Pediatrics

Amal Isaiah, MD, PhD, on Polysomnography for Pediatric OSA and the Need to Update Guidelines

Each year, 500,000 children undergo adenotonsillectomy, oftentimes to treat obstructive sleep apnea (OSA).1 The need for these procedures is commonly based on results from a polysomnography. However, findings of a new study suggest that polysomnography alone may not be an adequate determinant of adenotonsillectomy for pediatric OSA.2

According to the new research—and contrary to past belief—resolution of an airway obstruction measured by polysomnography following an adenotonsillectomy does not correlate with improvement in sleep apnea symptoms.

Study coauthor Amal Isaiah, MD, PhD, an assistant professor of otorhinolaryngology and pediatrics at the University of Maryland School of Medicine, answered our questions about his study, its findings, and what they may mean for current OSA guidelines.

PULMONOLOGY CONSULTANT: What prompted you to conduct this study?

Amal Isaiah: Much of the literature directs the use of thresholds from polysomnography (i.e., the use of apnea hypopnea index) as a principal outcome measure that guides the treatment of OSA in children. However, polysomnography remains expensive and inaccessible to a majority of the otolaryngologists prior to tonsillectomy and adenoidectomy. Therefore, we became interested in determining how critical this outcome measure is to the management of OSA in otherwise healthy children.

PULM CON: What significant mediated effects did your study show? And what knowledge gaps in pediatric OSA do these results help fill? 

AI: The study showed statistically significant mediation effects for improvement in symptoms of sleep disordered breathing and disease-specific quality of life. While these results certainly are interesting, the most important results are that 16 out of 18 outcome measures—including those that showed improvement in the Childhood Adenotonsillectomy Trial (CHAT), such as behavior and overall quality of life1—were not mediated by changes in the Apnea-Hypopnea Index (AHI) or the resolution of OSA.

PULM CON: What do these results reveal about the current diagnostic and management standards of pediatric OSA?

AI: Many treatment guidelines consider AHI to be integral to the management of OSA. Our analysis suggests that the role of AHI may be adjunctive, in that it helps define the severity of the obstruction but not the severity of the actual morbidity and its response to treatment. Caution should be exercised when using AHI as the universal yardstick to determine surgical candidacy, as it discards physiologic variation related to how each child responds differently to the severity of obstruction measured by polysomnography. 

PULM CON: How do your results compare with current recommendations, such as those from the American Academy of Pediatrics (AAP), on pediatric OSA?

AI: The AAP recommends polysomnography in its 2012 guidelines or a recommendation to refer children to specialists such as otolaryngologists.3 Although the AAP guidelines do not define the thresholds for polysomnographic severity of OSA to guide treatment of OSA, this practice would be considered implicitly related to the recommendation for polysomnography in all symptomatic children. The results from the current study could contribute to the next set of guidelines to formalize when and how polysomnographic thresholds could be used for the management of pediatric OSA.

PULM CON: What impact do you hope this study has on clinical practice?

AI: We hope that these results could help define the role of polysomnography in the management of OSA by encouraging clinicians to use personalized medicine that is tailored to the patient (i.e., polysomnographic severity of OSA should not be the only defining criteria for determining surgical candidacy).

References:

  1. Marcus CL, Moore RH, Rosen CL, et al; Childhood Adenotonsillectomy Trial (CHAT). A randomized trial of adenotonsillectomy for childhood sleep apnea. N Eng J Med. 2013;386(25):2366-2376. doi:10.1056/NEJMoa1215881.
  2. Isaiah A, Pereira KD, Das G. Polysomnography and treatment-related outcomes of childhood sleep apnea. Pediatrics. 2019;144(4):e20191097. https://doi.org/10.1542/peds.2019-1097.
  3. Marcus CL, Brooks LJ, Draper KA, et al; American Academy of Pediatrics. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130(3)576-584. https://doi.org/10.1542/peds.2012-1671.