The most common sleep breathing disorder in children is obstructive sleep apnea syndrome (OSAS), also known as obstructive sleep apnea hypoventilation syndrome (OSAHS), which is characterized by intermittent partial or total obstruction of the upper airway during sleep.
A 2002 questionnaire survey of 28,484 children aged 2-12 years in 8 cities nationwide showed that the prevalence of sleep disorder symptoms in children was 27.1%. The prevalence of OSAS in children is estimated to be 2%. 2-6 years of age is the peak incidence period.
I. Definition.
Obstructive sleep apnea hypoventilation syndrome (OSAHS) in children: is a series of pathophysiological changes caused by frequent partial or total upper airway obstruction during sleep, which disrupts the normal ventilation and sleep structure during sleep.
II. Etiology.
Factors affecting upper airway resistance or compliance and neuromodulation.
1, nasopharynx and oropharynx: tonsillar hypertrophy, adenoid hypertrophy, tongue hypertrophy, fat accumulation, pharyngeal and nasopharyngeal masses, palatopharyngeal flap surgery, etc. Hyperplasia of tonsils and adenoids can cause upper air passage obstruction, which is the most common cause of pediatric OSAHS.
2.Nose: chronic rhinitis (infectious, allergic), deviated nasal septum, nasal polyps, posterior nostril atresia and nasal masses, etc.
3.Larynx: congenital laryngeal cartilage softening, laryngeal webbing, tracheal atresia, etc.
4.Craniofacial anomalies: mid-facial dysplasia (Down syndrome, Grouzon syndrome, chondrodysplasia), mandibular dysplasia (Piere’s-Robin syndrome, Treacher-Collin syndrome, Shy-Drager syndrome, etc.), mucopolysaccharidosis (Hunter’s syndrome, Hurler’s syndrome, other syndromes), metabolic diseases (osteosclerosis) factors affecting neuromodulation: generalized hypotonia (dahl’s syndrome, neurofemoral disease), application of sedative drug therapy, alcohol consumption, etc.
III. Symptoms.
1. snoring, inability to sleep on the back, open-mouth breathing, slow growth, etc;
2, and bedwetting, night sweating, abnormal sleeping position, recurrent respiratory infections and other manifestations;
3, and may appear inattentive, hyperactive, academic performance decline, neurobehavioral changes, cognitive impairment, etc.;
4. Long-term episodes may include signs of growth retardation, hypertension, heart enlargement, right heart failure and pulmonary heart disease.
IV. Diagnostic criteria.
1, obstructive sleep apnea (OSA) refers to the cessation of oral and nasal airflow during sleep, but chest and abdominal breathing still exist.
2, hypopnea (hypopnea) is defined as a 50% decrease in peak oral and nasal airflow signal with more than 3% decrease in oxygen saturation and/or arousal (microarousal).
3.And the length of respiratory events (including apnea and hypoventilation) was defined as greater than or equal to two respiratory cycles.
4.Polygraphic sleep monitoring examination: OAI (obstructive sleep apnea index) greater than or equal to 1 or AHI (sleep apnea hypoventilation index) greater than 5 during each night of sleep is considered abnormal, and the minimum oxygen saturation is defined as hypoxemia below 92%.
5. It is not difficult to diagnose OSAS through history, clinical manifestations, radiological examination and polysomnography, but attention should be paid to the differential diagnosis with primary snoring, which has no frequent awakenings and no clear obstructive sleep apnea or abnormal gas exchange.
V. Objectives of polysomnography PSG examination.
1.Differentiate simple snoring from OSAHAS;
2.To determine the diagnosis of OSAHS;
3.Evaluate the severity of OSAHS;
4.Evaluate the postoperative effect;
5.Differentiate central apnea and alveolar hypoventilation;
6.Evaluate sleep structure and non-breathing related sleep disorders (such as nocturnal seizures, etc.).
Judgment of OSAHS disease procedures in children based on
Degree of illness AHI (times/h) or OAI (times/h) Minimum SO2
Mild 5-10 or 1-5- ≤91
Moderate 10-20 or -10- ≤85
Severe >20 or >10 ≤75
VI. Treatment.
(i) Surgical treatment: adenoidectomy and tonsillectomy: the first-line treatment for OSAHS in children, with an efficiency of 90%. 75%-100% of children have improved PSG and disappearance of corresponding symptoms after surgery. It is possible that some obese children have less satisfactory results after surgery, and a detailed preoperative evaluation must be performed for patients with severe OSAHS younger than 3 years old. The harm of pediatric snoring is more serious than that of adults, because the airway gas exchange is obstructed during sleep, the blood oxygen level decreases, and the low oxygen can cause brain intellectual development disorder and abnormal cardiovascular function, and also affect the child’s maxillofacial development, which is extremely harmful to children’s physical and intellectual development, so it should be paid attention to. Snoring in children is mainly caused by large tonsils and/or adenoids, so once it is diagnosed, it should be operated early, and the earlier the operation, the better the results.
(II) Non-surgical treatment.
1.Continuous positive airway pressure ventilation therapy (CPAP): patients with contraindications to surgical procedures, adenoid tonsils are not large, OSAHS still exists after adenoid tonsillectomy, and patients who choose non-surgical treatment.
2, other treatment methods: treatment of rhinitis: rhinitis, allergic rhinitis, sinusitis, preoperative and postoperative should be systematic and regular treatment; weight loss; oral orthodontic appliances (jaw and face deformities can be corrected by orthodontics). A lot of residuals can be removed with a scraper under blind vision, which can only solve part of the ventilation problem and cannot achieve the purpose of “removing chronic sinusitis lesions”; the application of endoscopic transoral and transnasal combined access to the application of Schimmel’s straight drill and 60-degree external opening drill can ensure clean removal.
VII. Efficacy assessment.
Follow-up time: All patients should be followed up clinically after initial treatment.
Immediate follow-up: A re-evaluation is recommended at 8 weeks postoperatively. At this time the remodeling of the upper airway, heart, and central nervous system is complete.
Long-term follow-up: 6 months or more.
Efficacy assessment of OSAHS in children
Efficacy AHI (times/h) OAI (times/h) Minimum SaO2 Clinical symptoms
Cured <5 <1 >0.92 Basically disappeared
Effective Decreased ≥50% Improved ≥0.50 Significantly improved
Effective Decrease ≥25% Increase ≥0.25 Decrease
Ineffective Decrease <25% Increase <0.25 No significant change or even aggravation
Polysomnography (PSG) polysomnography
Obstructive sleep apnea hypopnea syndrome (OSAHS) Obstructive sleep apnea hypoventilation syndrome
(OAI) Obstructive Sleep Apnea Index
(AHI) Sleep apnea hypopnea index
(CPAP) Continuous Positive Airway Ventilation