Elsevier

Sleep Medicine Reviews

Volume 17, Issue 1, February 2013, Pages 75-85
Sleep Medicine Reviews

Clinical Review
Does treatment of SDB in children improve cardiovascular outcome?

https://doi.org/10.1016/j.smrv.2012.04.004Get rights and content

Summary

Sleep disordered breathing (SDB) is a common disorder in both adults and children and is caused by the obstruction of the upper airway during sleep. Unlike adults, most cases of paediatric SDB are due to the presence of enlarged tonsils and adenoids, thus the main treatment option is adenotonsillectomy (T&A). It is well known that obstructive sleep apnoea in adults increases the risk for hypertension, coronary artery disease and stroke, and there is now mounting evidence that SDB also has a significant impact on the cardiovascular system in children with reports of elevated blood pressure, endothelial dysfunction and altered autonomic cardiovascular control. As there is now substantial evidence that elevated blood pressure in childhood is carried on to adulthood it is important to know if treatment of SDB improves cardiovascular outcomes. Studies in adults have shown that treatment of SDB leads to improvements in cardiovascular function, including a reduction in pulmonary artery pressure, systemic blood pressure and endothelial dysfunction. However, studies exploring the outcomes of treatment of SDB in children on the cardiovascular system are limited and varied in their methodology and outcome measures. As a number of cardiovascular disturbances are sequelae of SDB, early detection and management could result in the reduction of elevated blood pressure in children, and consequently a reduction in cardiovascular morbidity in adulthood. The aim of this review is to summarise the findings of studies to date which have investigated the cardiovascular outcomes in children treated for SDB and to make recommendations for future management of this very common disease.

Introduction

Sleep disordered breathing (SDB) is caused by the obstruction of the upper airway during sleep with the presence of snoring being the cardinal symptom. SDB exhibits a spectrum of severity with primary snoring (PS), which is not associated with any gas exchange abnormalities or significant sleep fragmentation, being the mildest form and obstructive sleep apnoea (OSA) the most severe. OSA is characterised by repetitive and prolonged partial and/or complete episodes of obstruction of the upper airway which disrupt normal ventilation during sleep and are associated with oxygen desaturations and/or arousals from sleep.1 An estimated 2–3% of children suffer from OSA.2, 3 However, the occurrence of snoring is at least four-fold higher, with snoring being present in 10–35% of children.4, 5 Both snoring and OSA have been shown to have a profound impact on quality of life,6 behaviour and neurocognition7 and the cardiovascular system in children.8 Furthermore, there is a 2.3-fold increase in health care utilisation among children with OSA.9

In most cases, paediatric SDB occurs due to the presence of enlarged tonsils and adenoids, hence the main treatment option is the surgical removal of this obstructive lymphoid tissue through adenotonsillectomy (T&A).10 Whilst the efficacy of this procedure in treating SDB and the impact of treatment on behaviour, quality of life and neurocognition has been discussed in the literature, the precise impact of treatment on these outcomes is yet to be determined. Studies exploring the implications of treatment of SDB on the cardiovascular system in children are even more limited, and are also varied in their methodology and outcome measures, thus making interpretation of the findings difficult. It is well known that OSA in adults increases the risk for hypertension, coronary artery disease and stroke (for reviews see11, 12). Hence, the lack of research and understanding of long-term cardiovascular outcomes in children is of great importance. Studies in adults have shown that treatment leads to significant improvements in cardiovascular function including a reduction in pulmonary artery pressure, systemic blood pressure (BP) and endothelial dysfunction.13 The aim of this review is to discuss the findings of studies to date which have investigated the cardiovascular outcomes in children treated for SDB.

Section snippets

Aetiology of SDB: differences between adults and children

An adult with SDB will typically present with signs of upper airway obstruction during sleep (i.e., snoring, gasping, snorting, choking and witnessed apnoeas) and excessive daytime sleepiness (EDS).14 Adults with OSA are also more likely to be obese, male or postmenopausal women.15 At sleep onset, there is a normal reduction in pharyngeal dilator muscle tone which affects the patency of the upper airway. An anatomically small airway, either due to abnormalities in bone, soft tissue structures

Treatment of SDB in children

As adenotonsillar hypertrophy is the leading cause of OSA in children, T&A remains the first line treatment. The overall incidence of tonsillectomy has increased in recent years, with SDB now being the primary indication for surgery.23 In some cases, either tonsillectomy or adenoidectomy alone are performed, however, this is not recommended as it carries a significant risk of recurrent or persistent OSA.24 T&A however, is usually reserved for patients diagnosed with moderate to severe OSA –

Cardiovascular consequences of SDB: adults and children

The termination of an apnoea in adults is accompanied by marked surges in BP and heart rate. Approximately 7–10 s after termination, BP is seen to increase by up to 20 mmHg,33 and heart rate (HR) by 15 beats per minute (bpm).34 Recurrent hypoxic and hypercapnoeic insults due to OSA can lead to an elevation of pulmonary vascular resistance and result in pulmonary hypertension.11 It has been demonstrated in both animal and human studies that repetitive apnoeas not only induce these acute changes,

The effects of treatment on SDB in children

Several studies have demonstrated that T&A is an efficacious treatment for OSA in children, with an improvement in both symptoms (parental report of snoring, gasping and witnessed apnoeic events) and PSG results post-surgery.45, *46 Early reports investigating the effect of T&A as an intervention for OSA suggested relatively high (85–95%) cure rates.45, 47 A meta-analysis assessing the effectiveness of tonsillectomy and adenoidectomy in paediatric OSA concluded that T&A was effective in

The effects of treatment on cardiovascular outcomes in children

Several studies and meta-analyses demonstrate that treatment of OSA in adults (namely administration of CPAP) leads to a reduction in BP and the incidence of hypertension.13, 51 It has also been shown that successful treatment has positive effects on cardiovascular function, reduces the occurrence of atrial fibrillation and even reduces cases of cardiovascular mortality.13 While there are numerous studies looking at respiratory, neurocognitive and behavioural outcomes in children treated for

Conclusions

SDB is undoubtedly associated with cardiovascular morbidity in adults and if left untreated, can result in deleterious and even fatal consequences. Although childhood SDB differs from the adult form in aetiology and clinical manifestations, there is now strong evidence that it too is associated with cardiovascular morbidity. Despite the paucity of studies investigating the effects of treatment for SDB in children on cardiovascular outcomes, preliminary studies suggest that, in general,

Acknowledgements

Anna Vlahandonis received funding from the JE and HTE Maloney scholarship for her PhD. Lisa Walter is supported by a project grant from the National Health and Medical Research Council of Australia and the Victorian Government's Operational Support Programme. Rosemary Horne is a National Health and Medical Research Council of Australia Senior Research Fellow.

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