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Original Research |

Esophageal Pressures, Polysomnography, and Neurobehavioral Outcomes of Adenotonsillectomy in Children

Ronald D. Chervin, MD; Deborah L. Ruzicka, PhD, RN; Timothy F. Hoban, MD; Judith L. Fetterolf, RPSGT, REEGT; Susan L. Garetz, MD; Kenneth E. Guire, MS; James E. Dillon, MD; Barbara T. Felt, MD; Elise K. Hodges, PhD; Bruno J. Giordani, PhD; for the American Academy of Sleep Medicine
Author and Funding Information

From the Sleep Disorders Center and Department of Neurology (Drs Chervin and Ruzicka and Ms Fetterolf), Sleep Disorders Center and Division of Pediatric Neurology, Department of Pediatrics and Communicable Diseases (Dr Hoban), Sleep Disorders Center and Department of Otolaryngology/Head and Neck Surgery (Dr Garetz), Department of Biostatistics (Mr Guire), Division of Child and Adolescent Psychiatry, Department of Psychiatry (Dr Dillon), Division of Child Behavioral Health, Department of Pediatrics and Communicable Diseases (Dr Felt), and Neuropsychology Section, Department of Psychiatry (Drs Hodges and Giordani), University of Michigan, Ann Arbor, MI.

Correspondence to: Ronald D. Chervin, MD, Michael S. Aldrich Sleep Disorders Laboratory, C728 Med Inn, Box 5845, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5845; e-mail: chervin@umich.edu

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Chervin has received gifts to support education from Philips Respironics and Fisher & Paykel Healthcare Limited, holds a professorship funded in part by Philips Respironics, and serves as a member of the board of directors for the American Academy of Sleep Medicine and the International Pediatric Sleep Association. The remaining authors have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or in the preparation of the manuscript.

Funding/Support: This work was supported by the National Institutes of Health [Grants R01 HL080941, R01 HL105999, UL1 RR024986].


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

Funding/Support: This work was supported by the National Institutes of Health [Grants R01 HL080941, R01 HL105999, UL1 RR024986].


Chest. 2012;142(1):101-110. doi:10.1378/chest.11-2456
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Background:  Esophageal pressure monitoring during polysomnography in children offers a gold-standard, “preferred” assessment for work of breathing, but is not commonly used in part because prospective data on incremental clinical utility are scarce. We compared a standard pediatric apnea/hypopnea index to quantitative esophageal pressures as predictors of apnea-related neurobehavioral morbidity and treatment response.

Methods:  Eighty-one children aged 7.8 ± 2.8 (SD) years, including 44 boys, had traditional laboratory-based pediatric polysomnography, esophageal pressure monitoring, multiple sleep latency tests, psychiatric evaluations, parental behavior rating scales, and cognitive testing, all just before clinically indicated adenotonsillectomy, and again 7.2 ± 0.8 months later. Esophageal pressures were used, along with nasal pressure monitoring and oronasal thermocouples, not only to identify respiratory events but also more quantitatively to determine the most negative esophageal pressure recorded and the percentage of sleep time spent with pressures lower than −10 cm H2O.

Results:  Both sleep-disordered breathing and neurobehavioral measures improved after surgery. At baseline, one or both quantitative esophageal pressure measures predicted a disruptive behavior disorder (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-defined attention-deficit/hyperactivity disorder, conduct disorder, or oppositional defiant disorder) and more sleepiness and their future improvement after adenotonsillectomy (each P < .05). The pediatric apnea/hypopnea index did not predict these morbidities or treatment outcomes (each P > .10). The addition of respiratory effort-related arousals to the apnea/hypopnea index did not improve its predictive value. Neither the preoperative apnea/hypopnea index nor esophageal pressures predicted baseline hyperactive behavior, cognitive performance, or their improvement after surgery.

Conclusions:  Quantitative esophageal pressure monitoring may add predictive value for some, if not all, neurobehavioral outcomes of sleep-disordered breathing.

Trial registry:  ClinicalTrials.gov; No.: NCT00233194; URL: www.clinicaltrials.gov

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