Extreme pediatric obstructive sleep Apnea: Clinical Features, management, long-term outcomes and mortality

Extreme obstructive sleep apnea (OSA), defined by an obstructive apnea-hypopnea index (OAHI) ≥100 events/hr, presents management challenges in pediatric patients due to its severity and associated comorbidities. This study aims to review the clinical characteristics, management strategies, and outcomes in this population.

Retrospective reviewed patients aged ≤18 years with extreme OSA who underwent level 1 polysomnography (PSG) from 2010 to 2024. Logistic regression was performed to identify factor associated with surgical management, residual OSA, and revision surgery. Kaplan-Meier analysis was used to estimate 5-year mortality.

Fifty patients were reviewed, with a median (IQR) age: 4.9 (1.9, 12.8) years and 32 (64 %) were male. Median (IQR) OAHI was 123.2 (112, 143.1) events/hour, with median (IQR) nadir SpO₂ of 65.5 % (52.3, 74.3). The residual OSA was noted 77.8 % on follow-up PSG after initial surgery. A BMI Z-score < -2 was significantly associated with surgical management [OR 19.8, 95 % CI 1.9-21.7, p = 0.013]. A nadir SpO₂ ≤ 60 % was associated with residual OSA [OR 12.5, 95 % CI 1.2-13.6, p = 0.03]. Additionally, spending more than 10 % of total sleep time with SpO₂ < 90 % was associated with the need for revision surgery [OR 7.6, 95 % CI 1.1-12.4, p = 0.04]. The 5-year respiratory illness-related mortality rate was 8 % (n = 4), with higher mortality observed in children age ≤2 years (p = 0.003) and those with craniofacial anomalies or symptomatic laryngomalacia (p = 0.004).

Early identification of high-risk patients, vigilant care, and multidisciplinary follow-up are essential for optimizing outcomes in extreme OSA.