What pulmonology 3 sonno

Pulmonology 3
Sleep disorders
Attilio Boner
University of Verona, Italy
attilio.boner@univr.it
WHAT YOU SOULD HAVE READ BUT ………………… 2018

 Telomeres are repetitive DNA sequences
(in humans, TTAGGGn) and associated
proteins that cap the end of chromosomes.
 With each cycle of chromosomal replication
and cellular division, the telomere becomes
shorter, except in specialized cells
expressing telomerase.
 This means that telomere length gradually
decreases with age in most cells.
 Difficult life experiences may be associated with an accelerated rate
of telomere attrition.
Sleep Duration and Telomere Length in Children
S James, J Pediatr. 2017;187:247-252

S James, J Pediatr. 2017;187:247-252
 Inadequate nightly sleep duration is linked to morbidities and mortality, as
well as a number of physiological sequelae, including inflammation,
oxidative stress, increased sympathetic tone, and neuroendocrine
dysregulation.
 Short sleep duration in childhood is associated with changes
in hypothalamic–pituitary–adrenocortical system activity,
autonomic nervous system activity, and metabolic regulation.
 This type of stress-altered hypothalamic–pituitary–adrenocortical activity
is known to correlate with telomere length.

S James, J Pediatr. 2017;187:247-252
Distribution of children's hours of sleep
at 9 years of age in the analytic sample
 Data for 1567 children
from a population-based
birth cohort of children
born between 1998 and
2000.
 Telomere length using
quantitative polymerase
chain reaction.

2000.
chain reaction.
S James, J Pediatr. 2017;187:247-252
• Children with shorter sleep
durations have shorter telomeres
than children with longer sleep
durations.
• Each hour less of nightly sleep
duration is associated with having
telomeres that are 0.015 log-
kilobases per chromosome shorter
(P < 0.05).

2000.
chain reaction.
S James, J Pediatr. 2017;187:247-252
• Children with shorter sleep
durations have shorter telomeres
than children with longer sleep
durations.
• Each hour less of nightly sleep
duration is associated with having
telomeres that are 0.015 log-
kilobases per chromosome shorter
(P < 0.05).
That suboptimal
sleep duration is a
risk for increased
physiological stress
and impaired health.

S James, J Pediatr. 2017;187:247-252
 The biological mechanism by which sleep duration becomes linked to
telomere length in children, may be:
• telomere erosion (eg, owing to oxidative stress)
• suppression of telomerase activity
• hypothalamic–pituitary–adrenal axis activation,
• inflammation,
• oxidation.

Parental restriction reduces the harmful effects
of in-bedroom electronic devices
King-wa Fu, Arch Dis Child. 2017;102:1125-1131
 Cross-sectional study with
bedroom electronic devices
(EDs) placement and
parental restriction
reported by parents.
 Relationship between
school readiness
and ED placement.
 556 young children
attending the 3° year
of kindergarten.
% parents placing at least one electronic
devices in their children’s bedroom
30%
30 –
25 –
20 –
15 –
10 –
05 –
00 –

(EDs) placement and
school readiness
and ED placement.
of kindergarten.
30%
30 –
25 –
20 –
15 –
10 –
05 –
00 –
Placement of television in the bedroom
was associated with
lower overall school readiness
and
the placement of game console with
lower social competence

(EDs) placement and
school readiness
and ED placement.
of kindergarten.
30%
30 –
25 –
20 –
15 –
10 –
05 –
00 –
Such harmful effect was more
prominent among lower
socioeconomic status families

School readiness
• School readiness is an indicator of whether a child possesses the
cognitive, social and emotional skills necessary for success in school
and has been shown to predict
long-term educational outcomes.
Forget-Dubois N,
Early Educ Dev 2007;18:405–26
Silburn SR,
Early Hum Dev 2007;83:S125
• School readiness was measured
using the Early Development
Instrument (EDI), a comprehensive
teacher-rated scale.
Janus M, Can J Behav Sci 2007;39:1–22

Effect of bedroom electronic device (ED) placement on school readiness moderated
by family socioeconomic status (SES)
P<0.05

Effect of bedroom ED placement on school readiness moderated by parental restriction
P<0.001

Effect of bedroom ED placement on school readiness moderated by parental restriction
P<0.001
ED placement in
children’s bedroom was
associated with lower
school readiness,
particularly among lower
SES families.
Parental restriction
might help
to alleviate the harm.

Bidirectional Associations Between Child Sleep Problems
and Internalizing and Externalizing Difficulties
from Preschool to Early Adolescence.
Quach JL, JAMA Pediatr. 2018 Feb 5;172(2):e174363.
Importance:
Although multiple cross-sectional and longitudinal
studies have established that sleep problems and
behavioral difficulties are associated in children,
the directionality of this association and whether
sleep problems are differentially associated with
different types of childhood behavioral difficulties
are unclear. Understanding these associations will
inform the focus and timing of interventions.
Objective:
To determine whether longitudinal and reciprocal associations exist between child
sleep problems and externalizing, internalizing, or both behavioral difficulties.

Prospective cohort study using
nationally representative data
from 5 waves
2004 (4983 children mean age of 4.7 ),
2006,
2008,
2010, and
2012)
kindergarten cohort
(4983 children aged
4-5 years in 2004)
Sleep problems were defined using
parent-reported child sleep problem
severity and specific difficulties:
1. difficulty getting to sleep at night,
2. not happy sleeping alone,
3. waking during the night,
4. restless sleep
on 4 or more nights of the week.

Child behavioral difficulties using the
parent-reported Strengths and
Difficulties Questionnaire for
1. externalizing difficulties
(conduct problems and
hyperactivity/inattention subscales)
and
2. internalizing difficulties
(emotional problems subscale).
from 5 waves
2006,
2008,
2010, and
2012)
(4983 children aged
4-5 years in 2004)

from 5 waves
2006,
2008,
2010, and
2012)
(4983 children aged
4-5 years in 2004)
Significant bidirectional associations
were detected between sleep
problems and externalizing
difficulties during the elementary
school transition period,
with
greater sleep problems
associated with
later externalizing
behavior
and vice versa

from 5 waves
2006,
2008,
2010, and
2012)
(4983 children aged
4-5 years in 2004)
Although sleep was a significant
driver of later internalizing
difficulties,
the reverse association
was not significant.

from 5 waves
2006,
2008,
2010, and
2012)
(4983 children aged
4-5 years in 2004)
Conclusions and Relevance:
These results suggest that future
studies should investigate whether
implementing sleep problem
intervention decreases the
occurrence of both externalizing and
internalizing difficulties.
Interventions targeting
externalizing, but not internalizing,
difficulties may benefit childhood
sleep

•Sleep-
Disordered
Breathing
General
considerations

ERS statement on obstructive sleep disordered breathing
in 1- to 23-month-old children.
Kaditis AG, Eur Respir J. 2017 Dec 7;50(6). pii: 1700985.
The present statement was produced by a European Respiratory Society
Task Force to summarise the evidence and current practice on the diagnosis
and management of obstructive sleep disordered breathing (SDB) in children
aged 1-23 months.
A systematic literature search was completed and 159 articles were
summarised to answer clinically relevant questions.
SDB is suspected when symptoms or abnormalities related to upper airway
obstruction are identified.
Morbidity (pulmonary hypertension, growth delay, behavioural problems) and
coexisting conditions (feeding difficulties, recurrent otitis media) may be
present. SDB severity is measured objectively, preferably by
polysomnography, or alternatively polygraphy or nocturnal oximetry.

Children with apparent upper airway obstruction during wakefulness, those
with abnormal sleep study in combination with SDB symptoms (e.g. snoring)
and/or conditions predisposing to SDB (e.g. mandibular hypoplasia) as well as
children with SDB and complex conditions (e.g. Down syndrome, Prader-Willi
syndrome) will benefit from treatment.
Adenotonsillectomy and continuous positive airway pressure are the most
frequently used treatment measures along with interventions targeting
specific conditions (e.g. supraglottoplasty for laryngomalacia or
nasopharyngeal airway for mandibular hypoplasia).
Hence, obstructive SDB in children aged 1-23 months is a multifactorial
disorder that requires objective assessment and treatment of all underlying
abnormalities that contribute to upper airway obstruction during sleep.

•American Thoracic Society. Standards and indications for cardiopulmonary sleep studies in
children. Am J Respir Crit Care Med 1996; 153: 866–878.
•Dayyat E, Kheirandish-Gozal L, Gozal D. Childhood obstructive sleep apnea: one or two
distinct disease entities? Sleep Med Clin 2007; 2: 433–444.

A stepwise approach to the management of obstructive sleep disordered breathing
in 1- to 23-month-old children

FIGURE 1 A stepwise approach to the management of obstructive sleep disordered breathing
in 1- to 23-month-old children reflecting the Task Force members’ current practice.
This scheme is not intended as a recommendation for clinicians.
OSAS: obstructive sleep apnoea syndrome;
ALTE: apparent life-threatening event;
GOR: gastro-oesophageal reflux;
ENT: ear, nose and throat;
PSG: polysomnography;
AHI: apnoea–hypopnoea index;
UAO: upper airway obstruction;
CPAP: continuous positive airway pressure;
NPPV: non-invasive positive pressure ventilation;
nCPAP: nasal CPAP.

Allergic sensitization and objective measures of sleep
in urban school-aged children with asthma
CA Esteban, Ann Allergy Asthma Immunol 2017;119:238-245
Background
• Allergic sensitization is associated with increased child asthma morbidity
and decreased pulmonary function.
• Nocturnal symptoms and/or awakenings typically are measured
by self-report from diary data, whereas objective assessments
of sleep in child asthma studies are lacking.
Objective
• To investigate the association between increased allergic sensitization
(number of positive allergy test results measured by SPTs or sIgE)
and sleep outcomes (sleep efficiency, sleep duration,
and mean number of awakenings measured by actigraphy)
in urban schoolchildren with persistent asthma.

 196 children with
persistent asthma
(7–9 years old).
 Sleep outcomes were
measured with a wrist
Actiwatch during a
1-month period in the
fall and winter seasons.
• Children with more positive test
results experienced:
• less efficient sleep.
• more night awakenings. P=0.05.

Number of positive allergy test results and variability in sleep efficiency
by variability in FEV1 (median split).
For children above the median FEV1 value of variability, more allergy tests were associated with more variability in sleep efficiency
(b = .38, P = .00, R2 adjusted = 0.13). In contrast, for children below the median (less variability in FEV1),
there was no significant association between number of positive allergy test results and variability in sleep

 42 obese adolescents with the
obstructive sleep apnoea
syndrome (OSAS) and
37 weight-matched controls.
 Upper airway MRI,
measurements of upper airway
critical closing pressure (Pcrit),
genioglossal electromyography
and ventilatory response to
CO2 during wakefulness and
sleep.
• Adenotonsillar volume (ATV),
• nasopharyngeal airway volume
(NPAV),
• activated and hypotonic upper
airway critical closing pressure
(Pcrit),
• genioglossal electromyography
• ventilatory response to CO2
during sleep
were all associated
with OSAS risk.
The obstructive sleep apnoea syndrome in adolescents
Marcus CL, Thorax 2017;72:720–728

syndrome (OSAS) and
sleep.
• Adenotonsillar volume (ATV),
• nasopharyngeal airway volume
(NPAV),
• activated and hypotonic upper
airway critical closing pressure
(Pcrit),
• genioglossal electromyography
• ventilatory response to CO2
during sleep
were all associated
with OSAS risk.
OSAS in adolescents
is mediated by a
combination of anatomic
(ATV, NPAV) and
neuromotor factors
(activated Pcrit).

3D plots of the predicted probability (Pr) of
obstructive sleep apnoea syndrome (OSAS)
High predicted probabilities of OSAS are
shown in red, probabilities around 0.5 in grey
and low predicted probabilities in blue
Nasopharyngeal airway volume (NPAV)
syndrome (OSAS) and
sleep.

Activated critical closing pressure (Pcrit)
syndrome (OSAS) and
sleep.

Nasopharyngeal airway volume (NPAV)
syndrome (OSAS) and
sleep.

•Sleep-
Disordered
Breathing
Diagnosis
questionnaires

•Sleep-
Disordered
Breathing
Diagnosis
polisonnigraphy

Nocturnal Oximetry-based Evaluation of Habitually
Snoring Children.
Hornero R, Am J Respir Crit Care Med. 2017;196(12):1591-1598.
RATIONALE:
The vast majority of children around the world undergoing
adenotonsillectomy for obstructive sleep apnea-hypopnea syndrome
(OSA) are not objectively diagnosed by nocturnal polysomnography
because of access availability and cost issues.
Automated analysis of nocturnal oximetry (nSpO2), which is readily and
globally available, could potentially provide a reliable and convenient
diagnostic approach for pediatric OSA.

Snoring Children.
Deidentified nocturnal
oximetry (nSpO2 ) recordings
from a total of 4,191 children
originating from 13 pediatric
sleep laboratories
prospectively evaluated after
developing and validating an
automated neural network
algorithm using an initial set
of single-channel nSpO2
recordings from 589 patients
referred for suspected OSA.
The automatically estimated
apnea-hypopnea index (AHI)
showed high agreement with
AHI from conventional
polysomnography
(intraclass correlation coefficient, 0.785)
when tested in 3,602 additional
subjects.

Snoring Children.
Deidentified nocturnal
oximetry (nSpO2 ) recordings
from a total of 4,191 children
originating from 13 pediatric
sleep laboratories
prospectively evaluated after
developing and validating an
automated neural network
algorithm using an initial set
of single-channel nSpO2
recordings from 589 patients
referred for suspected OSA.
the widely used AHI cutoff points
of 1, 5, and 10 events/h revealed
an incremental diagnostic ability
(75.2, 81.7, and 90.2% accuracy;
0.788, 0.854, and 0.913 area under
the receiver operating
characteristic curve,
respectively).

Machines Learning to Detect Obstructive Sleep Apnea
in Children. Are We There Yet? Editorial
Combs D, Am J Respir Crit Care Med. 2017;196(12):1506-1507.
•In this issue of the Journal, Hornero and colleagues (pp. 1591–1598) take a
new approach to nocturnal pulse oximetry screening tool.
•Specifically, they used an innovative approach of machine learning to
generate a neural network algorithm to detect OSA from overnight pulse
oximetry tracings.
•Most prior attempts involved manual interpretation
of nocturnal pulse oximetry as a screening tool
for OSA.
•Such a machine learning approach enabled the
authors to evaluate thousands of potential
algorithms to optimize a screening algorithm.

•On the basis of their results, the authors suggest a diagnostic protocol
for applying this tool in clinical practice.
•Children with an estimated AHI lower than 1 based on overnight pulse
oximetry are unlikely to have moderate or severe sleep apnea and may
not require polysomnography.
•Children with a machine-estimated AHI of 5 or more per hour are likely to
have at least mild OSA by polysomnography (AHI >1), and could be referred
to treatment directly without undergoing polysomnography.
•Children with a machine-estimated AHI of 1–5 per hour would be considered
indeterminate and can be referred for polysomnography.
•Based on the author’s findings, approximately 1 in 20 children would be
incorrectly diagnosed with OSA and potentially treated unnecessarily.
Machines Learning to Detect Obstructive Sleep Apnea
in Children. Are We There Yet? Editorial
Combs D, Am J Respir Crit Care Med. 2017;196(12):1506-1507.

•Sleep-
Disordered
Breathing
Etiology
Comorbidities
And
Risk factors

Asthma outcomes improve with continuous positive
airway pressure for obstructive sleep apnea
J Serrano-Pariente, Allergy 2017;72:802-812
• The mean ± SD score of
the ACQ decreased from
1.39 ± 0.91 at baseline to
1.0 ± 0.78 at 6 months
(P = 0.003).
 Continuous positive airway
pressure (CPAP).
 Asthma outcomes after
6 months of CPAP in
99 adult asthma patients
(mean age 57 years)
with OSAS.
 Asthma Control
Questionnaire (ACQ).

• The mean ± SD score of
the ACQ decreased from
1.39 ± 0.91 at baseline to
1.0 ± 0.78 at 6 months
(P = 0.003).
pressure (CPAP).
6 months of CPAP in
(mean age 57 years)
with OSAS.
 Asthma Control
Asthma control
(both actual and future risk),
quality of life, and lung
function improved after
starting continuous
positive airway pressure
in asthmatics with
moderate to severe
obstructive sleep
apnea syndrome.

Pre
41.4%
17.2%
Post
50 –
40 –
30 –
20 –
10 –
00 –
CPAP
% patients with
uncontrolled asthma
% patients with asthma
attacks in the 6 months
Pre
35.4%
17.2%
Post
50 –
40 –
30 –
20 –
10 –
00 –
CPAP
P=0.006
P=0.015

Number of patients with well-controlled asthma (ACQ score ≤ 0.75)
and not well-controlled asthma (ACQ score ≥ 1.5) after starting
continuous positive airway pressure
pressure (CPAP).
6 months of CPAP in
(mean age 57 years)
with OSAS.
 Asthma Control

 The mechanisms by which treatment with CPAP may improve symptoms and
asthma control are multiple.
 OSAS is associated with a systemic and local inflammation of the airways, as well
as pulmonary vascular changes and release of endothelial factors (such as vascular
endothelial growth factor) with proinflammatory effects.
 The use of CPAP reduces inflammation and its mediators.
 Improvement of gastroesophageal reflux may also be accompanied by a reduction
in nocturnal asthma symptoms.
 Additionally, reduction in bronchial hyperresponsiveness produced by CPAP can be
also associated with a clinical improvement of asthma.

•Sleep-
Disordered
Breathing
Red-Ox
Epigenetic
inflammation

•Sleep-
Disordered
Breathing
Consequences
in children

•Sleep-
Disordered
Breathing
Consequences
in adults

•Sleep-
Disordered
Breathing
Treatment
adenotonsillectomy

• Although adenotonsillectomy is the first line
treatment for children with obstructive sleep apnea
syndrome (0SAS), improvement in objectively
documented outcomes is often inadequate and a substantial number
of children have residual disease, as most of them have additional
risk factors for OSAS and comorbidities.
Adenotonsillectomy to treat obstructive sleep apnea:
Is it enough?
A Boudewyns, Pediatr Pulmonol 2017;52:699-709

Is it enough?
Non-syndromic uncomplicated children
Syndromic children and children with complex
medical conditions
OSA with an AHI > 5 episodes/h Major craniofacial abnormalities
Children with cardiovascular morbidity (e.g.,
elevated blood pressure
Neurological disorders including neuromuscular
disorders and neurodisability
Children with neurological morbidity (e.g.,
excessive daytime sleepiness, hyperactivity,
inattention, academic difficulties)
Achondroplasia
Enuresis Down syndrome
Somatic growth delay or failure to thrive Prader–Willi syndrome
Obesity Mucopolysaccharidoses
Asthma
Priority Indication for adenotonsillectomy

Which Examinations Should/Could Be Performed In Children With Residual
Disease To Guide Further Treatment?
• Many children with OSAS have multiple sites of upper airway (UA)
obstruction during sleep and this may contribute to persistent OSAS
following AT.
• Possible sites of persistent UA obstruction are the region of the soft
palate, tongue base with lingual tonsillar hypertrophy, the supraglottis,
inferior turbinates, and the adenoid region with regrowth of adenoids.
• The diagnostic work-up to identify the levels of persistent UA obstruction
starts with a detailed history and flexible nasopharyngoscopy up to the
level of the larynx in the awake patient.
Is it enough?

Which Examinations Should/Could Be Performed In Children With Residual
Disease To Guide Further Treatment?
• Sleep cine-magnetic resonance imaging (MRI) and drug induced sedation
endoscopy (DISE) were the most commonly used tools for dynamic
evaluation of the pediatric UA.
• Children with persistent OSAS had a higher percentage of lingual tonsillar
hypertrophy compared to controls (33% vs. 0%), and lingual tonsillar
hypertrophy occurred predominantly in children with Down syndrome.
• DISE might be particularly useful for the evaluation
of lingual tonsillar hypertrophy
and late-onset laryngomalacia.
Is it enough?

Site-specific Treatment: Orthodontic Treatment
• An orthodontic treatment is indicated in children with OSAS and
craniofacial alterations such as retrusive chin, steep mandibular plane,
vertical direction of growth and a Class II malocclusion
• Oral appliances may improve UA patency during sleep by enlarging the UA,
decreasing UA collapsibility and improving UA muscle tone.
• Rapid maxillary expansion (RME) and mandibular advancement by an oral
jaw-positioning device are the available orthodontic treatment options in
the pediatric population.
Is it enough?

Site-specific Treatment: Upper Airway Surgery
• Late-onset laryngomalacia is typically characterized by inspiratory
prolapse of prominent mucosal folds on the accessory cartilages
above the arytenoids resulting in supraglottic obstruction and has
a prevalence of 3.9% among older children with OSAS.
• Potential surgical interventions for upper airway obstruction
in children with residual OSAS include:
(i) adenoidectomy for those with regrowth of adenoids;
(ii) lingual tonsillectomy;
(iii) supraglottoplasty; and
(iv) partial midline glossectomy and tongue suspension with or without
lingual tonsillectomy.
Is it enough?

Treatment That Alters Underlying Conditions Contributing To Osas:
Weight Loss
• There is consensus that weight loss therapy should be initiated in every
child with OSAS because of its beneficial effects on other obesity-
related complications.
Medical Treatment
• Intranasal budesonide and montelukast.
Is it enough?

Treatment That Alters Underlying Conditions Contributing To Osas:
Myofunctional Therapy
• Mouth breathing is associated with malposition of the tongue, hypotonic
lips, and incorrect swallowing pattern and may predispose subjects to
persistent or recurrent OSAS following adenotonsillectomy.
• Myofunctional therapy consist of oropharyngeal exercises, that is,
repetitive isotonic and isometric exercises of tongue, soft palate and
lateral pharyngeal walls, increasing muscle tone throughout the upper
respiratory tract and helping to obtain correct nasal breathing habits,
speech, swallowing and chewing.
Is it enough?

Is it enough?
 Endoscopic view of lingual tonsillar
hypertrophy in a child residual OSA
following prior AT.
 Note: A complete obstruction the
UA at the level of the tongue with
the epiglottis pushed backwards
against the pharyngeal wall.
Lingual tonsillar hypertrophy

Is it enough?
• Endoscopic view of supraglottic
obstruction in a child with OSA
cause by late-onset laryngomalacia.
• Note: A complete obstruction of
the glottis inlet by inspiratory
collaps of redundant
supra-arythenoidal mucosa.
Late-onset laryngomalacia

Is it enough?
Proposed algorithm for the management of persistent OSAS post-AT (part1)

Is it enough?
Proposed algorithm for the management of persistent OSAS post-AT (part2)

Adenotonsillotomy Versus Adenotonsillectomy
in Pediatric Obstructive Sleep Apnea: An RCT
Borgström A, Pediatrics 2017;139:e20163314
• An important risk factor for OSA in children
is adenotonsillar hypertrophy.
• Adenotonsillectomy (ATE) is considered first-line
treatment and is one of the most common surgical
procedures throughout the world.
• ATE is an effective treatment of pediatric OSA but has the
disadvantages of risk of postoperative hemorrhage and pain.
• In recent decades, partial tonsillectomy, or adenotonsillotomy
(ATT), with subtotal removal of the tonsils, has gained
popularity because it is associated with less postoperative
hemorrhage and pain.

Adenotonsillotomy Versus Adenotonsillectomy in
Pediatric Obstructive Sleep Apnea: An RCT
 79 children, aged 2
to 6 years, with OSA
(Apnea-Hypopnea
Index [AHI] 5-30).
 Randomized to
adenotonsillotomy
(ATT) (n = 40)
or adenotonsillectomy
(ATE) (n = 39).
 Polysomnography
and questionnaire
at baseline and
1 year postsurgery.
12.7
BEFORE
Apnea-Hypopnea Index (median)
20 –
15 –
10 –
05 -
00
15.8
2.0
4.0
BEFOREAFTER AFTER
ATE ATT

(Apnea-Hypopnea
Index [AHI] 5-30).
 Randomized to
adenotonsillotomy
(ATT) (n = 40)
(ATE) (n = 39).
 Polysomnography
and questionnaire
at baseline and
1 year postsurgery.
12.7
BEFORE
20 –
15 –
10 –
05 -
00
15.8
2.0
4.0
BEFOREAFTER AFTER
ATE ATT
For both groups,
significant
improvements of PSG
and OSA-18
questionnaire outcomes
were observed,
with no significant
differences
between groups.

(Apnea-Hypopnea
Index [AHI] 5-30).
 Randomized to
adenotonsillotomy
(ATT) (n = 40)
(ATE) (n = 39).
 Polysomnography
and questionnaire
at baseline and
1 year postsurgery.
12.7
BEFORE
20 –
15 –
10 –
05 -
00
15.8
2.0
4.0
BEFOREAFTER AFTER
ATE ATT
5 children (13%) in the
ATT group needed
repeated surgery for
tonsil regrowth
and recurrence of OSA.

(Apnea-Hypopnea
Index [AHI] 5-30).
 Randomized to
adenotonsillotomy
(ATT) (n = 40)
(ATE) (n = 39).
 Polysomnography
and questionnaire
at baseline and
1 year postsurgery.
12.7
BEFORE
20 –
15 –
10 –
05 -
00
15.8
2.0
4.0
BEFOREAFTER AFTER
ATE ATT
• The results suggest that
ATT is noninferior to
ATE in treating pediatric
OSA regarding PSG
outcomes after 1 year.
• However, after ATT,
there is a nonnegligible
risk of recurrence of
OSA.

Boxplots and lines showing the AHI 1 (before surgical intervention)
and AHI 2 (after surgical intervention)

Tonsil regrowth and recurrence of OSA are known
disadvantages after ATT, and 13% of the children
in the ATT group underwent repeated tonsil surgery
within the follow-up period.
A recent Swedish study based on >28 000 children reported a 7 times
higher risk of reoperation after TT than after TE, with the difference most
markedly among the youngest children.
In our study, the children undergoing reoperation were also among the
youngest (median age 32 months).

Predicting the effect of treatment in paediatric OSA
by clinical examination and functional respiratory imaging
M Slaats, Pediatr Pulmonol 2017;52:799-805
 91 normal weight children
diagnosed with OSA by
polysomnography (PSG)
 Thorough evaluation and
an ultra-low dose computed
tomography scan
of the upper airway (UA).
 A 3-D reconstruction
of functional respiratory
imaging (FRI).
 A second PSG 3-12 months
after surgery (A&T).
• Children with more severe
OSA had a smaller volume
of the overlap region
between the adenoids and
tonsils
*
*

% children with persistent
OSA (oAHI >2/h)
3-12 months after
surgery (A&T).
32%
40 –
30 –
20 –
10 –
00
tomography scan
imaging (FRI).

OSA (oAHI >2/h)
3-12 months after
surgery (A&T).
32%
40 –
30 –
20 –
10 –
00
tomography scan
imaging (FRI).
A higher tonsil score
predicted successful
treatment.

OSA (oAHI >2/h)
3-12 months after
surgery (A&T).
32%
40 –
30 –
20 –
10 –
00
tomography scan
imaging (FRI).
A less constricted
airway, as
characterized by both
FRI and a lower tonsil
score, was associated
with a less favorable
response to (adeno)
tonsillectomy.

3-D reconstruction of the UA Computerized 3-D model of the UA
Nostril to anterior end of
inferior turbinate (zone1),
anterior end of inferior
turbinate to choanae (zone2),
choanae to tip of uvula (zone3),
uvula to epiglottis (zone4), and
epiglottis to the first thoracic
vertebra (zone5)

3-D reconstruction of the UA Computerized 3-D model of the UA
Zone1: Nostril to anterior end
of inferior turbinate;
Zone2: anterior end of inferior
turbinate to choanae;
Zone3: choanae to tip of uvula;
Zone4 : uvula to epiglottis;
Zone5 : epiglottis to the first
thoracic vertebra .

•Sleep-
Disordered
Breathing
Treatment
Oropharyngeal
Exercises
CPAP
Ortodonzia
Oral-palatal
surgery

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