September 2019 HSC Section 1 Congenital and Pediatric Problems

Research Original Investigation

Predictors of Obstructive Sleep Apnea Severity in Adolescents

in adults. 9 Because the mean age of the patients in our study was 14.6 years, a plausible explanation for the discord be- tween adolescents and adults is that there are changes in air- way physiology or fat distribution that occur in late adoles- cenceor adulthood thatwerenot detected inour comparatively younger population. There are a number of strengths to this study. It included a large and heterogeneous population of adolescents who all had PSG. All PSGwas performed at the same facility over a set time period, whichmay reduce interfacility variation in tech- nique and analysis. In addition, to our knowledge, this is 1 of a few studies that focused onOSA in adolescents. Limiting the age range for subjects may remove an important potential source of confounding. Limitations There are limitations that need further discussion. The study was retrospective, and some patients were excluded owing to incomplete data availability that introduces a potential source of confounding. While whites, African Americans, and Hispanics were well represented, Asians and Native Ameri- cans were poorly represented, so our results may be less ap- plicable to those ethnicities. Our study population was also composed of only adolescents referred to a tertiary pediatric center for PSG for suspected OSA and, as such, may not rep- resent the general population of adolescents. In addition, ado- lescents with considerable comorbidities were excluded from this study and predictors of OSA severity may be different if considerable comorbidities are present. Conclusions In this study of 224 adolescents aged 12 to 17 years with sub- jective sleep disturbances, increasing AHI was associatedwith obesity and tonsillar hypertrophy while severe OSA was pre- dicted by obesity, male sex, and tonsillar hypertrophy. A low threshold for obtaining PSG to screen for OSA is warranted in obese,male adolescentswith tonsillar hypertrophy and symp- toms of sleep disordered breathing. Additional large prospec- tive studies focusing on OSA in adolescents are needed.

cents, our findings agree with Redline et al, 15 who found in- creased rates of OSA in adolescent males. Similarly, we report that tonsillar hypertrophywas associatedwithOSA severity. In a study of 69 obese children aged 10 to 18 years, Verhulst et al 22 reported an associationbetween tonsillar hypertrophy andAHI in childrenwithmild (AHI <2), but notmoderate or severe OSA (AHI ≥2). At least 3 other studies have also reported a correla- tion between tonsillar hypertrophy and OSA severity in chil- dren and adolescents. 6,21,23 We did not find a correlation between African American ethnicity or age and OSA severity in adolescents. These find- ings are consistent with Redline et al, 15 who found no signifi- cant difference inOSAseverity inadolescents or betweenwhite andAfrican-Americanadolescents. These findings are also con- sistent with a number of studies in younger children that have failed to find differences in OSA severity between children of different ethnicities, 16,17,20 or ages. 6,7,17 However, African American ethnicity has been strongly linked to OSA severity Table 4. Univariate Logistic Regression Model of Predictors of Severe OSA (AHI ≥ 10) Variable OR (95% CI) Age 1.1 (0.9-1.3) Male 1.8 (1.0-3.2) Weight classification a 2.0 (1.3-3.2) Tonsillar hypertrophy 3.2 (1.8-5.8) African American 1.2 (0.68-2.2) Abbreviations: AHI, apnea hypopnea index; OR, odds ratio; OSA, obstructive sleep apnea. a Weight classification; normal weight, overweight, obese. Based on ANOVA. Table 5. Multiple Logistic Regression Model of Predictors of Severe OSA (AHI ≥ 10) Variable OR (95% CI) Male 2.3 (1.2-4.3) Weight classification a 2.2 (1.4-3.6) 3+/4+ Tonsils 3.8 (2.0-7.1) Abbreviations: AHI, apnea hypopnea index; OSA, obstructive sleep apnea. a Weight classification; normal weight, overweight, obese. Based on ANOVA.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. REFERENCES 1 . Jackson ML, Howard ME, Barnes M. Cognition and daytime functioning in sleep-related breathing disorders. Prog Brain Res . 2011;190:53-68 . 2 . Lumeng JC, Chervin RD. Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc . 2008;5(2):242-252 . 3 . Gabbay IE, Lavie P. Age- and gender-related characteristics of obstructive sleep apnea. Sleep Breath . 2012;16(2):453-460 . 4 . Mitchell RB, Garetz S, Moore RH, et al. The use of clinical parameters to predict obstructive sleep apnea syndrome severity in children: the Childhood

ARTICLE INFORMATION Accepted for Publication: January 10, 2017. Published Online: February 23, 2017. doi: 10.1001/jamaoto.2016.4130 Author Contributions: Dr Mitchell had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: All authors. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: All authors. Critical revision of the manuscript for important intellectual content: Scott, Johnson, Mitchell. Statistical analysis: Scott, Johnson. Administrative, technical, or material support: Johnson, Mitchell. Supervision: Johnson.

Adenotonsillectomy (CHAT) study randomized clinical trial. JAMA Otolaryngol Head Neck Surg . 2015;141(2):130-136 . 5 . Redline S, Tishler PV, Schluchter M, Aylor J, Clark K, Graham G. Risk factors for sleep-disordered breathing in children. Associations with obesity, race, and respiratory problems. Am J Respir Crit Care Med . 1999;159(5 Pt 1):1527-1532 . 6 . Lam YY, Chan EY, Ng DK, et al. The correlation among obesity, apnea-hypopnea index, and tonsil size in children. Chest . 2006;130(6):1751-1756 . 7 . Kohler MJ, Thormaehlen S, Kennedy JD, et al. Differences in the association between obesity and obstructive sleep apnea among children and adolescents. J Clin Sleep Med . 2009;5(6):506-511 . 8 . Graw-Panzer K, Muzumdar H, Jambhekar S, Goldstein N, Rao M. Effect of increasing body mass

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