Diagnosis and perioperative management in pediatric sleep‐ disordered breathing.
This article is a review of the recent literature on the perioperative management of children with Sleep Disordered Breathing (SDB). Areas covered are the diagnosis of obstructive sleep apnoea (OSA), the importance of individualised anaesthetic and analgesic plans and post-operative monitoring
Clinical Polysomnography is the gold standard test for OSA. It ideally should be used to guide the perioperative management of children with SDB, in particular those who present for adenotonsillectomy. However, the test is costly, inconvenient and difficult to acquire in a timely manner due to a lack of paediatric sleep laboratories. This paper looks at alternative methods for identifying SDB. Screening questionnaires are one such alternative. However, few have been validated and standardized. For a number of reasons, including their inherent subjectivity, the authors conclude that screening questionnaires do not consistently diagnose or stratify OSA. Clinical parameters such as snoring, daytime somnolence, hyperactivity or drowsiness and witnessed apnoea and physical examination are the most commonly used factors for determining the need for adenotonsillectomy. The authors highlight that diagnosis based on history and examination correlates with PSG findings in only 30% to 50% of cases. Moreover, tonsil size and palate position do not predict disease severity, nor do they predict the degree of improvement in OSA following adenotonsillectomy. Serum biomarkers have not proven to be useful in screening for paediatric OSA.
According to the review, Home Sleep Apnoea Testing (HSAT) is used to evaluate adult OSA and has not been found to be inferior to sleep laboratory PSG. The role of HSAT has not been clarified in the paediatric population. Overnight oximetry, classified as single channel HSAT, has not been found to correlate well with sleep laboratory PSG and has a sensitivity of 67 % and a specificity of 60 % in identifying children with moderate OSA. Overnight oximetry also has the limitations of being unable to identify arousals and total sleep time as well as being unable to differentiate between obstructive and central apnoea. Multi-channel HSAT have been found to be effective only when applied by a trained technician and often requires use over two nights to improve sensitivity and specificity. HSAT cannot replace laboratory PSG in the diagnosis and stratification of OSA in children but they may be useful as screening tools where there is limited access to formal testing.
Take Home Message
Children with SDB and OSA are at increased risk of perioperative respiratory adverse events. Identifying these children is therefore not only important to guide decisions on surgical management but also to allow strategies to mitigate the risk of respiratory complications in the post-operative period. Given the difficulties associated with formal diagnosis of OSA, clinicians rely on clinical history to determine if and when patients should undergo adenotonsillectomy. American guidelines recommend formal clinical PSG for paediatric patients with comorbidity (e.g. Down Syndrome, MPS, neuromuscular disorders, sickle cell disease) and for children in whom the diagnosis is unclear. According to the review, only 10% of children have a formal sleep study prior to adenotonsillectomy for SDB.
Reviewed by: Dr Catherine Olweny