Pulse-oximetery is useful in determining the indications for adeno-tonsillectomy in pediatric sleep-disordered breathing

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Summary

Objective

Although first line therapy of sleep-disordered breathing (SDB) in children is adeno-tonsillectomy, the indications for this operation have not yet been clearly established. We investigated whether pulse-oximetry is useful for determining the optional treatment modality for pediatric SDB.

Method

Two hundred and thirty-two children presenting with snoring and gasping had their oxygen saturation levels examined during sleep. Among them, 86 underwent on adeno-tonsillectomy and were evaluated pre- and post-surgery. We also examined 25 healthy children as controls.

Results

Little desaturation was observed in healthy children. The difference in oxygen saturation levels of the patients between pre- and post-surgery was closely correlated with the pre-surgery levels. We examined the reaction operation characteristics and concluded that children with an oxygen desaturation index of 4% or more (ODI4) of more than 1.5 and/or ODI3 of more than 3.5 should undergo surgery.

Conclusion

Pulse-oximetry is useful in determining the indications for adeno-tonsillectomy.

Introduction

Sleep-disordered breathing (SDB), such as obstructive sleep apnea syndrome (OSAS), in children due to adenoid and tonsillar hypertrophy is a well-defined clinical entity and it is well-known to induce such sequelae as failure to thrive [1], [2], neurocognitive abnormalities [3], [4], systemic hypertension [5] and right heart failure including cor pulmonale [6], [7]. Its symptoms are non-specific and widely variable and therefore performing physical examination and evaluating the patient history is of limited value [8], [9]. Adeno-tonsillectomy (T&A) is known to relieve such conditions in most otherwise healthy cases [10], [11], [12], however, a number of studies have shown no relationship to exist between the presence of SDB and the size of the tonsils and adenoids [13], [14], [15]. Currently, polysomnography (PSG) is widely considered to be the gold standard in diagnosing SDB in childhood [8], [16]. However, PSG is very expensive, time consuming and not easy to carry out on children. As a result, we think that more simplified method is needed for such cases.

Measuring hemoglobin oxygen saturation level with a pulse-oximeter is a very simple, widely used method for the screening of sleep apnea syndrome [8], [17], [18], [19]. Brouillette et al. compared the results of nocturnal pulse-oximetry with those of PSG and reported oximetry to be useful when the results were positive [8], but there have been only a few studies comparing the results of pulse-oximetry with those of normal candidates, and no definite indication for T&A based on the severity of desaturation have not yet been established. We therefore examined the percutaneously measured hemoglobin oxygen saturation (SpO2) of children who were suspected to have SDB and then compared the results with those for healthy children, while also comparing the pre- and post-operative SpO2 of patients who underwent T&A.

Section snippets

Subjects

We conducted a prospective study of all children between 1-year-old and 10-year-old that consulted the oto-rhino-laryngological clinic of Saiseikai Utsunomiya Hospital with such complaints as snoring, choking or gasping during sleep, oral breathing and other complaints that are usually associated with OSAS. Of these, 232 were evaluated by pulse-oximetry between April 1998 and July 2004. Because some children were evaluated several times, the total number of the tests was 535. When we examined a

Results

We performed 535 examinations on 232 children. Five children were excluded from the analysis because of their physiological condition and 30 examinations were excluded because of either an inadequate operation of the pulse-oximeter and/or malfunction (Table 1). Consequently, we analyzed 495 examinations of 225 children consisting of 144 (64.3%) boys and 81 girls. The age of the patients ranged from 1-year and 5 months to 10-year old.

As written previously, 86 children, 55 boys (64.0%) and 31

Discussion

The diagnostic value of pulse-oximetry for pediatric OSAS remains controversial. There have been several reports describing the usefulness of pulse-oximetry [4], [10], [21]. In general, the role of pulse-oximetry in the diagnosis of pediatric sleep apnea is thought to be limited. Brouillette et al. [8] compared results of pulse-oximetry with those of simultaneous PSG and came to the conclusion that the oximetry was useful when the results were positive and he also noted that the children

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      We have however refrained from commenting on reference values for SpO2 nadir values, since they have relatively high variability, especially when oximeters without motion-resistant algorithms are used [23,43]. Of note, lower centiles for ODI values in children with OSAS overlap with upper centiles for ODI values in asymptomatic children [22]. A similar problem also occurs when polysomnography is used to determine severity of SDB, i.e. both children without SDB and those with primary snoring have an AHI <1 episode/h [2].

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      Oximetry's specificity is good provided that rigorous analysis technique is respected with manual reading of each recording, which required a mean of 30 min per patient in the present study. Optimal precision in the search for and elimination of the artifactual parts of the recording is crucial so as not to overestimate the existence of positive oximetry recordings [14]. The present study, conducted in a population of children referred by their ENT physician for suspected SDB, is original on many counts.

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