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Adenotonsillectomy and Sleep Apnea in ChildrenAdenotonsillectomy and Sleep Apnea in Children FREE TO VIEW

Oreste Marrone, MD; Giuseppe Insalaco, MD; Adriana Salvaggio, MD
Author and Funding Information

Affiliations: Consiglio Nazionale delle Ricerche, Palermo, Italy,  Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel

Correspondence to: Oreste Marrone, MD, Consiglio Nazionale delle Ricerche, IBIM, Sezione di Fisiopatologia Respiratoria, Via Ugo La Malfa, 153, 90146 Palermo, Italy; e-mail: marrone@ibim.cnr.it



Chest. 2004;125(6):2363-2365. doi:10.1378/chest.125.6.2363
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Published online

To the Editor:

We read with interest the article by Tal et al (September 2003)1 on the effects of adenotonsillectomy on respiratory disorders in non-rapid eye movement (REM) and REM sleep, and on sleep architecture in children with obstructive sleep apnea syndrome. The authors demonstrated that surgery is followed by a significant reduction in respiratory disturbance index (RDI) both in non-REM and REM sleep. However, because in non-REM sleep the RDI on average decreased to < 1, while in REM sleep it did not, they conclude that adenotonsillectomy induces a greater improvement in non-REM than in REM respiratory disorders.

We previously explored the effects of upper airway surgery on respiratory disorders in non-REM and REM sleep in adults with obstructive sleep apnea syndrome.2 We found that all respiratory parameters changed similarly in the two sleep states, and that there was no statistically significant interaction between treatment and sleep state. Only a small subgroup of subjects showed a greater improvement in RDI during non-REM sleep, but this was not associated with a better improvement in arterial oxygen saturation. On average, AHI was not normalized in the patients in our study during either non-REM or REM sleep, which is different from the results of the study of Tal et al.1 The conclusion of our study was that the effects of surgery on breathing during sleep are similar in the two sleep states.

Because our study investigated adult patients, while the study of Tal et al1 investigated only children, different results could be expected. However, we believe that, from the point of view of the absolute decrease in RDI, the effects of surgery may be considered to be similar in adults and children.

In consideration of the RDI values recorded in the study of Tal et al1 after surgery, we agree that in the children the correction of respiratory disorders was more complete in non-REM sleep, so that adenotonsillectomy can be considered a more effective treatment for non-REM obstructive disorders than for REM obstructive disorders. However, in absolute terms, RDI did not decrease more in non-REM sleep (median value before surgery, 3.0; after surgery, 0.4) than in REM sleep (before surgery, 7.8; after surgery, 2.3). The more satisfactory RDI in non-REM sleep after surgery may depend, at least in part, on a lower RDI before surgery, and not on a greater effect of the adenotonsillectomy in this sleep state.

Figure Jump LinkFigure 1. The effect of adenotonsillectomy on respiratory disturbance index (RDI) during REM and non-REM sleep. Each circle represents an individual child’s REM and NREM RDI. The solid line represents the identity of RDI during REM and non-REM sleep. Note that following adenotonsillectomy (T & A), NREM RDI was corrected (≤ 1.5 events/h) in most of the children (n = 28, 77.8%), while REM RDI was corrected only in 16 children (44%).Grahic Jump Location
Tal, A, Bar, A, Leiberman, A, et al (2003) Sleep characteristics following adenotonsillectomy in children with obstructive sleep apnea syndrome.Chest124,948-953. [CrossRef] [PubMed]
 
Marrone, O, Salvaggio, A, Insalaco, G, et al Respiration in NREM and REM sleep after upper airway surgery for obstructive sleep apnoea.J Sleep Res1995;4,189-195. [CrossRef] [PubMed]
 

Adenotonsillectomy and Sleep Apnea in Children

To the Editor:

We thank Dr. Marrone and colleagues for their interest in our article1on the effect of adenotonsillectomy on respiratory events during rapid-eye movement (REM) and non-REM (NREM) sleep in children with obstructive sleep apnea syndrome (OSAS). In otherwise healthy children, hypertrophied adenoids and tonsils are the main cause of OSAS; therefore, adenotonsillectomy is the treatment of choice, which is not the case in adults. Marrone et al2found in adults with severe OSAS (apnea hypopnea index [AHI] > 60/h) that the degree of improvement in respiration after upper airway surgery was similar in NREM and REM sleep. This makes their data difficult to compare to results from children, because surgical treatment for adults is more beneficial in mild-to-moderate cases of OSAS (AHI < 25/h). Oksenberg et al3 showed that in adult patients treated with continuous positive airway pressure, higher pressures are needed during REM sleep, indicating that the upper airway resistance is higher during REM sleep. This effect is probably due to greater atonia of the skeletal muscles during REM sleep, which results in an increased upper airway resistance.

In children, OSAS is very much an REM-related disease (Fig 1 ),1 with obstructive apneas occurring more frequently, for a longer duration, and with more oxygen desaturation during REM than NREM sleep.4 Following adenotonsillectomy (Fig 1), mean respiratory disturbance index (RDI) during REM sleep was higher than NREM.,1 Mean REM RDI improved following adenotonsillectomy by 83% as compared to 60% improvement in NREM RDI. Thus, we can safely conclude that OSAS in children is REM related, and adenotonsillectomy resulted in a greater improvement in non-REM RDI as compared with REM RDI.

References
Tal, A, Bar, A, Leiberman, A, et al Sleep characteristics following adenotonsillectomy in children with obstructive sleep apnea syndrome.Chest2003;124,948-953. [CrossRef] [PubMed]
 
Marrone, O, Salvaggio, A, Insalaco, G, et al Respiration in NREM and REM sleep after airway surgery for obstructive sleep apnoea.J Sleep Res1995;4,189-195. [CrossRef] [PubMed]
 
Oksenberg, A, Silverberg, DS, Arons, E, et al The sleep supine position has a major effect on optimal nasal continuous positive airway pressure: relationship with rapid eye movements and non-rapid eye movements sleep, body mass index, respiratory disturbance index, and age.Chest1999;116,1000-1006. [CrossRef] [PubMed]
 
Goh, YTD, Galster, P, Marcus, CL Sleep architecture and respiratory disturbances in children with obstructive sleep apnea.Am J Respir Crit Care Med2000;162,682-686. [PubMed]
 

Figures

Figure Jump LinkFigure 1. The effect of adenotonsillectomy on respiratory disturbance index (RDI) during REM and non-REM sleep. Each circle represents an individual child’s REM and NREM RDI. The solid line represents the identity of RDI during REM and non-REM sleep. Note that following adenotonsillectomy (T & A), NREM RDI was corrected (≤ 1.5 events/h) in most of the children (n = 28, 77.8%), while REM RDI was corrected only in 16 children (44%).Grahic Jump Location

Tables

References

Tal, A, Bar, A, Leiberman, A, et al (2003) Sleep characteristics following adenotonsillectomy in children with obstructive sleep apnea syndrome.Chest124,948-953. [CrossRef] [PubMed]
 
Marrone, O, Salvaggio, A, Insalaco, G, et al Respiration in NREM and REM sleep after upper airway surgery for obstructive sleep apnoea.J Sleep Res1995;4,189-195. [CrossRef] [PubMed]
 
Tal, A, Bar, A, Leiberman, A, et al Sleep characteristics following adenotonsillectomy in children with obstructive sleep apnea syndrome.Chest2003;124,948-953. [CrossRef] [PubMed]
 
Marrone, O, Salvaggio, A, Insalaco, G, et al Respiration in NREM and REM sleep after airway surgery for obstructive sleep apnoea.J Sleep Res1995;4,189-195. [CrossRef] [PubMed]
 
Oksenberg, A, Silverberg, DS, Arons, E, et al The sleep supine position has a major effect on optimal nasal continuous positive airway pressure: relationship with rapid eye movements and non-rapid eye movements sleep, body mass index, respiratory disturbance index, and age.Chest1999;116,1000-1006. [CrossRef] [PubMed]
 
Goh, YTD, Galster, P, Marcus, CL Sleep architecture and respiratory disturbances in children with obstructive sleep apnea.Am J Respir Crit Care Med2000;162,682-686. [PubMed]
 
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