Clinical guideline for diagnosis and surgical treatment of obstructive sleep apnea syndrome in patients from two to eight years old
Abstract Introduction and objective: The adenotonsillar hypertrophy is the fundamental cause of childhood obstructive sleep apnea syndrome (OSAS), a frequent pathology that can cause a series of important complications. In certain circumstances, it can be diagnosed without the need of complex tests and treated effectively, with adenotonsillectomy being the choice; since, with the current resources, assuming all the recommendations of the main guidelines are impractical, the number of children that would require referral for diagnostic polysomnography (PSG) and adenotonsillectomy would exceed our capacity. Limiting the guidelines to available means would significantly ignore the health repercussions of childhood OSA, making it difficult to recognize children at risk, as well as being able to offer adequate treatment. Our objective is to establish the recommendations based on the best available scientific evidence to increase, in an efficient way, the diagnosis of pediatric OSAS and to establish the adequate surgical recomendation as well as the safety in the perioperative procedure. Sections: Review of the bibliography of national and international guidelines on the management of childhood OSAS and assessment of own experience derived from clinical practice and prospective follow-up studies of operated patients. Summary of the evidence on childhood OSAS. Resolution of disagreements between scientific evidence and current clinical practice with proposals to minimize them. Recommendations for the diagnostic procedure and the surgical procedure. Perioperative management scheme and post-surgical follow-up. Conclusions: The application of the suggested changes regarding the management of children with suspected OSAS will allow: 1) greater prominence in the process of Primary and Secondary Care provided by general pediatricians to consider adenotonsillectomy; 2) the widespread use of specific questionnaires for the detection of OSAS, nocturnal oximetry and video recording during sleep as assessment tools; and 3) greater availability of complex sleep studies (PSG) to meet international standards for certain conditions.
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American Thoracic Society. Cardiorespiratory sleep studies in children. Establishment of normative data and polysomnographic predictors of morbidity. Am J Respir Crit Care Med. 1999; 160:1381-7.
Bixler EO, Vgontzas AN, Lin HM, Liao D, Calhoun S, Vela-Bueno A, et al. Sleep disordered breathing in children in a general population sample: prevalence and risk factors. Sleep. 2009; 32:731-6.
Brodsky L. Modern assessment of tonsils and adenoids. Pediatr Clinic N Am. 1989; 36: 1551-69.
Brouillette RT, Morielli A, Leimanis A, Waters KA, Luciano R, Ducharme FM. Nocturnal pulse oximetry as an abbreviated testing modality for pediatric obstructive sleep apnea. Pediatrics. 2000; 105:405-12.
Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al on behalf of the AGREE Next Steps Consortium. AGREE II: Advancing guideline development, reporting and evaluation in healthcare. Can Med Assoc J [Internet]. Dec 2010 (citado 12 ene 2016); 182:E839-42; doi: 10.1503/cmaj.090449 Disponible en español: http://www.guiasalud.es/contenidos/documentos/Guias_Practica_Clinica/Spanish-AGREE-II.pdf.
Brown KA. Outcome, risk, and error and the child with obstructive sleep apnea. Paediatr Anaesth. 2011 Jul; 21(7):771-80.
Ebert CS Jr., Drake AF. The impact of sleepdisordered breathing on cognition and behavior in children: a review and meta-synthesis of the literature. Otolaryngol Head Neck Surg. 2004; 131:814-26.
Fitzgerald NM, Fitzgerald DA. Managing snoring and obstructive sleep apnoea in childhood. J Paediatr Child Health. 2013; 49:800-6.
García Fernández E, Ríos LLorente A, Ruiz Chirosa MC, Pascual Lorenzo MJ, Rodríguez M, Morales C. 05AP07-10 Assessment of postoperative management in patient with OSA after tonsillectomy. Eur J Anaesthesiol. 2017; 34 (e-Suppl 55):147-8.
Garrido C, Flores CS y Núñez CE. Diferencias anatomofuncionales y endoscópicas entre la vía aérea del niño y la del adulto. Rev Inst Enf Resp Mex. 2007; 20:142-8.
Guilleminault C. Treatments in obstructive sleep apnea. In: Guilleminault C, Partinen C, editors. Obstructive sleep apnea syndrome. New York: Rave Press; 1990. p. 99-118.
Grupo de trabajo de la Guía de Práctica Clínica sobre Trastornos del Sueño en la Infancia y Adolescencia en Atención Primaria. Guía de Práctica Clínica sobre Trastornos del Sueño en la Infancia y Adolescencia en Atención Primaria. Plan de Calidad para el Sistema Nacional de Salud del Ministerio de Sanidad, Política Social e Igualdad. Unidad de Evaluación de Tecnologías Sanitarias de la Agencia Laín Entralgo [internet]; 2011[citado 12 Dic 2016]. Guías de Práctica Clínica en el SNS: UETS Nº 2009/8. Disponible en: http://www.guiasalud.es/GPC/GPC_489_Trastorno_sue%C3%B1o_infadol_Lain_Entr_compl.pdf
Kheirandish-Gozal L. What is “abnormal” in pediatric sleep? Respir Care. 2010; 55:1366-76.
Li AM, Au CT, Ng SK, Abdullah VJ, Ho C, Fok TF, et al. Natural history and predictors for progression of mild childhood obstructive sleep apnoea. Thorax. 2010; 65:27-31.
Lumeng JC, Chervin RD. Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc. 2008; 5:242-52.
Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130:576-84.
Marcus CL, Hamer A, Loughlin GM. Natural history of primary snoring in children. Pediatr Pulmonol. 1998; 26:6-11.
Morielli A, Ladan S, Ducharme FM, Brouillette RT. Can sleep and wakefulness be distinguished in children by cardiorespiratory and videotape recordings? Chest. 1996; 109 (3):680-7.
Paediatric Sleep Medicine Clinical Network group. Paediatric Society of New Zealand, “New Zealand Guidelines for the Assessment of Sleep-Disordered Breathing in Childhood”, Wellington [internet], 2015 [citado 20 dic 2016]. Disponible en: https://www.sleep.org.au/documents/item/2008
Raghavendran S, Bagry H, Detheux G, Zhang X, Brouillette RT, Brown KA. An anesthetic management protocol to decrease respiratory complications after adenotonsillectomy in children with severe sleep apnea. Anesth Analg. 2010 Apr 1; 110(4):1093-101.
Redline S, Tishler PV, Schluchter M, Aylor J, Clark K, and Graham G. Risk factors for sleep-disordered breathing in children. Associations with obesity, race, and respiratory problems. Am J Respir Crit Care Med. 1999; 159(5 Pt 1):1527-32.
Roland PS, Rosenfeld RM, Brooks LJ, Friedman NR, Jones J, Kim TW, et al. Clinical Practice Guideline: Polisomnography for sleep disordered breathin prior to tonsillectomy in children. Otolaringol Head Neck Surg. 2011; 145:S1-S15.
Sadhasivam S, Davidson A, Crowley M. Anesthesia for tonsillectomy with or without adenoidectomy in children [Internet]. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. 2018 [12 abr 2018;12 may 2018] Disponible en: https://www.uptodate.com/
Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome American Academy of Pediatrics. Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2002;109:704-12.
Sivan Y, Kornecki A, Schonfeld T. Screening obstructive sleep apnoea syndrome by homevideotape recording in children. Eur Respir J. 1996; 9:2127-31.
Thongyam A, Marcus CL, Lockman JL, Cornaglia MA, Caroff A, Gallagher PR, et al. Predictors of perioperative complications in higher risk children after adenotonsillectomy for obstructive sleep apnea: a prospective study. Otolaringol Head Neck Surg. 2014 December; 151(6):1046-54.
Vicente González E, Adiego Leza I, Maltrana García JA, Aznar Facerías E, Ortiz García A. Fisiopatología de los trastornos respiratorios del sueño en los niños. Acta Otorrinolaringol Esp. 2010; 61 (supl1):14-21.
Weinstock TG, Rosen CL, Marcus CL, Garetz S, Mitchell RB, Amin R, et al. Predictors of obstructive sleep apnea severity in adenotonsillectomy candidates. Sleep. 2014; 37:261-9.
Alonso-Álvarez ML, Terán J y Navazo AI. Patología respiratoria en sueño en niños. En: Sociedad Española de Sueño eds. Tratado de Medicina de Sueño. Madrid: Editorial Médica Panamericana; 2015.
American Thoracic Society. Cardiorespiratory sleep studies in children. Establishment of normative data and polysomnographic predictors of morbidity. Am J Respir Crit Care Med. 1999; 160:1381-7.
Bixler EO, Vgontzas AN, Lin HM, Liao D, Calhoun S, Vela-Bueno A, et al. Sleep disordered breathing in children in a general population sample: prevalence and risk factors. Sleep. 2009; 32:731-6.
Brodsky L. Modern assessment of tonsils and adenoids. Pediatr Clinic N Am. 1989; 36: 1551-69.
Brouillette RT, Morielli A, Leimanis A, Waters KA, Luciano R, Ducharme FM. Nocturnal pulse oximetry as an abbreviated testing modality for pediatric obstructive sleep apnea. Pediatrics. 2000; 105:405-12.
Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al on behalf of the AGREE Next Steps Consortium. AGREE II: Advancing guideline development, reporting and evaluation in healthcare. Can Med Assoc J [Internet]. Dec 2010 (citado 12 ene 2016); 182:E839-42; doi: 10.1503/cmaj.090449 Disponible en español: http://www.guiasalud.es/contenidos/documentos/Guias_Practica_Clinica/Spanish-AGREE-II.pdf.
Brown KA. Outcome, risk, and error and the child with obstructive sleep apnea. Paediatr Anaesth. 2011 Jul; 21(7):771-80.
Ebert CS Jr., Drake AF. The impact of sleepdisordered breathing on cognition and behavior in children: a review and meta-synthesis of the literature. Otolaryngol Head Neck Surg. 2004; 131:814-26.
Fitzgerald NM, Fitzgerald DA. Managing snoring and obstructive sleep apnoea in childhood. J Paediatr Child Health. 2013; 49:800-6.
García Fernández E, Ríos LLorente A, Ruiz Chirosa MC, Pascual Lorenzo MJ, Rodríguez M, Morales C. 05AP07-10 Assessment of postoperative management in patient with OSA after tonsillectomy. Eur J Anaesthesiol. 2017; 34 (e-Suppl 55):147-8.
Garrido C, Flores CS y Núñez CE. Diferencias anatomofuncionales y endoscópicas entre la vía aérea del niño y la del adulto. Rev Inst Enf Resp Mex. 2007; 20:142-8.
Guilleminault C. Treatments in obstructive sleep apnea. In: Guilleminault C, Partinen C, editors. Obstructive sleep apnea syndrome. New York: Rave Press; 1990. p. 99-118.
Grupo de trabajo de la Guía de Práctica Clínica sobre Trastornos del Sueño en la Infancia y Adolescencia en Atención Primaria. Guía de Práctica Clínica sobre Trastornos del Sueño en la Infancia y Adolescencia en Atención Primaria. Plan de Calidad para el Sistema Nacional de Salud del Ministerio de Sanidad, Política Social e Igualdad. Unidad de Evaluación de Tecnologías Sanitarias de la Agencia Laín Entralgo [internet]; 2011[citado 12 Dic 2016]. Guías de Práctica Clínica en el SNS: UETS Nº 2009/8. Disponible en: http://www.guiasalud.es/GPC/GPC_489_Trastorno_sue%C3%B1o_infadol_Lain_Entr_compl.pdf
Kheirandish-Gozal L. What is “abnormal” in pediatric sleep? Respir Care. 2010; 55:1366-76.
Li AM, Au CT, Ng SK, Abdullah VJ, Ho C, Fok TF, et al. Natural history and predictors for progression of mild childhood obstructive sleep apnoea. Thorax. 2010; 65:27-31.
Lumeng JC, Chervin RD. Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc. 2008; 5:242-52.
Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130:576-84.
Marcus CL, Hamer A, Loughlin GM. Natural history of primary snoring in children. Pediatr Pulmonol. 1998; 26:6-11.
Morielli A, Ladan S, Ducharme FM, Brouillette RT. Can sleep and wakefulness be distinguished in children by cardiorespiratory and videotape recordings? Chest. 1996; 109 (3):680-7.
Paediatric Sleep Medicine Clinical Network group. Paediatric Society of New Zealand, “New Zealand Guidelines for the Assessment of Sleep-Disordered Breathing in Childhood”, Wellington [internet], 2015 [citado 20 dic 2016]. Disponible en: https://www.sleep.org.au/documents/item/2008
Raghavendran S, Bagry H, Detheux G, Zhang X, Brouillette RT, Brown KA. An anesthetic management protocol to decrease respiratory complications after adenotonsillectomy in children with severe sleep apnea. Anesth Analg. 2010 Apr 1; 110(4):1093-101.
Redline S, Tishler PV, Schluchter M, Aylor J, Clark K, and Graham G. Risk factors for sleep-disordered breathing in children. Associations with obesity, race, and respiratory problems. Am J Respir Crit Care Med. 1999; 159(5 Pt 1):1527-32.
Roland PS, Rosenfeld RM, Brooks LJ, Friedman NR, Jones J, Kim TW, et al. Clinical Practice Guideline: Polisomnography for sleep disordered breathin prior to tonsillectomy in children. Otolaringol Head Neck Surg. 2011; 145:S1-S15.
Sadhasivam S, Davidson A, Crowley M. Anesthesia for tonsillectomy with or without adenoidectomy in children [Internet]. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. 2018 [12 abr 2018;12 may 2018] Disponible en: https://www.uptodate.com/
Section on Pediatric Pulmonology, Subcommittee on Obstructive Sleep Apnea Syndrome American Academy of Pediatrics. Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2002;109:704-12.
Sivan Y, Kornecki A, Schonfeld T. Screening obstructive sleep apnoea syndrome by homevideotape recording in children. Eur Respir J. 1996; 9:2127-31.
Thongyam A, Marcus CL, Lockman JL, Cornaglia MA, Caroff A, Gallagher PR, et al. Predictors of perioperative complications in higher risk children after adenotonsillectomy for obstructive sleep apnea: a prospective study. Otolaringol Head Neck Surg. 2014 December; 151(6):1046-54.
Vicente González E, Adiego Leza I, Maltrana García JA, Aznar Facerías E, Ortiz García A. Fisiopatología de los trastornos respiratorios del sueño en los niños. Acta Otorrinolaringol Esp. 2010; 61 (supl1):14-21.
Weinstock TG, Rosen CL, Marcus CL, Garetz S, Mitchell RB, Amin R, et al. Predictors of obstructive sleep apnea severity in adenotonsillectomy candidates. Sleep. 2014; 37:261-9.
Sánchez-Serrano, A., Calvo-Boizas, E., Morales-Martín, A. C., Sánchez-Velez, T., Fernández-Sánchez, J. L., Benito-González, F., Diego-Pérez, C., Gil-Melcón, M., Sánchez-Barrado, E., Morán-Sánchez, J. C., Marín-Cassinello, A., De Paz-sánchez, A., Blanco-Rueda, J. A., Vázquez-Casares, G., Martín-Gómez, M. C., Santos-Gorjón, P., & Barajas-Sánchez, V. (2019). Clinical guideline for diagnosis and surgical treatment of obstructive sleep apnea syndrome in patients from two to eight years old. Revista ORL, 10(4), 279–294. https://doi.org/10.14201/orl.20736
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