Cardiopulmonary Testing before Pediatric Adenotonsillectomy for Severe and Very Severe Obstructive Sleep Apnea Syndrome

Abstract

Objectives/Hypothesis: Adenotonsillectomy is first-line treatment for pediatric obstructive sleep apnea syndrome (OSAS) when not otherwise contraindicated. There is concern severe OSAS increases risk of comorbid cardiopulmonary abnormalities, such as ventricular hypertrophy or pulmonary hypertension, which preoperative testing could detect. Our objective is to determine if there is a severity of pediatric OSAS where previously undetected cardiopulmonary comorbidities are likely.Study Design: Retrospective chart review. Methods: We performed a retrospective review of 358 patients ≤21 years with severe OSAS who underwent adenotonsillectomy at a tertiary hospital June 1, 2016 to June 1, 2018. We extracted demographics, comorbidities, polysomnography, and preoperative tests. Wilcoxon rank-sum and logistic regression estimated associations of OSAS severity (based on obstructive apnea-hypopnea index [OAHI], hypoxia, hypercarbia) with preoperative echocardiograms and chest Xrays (CXRs).Results: Mean age was 5.9 (AE3.6) years and 52% were male. Mean OAHI and oxygen saturation nadir were 30.3 (AE23.8) and 80.7% (AE9.2), respectively. OAHI ≥60 was associated with having a preoperative echocardiogram (OR, 3.8; 95% CI, 1.7-8.5) or CXR (OR, 3.0; 95% CI, 1.4-6.8) compared to OAHI 10-59. There were no significant associations between OSAS severity and test abnormalities. The presence of previously diagnosed cardiopulmonary comorbidities was associated with abnormalities on echocardiogram (OR, 36; 95% CI, 4.1-320.1) and CXR (OR, 4.1; 95% CI, 1.2-14.4).Conclusions: Although pediatric patients with very severe OSAS (OAHI ≥60) underwent more pre-adenotonsillectomy cardiopulmonary tests, OSAS severity did not predict abnormal findings. Known cardiopulmonary comorbidities may be a better indication for cardiopulmonary testing than polysomnographic parameters, which could streamline pre-adenotonsillectomy evaluation and reduce cost.

Prevalence of pulmonary hypertension in children with obstructive sleep apnea living at high altitude

“…Recent studies on the prevalence of PH in children with OSA show variable results, mostly with findings similar to ours with a low prevalence of PH in this group of children; similar to our results, the studies by Clements et al [ 44 ] and Teplitzky et al [ 45 ] found no association between the degree of severity of OSA and abnormal echocardiographic findings. Similarly, a systematic review of echocardiographic findings in children with obstructive sleep apnea in the pediatric population found no consistent results; of the 13 studies that met the inclusion criteria, only 2 measured the TRV, and of these, only one found a positive correlation with AHI([ 46 ]).…”

Cardiac Implications of Adenotonsillar Hypertrophy and Obstructive Sleep Apnea in Pediatric Patients: A Comprehensive Systematic Review

“…Tables 1 and 2 show studies conducted over the past 20 years, each with a different research purpose and study methods. The available studies can be classified as observational studies (n.2) [16,17], retrospective studies (n.3) [18][19][20], cross-sectional studies (n.4) [21][22][23][24], comparative studies (n.2) [25,26], prospective studies (n.8) [27][28][29][30][31][32][33][34], and clinical trial (n.1) [35].…”

“…The minimum number of children in one study was 23 [33], while the maximum number in a study was 620 [19]. The minimum age was 2.5 years [27], and the maximum was 21 years [20]. The authors of these studies used various methods to assess OSA and its effects on the cardiovascular system in children.…”

“…The authors of these studies used various methods to assess OSA and its effects on the cardiovascular system in children. The diagnosis of OSA was obtained by PSG [18][19][20][21]26,28,35], oximetry [34], and questionnaire OSA-18 [16,17,22,23,32]. Diagnosis of adenoid/tonsillar hypertrophy was obtained using Brodsky's Scale in three studies [22][23][24] and by taking X-rays in four studies [22,30,32,35].…”

“…Diagnosis of adenoid/tonsillar hypertrophy was obtained using Brodsky's Scale in three studies [22][23][24] and by taking X-rays in four studies [22,30,32,35]. ENT surgery was reported as adenoidectomy [16,17,[20][21][22]25,[27][28][29][30][31][32][33]35], tonsillectomy [29,32], and A&T [16,17,[20][21][22]25,[28][29][30][31][32][33]35]. A cardiac evaluation was performed by Doppler echocardiography [16,17,22,24,[27][28][29][30] and the analysis of various cardiac parameters [16,17,25,27,…”