1. Obstructive Sleep Apnea
Do I need a sleep study?
Alicia Chaves, MD

2. Clinical Case
You are at your continuity clinic and are seeing your eighth patient. You are about to finish the visit, but Mom has one more issue to discuss:
Your patient snores, seems very sleepy during the day, and Mom has noticed that sometimes he stops breathing in his sleep.
What is your next step?
Sleep study vs. ENT referral?

3. Clinical Question
In a patient with clinical signs and symptoms of OSA, does T&A improve symptoms, despite sleep study results?
In other words, do you really need that sleep study?

4. Obstructive Sleep Apnea
Sleep disorder characterized by cessation of breathing caused by upper airway obstruction
May affect 1-3% of children
Gold standard of diagnosis is polysomnography.
In otherwise healthy children, T&A can eliminate obstruction in 85-95%.

5. Clinical effects of OSA
Disordered sleep patterns
Daytime sleepiness
Behavioral problems
Depression
Poor school performance
Pulmonary hypertension
Growth failure

6. Polysomnography
Measures EEG, EMG, pulse oximetry, apneic/hypopneic events
Expensive, requires overnight stay
Delayed diagnosis and treatment

7. Literature Search PubMed AND…. Obstructive sleep apnea and diagnosis
Limits: full text, English, all child, RCT
Six results:
2: using CPAP in OSA
1: abx use for tonsillar hypertrophy in OSA
1: atrial overdrive pacing vs. CPAP
1: nonsurgical methods of treating upper airway obstruction
AND….

8. The Article Clinical Assessment of Pediatric Obstructive Sleep Apnea
Goldstein, et al. Pediatrics Jul;114(1):33-43.
OBJECTIVE: To determine whether children with a clinical assessment suggestive of obstructive sleep apnea (OSA) but with negative polysomnography (PSG) have improvement in their clinical assessment score after tonsillectomy and adenoidectomy (T&A) as compared with similar children who do not undergo surgery.

9. Initial Analysis Prospective, RCT
Patients: children with clinical diagnosis of OSA
Intervention: T&A
Outcome: change in clinical score of OSA

10. Patient Population
78 children, ages 2-14 yrs, with “clinical diagnosis” of OSA
Inclusion criteria: score >40 on clinical assessment
Exclusion criteria: craniofacial syndromes, neuromuscular disorders, cranial nerve palsies

11. Methods Clinical assessment score
Scores patients for signs and symptoms of OSA
Includes questions for parents, physical exam findings, sleep tape, lateral neck film, echo
Score of >40 is “positive”

14. Clinical Assessment Score
Goldstein NA, et al. Otolaryngol Head Neck Surg Nov;111(5):611-7.
Used clinical assessment score prospectively to “predict which pts would have + PSG
Sensitivity: 92%, specificity: 29%
PPV: 50%

15. Are the results valid? Was treatment randomized?
Yes, but only the PSG- group
Was randomization concealed?
Yes
Were patients and clinicians blinded to treatment?
Patients-no, some clinicians-yes
Intention to treat analysis? No
Was follow-up sufficiently long and complete?
Yes and no

17. Are the results valid?
Were groups similar at the start? NO

18. Results PPV of clinical assessment score for +PSG was 48%
Change score for PSG- T&A group was significantly higher than PSG- nonsurgery group.
The number of pts with a score of <40 following intervention was significantly higher in PSG- T&A group vs nonsurgery group

20. (Relative Risk Reduction) ARR (Absolute Risk Reduction) NNT
Score:
>20
>40
RRR
(Relative Risk Reduction)
ARR
(Absolute Risk Reduction)
NNT
(Number Needed to Treat)
CER
(Control Event Rate)
EER
(Experimental Event Rate)
CER-EER
1/ARR
0.78
 0.44
0.18
0.77 1
0.6
0.44 2 3

21. Confidence Intervals Score >20 Score >40 95% CI for ARR
95% CI for NNT
2-4
2-9

22. Are the results useful? Can the results be applied to my patient?
Yes…
Were clinically important outcomes considered?
Yes, but…

24. Are the results useful?
Are the likely treatment benefits worth the harms and costs?
Risks of T&A
Spontaneous resolution of OSA sxs
Intensive clinical assessment score