Key Points
Question
Do children with baseline apnea-predominant obstructive sleep apnea (OSA) have treatment outcomes similar to those with baseline hypopnea-predominant OSA?
Findings
In this case-control study, children with apnea-predominant OSA were more likely than those with hypopnea-predominant OSA to have severe OSA at baseline. Baseline apnea predominance was not associated with polysomnogram outcomes in children managed with watchful waiting or adenotonsillectomy.
Meaning
These findings suggest that baseline apnea vs hypopnea predominance is not associated with treatment outcomes in children with OSA, but further research is needed to assess whether baseline apnea predominance affects treatment in children with more severe forms of this disease.
This case-control study assesses the association between baseline apnea-predominant or hypopnea-predominant obstructive sleep apnea on polysomnography and quality of life outcomes in children managed by watchful waiting with supportive care or adenotonsillectomy.
Abstract
Importance
Children with apnea-predominant obstructive sleep apnea (OSA) are hypothesized to have a more severe form of the disease. However, research is lacking as to whether there is a significant difference in outcomes between children with apnea-predominant vs hypopnea-predominant OSA.
Objective
To assess the association between baseline apnea-predominant or hypopnea-predominant OSA on polysomnography and quality of life (QOL) outcomes in children with obstructive sleep apnea managed by watchful waiting with supportive care (WWSC) or adenotonsillectomy (AT).
Design, Setting, and Participants
This case-control study is a secondary analysis of a randomized clinical trial, the Childhood Adenotonsillectomy Trial, which was conducted at multiple tertiary children’s hospitals from October 2007 to June 2012. Children aged 5.0 to 9.9 years with OSA were randomized to WWSC or AT and underwent polysomnography and completed validated QOL and symptom assessments at baseline and 7 months. The current data analysis was performed from October 2020 to February 2022.
Main Outcomes and Measures
Apnea-predominant OSA was defined as an apnea hypopnea index (AHI) greater than 2 with more than 50% of the obstructive events being apneas. Patients were considered to have hypopnea-predominant OSA if they had an AHI greater than 2 and more than 50% of the obstructive events were hypopneas.
Results
A total of 386 children (185 boys [48%]; mean [SD] age, 6.56 [1.4] years) were analyzed. The mean (SD) obstructive AHI for patients was 6.98 (5.62), with 198 patients (51%) having mild disease. Thirty-seven children (10%) had apnea-predominant OSA at baseline. Black children were at increased risk for apnea-predominant OSA vs White children (odds ratio [OR], 13.40; 95% CI, 5.70-33.90). Children with apnea predominance were more likely to have severe OSA (AHI >10) compared with children with hypopnea predominance (OR, 2.30; 95% CI, 1.03-5.03); baseline Pediatric Sleep Questionnaire and OSA-18 QOL scores were similar between the 2 groups. Among children undergoing AT, those with baseline apnea predominance were more likely to have a Pediatric Sleep Questionnaire score greater than 0.33 at follow-up (OR, 3.30; 95% CI, 1.01-10.80). Rates of OSA resolution and improvements in QOL scores following AT or WWSC were similar between the apnea-predominant and hypopnea-predominant groups.
Conclusions and Relevance
In children with OSA, apnea-predominant disease is uncommon. Apnea predominance was not associated with symptom resolution and cure rates in children undergoing AT or WWSC for OSA. Further research is needed to assess how apnea predominance affects AT outcomes in children with more severe disease.
Introduction
Obstructive sleep apnea (OSA) is characterized by upper airway obstruction and can be associated with oxygen desaturation and sleep fragmentation.1 Approximately 4% of healthy school-aged children receive a diagnosis of OSA, with a much higher prevalence of this disease found in children with certain comorbidities including obesity.2 OSA can have substantial sequelae in children, including poor focus, behavioral problems, and daytime sleepiness.3
The current criterion standard for diagnosing pediatric OSA is full-night polysomnogram (PSG). The PSG measures upper airway airflow during sleep; respiratory sensors are used to detect apneas and hypopneas. Apneas represent the most severe form of obstruction, featuring a 90% decrease in air movement, whereas hypopneas represent a partial (30%) cessation in airflow associated with arousal or desaturation. Researchers have hypothesized that OSA characterized by mostly hypopneas may be a less-severe form of disease compared with OSA in which apneic events predominate.4 However, definitive data on the importance of apnea-predominant vs hypopnea-predominant OSA are lacking; thus, the current pediatric OSA classification system is based on the apnea-hypopnea index (AHI) and does not include this parameter when accounting for disease severity. In addition to the objective sleep parameters provided by PSG, other pediatric OSA outcomes include quality of life (QOL) and symptom burden assessment. Interestingly, OSA severity as determined by AHI fails to correlate with QOL scores in children.5 There is a lack of data on the relationship between QOL and apnea and hypopnea predominance.
Adenotonsillar hypertrophy is a common cause of obstruction in children with OSA. Thus, adenotonsillectomy (AT) is the primary treatment for pediatric OSA. Although AT results in improvement in both PSG parameters and QOL in children with OSA, 25% to 70% of children can have persistent disease, including ongoing evidence of obstruction on PSG, following surgery.6,7 Certain demographic and clinical factors, including Black race and craniofacial anomalies, predispose children to persistent disease.8,9,10 Polysomnography can also estimate residual OSA, as children with severe OSA at baseline (typically AHI >10) are also at risk for residual disease after AT. However, research is lacking as to whether children with apnea-predominant baseline OSA are at increased risk for persistent obstruction following AT. To that end, the objective of this case-control study is to assess the association of baseline apnea predominance vs hypopnea predominance with pediatric OSA treatment outcomes. We hypothesized that children with apnea-predominant OSA at baseline would be at higher risk for persistent obstruction following AT or watchful waiting with supportive care (WWSC).
Methods
This study is a secondary analysis of the Childhood Adenotonsillectomy Trial (CHAT) data set.11,12 Briefly, the CHAT was a multi-institutional, National Institutes of Health–funded study conducted from October 2007 to June 2012 that included approximately 400 healthy children with OSA who were randomized to surgical intervention with AT or WWSC. A PSG, neurocognitive testing, validated QOL, behavior, and symptom burden assessments were performed at baseline and 7-month follow-up.
During the initial CHAT trial, written informed consent was provided by caregivers of the participants. In addition, children aged 7 years or older provided written asset. Because the current study is a secondary analysis of deidentified data, it was exempt from institutional review board approval in accordance with 45 CFR §46. This study followed the Consolidated Standards of Reporting Trials (CONSORT) reporting guideline. The trial protocol is available in Supplement 1. A more detailed summary of the CHAT methods has been published previously.13
Participants
Children were eligible for inclusion in CHAT if they were aged 5.0 to 9.9 years and had a baseline PSG showing OSA, defined as an AHI ranging from 2 to 30 or obstructive apnea index ranging from 1 to 20, with higher numbers indicating worse apnea. In addition, the participants had to have tonsil hypertrophy and be deemed candidates for AT. Children with major comorbid conditions, such as craniofacial anomalies, cerebral palsy, attention-deficit/hyperactivity disorder, and developmental delay, were excluded. Participants’ race was determined by caregiver report and was evaluated in this study because previous research14,15 has noted racial differences in the prevalence of OSA.
Assessments
All PSGs were performed in dedicated pediatric sleep laboratories and were scored at a centralized location by pediatric sleep medicine specialists using the American Academy of Sleep Medicine guidelines.16 Data from baseline and 7-month follow-up PSGs were reviewed. Children were considered to have apnea-predominant OSA if greater than 50% of their obstructive events were apneas. Apnea predominance was determined by adding mixed apneas and obstructive apneas and dividing the total number of obstructive events (obstructive apneas, mixed apneas, and hypopneas). Children were classified as having hypopnea-predominant OSA when more than 50% of their total obstructive events were hypopneas.
The Sleep Related Breathing Disorder Scale of the Pediatric Sleep Questionnaire (PSQ) is a 22-item validated survey that is used to assess symptom burden in children presenting for evaluation of sleep-disordered breathing. Scores greater than 0.33 indicate a high symptom burden and are associated with OSA on PSG and correlate with neurobehavioral morbidity.17,18,19 The OSA-18 is an 18-item, validated instrument that has been widely used to assess the association of OSA with QOL. This disease-specific QOL, caregiver-report survey features questions in the 5 domains of sleep disturbances, physical symptoms, emotional symptoms, daytime function, and caregiver concerns.20 Higher scores indicate poorer QOL.
We used widely accepted clinically meaningful outcomes for PSG, symptom burden, and QOL to assess for the possible impact of baseline apnea predominance. Children with AHI less than 2 on 7-month follow-up PSG were considered to have disease resolution. Children with PSQ score greater than 0.33 were deemed to have high symptom burden related to their OSA.19 An OSA-18 score greater than or equal to 60, which indicates at least a moderate to severe impact of OSA on QOL, was used as the threshold for QOL outcomes.5
Statistical Analysis
Baseline and 7-month demographic and outcome data obtained from the CHAT database were analyzed. Continuous variables are presented as mean (SD) or median (IQR). Categorical variables are presented as frequency and percentage. The mean difference and 95% CI were evaluated to compare the distribution of normally distributed continuous level variables, and the median difference and 95% CI were calculated using the Hodges-Lehmann method were used for nonnormally distributed variables. Odds ratios (ORs) and 95% CIs were used to explore the association of group with categorical level variables. The association of confounders with the outcomes was assessed using regression model (continuous outcomes) and logistic regression model (categorical outcomes). All analyses were performed using R Core Team version 4.2.0 (R Project for Statistical Computing). Data analysis was performed from October 2020 to February 2022.
Results
Four hundred fifty-three patients were randomized to intervention in the CHAT. Three hundred eighty-six children with complete baseline and follow-up assessment data were included in this secondary analysis. Forty-eight percent of the children were male (185 boys), with a mean (SD) age of 6.56 (1.4) years. The mean (SD) obstructive AHI at enrollment was 6.98 (5.62), and 198 patients (51%) had mild OSA (AHI >2 to <5) at baseline.
Only 37 children (10%) participating in the CHAT had baseline apnea-predominant disease. Table 1 depicts a comparison of the baseline demographic characteristics between the apnea-predominant and hypopnea-predominant groups. Although the groups were mostly similar, Black children were 13 times more likely than White children to have apnea-predominant OSA (OR, 13.40; 95% CI, 5.70 to 33.90). In addition, children with apnea-predominant disease were more likely to have severe OSA (AHI >10) than patients with hypopnea-predominant disease (OR, 2.30; 95% CI, 1.03 to 5.03). Symptom burden between the apnea-predominant and hypopnea-predominant groups as assessed by PSQ score greater than 0.33 was similar (percentage difference, 0.09; 95% CI, −0.08 to 0.26); 272 children in the hypopnea-predominant OSA group (79%) had a PSQ score greater than 0.33, indicating clinically meaningful symptoms, compared with 25 children (69%) in the apnea-predominant group. Finally, the hypopnea-predominant and apnea-predominant groups had similar baseline QOL as assessed by OSA-18 scores greater than 60 (difference, 0.15; 95% CI, −0.03 to 0.34).
Table 1. Baseline Patient Demographic Characteristics.
| Characteristic | Patients, No. (%) | Difference (95% CI) | ||
|---|---|---|---|---|
| Apnea-predominant OSA (n = 37) | Hypopnea-predominant OSA (n = 349) | Total (N = 386) | ||
| Age, median (IQR), y | 6.0 (5.0 to 7.0) | 6.0 (5.0 to 8.0) | 6.0 (5.0 to 8.0) | 0.0 (0.0 to 1.3) |
| BMI z score, median (IQR) | 0.66 (−0.21 to 1.64) | 0.99 (−0.09 to 2.06) | 0.95 (−0.10 to 2.01) | −0.30 (−0.80 to 0.10) |
| Sex | ||||
| Female | 22 (59) | 179 (51) | 201 (52) | 0.08 (−0.10 to 0.26) |
| Male | 15 (41) | 170 (49) | 185 (48) | |
| Race | ||||
| Black | 20 (54) | 187 (54) | 207 (53) | 0.01 (−0.17 to 0.17) |
| White | 9 (24) | 129 (37) | 138 (36) | 0.13 (0.01 to 0.29) |
| Othera | 8 (22) | 33 (9) | 41 (11) | 0.13 (−0.03 to 0.27) |
| Obesity, BMI >95th percentile | 9 (24) | 124 (35) | 133 (34) | 0.11 (−0.27 to 0.05) |
| Second-hand smoke exposure | 10 (27) | 74 (21) | 84 (22) | 0.06 (−0.11 to 0.22) |
| Baseline Pediatric Sleep Questionnaire score >0.33 | 25 (69) | 272 (79) | 297 (77) | 0.09 (−0.08 to 0.26) |
| Baseline OSA-18 score >60 | 17 (46) | 107 (31) | 124 (32) | 0.15 (−0.03 to 0.34) |
| Obstructive apnea-hypopnea index, median (IQR) | 5.73 (2.92 to 12.54) | 4.79 (2.91 to 8.84) | 4.95 (2.91 to 8.95) | 0.93 (−0.81 to 4.11) |
| Oxygen nadir, median (IQR), % | 89.0 (86.0 to 92.0) | 90.0 (86.0 to 92.0) | 89.0 (86.0 to 92.0) | −1.00 (−5.54 to 1.27) |
Abbreviations: BMI, body mass index; OSA, obstructive sleep apnea.
Other refers to American Indian or Alaska Native, Asian, and Native Hawaiian or other Pacific Islander.
When we divided patients according to baseline apnea vs hypopnea predominance and then examined postintervention (AT or WWSC) outcomes, baseline apnea vs hypopnea predominance was not associated with WWSC or AT outcomes among children with OSA. Mean obstructive AHI was similar (difference, 0.12; 95% CI, −0.56 to 0.68) in the apnea-predominant and hypopnea-predominant groups following AT (Table 2). Children undergoing WWSC also had comparable AHI outcomes (difference, 1.40; 95% CI, −0.66 to 2.84) regardless of baseline apnea-predominant vs hypopnea-predominant status. We did not identify a difference in disease resolution (AHI <2) between the apnea-predominant and hypopnea-predominant groups who underwent AT (OR, 0.68; 95% CI, 0.13 to 2.55) or WWSC (OR, 1.86; 95% CI, 0.58 to 7.02) (Table 3). In addition, no significant association of confounders with the outcomes was supported. On 7-month follow-up PSG, no child had evidence of ongoing apnea predominance. Children with baseline apnea-predominant OSA who underwent AT were more likely to have a PSQ score greater than 0.33 at follow-up compared with children with baseline hypopnea predominance (OR, 3.30; 95% CI 1.01 to 10.80). Apnea predominance was not associated with a positive PSQ score in the observation group (OR, 0.93; 95% CI, 0.28 to 3.58). Postintervention OSA-18 QOL scores were not different in the apnea-predominant vs hypopnea-predominant groups. Within the AT group, no association was identified between apnea predominance and follow-up OSA-18 score greater than 60 (OR, 3.50; 95% CI, 0.55 to 16.44). This also held true for the observation group (OR, 1.70; 95% CI, 0.43 to 9.60).
Table 2. Polysomnogram and Quality of Life Outcomes Following Management With Adenotonsillectomy or Watchful Waiting.
| Outcomes and management | Hypopnea-predominant OSA (n = 349) | Apnea-predominant OSA (n = 37) | OR (95% CI) |
|---|---|---|---|
| Obstructive apnea-hypopnea index, median (IQR) | |||
| Adenotonsillectomy | 0.79 (0.37 to 1.67) | 0.67 (0.27 to 0.86) | 0.12 (−0.56 to 0.68)a |
| Watchful waiting | 2.38 (0.99 to 7.24) | 3.86 (1.61 to 5.36) | 1.4 (−0.66 to 2.84)a |
| Nadir oxygen, mean (SD), % | |||
| Adenotonsillectomy | 91.13 (3.79) | 92.70 (2.41) | 1.0 (−0.50 to 3.5)a |
| Watchful waiting | 89.55 (5.90) | 88.59 (3.79) | −2.0 (−4.75 to 1.50)a |
| PSQ score >0.33, patients, No. (%) | |||
| Adenotonsillectomy | 35 (23) | 8 (50) | 3.3 (1.01 to 10.8) |
| Watchful waiting | 121 (70) | 11 (69) | 0.93 (0.23 to 3.58) |
| Mean OSA-18 score >60, patients, No. (%) | |||
| Adenotonsillectomy | 8 (5) | 3 (15) | 3.5 (0.55 to 16.44) |
| Watchful waiting | 51 (30) | 3 (20) | 1.7 (0.43 to 9.60) |
Abbreviations: OR, odds ratio; OSA, obstructive sleep apnea; PSQ, Pediatric Sleep Questionnaire.
Data are difference (95% CI).
Table 3. OSA Resolution at 7-Month Follow-up.
| Treatment and type of OSA | Patients, No. (%) | |
|---|---|---|
| Postintervention AHI <2 | Postintervention AHI ≥2 | |
| Adenotonsillectomya | ||
| Hypopnea-predominant OSA | 67 (72) | 26 (28) |
| Apnea-predominant OSA | 11 (85) | 2 (15) |
| Watchful waitinga | ||
| Hypopnea-predominant OSA | 33 (35) | 61 (65) |
| Apnea-predominant OSA | 2 (29) | 5 (71) |
Abbreviations: AHI, apnea hypopnea index; OSA, obstructive sleep apnea.
Indicates baseline predominance.
Discussion
AT is the primary treatment for pediatric OSA and has been shown to lead to improvements in PSG parameters, behavior, and QOL.3,12 However, numerous studies21,22 have demonstrated that OSA can persist after surgery. In the CHAT study, Black children, children with obesity, and those with a higher baseline AHI were less likely to experience normalization of AHI on 7-month PSG. The reason for poorer AT outcomes in certain groups of children remains unknown. In the current case-control study, we sought to assess whether apnea predominance is associated with pediatric OSA outcomes.
The clinical importance of apnea-predominant vs hypopnea-predominant OSA is still being investigated. Apneas are considered to be a more severe form of obstruction since they feature complete cessation of airflow. However, a recent retrospective review23 in adult patients with OSA demonstrated that patients with apnea-predominant and hypopnea-predominant OSA had similar comorbid medical conditions, including hypertension and cardiovascular disease. Another study24 failed to demonstrate a difference in clinical outcomes among adult patients with OSA stratified according to apnea vs hypopnea predominance treated with mandibular advancement devices.
To our knowledge, there has only been a single prior study, Tang et al,4 that has examined apnea and hypopnea predominance in children being treated for OSA. In that retrospective review,4 approximately one-quarter of the 58 children undergoing AT had baseline apnea predominance. This is much higher than the frequency of apnea predominance in our study, which was 10%. The increased likelihood of apnea predominance in the analysis by Tang et al4 is likely related to the finding that their patients had more severe baseline disease compared with the children participating in CHAT, with a mean AHI of 23.4 vs 6.98. Indeed, in the current study, we found that severe OSA (AHI >10) was more common among children with apnea-predominant OSA at baseline. The significance of higher apnea predominance among Black children is unclear as apnea predominance does not appear to be associated with worse OSA treatment outcome. Prior studies14,15 have also reported increased OSA severity among Black children. Why Black children have a higher burden of disease is unclear. A recent analysis25 of CHAT data suggested that neighborhood-level socioeconomic factors may at least partially explain the association between race and disease severity.
Our findings did show improvements in both PSG and QOL outcomes after AT, regardless of apnea or hypopnea predominance. In both our study and that of Tang et al,4 baseline apnea predominance was not associated with PSG outcomes in terms of disease resolution; rates of resolution were similar between AT groups with baseline apnea predominance vs baseline hypopnea predominance. This finding is surprising as apneas have been considered to be a more severe form of obstruction. Certainly, the low number of children with apnea predominance may have affected this finding. If future research that includes children with more severe disease confirms that apnea predominance is not associated with OSA treatment outcomes in children, the utility of distinguishing apnea vs hypopnea when scoring PSGs may need to be revisited.
Our study adds to the literature information regarding the association of baseline apnea predominance with outcomes in children with OSA who are being managed with WWSC. There was not an association with disease progression as assessed by AHI on PSG in those children with apnea-predominant disease who were managed with WWSC. Thus, in children with OSA, having more apneas at baseline is not associated with short-term prognosis.
Numerous studies have demonstrated a poor correlation between PSG parameters and QOL scores.3 For example, children with mild baseline OSA can still have a high symptom burden in terms of QOL.5 Thus, we were interested in examining whether apnea predominance was associated with QOL or symptom burden outcomes at baseline and following OSA treatment. Apnea-predominant and hypopnea-predominant groups had similar symptom-related disease burden at baseline with the majority of children (79% in hypopnea-predominant group vs 69% in the apnea-predominant group) having PSQ scores greater than 0.33. Interestingly, among children undergoing AT, children within the apnea-predominant group were more likely than those in the hypopnea-predominant group to have a postsurgery PSQ score greater than 0.33. We found no significant differences within the hypopnea-predominant or apnea-predominant groups regarding the OSA-18 scores. Further research is needed to confirm that apnea predominance at baseline may be associated with a poorer response to AT in terms of symptom burden.
To our knowledge, this is the largest study to examine the association of apnea predominance with outcomes in otherwise healthy school-aged children with OSA. The CHAT data set allowed for analysis of a large, multi-institutional cohort of diverse children. The heterogeneity of OSA as a disease process has become increasingly evident in recent years. Studies have attempted to identify different OSA phenotypes in adults with varying prognoses and may require different treatment strategies.26,27 Pediatric OSA phenotypes have yet to be defined. Future research is necessary to determine whether factors beyond the traditional AHI such as apnea predominance can be used to establish such phenotypes and potentially improve treatment outcomes.
Limitations
The primary limitation of this study is the small number of children who had apnea-predominant disease, likely related to the finding that most children in the CHAT had mild baseline OSA. Thus, our study may have been underpowered to assess for differences in PSG and QOL outcomes between apnea-predominant and hypopnea-predominant groups. Future research should focus on prospectively evaluating children with more severe baseline disease to definitively answer whether baseline apnea predominance affects treatment response in this group. In addition, the follow-up period for CHAT was only 7 months, so we cannot comment how apnea predominance relates to long-term outcomes. Although we did compare several baseline demographic factors between the apnea-predominant and hypopnea-predominant groups (Table 1), there are additional factors that may have affected treatment outcomes, such as tonsil size and asthma, that merit study during future trials. In addition, although we did use a consistent method to define apnea-predominant disease for all study participants, formal, well-established diagnostic criteria for this phenotype are lacking.
Conclusions
In this case-control study, among patients with OSA, only a small portion of otherwise healthy children had apnea-predominant disease. Severe OSA was associated with baseline apnea predominance. Apnea predominance may affect symptom resolution in children undergoing AT for OSA but was not associated with postintervention PSG outcomes. Further research is needed to assess whether apnea predominance affects treatment response in children with more severe disease.
Trial Protocol
Data Sharing Statement
References
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Trial Protocol
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