The purpose of this study was to determine the associations between cardiac function and postoperative adverse events in pediatric patients with obstructive sleep apnea (OSA).
Patients between birth and 18 years of age diagnosed with OSA between January 1, 2015, and December 31, 2018, who underwent echocardiographic evaluation within 6 months of surgery at a tertiary care children’s hospital were evaluated. Exclusion criteria included history of neuromuscular disorders, tracheostomy placement, or a predominance of central apneic events recorded during polysomnography (PSG). Patients were grouped by OSA severity. Chi-squared analysis and logistic regression were utilized to determine associations between demographic characteristics, OSA severity, preoperative echocardiographic abnormalities, and postoperative adverse events.
One hundred ten children met inclusion criteria for the study, including 22 with mild OSA, 22 with moderate OSA, and 66 with severe OSA. Race and the presence of congenital heart disease (CHD) were significantly associated with differences in OSA severity. Echocardiographic abnormalities were found in 45 patients, but exclusion of patients with CHD revealed no significant associations with differences in OSA severity. Postoperative adverse events were identified in 18 (16%) patients, and only O2 saturation nadir was found to be a significant predictor of these complications.
Preoperative echocardiogram abnormalities are not commonly found in children with OSA and presence of abnormalities does not predict postoperative adverse events. O2 saturation nadir measured on preoperative PSG is a significant predictor of postoperative adverse events and should be examined as a clinical indicator of OSA severity.
Obstructive sleep apnea (OSA) is a relatively common pediatric disorder, affecting up to 5% of children, and has been associated with significant comorbid conditions . In recent years, increased attention has been paid to the association of chronic upper airway obstruction with subclinical cardiac remodeling. Cases of left ventricular hypertrophy, reduced left ventricular diastolic function, pulmonary hypertension, and cor pulmonale have been reported in children with OSA, especially in those with greater severity of disease, as measured by the apnea-hypopnea index (AHI) recorded during overnight polysomnography [2,3,4,5]. Assessing cardiac function is of particular importance to the pediatric otolaryngologist in preparation for surgical treatment of the condition because of the reportedly increased incidence of postoperative complications in children with structural or functional cardiac abnormalities [6,7,8,9]. A preoperative echocardiogram is thus often ordered for patients considered to be at high risk for subclinical cardiac disease .
However, despite the regular use of echocardiography in the preoperative evaluation of pediatric patients with OSA, little agreement exists on the exact indications for this workup. Furthermore, although the association between OSA and cardiac remodeling is well established in the adult population , the evidence supporting a significant association between OSA and echocardiographic abnormalities in the pediatric population remains sparse; and even in cases where echocardiographic abnormalities are detected, correlation with postoperative adverse events has not been demonstrated [5,6,7]. Furthermore, the clinical management of these patients often remains unchanged, as the severity of their OSA and underlying comorbidities are sufficient indication for postoperative intensive care.
The objectives of this study are (1) to identify associations between demographic and clinical characteristics of patients who underwent surgery for OSA and the severity of their disease, the presence of preoperative echocardiographic abnormalities, and the incidence of postoperative complications; and (2) to identify associations between their cardiac function, the severity of their OSA, and the incidence of postoperative complications. Recognizing that a large proportion of children referred for preoperative echocardiography have underlying structural heart disease, we also sought to characterize these patients separately through subgroup analysis. Such information will enable healthcare practitioners to more precisely select patients who would benefit from preoperative cardiac evaluation and anticipate patients that require closer postoperative care.
This retrospective review study was approved by the Children’s Healthcare of Atlanta Institutional Review Board. Medical charts were reviewed to identify patients between birth and 18 years of age who were diagnosed with OSA (total AHI ≥ 1 during overnight polysomnography) between January 1, 2015, and December 31, 2018, and subsequently underwent both echocardiographic evaluation and surgery. Patients were included only if they underwent echocardiographic evaluation within 6 months of surgery and after polysomnographic evaluation. Surgeries to correct obstruction included tonsillectomy, adenoidectomy, lingual tonsillectomy, supraglottoplasty, palate surgery, and turbinate reduction. If patients had surgeries on multiple occasions for refractory OSA, polysomnographic, echocardiographic, and postoperative data were collected from the first surgery to avoid incorrect estimation of OSA severity and cardiac function due to potential improvement after prior surgeries. Patients were excluded if they had a history of neuromuscular disorders, tracheostomy placement, or a majority of central apneas or central hypopneas recorded on polysomnography.
Demographic data were collected for all patients from the date of polysomnography, including age, sex, race, ethnicity, weight, height, and systolic and diastolic blood pressure. Body mass index (BMI) was calculated and each patient’s BMI percentile for age was calculated using age- and gender-based growth charts for children and teens from the Centers for Disease Control and Prevention (CDC). For children less than 2 years old, weight-for-age charts were used as a substitute. Relevant patient comorbidities were also recorded, including chronic lung disease, developmental delay, congenital heart disease, allergy/eczema, gastroesophageal reflux disease (GERD), asthma, Down syndrome, and other congenital and chronic conditions. Charts were also reviewed for history of prior OSA surgeries.
All patients had undergone overnight polysomnography in an American Academy of Sleep Medicine-accredited laboratory at our institution. Polysomnographic data collected included total sleep time (TST), rapid eye movement (REM) TST, AHI, REM AHI, sleep efficiency, arousal index, O2 saturation nadir, TST with O2 saturation less than 90%, peak end-tidal CO2 level on expiration during sleep, and TST with end-tidal CO2 greater than 50 mmHg. Obstructive, mixed, and central apneas and hypopneas were included in the total AHI for each patient. If patients received respiratory intervention during the polysomnogram, the type of intervention (oxygen by nasal cannula or noninvasive positive pressure ventilation) was recorded and the polysomnographic data captured prior to intervention was collected. Based on total AHI, patients were grouped into three categories of OSA severity: mild (AHI 1 to < 5), moderate (AHI 5- to < 10), and severe (AHI ≥ 10) .
Standard transthoracic echocardiography was performed for each patient and interpreted by a board-certified pediatric cardiologist at our institution. Echocardiograms were evaluated for structural or functional abnormalities of the atria, ventricles, and valves. Qualitative descriptions of cardiac function by the attending pediatric cardiologist were also recorded for each patient.
Postoperative data were collected for each patient up to the date of discharge. Length of stay in the hospital and length of stay in the intensive care unit (ICU), if applicable, were recorded. Each patient’s postoperative course was then assessed for adverse events, including acute postoperative pulmonary edema, oxygen administration on postoperative day 1, positive pressure ventilation, nasopharyngeal airway, intubation, return to the operating room, laryngospasm, bronchospasm, admission to the ICU, postoperative cardiopulmonary evaluation by chest X-ray, electrocardiogram, or echocardiogram, postoperative cardiology consultation, hemorrhage at the surgical site, or death. If these events were expected supportive measures, such as planned admission to the ICU or planned oxygen administration, they were not considered adverse events. Concurrent OSA surgeries were also noted.
Statistical analysis was completed using JMP Pro (version 15.1, ©SAS Institute Inc., Cary, NC). Chi-squared analysis was performed to compare patient characteristics between patients with varying severity of OSA and between patients with presence or absence of postoperative adverse events. One-way ANOVA was performed to examine the differences between different OSA severities and the measures of polysomnogram and echocardiography. Multivariable logistic regression was performed to determine factors associated with postoperative adverse events.
During our 4-year observation period, 110 children who underwent OSA surgery met inclusion criteria for the study, including 22 (20%) with mild OSA, 22 (20%) with moderate OSA, and 66 (60%) with severe OSA. Demographic and clinical characteristics are listed in Table 1. The mean (standard deviation, SD) age of all patients was 4.7 (3.9) years, with 70 (63.6%) children of male sex. Race was significantly associated with differences in OSA severity (P value = 0.04), with 51 (77.3%) black patients diagnosed with severe OSA. The presence of any comorbidities was also significantly associated with differences in OSA severity (P value = 0.004), although further subgroup analysis revealed that this association was only significant for patients with congenital heart disease (CHD) and was not significant when these patients were excluded (P value < 0.0001 and 0.29, respectively). The most common comorbidities were CHD (n = 43), Down syndrome (n = 23), GERD (n = 22), developmental delay (n = 19), and asthma (n = 14). The most common forms of CHD were atrial septal defect (n = 15), ventricular septal defect (n = 11), patent foramen ovale (n = 9), patent ductus arteriosus (n = 6), and common atrioventricular canal (n = 5). No other demographic and clinical characteristics carried significant associations with differences in OSA severity.
Regarding polysomnographic data, the total AHI, REM AHI, arousal index, and O2 saturation nadir were all significantly associated with differences in OSA severity (Table 2). The mean (SD) total AHI was 23.1 (26.3) for all patients and 35.2 (28.0) in the severe group. The mean (SD) O2 saturation nadir measured during sleep was 76.2% (12.0) for all patients and 72.3% (11.6) in the severe group. The total number of patients that required supplemental O2 administration during overnight polysomnography was 28 (25.5%), but this variable was not statistically significant.
Echocardiographic abnormalities of any kind were found in 45 (40.9%) patients and were significantly associated with differences in OSA severity (P value < 0.0001) (Table 3). However, subgroup analysis of patients with and without accompanying CHD revealed that the presence of echocardiographic abnormalities and CHD was statistically significant (n = 43 [39.1%], P value <0.0001), while the presence of echocardiographic abnormalities without accompanying CHD carried no significant association (n = 2 [1.8%], P value = 0.51). The echocardiographic abnormalities of the two patients without CHD included mild flow acceleration across the aortic valve, moderately hypertrophied left ventricle, and mild septal hypertrophy. Of note, pulmonary hypertension was only found in one patient with echocardiographic abnormalities, and this patient had suffered from persistent pulmonary hypertension since birth, as well as congenital heart block secondary to maternal Sjogren’s disease.
Postoperative adverse events were found in 18 (16.4%) patients (Table 4). The most common adverse events included unexpected admission to the ICU (n = 9), unexpected supplemental O2 administration on postoperative day 1 (n = 9), intubation (n = 7), use of positive pressure ventilation (n = 6), and postoperative cardiopulmonary evaluation by chest X-ray, electrocardiogram, or echocardiogram (n = 4). Of note, neither of the patients with no CHD with echocardiographic abnormalities experienced postoperative complications, nor did the sole patient with pulmonary hypertension. Of the 29 patients who underwent concurrent OSA surgeries, 5 (27.8%) suffered an adverse event, but this association was not statistically significant.
The mean (SD) O2 saturation nadir on polysomnography for patients with any adverse event was 69.8% (15.4) and carried a significant association (P value = 0.01). Table 5 displays logistic regression analysis of possible factors determining the presence of adverse events. Higher O2 saturation nadir continued to be a protective factor with an odds ratio of 0.95 (CI: 0.91–0.99, P value = 0.03) after the model adjusted for age, sex, BMI percentile, the presence of CHD, and total AHI. All other demographic, clinical, polysomnographic, and echocardiographic characteristics carried no significant associations with the presence of adverse events.
This study examined the severity of pediatric OSA in relationship with both preoperative echocardiographic findings and postoperative adverse events. When accounting for the presence of CHD as a confounding factor, we found no significant associations between the presence of an echocardiographic abnormality and differences in OSA severity. Out of 67 patients without CHD, only two had an echocardiographic abnormality, and neither of them had abnormalities considered to be clinically significant by the attending cardiologist. Furthermore, pulmonary hypertension was only found in one patient who had been suffering from persistent pulmonary hypertension since birth. Regarding postoperative course, there were no significant associations between the presence of adverse events and differences in OSA severity or echocardiographic abnormalities; however, adverse events were significantly associated with the lowest O2 saturation recorded on overnight polysomnography.
Left untreated, the presence of partial or complete upper airway obstruction during sleep predisposes children to significant morbidity, including growth and developmental delays; behavioral problems such as enuresis, hyperactivity, and depression; poor school performance; and decreased quality of life [13,14,15]. Elevated systolic and diastolic blood pressure measurements have also been linked with pediatric OSA and increase the risk that the child will develop hypertension and metabolic syndrome as an adult [16,17,18]. The prevailing academic opinion also holds that pediatric patients with OSA are at greater risk for pulmonary hypertension (PH), an association already well established in adult patients with OSA, and that these patients have increased rates of postoperative complications . Current pediatric PH guidelines, established by the American Heart Association (AHA) and American Thoracic Society (ATS) in 2015, thus recommend echocardiography in patients with severe OSA to diagnose PH and other echocardiographic abnormalities that may influence clinical care .
Evidence that pediatric OSA is associated with subclinical cardiac remodeling originates from a number of studies that reported statistically significant echocardiographic abnormalities in children with sleep-disordered breathing. These abnormalities included findings of left and right ventricular hypertrophy and decreased diastolic function, as well as tricuspid regurgitation suggestive of pulmonary hypertension [3, 4, 21,22,23,24,25]. However, as Burns et al. noted, these studies did not uniformly diagnose OSA by overnight polysomnography, including the studies cited in the AHA/ATS guidelines . Furthermore, some studies identified statistically significant demographic and clinical variables, such as age, BMI, systemic blood pressure, serum C-reactive protein, and sickle cell disease that may have been contributing factors [10, 26,27,28].
In comparison, recent studies have suggested that OSA severity is not associated with echocardiographic abnormalities and even that the presence of OSA of any severity does not predict cardiac remodeling. Teplitzky et al. reviewed 47 patients with severe OSA, excluding those with underlying CHD and found no significant echocardiographic abnormalities . Searching specifically for PH in a cohort of 57 children with OSA and without underlying CHD, Revenaugh et al. found zero instances of the condition . In an even larger study, Burns et al. studied echocardiogram reports from 163 pediatric patients with OSA and found only three cases of PH. Each of the three patients had underlying CHD; two of them had obesity; and none of them had severe OSA .
Considering the putative purpose of preoperative echocardiograms is to identify patients at higher risk of postoperative complications; there is a relative paucity of literature examining the postoperative course of patients undergoing OSA surgery. Previous studies have found a significant association between OSA severity and the appearance of postoperative complications [6, 29]. However, very few have found any significant associations between these complications and preoperative echocardiographic abnormalities . Kalra et al. demonstrated in a case-control study of 24 patients who suffered postoperative complications that these patients had an increased prevalence of left ventricular hypertrophy; however, the authors did not have access to the patients’ preoperative polysomnograms and could not comment on OSA severity as a contributing factor . In a study of 241 obese children undergoing tonsillectomy-adenoidectomy (TA), Larrier et al. were able to identify a significant association between echocardiographic abnormalities and postoperative complications; however, these complications were heavily skewed towards hospital stay > 24 h, and, as the authors noted, the 2011 American Academy of Otolaryngology-Head and Neck Surgery clinical practice guidelines already recommend that obese children be monitored overnight following TA .
The purpose of our study was to clarify the contrasting theories currently held in the literature regarding these issues. However, our study is not without limitations, including selection bias based on a lack of standardized guidelines for referral to cardiology, a low number of patients without CHD who had echocardiographic abnormalities, and a low number of patients with pulmonary hypertension. Other limitations include inconsistent reporting of continuous echocardiographic data by the attending cardiologists. This hindered our ability to review reports, make our own assessments, and, importantly, distinguish between abnormalities likely caused by CHD and abnormalities likely caused by OSA. However, given the consistent findings across echocardiograms and postoperative clinical courses, we feel that our data may be generalizable.
Our investigation confirmed that the presence of CHD is significantly associated with differences in OSA severity, likely because CHD is often a comorbid condition with other chronic conditions that affect the upper airway, such as trisomies, craniofacial anomalies, and GERD . Future analysis could delineate the exact contributions of each comorbidity to the AHI. Our study did not find that OSA severity predicts echocardiographic abnormalities or postoperative complications. In fact, no demographic or clinical variable, including the presence of CHD, predicted adverse events. The use of an alternate anesthetic for children with CHD may have reduced our ability to identify a significant association with postoperative events, but this practice is already standard of care for these children and would not have been affected by the results of preoperative polysomnography or echocardiography. Finally, our study revealed that O2 saturation nadir on preoperative polysomnography is significantly associated with complications, even when accounting for other demographic and clinical variables, suggesting that clinicians should keep a wary eye on these patients.
Our study has provided further evidence that OSA severity in children is not significantly associated with abnormalities on preoperative echocardiogram and that postoperative complications cannot be predicted by either preoperative OSA severity or echocardiographic findings. The regular use of echocardiogram does not provide benefit or change clinical management and should be used selectively by the patient care team in order to reduce healthcare costs and unnecessary testing. Although the predictors of postoperative adverse events remain unclear, our results suggest that the lowest O2 saturation recorded on preoperative polysomnogram may be an important clinical measure of OSA severity and should be investigated as an indication for closer postoperative care.
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We thank Ms. Carol Price and Ms. Dollicia Purvis, from Children’s Healthcare of Atlanta REDCap Administration, who dedicated their time and efforts in supporting this research.
This study did not receive financial support.
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Pettitt-Schieber, B., Tey, C.S., Hill, R. et al. The utility of preoperative echocardiography in pediatric obstructive sleep apnea. Sleep Breath (2021). https://doi.org/10.1007/s11325-021-02303-5
- Obstructive sleep apnea
- Pulmonary hypertension
- Postoperative care