Echocardiographic screening in children with very severe obstructive sleep apnea
Introduction
Obstructive sleep apnea (OSA) in children is characterized by intermittent partial or complete airway obstruction resulting in a cycle of hypoxemia and arousal [1]. Pediatric OSA has an estimated prevalence of 5% in the United States [2]. The gold standard for the diagnosis and stratification of OSA is overnight, laboratory-based polysomnography. Untreated OSA has been shown to have detrimental effects on behavior, metabolism, and growth and development [1]. The first line treatment for pediatric OSA is tonsillectomy and adenoidectomy (T&A), which results in significant improvement or resolution of the condition in the majority of children [3].
Polysomnographic severity of OSA is an established risk factor for perioperative adverse events associated with T&A [4]. A relationship between adenotonsillar hypertrophy and cor pulmonale has been described, and complications related to cardiac dysfunction in these children have been associated with unexplained mortality following T&A [5]. Therefore, preoperative screening for cardiac abnormalities in children with chronic upper airway obstruction is recommended due to the potential for perioperative adverse events [6]. However, universal echocardiographic screening of 300,000 children undergoing T&A each year is impractical due to significant financial implications [7].
Descriptions of the detrimental effects of episodic upper airway obstruction have been mostly described in adults with OSA. Specifically, obstructive apneas result in increased intrathoracic pressures, causing changes in left ventricular relaxation, filling, and afterload [8]. At the end of an apnea, venous return to the right heart increases causing distension of the right ventricle, reduced left ventricular compliance by displacement of the interventricular septum, and therefore reduced left-ventricular end-diastolic filling and reduced left-ventricular stroke volume [9]. During the apnea, the sympathetic system is activated leading to vasoconstriction with sustained increased vasomotor tone and subsequent remodeling [10,11]. Together, these changes result in alterations in left ventricular mass and wall thickness, end diastolic dimensions, and interventricular septal thickness [9,11]. In addition, cyclic obstructive apneas may result in alveolar hypoventilation leading to hypoxemic pulmonary vasoconstriction and subsequent right ventricular dysfunction in the setting of pulmonary hypertension [11,12].
Most studies examining the prevalence of OSA-related cardiac dysfunction have focused on children with relatively mild OSA as defined by AHI. For example, Amin et al. prospectively evaluated 63 children in whom the majority (60%) had an AHI less than 5 [13]. Similarly, 73% of the 101 children enrolled in a community-based study examining cardiac dysfunction in children with OSA also had an AHI less than 5 [14]. However, there is a paucity of studies focusing on children with a greater severity of OSA who are likely to have more significant cardiovascular functional impairments, based on evidence suggesting this association [13].
We aimed to evaluate the prevalence of echocardiographic abnormalities in children screened for cardiovascular dysfunction due to a diagnosis of very severe OSA, defined as an AHI greater than or equal to 30 [15,16]. We hypothesized that this population was likely to have a greater prevalence of abnormal echocardiographic measurements based on the severity of upper airway obstruction. We also sought to identify the potential polysomnographic determinants of echocardiographic parameters in children with very severe OSA.
Section snippets
Study design and population
Medical records of children aged 1–17 years with very severe OSA diagnosed by polysomnography, defined as AHI ≥30 [15] undergoing T&A from January 1, 2016 to December 31, 2018 were reviewed. Children were included in the study if they underwent echocardiographic evaluation within six months prior to the procedure. The studies were ordered by the pediatric otolaryngologists as part of the institutional protocol at University of Maryland Medical Center. The exclusion criteria were the presence of
Demographics and chart review
Of 89 eligible children, 47 met inclusion criteria. The rest were excluded based on non-availability of data or the length of time elapsed between the echocardiography and the surgery date. The demographic and clinical characteristics are summarized in Table 1. The majority of the children were male (33/47, 70.2%). Thirty (63.8%) were African American. Twenty (42.6%) were obese with BMI percentile ≥ 95%. The mean AHI was 61.8 [54.5 to 69.0]. One child (2.1%) was documented to have hypertension
Discussion
In this case series of children who underwent echocardiographic screening prior to surgical management of very severe OSA, no significant functional or structural cardiac abnormalities were identified. Moreover, the majority of the echocardiographic parameters were predicted by non-polysomnographic parameters such as age. Apnea hypopnea index, which is used to stratify the severity of upper airway obstruction, was not identified as a predictor for any of the echocardiographic outcome variables.
Conclusions
In children with very severe OSA undergoing T&A, preoperative echocardiographic screening did not identify any abnormalities. The majority of the echocardiographic parameters were predicted by non-polysomnographic variables. Routine echocardiographic screening solely based on polysomnographic parameters is unlikely to yield relevant clinical information, could reduce cost-efficiency and delay treatment. Prospective studies are required to identify reliable markers of cardiovascular morbidity in
Disclosures
Amal Isaiah receives patent-related royalties from the University of Maryland, Baltimore. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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2022, International Journal of Pediatric OtorhinolaryngologyCitation Excerpt :Despite this, the American Heart Association (AHA) and American Thoracic Society (ATS) have advocated for preoperative echocardiograms in children with severe OSA or in children with cardiometabolic risk factors with the goal of identifying cardiac abnormalities that would increase the risk of peri- or postoperative complications [20,21]. However, studies focusing on severe OSA patients have been unsuccessful in finding associations between reliable predictors, such as apnea hypopnea index (AHI), respiratory depression index (RDI) and nadir oxygen saturation (Nadir O2), and abnormal findings on echocardiogram [22–24]. More studies have been unable to characterize which OSA related cardiac changes are associated with an increased risk of perioperative complications [25,26].
Echocardiographic findings in children with obstructive sleep apnea: A systematic review
2021, International Journal of Pediatric OtorhinolaryngologyCitation Excerpt :Full texts were retrieved for the remaining 125 articles and assessed for eligibility, with 112 excluded after agreement between all reviewers. Thirteen studies were included in the final study, including seven cross-sectional (CS) studies, five pre-post prospective cohort (PC) studies, and one retrospective cohort (RC) study[13–25]. In the 12 CS and PC studies, patients were recruited based off of symptoms of SDB, clinical findings of adenotonsillar hypertrophy (ATH), or risk of OSA as determined by a questionnaire.