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Contribution of body habitus and craniofacial characteristics to segmental closing pressures of the passive pharynx in patients with sleep-disordered breathing. Am J Respir Crit Care Med 2002, 165:260-265. 14 Haponik EF, Smith PL, Bohlman ME, Allen RP, Goldman SM, Bleecker ER: Computerized tomography in obstructive sleep apnea. Correlation of airway size with physiology during sleep and wakefulness. Am Rev Respir Dis 1983, 127:221-226. 15 Rivlin J, Hoffstein V, Kalbfleisch J, McNicholas W, Zamel N, Bryan AC: Upper airway morphology in patients with idiopathic obstructive sleep apnea. Am Rev Respir Dis 1984, 129:355-360. 16 Anch AM, Remmers JE, Bunce H 3rd: Supraglottic airway resistance in normal subjects and patients with occlusive sleep apnea. J Appl Physiol 1982, 53:1158-1163. 17 Stauffer JL, Zwillich CW, Cadieux RJ, Bixler EO, Kales A, Varano LA, White DP: Pharyngeal size and resistance in obstructive sleep apnea. Am Rev Respir Dis 1987, 136:623- 627. 18 Martin SE, Marshall I, Douglas NJ: The effect of posture on airway caliber with the sleep-apnea/hypopnea syndrome. Am J Respir Crit Care Med 1995, 152:721-724. 19 Rodenstein DO, Doom G, Thomas Y, Liistro G, Stanescu DC, Culee C, Aubert-Tulkens G: Pharyngeal shape and dimension in healthy subjects, snorers, and patients with obstructive sleep apnea. Thorax 1990, 45:722-727. 20 Verin E, Tardif C, Buffet X, Marie JP, Lacoume Y, Andrieu- Guitrancourt J, Pasquis P: Comparison between anatomy and resistance of upper airway in normal subjects, snorers and OSAS patients. Respir Physiol 2002, 129:335-343. 21 Sforza E, Bacon W, Weiss T, Thibault A, Petiau C, Krieger J: Upper airway collapsibility and cephalometric variables in patients with obstructive sleep apnea. Am J Respir Crit Care Med 2000, 161:347-352. 22 Tantucci C, Mehiri S, Duguet A, Similowski T, Arnulf I, Zelter M, Derenne JP, Milic-Emili J: Application of negative expiratory pressure during expiration and activity of genioglossus in humans. J Appl Physiol 1998, 84:1076-1082. 23 Tantucci C, Duguet A, Ferretti A, Mehiri S, Arnulf I, Zelter M, Similowski T, Derenne JP, Milic-Emili J: Effect of negative expiratory pressure on respiratory system flow resistance in awake snorers and nonsnorers. J Appl Physiol 1999, 87:969- 976. 24 American Academy of Sleep Medicine Task Force: Sleeprelated breathing disorders in adults: recommendation for syndrome definition and measurement techniques in clinical research. Sleep 1999, 22:667-689. 25 Quanjer PT, Tammeling GJ, Cotes JE, Fabbri LM, Matthys H, Pederson OF, Peslin R, Roca J, Sterk PG, Ulmer WT: Lung volume and forced ventilatory flows. Report Working Party Standardisation of Lung Function Tests, European Community for Steel and Coal. Official Statement of the European Respiratory Society. Eur Resp J Suppl 1993, 16:5- 40. 26 Koulouris NG, Valta P, Lavoie A, Corbeil C, Chasse M, Braidy J, Milic- Emili J: A simple method to detect expiratory flow limitation during spontaneous breathing. Eur Respir J 1995, 8:306-313. 27 Liistro G, Veriter C, Dury M, Aubert G, Stanescu D: Expiratory flow limitation in awake sleep-disordered breathing subjects. Eur Respir J 1999, 14:185-190. 28 Verin E, Tardif C, Portier F, Similowski T, Pasquis P, Muir JF: Evidence for expiratory flow limitation of extrathoracic origin in patients with obstructive sleep apnea. Thorax 2002, 57:423-428. 29 Van Meerhaeghe A, Delpire P, Stenuit P, Kerkhofs M: Operating characteristic of the negative expiratory pressure technique in predicting obstructive sleep apnea syndrome in snoring patients. Thorax 2004, 59:883-888. 30 Tamisier R, Wuyam B, Nicolle I, Pepin JL, Orliaguet O, Perrin CP, Levy P: Awake flow limitation with negative expiratory pressure in sleep disordered breathing. Sleep Medicine 2005, 6:205-213. 31 Insalaco G, Romano S, Marrone O, Salvaggio A, Bonsignore G: A new method of negative expiratory pressure test analysis detecting upper airway flow limitation to reveal obstructive sleep apnea. Chest 2005, 128:2159-2165. 32. Jan MA, Marshall I, Douglas NJ: Effect of posture on upper airway dimensions in normal human. Am J Respir Crit Care Med 1994, 149:145-148. 33 Yildirim N, Fitzpatrick MF, Whyte KF, Jalleh R, Wightman AJ, Douglas NJ: The effect of posture on upper airway dimensions in normal subjects and in patients with the sleeapnea/hyperpnea syndrome. Am Rev Respir Dis 1991, 144:845-847 70 Respiratory Therapy Vol. 2 No. 3 � June-July 2007
Who Should Have A Sleep Study For Sleep Related Breathing Disorders? L. Whiteford, P. Fleming, A. J. Henderson By the time children are 5 years old more of their life will have been spent asleep than awake. Sleep medicine is therefore especially relevant in pediatrics. However, one recent survey showed that pediatricians’ knowledge of sleep medicine is poor and that few pediatricians enquire about sleep as part of their general consultation. 1 Ventilatory function is physiologically reduced during sleep in adults and children. Therefore, respiratory disorders are exacerbated and may only be clinically apparent during sleep. Assessing respiratory status only when a child is awake will underestimate the severity of sleep related breathing disorders or miss them altogether. Such failure to recognize sleep related breathing disorders can have significant adverse consequences on children’s physical health and on their behavior and learning. How are sleep related problems identified? The first step towards identifying a sleep related breathing disorder is to take a careful history. Symptoms during sleep and wakefulness should be enquired about as part of the general pediatric consultation (table 1). Symptoms of sleep disturbance are commonly reported by parents and include behavioural problems, parasomnias, and insomnia. 2 The commonest symptom associated with possible sleep disordered breathing is snoring, which may occur occasionally, only in association with upper respiratory infection or seasonal rhinitis, or on the majority of nights, termed habitual snoring. A history of snoring may be accompanied by reports of apnea or dyspnea associated with cessation of the respiratory noise. Such events are frightening to parents who may then maintain increased vigilance over their child during the night. Restless sleep with frequent changes of body position may indicate subcortical arousals. 3 Children may sometimes adopt unusual sleeping postures, such as hyperextension of the neck to increase airway patency. The authors are with the Bristol Royal Hospital for Children, Department of Pediatric Respiratory Medicine & Sebastian Diamond Mother & Baby Sleep Laboratory, Bristol, UK. Reprinted from ADC Online, Arch Dis Child;89;851- 855, © BMJ British Medical Journal. Autonomic disturbances, including heart rate variability, 4 profuse sweating, and nocturnal enuresis, 5 have been reported in children with sleep disordered breathing. Children with breathing disturbances during sleep may be difficult to rouse or irritable on waking. Hypoventilation during sleep can be associated with the presence of morning headaches, vomiting, and lack of appetite for breakfast. Daytime symptoms include mouth breathing in children with adenoidal hypertrophy. Excessive daytime sleepiness is less common in children than in adults with sleep disordered breathing. 6 However, behavioural disturbances such as hyperactivity or aggression may occur, 7 and chronic sleep disturbance is associated with learning difficulties, 9 developmental delay, failure to thrive, and cardiovascular dysfunction. Populations of children at increased risk of sleep related breathing disorders include those with adenotonsillar hypertrophy, craniofacial abnormalities, obesity, chronic respiratory or chest wall disease, and neuromuscular disorders affecting upper airway control and respiratory muscle function. Physical examination should include assessment of factors predisposing to sleep related breathing disorders and of potential consequences of sleep disordered breathing. The former will include careful examination of the upper airway, looking particularly for signs of adenotonsillar hypertrophy, the commonest cause of increased upper airway resistance during sleep in children. Nasal patency should be assessed and the presence of craniofacial and palatal abnormalities noted. These include syndromes that affect the development of the mid-face and mandible, such as Pierre Robin, Apert, Treacher Collins, Charge, Goldenhar, and Pfeiffer, 10 and conditions that may be associated with multifactorial sleep related breathing disturbances, for example achondroplasia, 11 in which central and obstructive apneas and chest wall restriction can all contribute to sleep related breathing disturbances. Children who have had palatoplasty for cleft palate may also have narrow posterior airways and be at risk of obstructive sleep apnea. 12 Respiratory examination, including measurement of respiratory function in appropriately aged children with suspected Respiratory Therapy Vol. 2 No. 3 � June-July 2007 71
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