Sleep apnea surgery in children helps improve asthma control

Removing a child's tonsils and adenoids for sleep apnea can help his or her asthma control.

Researchers from the University of Chicago found that surgical removal of the tonsils and adenoids in children suffering from sleep apnea is associated with decreased asthma severity. The study was published in PLOS Medicine (November 4, 2014).

In the first year after the operation, the children who had their tonsils and adenoids removed had a 30% reduction in acute asthma exacerbations and a 38% decrease in acute status asthmaticus, episodes of severe asthma that do not respond to repeated courses of therapy.

"Several small studies have described a strong association between obstructive sleep apnea and asthma, two common inflammatory conditions that impair breathing in children. But we wanted to test the strength of the connection when studied in a much larger population," said lead study author Rakesh Bhattacharjee, MD, an assistant professor of pediatrics at the University of Chicago and an authority on pediatric sleep medicine, in a statement.

Obstructive sleep apnea is affects an estimated 2% to 3% of all children. The removal of the adenoids and tonsils, known as surgical adenotonsillectomy, is considered standard therapy.

Asthma is the third-most prevalent chronic pediatric disease in the U.S., affecting an estimated 7.1 million according to the Centers for Disease Control and Prevention and is the third-most common cause of hospitalization of U.S. children younger than age 15.

In the study, researchers also noted that pediatric patients who received the surgery had a 36% reduction in asthma-related hospitalizations and a 26% decline in asthma-related emergency room visits. Children who did not have the surgery did not have significant reductions in these categories.

"Our study adds weight to the growing sense that obstructive sleep apnea aggravates asthma and further tips the balance toward early identification of obstructive sleep apnea," Dr. Bhattacharjee said. "This will help physicians advocate for surgical intervention, not just to eradicate sleep-disordered breathing, but also to reduce asthma severity and decrease reliance on medications in asthmatic children."

Data on more than 40,000 children between the ages of 3 and 17, obtained from Truven Health's MarketScan databases were included in the study. More than 13,500 U.S. children with asthma who underwent removal of their adenoids and tonsils as treatment for obstructive sleep apnea were included. Asthma symptoms from the year before surgery to the year afterward were compared. Researchers also matched those results to the results of more than 27,000 children with asthma who still had their tonsils and adenoids.

Overall, adenotonsillectomy brought significant improvement: The frequency of acute status asthmaticus dropped almost 40%, from 562 in the year before surgery to 349 in the year after. In children who did not have surgery, such severe asthma attacks also decreased but by only 7%, from 837 to 778.

Acute asthma exacerbations fell from more than 2,200 before surgery to 1,566 after, a 30% reduction. Exacerbations for children who did not have surgery also fell from 3,403, to 3,336, a 2% drop.

Also decreasing significantly for those children who had the surgery was the incidence of secondary asthma outcomes, such as acute bronchospasm and wheezing, while rates were unchanged for those who did not. Prescription refills followed the same pattern.

The authors' concerns about the MarketScan database included that it only includes those patients with private insurance and a lack of available data why patients underwent adenotonsillectomy.

Despite the limitations, they emphasize the many plausible connections that link obstructive sleep apnea to asthma:

• Both are inflammatory diseases.
• Both share risk factors, such as allergies, obesity, and exposure to tobacco smoke.
• Severe obstructive sleep apnea is often associated with poorly controlled asthma.

A prospective, randomized, controlled clinical trial is still needed to show a direct causal relationship, Dr. Bhattacharjee noted.

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The link between childhood obesity and sleep apnea

This article discusses the link between childhood obesity and sleep apnea.

Sleep apnea is a disorder where a person’s breathing is interrupted and may stop during the sleep schedule. Recent reports claim that this disorder may afflict not only adults, but also children. Previous research has focused on behavioral issues for children suffering from sleep apnea as well as other health concerns such as diabetes.

CHEO Research Institute’s principal investigator Dr. Sherri Katz claims that there is a direct link between obesity and sleep apnea. “In the past we used to see predominantly preschool-age children who had large tonsils and large adenoids, that was the basis for their obstructive sleep apnea. As time goes on we are seeing a second wave of children with obstructive sleep apnea, predominantly over the age of eight, where obesity is the major factor contributing to their sleep disorder.” Dr. Katz said before adding, “Rates of sleep apnea are about three to 10 times higher in children with obesity. There aren’t sufficient pediatric sleep laboratory resources across the country to manage the growing demand.”

Dr. Indra Narang, who is the director of sleep medicine at The Hospital for Sick Children in Toronto, echoed the concerns voiced by Dr. Katz, explaining that a main determinant in children visiting the sleep medicine department that she oversees is due to obesity.

“We are inundated with referrals for obesity-related sleep apnea. We also believe that probably 60 to 70 per cent of obesity-related sleep apnea isn’t even diagnosed because of a lack of an awareness of sleep apnea associated with obesity. I think the disaster is happening as we speak. Not only do they not sleep well at night, but these children are affected during the day. They are sleeping, they are tired, they don’t learn as well, they don’t do as well at school. They can’t participate in physical activity. Our concern is 75 per cent of obese children will become obese adults and will have untreated obstructive sleep apnea and what we will see is an epidemic of premature cardiovascular death because of obesity and because of related obstructive sleep apnea,” Dr. Narang said.

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Sleep apnea symptoms persist after adenoid and tonsil removal in children

A study claims that children with severe obstructive sleep apnea saw residual sleep apnea symptoms following an adenotonsillectomy procedure.

Children with severe obstructive sleep apnea before adenotonsillectomy were more likely to experience residual symptoms after surgery, according to findings in a retrospective study.

Researchers evaluated data from 283 children younger than 3 years (mean age, 22 months). Each child underwent a preoperative polysomnogram between 2002 and 2010.

Of the study population, 61.8% were boys and 84.8% were black. According to their BMI, 46.7% of the children were obese, whereas 33.1% were classified as having a healthy weight. At baseline, 65.7% of the children had a severe apnea hypopnea index (>10).

Seventy of the children also underwent a post-adenotonsillectomypolysomnogram after a mean time of 7.7 months. Compared with the children who only underwent a preoperative polysomnogram, those who had preoperative and postoperative polysomnograms were younger (23 vs. 20 months; P=.002), shorter (81 cm vs. 79 cm; P=.04) and weighed less (13 kg vs. 11 kg; P=.01). They were also more likely to have had a severe index before surgery (22 vs. 35; P=.002) and lower mean minimal oxygen saturations (83% vs. 77%; P<.001).

Fifteen of the 70 children had residual obstructive sleep apnea (index, >5) and a significantly higher preoperative index (P=.02) compared with those without residual symptoms. However, these 15 children had a mean apnea hypopnea index that dropped from 55 to 21 (P=.03), whereas mean minimum oxygen saturations increased from 74% to 82% (P=.09) after surgery.

“Our data support the finding that, although [adenotonsillectomy] leads to a dramatic improvement in this age group, a high proportion of this population will have residual [obstructive sleep apnea],” the researchers wrote. “Although this proportion gives some insight into residual disease after [adenotonsillectomy] in this young population, the result is flawed because of the retrospective design of the study and the fact that only 25% of the children treated received postoperative [polysomnogram].”

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Removing both adenoids and tonsils for childhood sleep apnea

This study discusses the success of removing both the tonsils and the adenoids for childhood sleep apnea.

A recently published study evaluated the effect of early adenotonsillectomy on polysomnographic, cognitive, behavioral, and health outcomes assessed over a 7-month period.1 A total of 464 children aged 5 to 9 years with obstructive sleep apnea syndrome were randomized to a strategy of watchful waiting or early adenotonsillectomy, and outcomes were assessed at baseline and at 7 months. The primary outcome was the attention and executive-function score on the Developmental Neuropsychological Assessment. 

Results showed no significant change from baseline to follow-up for the primary outcome of attention and executive-function score (mean [±SD] improvement, 7.1 ± 13.9 in the early-adenotonsillectomy group, and 5.1 ± 13.4 in the watchful-waiting group; P = .16). 

Significant improvements were demonstrated in the secondary end points of behavior, quality of life, polysomnographic findings, and reduction in symptoms in the early-adenotonsillectomy group compared with the watchful-waiting group. The authors concluded that the study demonstrates beneficial effects of early adenotonsillectomy with regard to behavior, quality of life, and polysomnographic findings; however, early adenotonsillectomy did not significantly improve attention or executive function as measured by neuropsychological testing.

References

1. Marcus CL, Moore RH, Rosen CL, et al. A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med. 2013;368(25):2366-2376.
2. Leuppi JD, Schuetz P, Bingisser R, et al. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial. JAMA. 2013;309(21):2223-2231.
3. Buchs NC, Konrad-Mugnier B, Jannot AS, et al. Assessment of recurrence and complications following uncomplicated diverticulitis. Br J Surg. 2013;100(7):976-979.

- See more at: http://www.pharmacytimes.com/publications/issue/2013/August2013/Adenotonsillectomy-for-Childhood-Sleep-Apnea#sthash.kWnf9ATm.dpuf

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Adenoid and tonsil removal may help pediatric sleep apnea symptoms

This article discusses how adenoid removal or a tonsillectomy can help pediatric sleep apnea symptoms. Important - the AAP and AAFP recommend PRE-OPERATIVE sleep studies at PEDIATRIC sleep Centers- JR

Adenotonsillectomy, or the removal of the adenoids and tonsils, is performed 500,000 times a year in the United States, often as a treatment for children with obstructive sleep apnea. However, the procedure's ability to improve a child's attention and executive functioning, behavior, sleep apnea symptoms, and quality of life has not been rigorously evaluated until now. 

A study led by Susan Redline, MD, MPH, director of the Program in Sleep and Cardiovascular Medicine and Associate Clinic Director of the Division of Sleep Medicine at Brigham and Women's Hospital finds that early adenotonsillectomy in children with mild to moderately severe sleep apnea does not improve attention and executive functioning when compared to watchful waiting with supportive care. However, the study also found that early adenotonsillectomy can be beneficial in improving behavior, sleep apnea symptoms and quality of life. The research will be presented at the American Thoracic Society's International Conference and published online in the New England Journal of Medicine on May 21.

"This new evidence should be carefully considered by physicians and parents who are deciding on the best approach for a child's sleep apnea problem," said Dr. Redline. 

"Our study provided evidence that surgical treatment can lead to early improvements in many health-related areas of importance to children and their families, including children's behavior. Beneficial effects of surgery were shown even among overweight children, in whom the effectiveness of surgery has been questioned....

.... However, the study also showed that many times sleep apnea resolved without surgery and that cognitive functioning did not improve more with surgery than with medical management. Thus, watchful waiting is also a reasonable option for some children with sleep apnea without many symptoms."

The study, which was conducted in partnership with eight other institutions, examined 397 children between the ages of five and nine who had obstructive sleep apnea syndrome without prolonged levels of low oxygen. The children were randomly placed in two groups. One hundred and ninety-four children had their adenoids and tonsils removed within four weeks of being randomized to the study. The remaining 203 children underwent watchful waiting with supportive care to see if their sleep apnea symptoms resolved without surgery.

Seven months later, both groups of children underwent the Developmental Neuropsychological Assessment, which showed no significant difference between the groups in the improvement of attention and executive functioning. However, other tests, including assessments by parents and teachers, showed significant improvements in the quality of life, sleep apnea symptoms and behavior in the children who had the early adenotonsillectomy.

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