Risk factors and management countermeasures for obstructive sleep apnea hypoventilation syndrome in children

Abstract

BACKGROUND

Obstructive sleep apnea hypoventilation syndrome (OSAHS) in children is a sleep respiratory disorder characterized by a series of pathophysiologic changes. Statistics in recent years have demonstrated an increasing yearly incidence.

AIM

To investigate the risk factors for OSAHS in children and propose appropriate management measures.

METHODS

This study had a case–control study design. Altogether, 85 children with OSAHS comprised the case group, and healthy children of the same age and sex were matched at 1:1 as the control group. Basic information, including age, sex, height, weight and family history, and medical history data of all study participants were collected. Polysomnography was used to detect at least 8 h of nocturnal sleep. All participants were clinically examined for the presence of adenoids, enlarged tonsils, sinusitis, and rhinitis.

RESULTS

The analysis of variance revealed that the case group had a higher proportion of factors such as adenoid grading, tonsil indexing, sinusitis, and rhinitis than the control group.

CONCLUSION

A regression model was established, and glandular pattern grading, tonsil indexing, sinusitis, and pharyngitis were identified as independent risk factors affecting OSAHS development.

Key Words: Risk factors, Obstructive sleep apnea hypoventilation syndrome, Children, Tonsil indexing, Sinusitis

Core Tip: This case-control study of 85 children with obstructive sleep apnea hypoventilation syndrome (OSAHS) and matched healthy controls identified adenoid grading, tonsil indexing, sinusitis, and rhinitis as independent risk factors for OSAHS development using polysomnography and clinical examination.

INTRODUCTION

Obstructive sleep apnea hypoventilation syndrome (OSAHS) in children is a sleep respiratory disease characterized by a series of pathophysiological changes[1], such as growth restriction, behavioral abnormalities, and cardiovascular diseases, caused by static and dynamic narrowing of the upper airway during sleep. Such changes lead to frequent partial or total upper airway obstruction, which disrupts the normal ventilation and sleep structure of the child[2]. The clinical prevalence of OSAHS is approximately 1.0%–5.7% and is higher in boys than in girls[3]. In addition, studies have indicated that children with chronic diseases, such as asthma and allergic rhinitis, are at risk of developing OSAHS[4].

For the treatment of OSAHS in children, comprehensive therapeutic measures are generally adopted, including position change, diet control, and use of oral orthodontic appliances[5]. For children with obesity, weight loss is an important treatment method. If the condition is more serious, surgical treatment, such as adenoidectomy and tonsillectomy, may be required[5]. However, the clinical symptoms of some children do not improve significantly after treatment, or recur within a few months after treatment. Therefore, the risk factors for OSAHS in children need to be investigated. However, the risk factors for the development of OSAHS in children are controversial. Previous studies have suggested that the development of OSAHS in children is related to various factors[6]. Among them, anatomical abnormalities and abnormal neuromuscular regulation are the main causes. The most common causes are adenoid hypertrophy and tonsillar hypertrophy, both of which can lead to upper airway obstruction[7]. In addition, midface hypoplasia, small mandibles, obesity, craniofacial malformations, and neuromuscular dysregulation may also contribute to the development of OSAHS[8]. Clinical studies have concluded that the development of OSAHS in children is generally associated with neurobehavioral disorders and cardiovascular diseases in children. Thus, timely diagnosis and treatment of OSANS in children are crucial[9].

This case–control study aimed to analyze the risk factors affecting the development of children with OSANS by including 85 patients with OSAHS in children. This study also proposes a corresponding management policy to provide a scientific basis and treatment ideas for the prevention and treatment of children with OSAHS in clinical practice.

MATERIALS AND METHODS

Study population

This study utilized a case-control study design. Eighty-five children who had been diagnosed with OSAHS were included as the case group, matched 1:1, and healthy children of the same age and gender match were selected as the control group. All participants were from the same area to ensure the reliability and accuracy of the study results.

Sample selection and inclusion criteria

The inclusion criteria for the case group were as follows: age between 3 and 12 years, diagnosis of OSAHS by polysomnography (PSG), and no recent relevant treatment. The exclusion criteria were as follows: severe congenital diseases, receiving positive pressure ventilation and respiratory depressant therapy, previous tonsil and adenoidectomy, and combined growth disorders and neuromuscular diseases.

Meanwhile, the control group included healthy children matched to the case group in terms of age and sex, who did not have OSAHS or other sleep breathing disorders as confirmed by PSG as well as any chronic diseases.

Data collection

The basic information of all participants was collected, including age, sex, height, weight, and family history. The medical history data of all participants were also collected, and at least 8 h of nocturnal sleep should be detected by using PSG to obtain relevant data, including apnea hypoventilation index (AHI), lowest oxygen saturation (LsaO₂), and snoring index.

Referring to the diagnostic criteria of the Draft Guidelines for the Diagnosis and Treatment of Obstructive Sleep Apnea and Hypoventilation Syndrome in Chinese Children released in 2007[10], the length of respiratory events was defined as ≥ 2 respiratory cycles, and obstructive sleep apnea was defined as the cessation of orofacial and nasal airflow during sleep, although thoracic and abdominal respiration were still present[11]. Hypoventilation was defined as a 50% reduction in peak oro-nasal airflow signal with a decrease in oxygen saturation of ≥ 0.03 and/or arousal. An OAI of >1 breath/h or an AHI of > 5 breaths/h per night during sleep was considered abnormal. An LsaO₂ of < 0.92 was considered hypoxemia.

Clinical examination

For oropharyngeal examination, the pharynx of all children in the case and control groups was examined at the time of consultation with the open-mouth tongue-pressing method. The size of the tonsils is categorized as follows: Grade I (the tonsils were confined to the tonsil fossa); grade II (protruding from the tongue and palate arch, occupying 1/2 of the pharyngeal cavity); grade III (protruding from the tonsil fossa, occupying 3/4 of the pharyngeal cavity); and grade IV (almost the opposite of the tonsils on both sides, blocking the pharyngeal cavity)[11].

For electronic nasopharyngoscopy, all children in the case and control groups were examined using an electronic nasopharyngoscope (PENTAX VNL-1530T, Japan). The color of the nasal mucosa and turbinates, swelling, location and amount of secretions, whether the nasal septum was bulging or deviated, whether the nasal cavity was narrowed and its degree, the relationship between the adenoids and posterior nostrils, and the size and surface of the tonsils and their degree of causing pharyngeal stenosis were carefully observed. The degree of obstruction of the posterior nostril by enlarged adenoids was classified into grade I (≤ 25%); grade II (26%-50%); grade III (51%-75%), and grade IV (76%-100%). Rhinitis was diagnosed based on the criteria of Otorhinolaryngology-Head and Neck Surgery. Sinusitis was diagnosed based on the criteria of the Recommendations for the Diagnosis and Treatment of Rhinosinusitis in Children (2012). The diagnosis was based on the main symptoms and signs, and combined with the results of electronic nasolaryngoscopy[11].

Statistical analysis

The study data were analyzed using the SPSS 26.0 statistical software. The basic information of the two groups were analyzed descriptively. Differences were analyzed using χ² test and t-test, and risk factors affecting OSAHS were analyzed using a binary logistic regression model.

RESULTS

General information and one-way analysis of variance

Each group comprised 23 women and 52 men. The mean age of the case group was 6.00 ± 1.51 years, and that of the control group was 5.94 ± 1.51 years (Table 1). No significant difference in age was observed between the two groups (P > 0.05). The percentage of factors such as adenoid division, tonsil division, sinusitis, and rhinitis was significantly higher in the case group than in the control group (P < 0.05).

Table 1 General information on the study population, n (%).

Group		Cases	Controls	Χ²/T	P value
Age (yr)		6.00 ± 1.51	5.94 ± 1.51	−9.880	0.214
Adenoid grade	IV	14 (16.47)	8 (9.40)	13.458	0.004
	III	21 (24.71)	7 (8.20)
	II	30 (35.29)	34 (40.00)
	I	20 (23.53)	36 (42.4)
Tonsil grade	IV	23 (27.06)	9 (10.59)	17.215	0.001
	III	23 (27.06)	11 (12.94)
	II	18 (21.28)	26 (30.59)
	I	21 (24.71)	39 (45.88)
Sinusitis	Yes	56 (65.88)	18 (21.18)	34.555	0.000
	No	29 (34.12)	67 (78.82)
Rhinitis	Yes	46 (54.12)	13 (15.29)	28.268	0.000
	No	39 (45.88)	72 (84.71)
BMI		26.87 ± 0.95	26.34 ± 0.92	-8.121	0.264

BMI: Body mass index.

Correlation analysis

The Spearman's correlation analysis to analyze the factors associated with OSAHS incidence revealed a significant positive correlation between glandular pattern grading, tonsil indexing, sinusitis, and pharyngitis and the rate of poor prognosis (P < 0.05) (Tables 2 and 3).

Table 2 Correlation analysis.

	Group	Glandular pattern grading	Tonsil indexing	Sinusitis	Pharyngitis
Group	1.000	0.256a	0.301a	0.451a	0.408a

^aP < 0.01.

Table 3 Assignment table.

Variable	Division
Glandular pattern grading	Grade I = 0; Grade II = 1; Grade III = 2; Grade IV = 3
Tonsil indexing (grade I)	Grade I = 0; Grade II = 1; Grade III = 2; Grade IV = 3
Sinusitis	Yes = 0; No = 1
Pharyngitis	No = 1; Yes = 0

Regression analysis

Using a binary logistic regression model, the analysis revealed that glandular pattern grading, tonsil indexing, sinusitis, and pharyngitis were independent risk factors affecting the development of OSAHS (Table 4).

Table 4 Binary logistic regression model analysis.

	B	t value	P value	OR	EXP(B)
					Upper	Lower
Glandular pattern grading (grade I)		11.051	0.000
Grade II	0.927	1.321	0.571	1.814	0.688	3.964
Grade III	0.527	9.193	0.007	10.885	5.145	20.491
Grade IV	0.478	14.291	0.001	13.03	0.547	48.365
Tonsil indexing (grade I)		10.291	0.017
Grade II	2.304	3.757	0.053	10.091	0975	102.999
Grade III	3.223	4.338	0.037	25.094	1.209	520.727
Grade IV	2.754	5.264	0.022	0.064	0.006	0.669
Sinusitis	0.782	3.591	0.04	2.528	0.102	5.426
Pharyngitis	0.167	5.102	0.01	1.612	1.187	2.190

OR: Odds ratio.

DISCUSSION

OSAHS is a sleep-breathing disease of unknown etiology, whose clinical manifestations are mainly nighttime sleep snoring with apnea and daytime sleepiness[12]. A study conducted by the Sleep Research Center of Stanford University has indicated that 56.6% of patients with OSAHS suffered from hypertension, 16.7% had coronary heart disease, 8.1% had a history of myocardial infarction, and 7.1% had suffered a stroke[13]. In addition, many unexplained conditions such as hypertension, pulmonary hypertension, and abnormal glucose tolerance are relieved or cured with treatment of OSAHS[13]. With the OSAHS prevalence recently rising in children, an increasing number of studies have begun to focus on the risk factors affecting the development of OSAHS[14]. In this case–control study exploring the risk factors for the development of OSAHS, the analysis of variance revealed that the proportion of factors such as adenoid grading, tonsil indexing, sinusitis, and rhinitis were higher in the case group than in the control group. In the regression analysis, glandular pattern grading, tonsil indexing, and sinusitis, pharyngitis were identified as the independent risk factors affecting the development of OSAHS.

Adenoids and tonsils are lymphatic tissues in the pharynx that normally undergo a process of proliferation and then atrophy. However, in some children, the adenoids and tonsils may become overly enlarged, causing the upper airway to become narrow. When the upper airway is surrounded by soft tissues and becomes narrowed, inhaled air vibrates against these soft tissues, creating a "whistling" sound. This narrowing of the upper airway prevents normal breathing, thereby leading to the development of OSAHS[15]. More importantly, long-term adenoid hypertrophy can lead to disruption of the balance between the non-rapid and rapid eye movement phases of sleep, as well as recurrent hypoxemia and apnea[16]. The results of this study are consistent with those of previous studies and further confirm adenoid hypertrophy and tonsillar hypertrophy as important risk factors for the development of OSAHS in children. The proportion of patients with adenoid grade IV and tonsil grade IV in the case group was significantly higher than that in the control group, suggesting this group of patients should be provided special attention to ensure early intervention and treatment in clinical practice[17].

Sinusitis and rhinitis have been previously suggested as risk factors for the development of OSAHS, and this finding was proved in our study. Previous studies have suggested that the inflammatory process of sinusitis and rhinitis may lead to swelling and congestion of the nasal passages and sinuses[18]. This swelling and congestion can further affect the patency of the upper airway, making breathing difficult. During sleep, this difficulty in breathing may be further exacerbated by changes in position and muscle relaxation, leading to OSAHS, and sinusitis and rhinitis may lead to an increase in nasal and sinus secretions[19]. These secretions may block the upper airway and affect the smoothness of breathing. During sleep, these secretions may further accumulate, leading to complete obstruction of the upper airway, which may trigger apnea. In addition, our results suggest some interactions between adenoid and tonsil hypertrophy and sinusitis and rhinitis, which altogether affect the occurrence and development of OSAHS[20]. The pathological perspective suggests that adenoid and tonsil hypertrophy and sinusitis and rhinitis all involve inflammatory processes. These inflammatory processes may reinforce each other, thus creating a vicious cycle. For example, the inflammation of sinusitis and rhinitis may stimulate further hypertrophy of the adenoids and tonsils, which in turn may exacerbate the degree of inflammation in sinusitis and rhinitis[21]. This interaction may lead to the persistence and worsening of inflammation, thereby increasing the risk of OSAHS. Therefore, preventing inflammation of the airways in children with multiple risk factors is an important way to prevent and treat OSAHS.

Based on our findings, the following three management measures are recommended for the prevention of OSAHS in children. First, early screening and monitoring for OSAHS in children should be implemented, with special attention to those with symptoms such as adenoid hypertrophy, tonsillar hypertrophy, sinusitis, and rhinitis[22]. The risk of OSAHS should be detected and assessed through regular physical and ear–nose–throat (ENT) examinations. For children who have been diagnosed, regular follow-up and monitoring should be conducted to observe changes in the condition and adjust the treatment program in time. Second, lifestyle adjustment and education should involve encouraging children to maintain a healthy lifestyle, including a balanced diet, moderate exercise and regular work and rest[23]. Parents and children should be educated regarding OSAHS, such as avoiding sleeping on the back for a long time, reducing exposure to second-hand smoke, and controlling body weight. In addition, parents should pay attention to their children's sleep condition and seek medical treatment once symptoms such as snoring and apnea appear. Lastly, multidisciplinary collaboration and comprehensive treatment should be established through integrating the resources of ENT, pediatrics, stomatology, and other related departments, and working together to formulate a comprehensive treatment plan for children with OSAHS[24]. For children with enlarged adenoids or enlarged tonsils and other children who need surgical treatment, the indications for surgery should be strictly controlled to ensure the effect of surgery. Meanwhile, for children with sinusitis and rhinitis, the primary disease should be actively treated to reduce the impact of inflammation on the upper respiratory tract[25]. Through the implementation of the abovementioned three management measures, we can effectively reduce the incidence of OSAHS in children, improve the quality of life of the affected children, and promote their healthy growth. At the same time, these measures will also help to raise public awareness of and attention to OSAHS and promote research and development in related areas.

However, this study still has some limitations. First, the sample size is relatively small and may not fully reflect the overall situation. In the future, we may consider conducting a multicenter, large-sample study to obtain more accurate and reliable results. Second, this study mainly focused on the effects of adenoid hypertrophy, tonsillar hypertrophy, sinusitis, and rhinitis on OSAHS; other possible risk factors were not explored in depth. In future studies, we can further expand the scope of the study and synthesize more factors in order to comprehensively reveal the pathogenesis of OSAHS in children.

CONCLUSION

In conclusion, the results suggest that adenoid hypertrophy, tonsillar hypertrophy, sinusitis, and rhinitis are independent risk factors for the development of OSAHS in children, which need to be emphasized in clinical practice. We hope that these studies will provide a more accurate and effective basis for the diagnosis and treatment of OSAHS in children.