Clinical ReviewDoes treatment of SDB in children improve cardiovascular outcome?
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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2021, Paediatric Respiratory ReviewsCitation Excerpt :Yeboah et al. [50] performed a study on more than 3000 adults and found that brachial FMD was a significant predictor of incident cardiovascular events. It has been postulated that long-term intermittent hypoxia events during OSA induce oxidative stress, which can lead to the activation of inflammatory pathways contributing to endothelial dysfunction [51]. Gozal et al. [52] demonstrated that OSA increased both the risk for endothelial dysfunction (as measured by the FMD) and neurocognitive deficits.
Trajectory of ambulatory blood pressure after adenotonsillectomy in children with obstructive sleep apnea: comparison at three- and six-month follow-up
2020, Sleep MedicineCitation Excerpt :In children, T&A results in substantial improvement of OSA [16,17]. Recently, the effects of surgery on BP are gaining increasing scientific attention [20–30]. However, the data are scant, and the results are controversial [20–30].
Use of non-invasive ventilation in children with congenital tracheal stenosis
2019, International Journal of Pediatric Otorhinolaryngology24-Hour Ambulatory Blood Pressure after Adenotonsillectomy in Childhood Sleep Apnea
2018, Journal of Pediatrics
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