Childhood Obstructive Sleep Apnea: One or Two Distinct Disease Entities?

Abstract

The spectrum of sleep disordered breathing (SDB) encompasses habitual snoring at the low end of severity all the way to frank obstructive sleep apnea (OSA), with upper airway resistance syndrome (UARS) and obstructive alveolar hypoventilation being considered as less severe variants of this condition. SDB occurs in children of all ages, from neonates to adolescents, and is characterized by repeated events of increased upper airway resistance as well as with either partial or complete upper airway obstruction during sleep, all of which may result in disruption of normal gas exchange and sleep integrity [1]. SDB was initially described over a century ago [2] and was then rediscovered in children by Guilleminault in 1976 [3]. However, this complex and relatively prevalent disorder is only now being recognized as a major public health problem. During the initial years since the seminal paper by Guilleminault et al [3], it became apparent that the classic clinical syndrome of OSA in children markedly differed from the OSA seen in adults, in particular with respect to gender distribution, clinical manifestations, polysomnographic findings, and treatment approaches [4,5]. However in more recent years, the epidemic of obesity that affects the pediatric population all over the world has led, in our opinion, to the emergence of a phenotypic variant of OSA in children that closely resembles that of adults with the disease. In this paper, we will review the pathophysiological mechanisms of OSA in children, delineate the clinical manifestations associated with the disease, and provide arguments for our novel and hopefully useful proposition that aims to define 2 types of OSA in children. For the sake of convenience, and in analogy with type I and type II diabetes, we propose to divide pediatric OSA as types I and II. Keywordsobstructive sleep apnea; adenotonsillar hypertrophy; obesity; inflammation; upper airway; snoring Epidemiology of Pediatric OSAHabitual snoring during sleep, the hallmark indicator of increased upper airway resistance, is an extremely frequent occurrence during childhood, with up to 27% of children being affected [6][7][8][9][10][11][12][13][14]. SDB is most common in young children (pre-school and early school years), with a peak prevalence around 2-8 years, and subsequent declines in frequency [15]. However, accurate prevalence information is missing, particularly in infants, since most epidemiological studies have to date concentrated on older children. Furthermore, the exact polygraphic Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. demarcation betwee...

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“…It is sometimes difficult to determine whether obesity causes OSA, or if OSA causes obesity 19 . Some authors even purpose a need for classification to enable better treatment, declaring that there are two types; "type I OSA" is applied when there is hypertrophic lymphoid tissue and absence of obesity and "type II OSA" is applied when patients present with obesity, but only slight hypertrophy 20 .…”

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“…Dayyat et al suggest that OSA in obese children is a phenotypic variant of OSA closely resembling that in adults [25].…”

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“…В 1976 г. C. Guilleminault et al в статье «Синдром апноэ сна» [11] описал синдром об-структивного апноэ сна (СОАС) у детей, родив-шихся недоношенными, в раннем детском воз-расте. Имеются единичные работы о диагностике СОАС у детей в возрасте до 2 лет [9]. В настоящее время клинические характеристики СОАС у детей этой возрастной группы, в особенности родивших-ся недоношенными и имеющих БЛД и ЛГ, четко не определены.…”