| Spanish Society of Pneumology and Thoracic Surgery (SEPAR) |
This guide divides the OSA diagnostic methodology between primary care and hospital care in order to increase the diagnostic efficiency.
In primary care, the evaluation of the child with suspected OSA (presence of snoring and symptoms or suggestive clinical findings) should include the medical history and complete clinical examination.
Medical history: family history, events related to the child’s sleep and breathing, and sleep questionnaire (Chervin). Complete clinical examination: craniofacial and UA anatomy, cardiopulmonary examination and somatometry. Children with obesity represent a special risk group. Depending on the results, referral of the patient from primary care to the reference sleep unit is considered.
If there is suspected OSA in the clinical history and or/Chervin, retrognathia, adenotonsillar hypertrophy and Mallampati ≥ 2, hospital RP is performed. Otherwise, a control visit is carried out 6 months after baseline visit. When the index of respiratory events is ≥ 5 in the RP, children are referred to adenotonsillar surgery. With an inferior result, a PSG is performed. An AHI ≥ 5/h on PSG leads to adenotonsillar surgery. If the AHI is < 3/h, an anti-inflammatory therapy or review visit after 6 months is assessed. For an AHI 3–5/h comorbidities are evaluated. The presence of comorbidity leads to adenotonsillectomy and anti-inflammatory therapy is selected when there is absence of comorbidity. All children should be clinically reassessed after surgery (recommended in the next 6 months), performing a sleep study in children with severe preoperative OSA or when risk factors or OSA symptoms persist, where other treatments such as diet, CPAP, or orthodontics will be assessed.
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| European Respiratory Society |
The diagnosis and management for SDB is described as a stepwise approach in 7 steps.
Identification of risk of SDB: symptoms of UA obstruction, alterations in physical exam, objective findings related to SDB and/or prematurity or family history of SDB. Identification of comorbidities in CV system, CNS, nocturnal enuresis, growth delay or decreased QoL and conditions coexisting with SDB such as recurrent otitis media and history of tympanostomy tube placement, wheezing or asthma, metabolic syndrome or oral-motor dysfunction. Recognition of factors predicting long-term persistence of SDB: obesity, male sex, obstructive AHI > 5/h, African-American ethnicity and persistent tonsillar hypertrophy and narrow mandible. Objective diagnosis and assessment of SDB severity: PSG or RP is indicated in children at risk of SDB. (1) OSA definition 1: obstructive AHI ≥ 2/h or obstructive apnea index ≥ 1/h with SDB symptoms; (2) OSA definition 2: SDB symptoms and AHI ≥ 1/h. No alternative methods can substitute PSG but could be used in low resource settings: ambulatory PSG or RP, nocturnal oximetry, Pediatric Sleep Questionnaire or Sleep Clinical Record. Indications for treatment of SDB: indicated when AHI > 5/h. When PSG or RP are not available, treatment is considered when positive oximetry or SDB questionnaires or morbidity is present. It is unclear whether should treat primary snoring (evaluation annually). Stepwise treatment approach for SDB is usually implemented until complete resolution of SDB: (1) weight loss in overweight and obese children; (2) nasal corticosteroids and/or montelukast in non-obese and < 6 years children; (3) adenotonsillectomy in children with OSA and adenotonsillar hypertrophy; (4) rapid maxillary expansion or orthodontic appliances in children with OSA and maxillary constriction, retrognathia or malocclusion; (5) CPAP or NPPV when residual OSA after adenotonsillectomy or hypoventilation; (6) craniofacial surgery when syndromic craniofacial abnormalities; (7) tracheostomy in severe OSA when other nonsurgical or surgical interventions have failed or are contraindicated. Recognition and management of persistent SDB: outcomes monitored after intervention are: symptoms, PSG (or RP, oximetry/capnography when not available), QoL, CV or CNS morbidity, enuresis and growth rate. PSG or RP should be performed, between 6–12 weeks after treatment, in children at risk of persistent OSA, after adenotonsillectomy, in children with persistent symptoms or children with mild OSA treated with corticosteroids and/or montelukast. PSG should be performed 12 months after rapid maxillary expansion and after 6 months when oral appliance treatment is selected. At least, one PSG or RP annually should be used to titrate CPAP or NPPV.
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| American Academy of Pediatrics |
This practice guideline focuses on uncomplicated childhood OSA, associated with adenotonsillar hypertrophy and/or obesity in an otherwise child who is being treated in the primary care setting. It comprises 8 key action statements.
Screening for OSA. If the child presents signs or symptoms of OSA, clinicians should perform medical history and physical examination. Snoring and findings in the evaluation should lead to PSG (gold standard test) or alternative tests when PSG is not available (nocturnal video recording, nocturnal oximetry, daytime nap PSG or ambulatory PSG). Adenotonsillectomy is recommended when the child is determined to have OSA and adenotonsillar hypertrophy (and do not have contraindication to surgery). If the child has OSA but not adenotonsillar hypertrophy other treatment should be considered. Monitoring of high-risk patients undergoing adenotonsillectomy. Reevaluation. Clinical reassessment should be performed in all patients with OSA for persisting symptoms after therapy to determine whether further treatment is required (6 to 8 weeks after treatment). Clinicians should refer patients for CPAP management if symptoms persist after adenotonsillectomy or if it is not performed. Weight loss is recommended in addition to other therapy if the child with OSA is overweight or obese. Intranasal corticosteroids may be prescribed for children with mild OSA in whom surgery is contraindicated or have mild postoperative OSA (<5/h).
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