eMedicine Specialties > Pediatrics: General Medicine > Pulmonology

Obstructive Sleep Apnea Syndrome: Differential Diagnoses & Workup

Author: Timothy D Murphy, MD, Assistant Professor, Department of Pediatrics, Division of Pulmonology, University of Pittsburgh; Consulting Staff, Division of Pulmonology, Children's Hospital of Pittsburgh
Coauthor(s): Andrew J Lipton, MD, MPH and TM, Staff Pediatric Pulmonologist, Assistant Professor of Pediatrics, Department of Pediatrics, Walter Reed Army Medical Center; David Gozal, MD, Vice-Chairman of Research and Director, Kosair Children's Hospital Comprehensive Sleep Medicine Center, Professor, Department of Pediatrics, University of Louisville
Contributor Information and Disclosures

Updated: Feb 27, 2009

Differential Diagnoses

Other Problems to Be Considered

Primary snoring
Upper airway resistance syndrome
Other sleep disorders

Workup

Laboratory Studies

Polysomnography (PSG) is the study of choice in obstructive sleep apnea (OSA) and measures the following:

  • Sleep state (>2 EEG leads)
  • Electrooculogram (right and left)
  • Submental electromyelogram (EMG)
  • Airflow at nose and mouth (thermistor, capnography, or mask and pneumotachygraph)
  • Chest and abdominal wall motion (impedance or inductance plethysmography)
  • Electrocardiogram (preferably with R-R interval derivation technology)
  • Pulse oximetry (including a pulse waveform channel)
  • End-tidal carbon dioxide (sidestream or mainstream infrared sensor)
  • Video camera monitor with sound montage (analog or digital)
  • Transcutaneous oxygen and carbon dioxide tensions (in infants and children <8 y)

The following sleep study parameters are under investigation:

  • Nasal pressure–flow measurements
  • Esophageal manometry
  • Continuous noninvasive blood pressure monitoring
  • Autonomic nervous system tone using finger tonometry

PSG, continuously monitored by appropriately trained technical personnel, may be difficult to arrange due to relative unavailability, with long waiting periods between referral and testing times. For these reasons, attempts have recently been made to evaluate the role of outpatient overnight studies to provide more accessible and practical approaches to the diagnosis of pediatric obstructive sleep apnea. However, these outpatient studies are not well validated yet or covered by third party payers and, thus, remain largely available only as research tools.

The results of initial studies indicate that, although home audio tape recordings appear relatively insensitive, oximetry trend analysis with or without additional measures may provide a useful alternative in establishing the definitive cases that require intervention. However, despite high specificity, home oximetry has low sensitivity, and children with negative findings on studies still require complete nocturnal polysomnography.

Compared with the adult literature, the available normative data for sleep and cardiorespiratory parameters are rather sparse in the pediatric literature, such that most pediatric sleep laboratories use individually established reference ranges rather than referring to an authoritative text. Nevertheless, the general consensus criteria for a normal finding on sleep study are presented in the following table and have been derived from the published literature on this subject and the authors' experience.

Reference range parameters for sleep gas exchange and gas exchange in children are as follows:

  • Sleep latency - More than 10 minutes
  • Total sleep time (TST) - More than 5.5 hours
  • Percentage of rapid eye movement (REM) sleep - More than 15% of TST
  • Percentage of stage 3-4 non-REM sleep - More than 25% of TST
  • Respiratory arousal index (number per hour of TST) - Less than 5
  • Periodic leg movements (number per hour of TST) - Less than 1
  • Apnea index (number per hour of TST) - Less than 1
  • Hypopnea index (nasal/esophageal pressure catheter; number per hour of TST) - Less than 3
  • Nadir oxygen saturation - More than 92%
  • Mean oxygen saturation - More than 95%
  • Desaturation index (>4% for 5 s; number per hour of TST) - Less than 5
  • Highest carbon dioxide level - 52 mm Hg
  • Carbon dioxide level of more than 45 mm Hg - Less than 20% of TST

The adult criteria usually used around the world for the diagnosis of obstructive sleep apnea do not apply to children. In fact, the finding of 10-15 obstructive apneic events per hour of sleep, which represents mild obstructive sleep apnea in an adult patient in whom treatment may not even be contemplated, represents a sleep-related respiratory disturbance corresponding to a severely affected child definitely in need of therapeutic intervention. Thus, an apnea hypopnea index (AHI) of more than 5 events per hour clearly represents an indication for treatment in children. An AHI of fewer than 3 events per hour does not require any intervention, and, in children with an AHI of more than 3 but fewer than 5 events per hour, the benefit of treatment remains to be determined.

Imaging Studies

Assessment of tonsillar size usually does not require any type of imaging; however, lateral neck radiographs can be used to determine adenoid size. Although MRI can provide very detailed images of soft tissues and bony structures underlying the nasopharynx, such images are not usually required, except in cases of suspected aberrant anatomy.

Other diagnostic studies may be warranted to evaluate for complications of obstructive sleep apnea or to better assess the contribution of an underlying condition. In patients with severe obstructive sleep apnea, electrocardiography and echocardiography are particularly important to assess for pulmonary hypertension and cor pulmonale.

Other Tests

Currently, the only available tool for definitive diagnosis of obstructive sleep apnea is an overnight polysomnographic evaluation in the sleep laboratory. An overnight polysomnographic study usually includes multiple channels that aim to monitor sleep state, as well as cardiac and respiratory parameters (see Media file 2).

Procedures

Nasopharyngoscopy or direct laryngoscopy and bronchoscopy may be required to determine anatomy prior to contemplated otolaryngologic surgery.

More on Obstructive Sleep Apnea Syndrome

Overview: Obstructive Sleep Apnea Syndrome
Differential Diagnoses & Workup: Obstructive Sleep Apnea Syndrome
Treatment & Medication: Obstructive Sleep Apnea Syndrome
Follow-up: Obstructive Sleep Apnea Syndrome
Multimedia: Obstructive Sleep Apnea Syndrome
References
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References

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  2. Marcus CL, Lutz J, Carroll JL, Bamford O. Arousal and ventilatory responses during sleep in children with obstructive sleep apnea. J Appl Physiol. Jun 1998;84(6):1926-36. [Medline]. [Full Text].

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Further Reading

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Keywords

obstructive sleep apnea syndrome, OSA, sleep apnea, sleep-induced apnea, snoring, increased upper airway resistance, upper airway obstruction, anatomic narrowing, abnormal mechanical linkage between airway dilating muscles and airway walls, muscle weakness, abnormal neural regulation, sleep fragmentation, increased work of breathing, alveolar hypoventilation, intermittent hypoxemia, adenotonsillar hypertrophy, tonsillectomy and adenoidectomy, T&A, daytime tiredness, fatigue, sleep drunkenness, respiratory disorders, achondroplasia, Crouzon syndrome, Apert syndrome, Duchenne muscular dystrophy, spinal muscular atrophy, myelomeningocele, obesity, Pierre Robin sequence, cerebral palsy, Down syndrome, sickle cell disease, choanal stenosis, hypothyroidism, Klippel-Feil syndrome, Hallerman-Streiff syndrome, mucopolysaccharidosis, osteopetrosis, oropharyngeal papillomatosis, Beckwith-Wiedemann syndrome, Pfeiffer syndrome, Prader-Willi syndrome, Treacher-Collins syndrome 

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Contributor Information and Disclosures

Author

Timothy D Murphy, MD, Assistant Professor, Department of Pediatrics, Division of Pulmonology, University of Pittsburgh; Consulting Staff, Division of Pulmonology, Children's Hospital of Pittsburgh
Disclosure: Nothing to disclose.

Coauthor(s)

Andrew J Lipton, MD, MPH and TM, Staff Pediatric Pulmonologist, Assistant Professor of Pediatrics, Department of Pediatrics, Walter Reed Army Medical Center
Andrew J Lipton, MD, MPH and TM is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, and American Thoracic Society
Disclosure: Nothing to disclose.

David Gozal, MD, Vice-Chairman of Research and Director, Kosair Children's Hospital Comprehensive Sleep Medicine Center, Professor, Department of Pediatrics, University of Louisville
David Gozal, MD is a member of the following medical societies: Society for Pediatric Research
Disclosure: Nothing to disclose.

Medical Editor

Thomas Scanlin, MD, Chief, Division of Pediatric Pulmonary & Cystic Fibrosis, Assistant Professor, Department of Pediatrics, Robert Wood Johnson University Medical Group
Thomas Scanlin, MD is a member of the following medical societies: American Thoracic Society and Society for Pediatric Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Heidi Connolly, MD, Associate Professor of Pediatrics and Psychiatry, University of Rochester; Director, Pediatric Sleep Medicine Services, Strong Sleep Disorders Center
Heidi Connolly, MD is a member of the following medical societies: American Academy of Pediatrics, American Thoracic Society, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

CME Editor

Mary E Cataletto, MD, Associate Director, Division of Pediatric Pulmonology, Winthrop University Hospital; Professor of Clinical Pediatrics, State University of New York at Stony Brook; Director of Children's Sleep Services, Winthrop University Hospital
Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians
Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Chief Editor

Michael R Bye, MD, Professor of Clinical Pediatrics, Division of Pulmonary Medicine, Columbia University College of Physicians and Surgeons; Attending Physician, Pediatric Pulmonary Medicine, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center
Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, and American Thoracic Society
Disclosure: Merck Honoraria Speaking and teaching

 
 
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