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Childhood Sleep Apnea Workup

  • Author: Mary E Cataletto, MD; Chief Editor: Girish D Sharma, MD, FCCP, FAAP  more...
 
Updated: Apr 21, 2016
 

Approach Considerations

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 below 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 (see also the image below):

  • 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
    Normal parameters for sleep gas exchange and gas e Normal parameters for sleep gas exchange and gas exchange in children.

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.

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.

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 the images below).

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

Compressed overnight polysomnography tracing of a Compressed overnight polysomnography tracing of a 6-year-old boy who snores, showing multiple events of obstructive apnea (green-shaded areas) associated with oxyhemoglobin desaturation (yellow-shaded areas) and EEG arousals (red-shaded areas).
Parameters monitored during an overnight pediatric Parameters monitored during an overnight pediatric sleep study.
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Polysomnography

Polysomnography remains the criterion standard for establishing the diagnosis of obstructive sleep apnea (OSA) in infants, children, and adults. Ideally, polysomnography should be performed overnight and during the patient's usual bedtime.

Polysomnography provides the following measures:

  • 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)

Multiple physiologic parameters are monitored during polysomnography, although the specific montage may vary slightly between sleep laboratories. Generally, electrooculography, chin and leg surface electromyography (EMG), and at least 2 EEG channels are included to confirm sleep and assess sleep architecture. Breathing is assessed using nasal/oral airflow sensors, pulse oximetry, and end-tidal (ET) CO2 measurements monitoring and by placing piezo crystal belts across the chest and abdomen to detect respiratory efforts. At least one ECG channel is necessary to determine heart rate and rhythm. Occasionally, other channels are incorporated into the study as needed. These might include additional EEG leads to better detect seizure activity, esophageal pH measurements, or transcutaneous carbon dioxide monitoring.

Polysomnographic normal standards differ between children and adults. In the pediatric age range, abnormalities include oxygen desaturation under 92%, more than one obstructive apnea per hour, and elevations of ET CO2 measurements of more than 50 mm Hg for more than 9% of sleep time or a peak level of greater than 53 mm Hg.

See the related polysomnographic image below.

Example of an obstructive apnea and an obstructive Example of an obstructive apnea and an obstructive hypopnea recorded during polysomnography.

Polysomnography is necessary to document obstructive sleep apnea and gauge its severity. A history of snoring alone is not adequate for making a diagnosis of obstructive sleep apnea or for determining its seriousness.

Some children with obstructive sleep apnea have primarily obstructive hypoventilation in which repetitive partial obstructions occur with some degree of relative oxygen desaturation and hypercapnia. Because of this, pediatric polysomnographic testing should include some means of determining CO2 levels, such as end-tidal (ET) CO2 monitoring or transcutaneous CO2 monitoring.

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.

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Apnea Hypopnea Index

Individuals with obstructive sleep apnea syndrome have pathologic degrees of obstructive apnea, obstructive hypopnea, or both. Severity is quantified using a polysomnographic-derived index known as the apnea hypopnea index (AHI). The AHI is the total number of apneas and hypopneas that occur divided by the total duration of sleep in hours. An AHI of 1 or less is considered to be normal by pediatric standards. An AHI of 1-5 is very mildly increased, 5-10 is mildly increased, 10-20 is moderately increased, and greater than 20 is severely abnormal.

Obstructive hypopnea (OH) in children is a sleep-related breathing disorder that is considered a variation of obstructive sleep apnea. Children with OH may have an AHI in the normal range, but they have episodic periods of hypercapnia, as identified on the basis of end-tidal (ET) CO2 monitors. Peak ET CO2 measurements of greater than 53 mm Hg are considered abnormal. The percentage of sleep time spent with ET CO2 measurements greater than 50 mm Hg should not be more than 9%.

Most physicians who treat children with sleep apnea generally recommend specific interventions when the AHI is greater than 5 or respiratory events are associated with oxygen desaturations of less than 85%. When the AHI falls to between 1 and 5, other clinical factors must be taken into account to determine whether to pursue adenotonsillectomy or other therapy.

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Daytime Nap Studies

Daytime nap studies are specific, but not sensitive, in detecting sleep apnea. This is because obstructive events are more likely to occur during rapid eye movement (REM) sleep than during other sleep stages, and very little (if any) REM sleep occurs during daytime naps in noninfants. Therefore, children with symptoms of obstructive sleep apnea who have normal nap study findings must undergo nocturnal polysomnography to exclude the diagnosis. Sleep studies should be performed without sedation.

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Overnight Oximetry

Unattended home overnight oximetry has been proposed as a screening study. However, it may miss the child with significant obstructive sleep apnea who does not have marked episodes of oxygen desaturation.

Overnight pulse oximetry by itself is not adequate for establishing the diagnosis or excluding obstructive sleep apnea in children because it provides no information concerning sleep staging/sleep fragmentation or carbon dioxide.

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.

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Anteroposterior and Lateral Neck Radiography

Neck radiography for soft tissue detail help define upper airway anatomy and adenoid size and exclude the possibility of rare nasal pharyngeal neoplasms.

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.

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Cine MRI

Cine MRI during sleep may be helpful in identifying specific sites of airway obstruction in the complicated patient being evaluated for surgical interventions. This technique is currently only available at a handful of specialized tertiary care facilities.

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Thyroid-Stimulating Hormone and Thyroxine

Thyroid function studies are useful to exclude hypothyroidism, which is associated with tongue enlargement, weight gain, and obstructive sleep apnea.

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Electrocardiography and Echocardiography

These studies are not necessary in all children with suspected sleep apnea. However if very severe long-standing obstruction is suspected, an ECG and echocardiography are helpful in assessing ventricular thickness and function and to check for evidence of pulmonary hypertension.

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Multiple Sleep Latency Test (MSLT)

If the clinical history suggests the possibility of narcolepsy, the MSLT should be ordered in conjunction with overnight polysomnography.

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MRI of the Brain and Brainstem

A history of severe snoring, headaches, neck pain, urinary frequency, or swallowing problems raises the suspicion of Chiari malformation. Chiari malformations may occur in otherwise normal children and in association with congenital myelomeningocele. If brainstem dysfunction is suspected, MRI is necessary. Cranial CT imaging is not adequate to assess for brainstem and upper cervical cord lesions.

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Other Studies

Additional studies include the following:

  • CBC count may be useful because chronic hypoxia related to recurrent airway obstruction may lead to polycythemia
  • Cephalometric radiography and 3-dimensional CT reconstruction imaging are rarely, if ever, necessary in the pediatric age group
  • Multichannel studies lack reliable assessment of sleep disruption
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Emerging Studies

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
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Contributor Information and Disclosures
Author

Mary E Cataletto, MD Professor of Clinical Pediatrics, State University of New York at Stony Brook

Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Timothy D Murphy, MD Consulting and Attending Staff, Pediatric Pulmonary and Sleep Medicine, Mary Bridge Children's Hospital

Timothy D Murphy, MD is a member of the following medical societies: American Thoracic Society, American Academy of Sleep Medicine

Disclosure: Nothing to disclose.

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 is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Girish D Sharma, MD, FCCP, FAAP Professor of Pediatrics, Rush Medical College; Director, Section of Pediatric Pulmonology and Rush Cystic Fibrosis Center, Rush Children's Hospital, Rush University Medical Center

Girish D Sharma, MD, FCCP, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, Royal College of Physicians of Ireland

Disclosure: Nothing to disclose.

Additional Contributors

Susanna A McColley, MD Professor of Pediatrics, Northwestern University, The Feinberg School of Medicine; Director of Cystic Fibrosis Center, Head, Division of Pulmonary Medicine, Children's Memorial Medical Center of Chicago

Susanna A McColley, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Sleep Disorders Association, American Thoracic Society

Disclosure: Received honoraria from Genentech for speaking and teaching; Received honoraria from Genentech for consulting; Partner received consulting fee from Boston Scientific for consulting; Received honoraria from Gilead for speaking and teaching; Received consulting fee from Caremark for consulting; Received honoraria from Vertex Pharmaceuticals for speaking and teaching.

Acknowledgements

Heidi Connolly, MD Associate Professor of Pediatrics and Psychiatry, University of Rochester School of Medicine and Dentistry; 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.

David Gozal, MD Vice-Chairman of Research and Director, Comprehensive Sleep Medicine Center, Kosair Children's Hospital; Professor, Department of Pediatrics, University of Louisville School of Medicine

Disclosure: Nothing to disclose.

Michael Steffan, MD Director of Pediatric Sleep Center, Department of Pediatrics, Department of Pediatrics, Children's Medical Center; Associate Professor, Wright State University School of Medicine

Disclosure: Nothing to disclose.

References
  1. Verhulst SL, Van Gaal L, De Backer W, Desager K. The prevalence, anatomical correlates and treatment of sleep-disordered breathing in obese children and adolescents. Sleep Med Rev. 2008 Oct. 12(5):339-46. [Medline].

  2. Isono S, Shimada A, Utsugi M, Konno A, Nishino T. Comparison of static mechanical properties of the passive pharynx between normal children and children with sleep-disordered breathing. Am J Respir Crit Care Med. 1998 Apr. 157(4 Pt 1):1204-12. [Medline].

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

  4. Moon RY, Horne RS, Hauck FR. Sudden infant death syndrome. Lancet. 2007 Nov 3. 370(9598):1578-87. [Medline].

  5. Beebe DW, Gozal D. Obstructive sleep apnea and the prefrontal cortex: towards a comprehensive model linking nocturnal upper airway obstruction to daytime cognitive and behavioral deficits. J Sleep Res. 2002 Mar. 11(1):1-16. [Medline].

  6. Tauman R, Gulliver TE, Krishna J, Montgomery-Downs HE, O'Brien LM, Ivanenko A, et al. Persistence of obstructive sleep apnea syndrome in children after adenotonsillectomy. J Pediatr. 2006 Dec. 149(6):803-8. [Medline].

  7. Gozal D, Kheirandish-Gozal L. Obesity and excessive daytime sleepiness in prepubertal children with obstructive sleep apnea. Pediatrics. 2009 Jan. 123(1):13-8. [Medline].

  8. Guilleminault C, Huang YS, Glamann C, Li K, Chan A. Adenotonsillectomy and obstructive sleep apnea in children: a prospective survey. Otolaryngol Head Neck Surg. 2007 Feb. 136(2):169-75. [Medline].

  9. Bonnet MH. Effect of sleep disruption on sleep, performance, and mood. Sleep. 1985. 8(1):11-9. [Medline].

  10. Gozal D. Sleep-disordered breathing and school performance in children. Pediatrics. 1998 Sep. 102(3 Pt 1):616-20. [Medline].

  11. Montgomery-Downs HE, Crabtree VM, Gozal D. Cognition, sleep and respiration in at-risk children treated for obstructive sleep apnoea. Eur Respir J. 2005 Feb. 25(2):336-42. [Medline].

  12. Bixler EO, Vgontzas AN, Lin HM, Liao D, Calhoun S, Fedok F, et al. Blood pressure associated with sleep-disordered breathing in a population sample of children. Hypertension. 2008 Nov. 52(5):841-6. [Medline].

  13. Marcus CL, Carroll JL, Koerner CB, Hamer A, Lutz J, Loughlin GM. Determinants of growth in children with the obstructive sleep apnea syndrome. J Pediatr. 1994 Oct. 125(4):556-62. [Medline].

  14. Bar A, Tarasiuk A, Segev Y, Phillip M, Tal A. The effect of adenotonsillectomy on serum insulin-like growth factor-I and growth in children with obstructive sleep apnea syndrome. J Pediatr. 1999 Jul. 135(1):76-80. [Medline].

  15. Tal A, Leiberman A, Margulis G, Sofer S. Ventricular dysfunction in children with obstructive sleep apnea: radionuclide assessment. Pediatr Pulmonol. 1988. 4(3):139-43. [Medline].

  16. Gozal D, Serpero LD, Sans Capdevila O, Kheirandish-Gozal L. Systemic inflammation in non-obese children with obstructive sleep apnea. Sleep Med. 2008 Mar. 9(3):254-9. [Medline]. [Full Text].

  17. Li AM, Chan MH, Yin J, So HK, Ng SK, Chan IH, et al. C-reactive protein in children with obstructive sleep apnea and the effects of treatment. Pediatr Pulmonol. 2008 Jan. 43(1):34-40. [Medline].

  18. Barbé, Pericás J, Muñoz A, Findley L, Antó JM, Agustí AG. Automobile accidents in patients with sleep apnea syndrome. An epidemiological and mechanistic study. Am J Respir Crit Care Med. 1998 Jul. 158(1):18-22. [Medline].

  19. Marcus CL, Radcliffe J, Konstantinopoulou S, Beck SE, Cornaglia MA, Traylor J, et al. Effects of positive airway pressure therapy on neurobehavioral outcomes in children with obstructive sleep apnea. Am J Respir Crit Care Med. 2012 May 1. 185(9):998-1003. [Medline].

  20. Marcus CL. Nasal steroids as treatment for obstructive sleep apnea: Don't throw away the scalpel yet. J Pediatr. 2001 Jun. 138(6):795-7. [Medline].

  21. Mukhatiyar P, Nandalike K, Cohen HW, Sin S, Gangar M, Bent JP, et al. Intracapsular and Extracapsular Tonsillectomy and Adenoidectomy in Pediatric Obstructive Sleep Apnea. JAMA Otolaryngol Head Neck Surg. 2016 Jan 1. 142 (1):25-31. [Medline].

  22. Chervin RD, Ellenberg SS, Hou X, Marcus CL, Garetz SL, Katz ES, et al. Prognosis for Spontaneous Resolution of Obstructive Sleep Apnea in Children. Chest. 2015 Mar 26. [Medline].

  23. Kheirandish L, Goldbart AD, Gozal D. Intranasal steroids and oral leukotriene modifier therapy in residual sleep-disordered breathing after tonsillectomy and adenoidectomy in children. Pediatrics. 2006 Jan. 117(1):e61-6. [Medline].

  24. Perfect MM, Archbold K, Goodwin JL, Levine-Donnerstein D, Quan SF. Risk of behavioral and adaptive functioning difficulties in youth with previous and current sleep disordered breathing. Sleep. 2013 Apr 1. 36(4):517-25. [Medline]. [Full Text].

 
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Palate appearance following uvulopalatopharyngoplasty (UPPP) surgery.
Example of an obstructive apnea and an obstructive hypopnea recorded during polysomnography.
Medical complications associated with obstructive sleep apnea in children.
Compressed overnight polysomnography tracing of a 6-year-old boy who snores, showing multiple events of obstructive apnea (green-shaded areas) associated with oxyhemoglobin desaturation (yellow-shaded areas) and EEG arousals (red-shaded areas).
Parameters monitored during an overnight pediatric sleep study.
Normal parameters for sleep gas exchange and gas exchange in children.
 
 
 
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