Related Experiment Videos
Alternatives to tracheostomy in infants and children with obstructive sleep apnea
S R Cohen1, C Simms, F D Burstein
1Center for Craniofacial Disorders and the Department of Pediatric Otolaryngology, Scottish Rite Children's Medical Center, Atlanta, GA, USA.
Insights
Aggressive surgical treatment effectively treated obstructive sleep apnea (OSA) in children, avoiding tracheostomy in most cases. This approach significantly improved breathing and oxygen levels, offering a viable alternative to long-term airway support.
Area of Science:
- Pediatric Surgery
- Otolaryngology
- Sleep Medicine
Background:
- Obstructive sleep apnea (OSA) in children presents significant challenges, particularly in those with craniofacial disorders or neurological conditions.
- Many children with severe OSA fail conventional treatments and are candidates for tracheostomy (T).
- Previous tracheostomy does not guarantee successful decannulation in infants with severe OSA.
Purpose of the Study:
- To evaluate the efficacy of an aggressive, simultaneous surgical protocol for treating severe obstructive sleep apnea (OSA) in children.
- To determine the rate of tracheostomy avoidance or decannulation in a cohort of pediatric OSA patients with complex conditions.
Main Methods:
- A combined approach of craniofacial skeletal expansion and soft-tissue reduction was used to enlarge the airway caliber in 70 children with OSA.
- Patients included those with cerebral palsy, Down syndrome, hemifacial microsomia, Pierre Robin sequence, and other craniofacial anomalies.
- The study included patients who had failed prior treatments and were candidates for tracheostomy, as well as those previously tracheostomized.
Main Results:
- Tracheostomy was avoided in 90.4% of patients; only 9.6% required temporary or permanent tracheostomy.
- The average respiratory disturbance index decreased from 25.9 to 4.4, and lowest oxygen saturation improved from 61% to 92% post-surgery.
- Four of five patients with permanent tracheostomies were successfully decannulated; complications were mostly minor, related to mandibular distraction devices.
Conclusions:
- An aggressive, multi-site surgical strategy is highly effective for treating severe pediatric OSA.
- This approach successfully avoids tracheostomy or allows for decannulation in the majority of complex pediatric OSA cases.
- The findings support this surgical protocol as a primary treatment option for severe OSA in children with craniofacial and neurological conditions.
Purpose:
Since 1989, 70 children have been treated surgically with varying degrees of obstructive sleep apnea (OSA). Of these, 29 patients had completely failed conventional medical and surgical treatment and were considered tracheostomy (T) candidates, whereas five had previously undergone T for severe OSA as infants and did not respond to standard decannulation protocols. The preoperative diagnoses were cerebral palsy (n = 5), Down's syndrome (n = 5), hemifacial microsomia (n = 4), Pierre Robin sequence (n = 6), and a mixed group of craniofacial disorders (n = 14). The patients ranged in age from 2.5 weeks to > or =18 months (mean, 7.32 years). Preoperatively, four patients were on ventilators and one suffered a cardiac arrest, attesting to the severity of OSA.
Methods:
To enlarge the caliber of the airway, each patient underwent an aggressive surgical treatment protocol. All sites of upper airway obstruction were treated simultaneously by a combination of craniofacial skeletal expansion and soft-tissue reduction.
Results:
Tracheostomy was avoided in 90.4% of patients. Temporary or "permanent T" were required in three patients (9.6%). One patient with cerebral palsy had recurrent OSA and died. A second patient with severe laryngotracheomalacia and retrognathia who did not respond to apnea surgery underwent a tracheostomy and ultimately died of pulmonary causes. Four patients (7.8%) required supplemental home oxygen or continuous positive airway pressure. The average preoperative respiratory disturbance index, defined as the average number of apneic and hypopneic events per hour of sleep, dropped from 25.9 to 4.4 after surgery. The average lowest recorded oxygen saturation during overnight polysomnography rose from 61% to 92% after surgery. Of the five patients with permanent T, four had thus far been decannulated. Complications occurred in 10 patients, 50% of which were related to minor problems with mandibular distraction devices.
Conclusion:
Our results confirm the efficacy of an aggressive surgical approach to the treatment of OSA in children, avoiding the necessity for tracheostomy or permitting decannulation of permanent T in the majority of cases.