jakości snu. Ewaluacja jest również oparta na badaniach endoskopowych przy użyciu giętkich fiberoskopów oraz szerokiej puli radiologicznych badań obrazowych. Te dwie formy obrazowania pomagają zidentyfikować miejsce lub miejsca występującej obstrukcji dróg oddechowych.
Summary
Obstructive sleep apnea (OSA) is a frequent disorder in pediatric population characterized by airway blockage while asleep, leading to many adverse health effects. These involve foremost cardiovascular, neurocognitive, and metabolic systems. Early identification of OSA patient is crucial in order prevent serious negative health consequences. In this review article we provide up-to-date overview concerning assessment of a child with suspected OSA. We focus on available diagnostic modalities, which include attended in-lab sleep studies, with polysomnography (PSG) remaining a gold standard in diagnosing OSA in children, and widely developed home sleep apnea testing (HSAT) belonging to ambulatory sleep studies. The other presented matter apply to available evaluation techniques. These feature history and physical examination as well as sleep questionaires. Evaluation is also based on endoscopic procedures using mainly flexible devices, as well as wide variety of radiology imaging modalities. These two forms of imaging are used to help to identify site or sites of airway obstruction.
Introduction
Obstructive sleep apnea (OSA) is a common sleep-related breathing disorder (SRBD) characterized by episodes of complete and/or partial upper airway obstruction during sleep, followed by alteration in gas exchange. According to recent American Academy of Sleep Medicine (AASM) guidelines (1), diagnostic criteria for pediatric OSA include presence of one or more clinical symptoms as well as one or both polysomnographic (PSG) findings:
1. clinical criteria (A criteria):
– snoring,
– laboured/obstructive breathing,
– daytime consequences (sleepiness, hyperactivity, behavioral problems),
2. polysomnographic criteria (B criteria):
– one or more obstructive event per hour of sleep,
– obstructive hypoventilation, manifested by partial pressure of carbon dioxide (PaCO2) > 50 mmHg for at least 25 percent of total sleep time, coupled with snoring, paradoxical thoracoabdominal movement, or flattening of the nasal airway pressure waveform.
This study focuses on describing different possibilities to diagnose and evaluate child with suspected OSA and does not take into account indications to use certain diagnostic method, which may vary depending on guidelines, e.g. indications for PSG according to AASM, American Academy of Pediatrics (AAP) and American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF). In some cases though, usually when these guidelines comply with each other, indications are presented.
Epidemiology
The estimated prevalence of pediatric OSA range between 1 to 5% (2). It affects mostly children between two and eight years of age (2), which coincides with the peak age of the overgrowth of the upper airways’ lymphatic tissue.
Untreated OSA is associated with academic difficulties, behavioral and neurocognitive problems (3, 4), cardiovascular complications (5-7), metabolic disorders (7) as well as failure to thrive (8). Additionally children with OSA are more likely to have significant decrease in quality of life (4). Early identification and treatment can prevent or reverse many of these negative health effects. Nonetheless, diagnosis is often delayed.
Risk factors
Adenotonsillar hypertrophy and obesity are recognized as the most significant risk factors for OSA in otherwise healthy children. Other risk contributors to OSA include craniofacial anomalies, and neuromuscular disorders (9). Examples of certain conditions associated with SRBD are in listed in table 1 (10) (fig. 1, tab. 1).
Fig. 1. Tonsillar hypertrophy
Tab. 1. Conditions associated with an elevated prevalence for SRBD (including OSA)
| High risk for SRBD | Intermediate risk for SRBD |
| Obesity | History of prematurity |
| Down syndrome | African American race |
| Prader-Willi syndrome | Family history of OSA |
| Duchenne muscular dystrophy | Allergic rhinitis |
| Achondroplasia | |
| Pierre Robin sequence | |
| Craniofacial dysostoses | |
| Chiari malformations and myelomeningocele | |
Children suffering from above demonstrated, especially high-risk complex-conditions, should be supervised for signs and symptoms of OSA. If present, PSG is usually recommended in such patients.
Diagnosis
Attended in-lab studies
The gold standard test for the diagnosis of OSAS and assessment of its severity is an overnight, attended, in-laboratory PSG. Following parameters are recorded during a typical PSG examination in children: electroencephalography (EEG), bilateral electrooculography (EOG), submental electromyography (EMG), limb movement, electrocardiography (ECG), snoring, airflow, respiratory effort, blood oxygenation, end-tidal or transcutaneous capnography, body position and behavioral observation (video monitoring system).
Nap PSG is an abbreviated study which may be conducted in children who could go asleep in the sleep laboratory during daytime. It is not as reliable as overnight PSG and is not recommended for definite diagnosis of obstructive sleep apnea syndrome in children (10).
Obstructive events recorded on PSG are summarized by the apnea-hypopnea index (AHI), which represents the average number of apneas and hypopneas per hour of sleep. There are special pediatric scoring rules for OSA severity, which are practice-derived and not evidence based. These are presented in table 2.
Tab. 2. OSA severity according to AHI
| OSA severity | AHI (events/h) |
| Mild | 1 to 4.9 |
| Moderate | 5 to 9.9 |
| Severe | > 10 |
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