Practice Parameters for the Respiratory Indications for Polysomnography in Children
Practice Parameters for the Respiratory Indications for Polysomnography in Children
R. Nisha Aurora, MD1; Rochelle S. Zak, MD2; Anoop Karippot, MD3; Carin I. Lamm, MD4; Timothy I. Morgenthaler, MD5; Sanford H. Auerbach, MD6;
Sabin R. Bista, MD7; Kenneth R. Casey, MD8; Susmita Chowdhuri, MD9; David A. Kristo, MD10; Kannan Ramar, MD5
1Mount Sinai School of Medicine, New York, NY; 2Sleep Disorders Center, University of California, San Francisco, San Francisco CA; 3Penn State
University Hershey Medical Center, Hershey, PA and University of Louisville School of Medicine, Louisville, KY; 4Children’s Hospital of NY –
Presbyterian, Columbia University Medical Center, New York, NY; 5Mayo Clinic, Rochester, MN; 6Boston University School of Medicine, Boston, MA;
7University of Nebraska Medical Center, Omaha, NE; 8Cincinnati Veterans Affairs Medical Center, Cincinnati, OH; 9Sleep Medicine Section, John D.
Dingell VA Medical Center, and Wayne State University, Detroit, MI; 10University of Pittsburgh, Pittsburgh, PA
Background: There has been marked expansion in the literature and
practice of pediatric sleep medicine; however, no recent evidencebased
practice parameters have been reported. These practice parameters
are the first of 2 papers that assess indications for polysomnography
in children. This paper addresses indications for polysomnography
in children with suspected sleep related breathing disorders. These
recommendations were reviewed and approved by the Board of Directors
of the American Academy of Sleep Medicine.
Methods: A systematic review of the literature was performed, and the
American Academy of Neurology grading system was used to assess
the quality of evidence.
Recommendations for PSG Use:
1. Polysomnography in children should be performed and interpreted
in accordance with the recommendations of the AASM Manual
for the Scoring of Sleep and Associated Events. (Standard)
2. Polysomnography is indicated when the clinical assessment suggests
the diagnosis of obstructive sleep apnea syndrome (OSAS)
in children. (Standard)
3. Children with mild OSAS preoperatively should have clinical evaluation
following adenotonsillectomy to assess for residual symptoms.
If there are residual symptoms of OSAS, polysomnography
should be performed. (Standard)
4. Polysomnography is indicated following adenotonsillectomy to
assess for residual OSAS in children with preoperative evidence
for moderate to severe OSAS, obesity, craniofacial anomalies
that obstruct the upper airway, and neurologic disorders (e.g.,
Down syndrome, Prader-Willi syndrome, and myelomeningocele).
(Standard)
5. Polysomnography is indicated for positive airway pressure (PAP) titration
in children with obstructive sleep apnea syndrome. (Standard)
6. Polysomnography is indicated when the clinical assessment suggests
the diagnosis of congenital central alveolar hypoventilation
syndrome or sleep related hypoventilation due to neuromuscular
disorders or chest wall deformities. It is indicated in selected
cases of primary sleep apnea of infancy. (Guideline)
7. Polysomnography is indicated when there is clinical evidence of a
sleep related breathing disorder in infants who have experienced
an apparent life-threatening event (ALTE). (Guideline)
8. Polysomnography is indicated in children being considered for
adenotonsillectomy to treat obstructive sleep apnea syndrome.
(Guideline)
9. Follow-up PSG in children on chronic PAP support is indicated
to determine whether pressure requirements have changed as a
result of the child’s growth and development, if symptoms recur
while on PAP, or if additional or alternate treatment is instituted.
(Guideline)
10. Polysomnography is indicated after treatment of children for
OSAS with rapid maxillary expansion to assess for the level of
residual disease and to determine whether additional treatment
is necessary. (Option)
11. Children with OSAS treated with an oral appliance should have
clinical follow-up and polysomnography to assess response to
treatment. (Option)
12. Polysomnography is indicated for noninvasive positive pressure
ventilation (NIPPV) titration in children with other sleep related
breathing disorders. (Option)
13. Children treated with mechanical ventilation may benefit from
periodic evaluation with polysomnography to adjust ventilator settings.
(Option)
14. Children treated with tracheostomy for sleep related breathing
disorders benefit from polysomnography as part of the evaluation
prior to decannulation. These children should be followed clinically
after decannulation to assess for recurrence of symptoms of
sleep related breathing disorders. (Option)
15. Polysomnography is indicated in the following respiratory disorders
only if there is a clinical suspicion for an accompanying
sleep related breathing disorder: chronic asthma, cystic fibrosis,
pulmonary hypertension, bronchopulmonary dysplasia, or chest
wall abnormality such as kyphoscoliosis. (Option)
Recommendations against PSG Use:
16. Nap (abbreviated) polysomnography is not recommended for
the evaluation of obstructive sleep apnea syndrome in children.
(Option)
17. Children considered for treatment with supplemental oxygen do
not routinely require polysomnography for management of oxygen
therapy. (Option)
Conclusions: Current evidence in the field of pediatric sleep medicine
indicates that PSG has clinical utility in the diagnosis and management
of sleep related breathing disorders. The accurate diagnosis of SRBD
in the pediatric population is best accomplished by integration of polysomnographic
findings with clinical evaluation.
Keywords: Polysomnography, pediatric, indications, clinical utility,
sleep related breathing disorders, obstructive sleep apnea syndrome
Citation: Aurora RN; Zak RS; Karippot A; Lamm CI; Morgenthaler TI;
Auerbach SH; Bista SR; Casey KR; Chowdhuri S; Kristo DA; Ramar K.
Practice parameters for the respiratory indications for polysomnography
in children. SLEEP 2011;34(3):379-388.
RESPIRATORY INDICATIONS FOR POLYSOMNOGRAPHY IN CHILDREN
Practice Parameters for the Respiratory Indications for Polysomnography in Children
R. Nisha Aurora, MD1; Rochelle S. Zak, MD2; Anoop Karippot, MD3; Carin I. Lamm, MD4; Timothy I. Morgenthaler, MD5; Sanford H. Auerbach, MD6;
Sabin R. Bista, MD7; Kenneth R. Casey, MD8; Susmita Chowdhuri, MD9; David A. Kristo, MD10; Kannan Ramar, MD5
1Mount Sinai School of Medicine, New York, NY; 2Sleep Disorders Center, University of California, San Francisco, San Francisco CA; 3Penn State
University Hershey Medical Center, Hershey, PA and University of Louisville School of Medicine, Louisville, KY; 4Children’s Hospital of NY –
Presbyterian, Columbia University Medical Center, New York, NY; 5Mayo Clinic, Rochester, MN; 6Boston University School of Medicine, Boston, MA;
7University of Nebraska Medical Center, Omaha, NE; 8Cincinnati Veterans Affairs Medical Center, Cincinnati, OH; 9Sleep Medicine Section, John D.
Dingell VA Medical Center, and Wayne State University, Detroit, MI; 10University of Pittsburgh, Pittsburgh, PA
Submitted for publication December, 2010
Accepted for publication December, 2010
Address correspondence to: Sharon L. Tracy, PhD, American Academy of
Sleep Medicine, 2510 North Frontage Road, Darien, IL 60561-1511; Tel:
(630) 737-9700; Fax: (630) 737-9790; E-mail: stracy@aasmnet.org
SLEEP, Vol. 34, No. 3, 2011 380 Practice Parameters—Aurora et al
In particular, it involves development of a list of specific indications
derived from the scientific evidence. Completion of rating
sheets that evaluated the appropriateness of these indications
was conducted in 2 rounds by members from both the SPC and
task force. Based on these ratings, indications were classified as
appropriate, uncertain, or inappropriate. Indications that were
classified as appropriate were used to develop these recommendations;
indications that were uncertain or inappropriate were
rejected.
The Board of Directors of the AASM approved these recommendations.
All members of the AASM Standards of Practice
Committee and Board of Directors completed detailed conflictof-
interest statements and were found to have no conflicts of
interest with regard to this subject.
These practice parameters define principles of practice that
should meet the needs of most patients in most situations. These
guidelines should not, however, be considered inclusive of all
proper methods of care or exclusive of other methods of care
reasonably directed to obtaining the same results. The ultimate
judgment regarding propriety of any specific care must be
made by the physician, in light of the individual circumstances
presented by the patient, available diagnostic tools, accessible
treatment options, and resources.
The AASM expects these guidelines to have an impact on
professional behavior, patient outcomes, and, possibly, health
care costs. These practice parameters reflect the state of knowledge
at the time of publication and will be reviewed, updated,
and revised as new information becomes available. This parameter
paper is referenced, where appropriate, using squarebracketed
numbers to the relevant sections and tables in the
accompanying review paper, or with additional references at the
end of this paper. For this paper, the Standards of Practice Committee
decided to use an evidence grading system developed by
the American Academy of Neurology (AAN) for assessment of
diagnostic tests. The system involves 4 tiers of evidence, with
Level 1 studies judged to have a low risk of bias and Level 4
studies judged to have a very high risk of bias. Table 1 describes
the essential features of the evidence grading system used by
the task force. Definitions of levels of recommendations used
by the AASM appear in Table 2.
3.0 RECOMMENDATIONS
3.1 Methodology
3.1.1 Polysomnography in children should be performed and
interpreted in accordance with the recommendations of the AASM
Manual for the Scoring of Sleep and Associated Events. (Standard)
A detailed evidence-based and consensus-based review of
PSG was conducted during development of the AASM Manual
for the Scoring of Sleep and Associated Events under the aegis
of the AASM Scoring Manual Steering Committee.7 This document
specifies the optimal equipment for PSG and standardizes
the scoring of events. The SPC considers this the standard of
practice, and therefore did not conduct a separate, independent
review for this practice parameter.
In the opinion of the task force, PSG is best tolerated by
the child and parent under the following conditions: (a) when
PSG is performed with the caretaker present; (b) when the
1.0 INTRODUCTION
Assessment for sleep disorders in children has long relied
on a comprehensive history and physical exam. In certain
conditions, most commonly sleep related breathing disorders
(SRBD), polysomnography (PSG) was performed as an adjunctive
tool to aid in the diagnosis. PSG also has been used to evaluate
abnormal sleep related movements and behaviors as well
as part of the diagnostic assessment for narcolepsy. Because
PSG is relatively expensive, time consuming, and not consistently
applied by pediatric physicians, it is important to understand
its strengths, limitations, and clinical utility in children.
Over the past 30 years, pediatric sleep medicine has exponentially
advanced in terms of improved awareness of pediatric
sleep disorders and the development of many important technical
tools. The early data supporting the clinical utility of PSG
were limited because of inconsistency in polysomnographic
criteria for SRBDs. Clinical guidelines regarding indications
for pediatric PSG based on these early data were published by
professional organizations,1,2 but these older publications were
largely consensus-based due to a paucity of evidence-based data.
In 2007 the AASM commissioned a task force to review
the literature published on the indications for PSG in children.
Because the task force identified such a large number of publications,
it divided the project into 3 separate review papers:
(1) the respiratory indications for PSG; (2) the non-respiratory
indications for PSG; and (3) the indications for PSG in children
with attention deficit hyperactivity disorder (ADHD) or autistic
spectrum disorder (ASD). It should be noted that in 2009 the
SPC changed its grading system to the GRADE methodology,
redefining criteria for Standards, Guidelines, and Options to be
consistent with GRADE specifications.3 Because this project
began in 2007, the older grading process in use at that time was
used to grade the evidence.
This parameter paper focuses on the respiratory indications
for PSG. It is based on a comprehensive review of the literature
to evaluate the validity and reliability of PSG and to determine
its clinical utility for assessment and management of various
respiratory disorders. It highlights pediatric respiratory disorders
with a high prevalence of polysomnographic abnormalities
and addresses various treatment modalities such as surgery and
positive airway pressure.
2.0 METHODS
The Standards of Practice Committee of the AASM, in conjunction
with specialists and other interested parties, developed
these practice parameters based on the accompanying review
paper.4 A task force of content experts was appointed by the
AASM in 2007 to review and grade evidence in the scientific
literature regarding the validity, reliability, and clinical utility
of PSG in pediatric sleep disorders. In most cases recommendations
are based on evidence from studies published in
the peer reviewed literature or on generally accepted patient
care strategies. When scientific data were absent, insufficient
or inconclusive, the Rand/UCLA Appropriateness Method was
used to develop consensus recommendations by identifying the
collective opinion of the SPC and task force. The Rand/UCLA
Appropriateness Method combines the best available scientific
evidence with the collective judgment of experts to yield statements
regarding the appropriateness of performing procedures.
SLEEP, Vol. 34, No. 3, 2011 381 Practice Parameters—Aurora et al
symptoms rather than for any individual parameter.13,24 Audio or
video recordings correlated with PSG respiratory parameters,
but 2 Level 211,47 and 2 Level 348,49 studies showed they were
not sufficient to establish a diagnosis of OSAS. Pediatric sleep
questionnaires were evaluated in 9 articles in children referred
for snoring, including 2 with Level 2 evidence,10,50 3 with Level
3 evidence,14,51 and 4 with Level 4 evidence.27,34,37,41 The 2 Level
2 studies showed low sensitivities for questionnaires to predict
polysomnographic evidence of OSAS with better specificities
but were still insufficient to differentiate primary snoring from
OSAS. Two of the 3 level 3 studies and all of the level 4 studies
showed insufficient correlation between sleep questionnaires
and PSGs.
The task force found that PSG in children is a reliable and
valid measure of the presence of OSAS. Test-retest reliability,
or consistency of results across multiple nights of polysomnographic
testing, was demonstrated in 1 Level 2,52 2 Level 3,18,53
and 1 Level 454 studies. There were no studies designed to test
interrater reliability for scoring PSGs in children. Test-retest validity
for PSG, or movement of various PSG parameters in the
parent and child have
been oriented to the sleep
laboratory in advance,
including, in some cases,
application of a limited
number of sensors to illustrate
the procedure to
the child; (c) when the
PSG technologist is experienced
and comfortable
in dealing with children
in the sleep laboratory
environment that is childfriendly;
and (d) when
the sleep specialist provides
specific guidance
and recommendations in
advance of the PSG with
regard to the child’s care
during the night.
Unattended testing outside
the sleep laboratory in
children has been used predominantly in research settings. There
is a paucity of research comparing it to traditional in-laboratory
attended sleep studies or other objective clinical outcomes, and
there are insufficient data upon which to base reliable clinical
recommendations for children at this time.
3.2 Diagnostic Indications for Polysomnography in Sleep
Related Breathing Disorders
3.2.1 Polysomnography is indicated when the clinical assessment
suggests the diagnosis of obstructive sleep apnea syndrome in
children. [Review Section 4.2.1] (Standard)
3.2.2 Polysomnography is indicated when the clinical
assessment suggests the diagnosis of congenital central alveolar
hypoventilation syndrome or sleep related hypoventilation due to
neuromuscular disorders or chest wall deformities. It is indicated in
selected cases of primary sleep apnea of infancy. (Guideline)
Obstructive sleep apnea syndrome should be diagnosed
based upon clinical and polysomnographic criteria. This parameter
is based on an extensive literature review conducted by the
Indications for PSG in Children task force.
The task force found that clinical evaluation alone does not
have sufficient sensitivity or specificity to establish a diagnosis
of OSAS. Clinical parameters such as history [4.2.1.1.1,
4.2.1.1.3, 4.2.1.1.4.1], physical examination [4.2.1.1.5], audio
or visual recordings [4.2.1.1.2], and standardized questionnaires
[4.2.1.1.3] did not consistently identify the presence or
absence of OSAS when compared with PSG. Snoring and other
nocturnal symptoms in 2 Level 1,8,9 4 Level 2,10-13 11 Level 3,14-
24 and 18 Level 425-42 studies showed inconsistent correlations
with respiratory parameters of PSG. Physical features of children
evaluated in 11 papers (2 Level 211,13; 3 Level 323,24,43; 6
Level 4)25,40,41,44-46 showed variable strengths of association with
respiratory PSG parameters with obesity demonstrating the
strongest association (see below). Polysomnographic parameters
correlated best with a combination of multiple signs and
Table 2—AASM levels of recommendations
Term Definition
Standard This is a generally accepted patient-care
strategy that reflects a high degree of clinical
certainty and generally implies the use of Level
1 evidence or overwhelming Level 2 evidence.
Guideline This is a patient-care strategy that reflects a
moderate degree of clinical certainty and implies
the use of Level 2 evidence or a consensus of
Level 3 evidence.
Option This is a patient-care strategy that reflects
uncertain clinical use and implies inconclusive or
conflicting evidence or conflicting expert opinion.
Adapted from Eddy6
Table 1—Levels of evidence5
Level Description
1 Evidence provided by a prospective study in a broad spectrum of persons with the suspected condition,
using a reference (gold) standard for case definition, where test is applied in a blinded fashion, and
enabling the assessment of appropriate test of diagnostic accuracy. All persons undergoing the diagnostic test
have the presence or absence of the disease determined. Level 1 studies are judged to have a low risk of bias.
2 Evidence provided by a prospective study of a narrow spectrum of persons with the suspected condition,
or a well designed retrospective study of a broad spectrum of persons with an established condition (by
“gold standard”) compared to a broad spectrum of controls, where test is applied in a blinded evaluation,
and enabling the assessment of appropriate tests of diagnostic accuracy. Level 2 studies are judged to have a
moderate risk of bias.
3 Evidence provided by a retrospective study where either person with the established condition or controls are
of a narrow spectrum, and where the reference standard, if not objective, is applied by someone other
than the person that performed (interpreted) the test. Level 3 studies are judged to have a moderate to
high risk of bias.
4 Any study design where test is not applied in an independent evaluation or evidence is provided by
expert opinion alone or in descriptive case series without controls. There is no blinding or there may
be inadequate blinding. The spectrum of persons tested may be broad or narrow. Level 4 studies are
judged to have a very high risk of bias.
SLEEP, Vol. 34, No. 3, 2011 382 Practice Parameters—Aurora et al
also indicated for the diagnosis of sleep related hypoventilation
due to neuromuscular or chest wall deformities and congenital
central alveolar hypoventilation syndrome and in selected cases
of primary sleep apnea of infancy, with the realization that
some of these patients will be in a NICU and not have access
to polysomnography; these conclusions are based less on evidence
than on a consensus of expert opinion. Children should
be diagnosed with SRBDs by an integration of clinical evaluation
and PSG. In addition, certain clinical conditions, as delineated
above, are associated with a high prevalence of SRBD.
These patients should be screened for symptoms and signs of
SRBD and undergo PSG if present.
3.2.3 Nap (abbreviated) polysomnography is not recommended for
the evaluation of obstructive sleep apnea syndrome in children.
[Review Section 4.2.1.3] (Option)
Three Level 4 studies74,105,106 in children demonstrated that
nap PSG is not as reliable as overnight PSG for identifying
SRBD [4.2.1.3] and underestimated the prevalence and severity
of SRBD, with sensitivities ranging from 69% to 75% and
specificities from 60% to 100%. This recommendation is based
on these limited studies and collective expert opinion using the
Rand/UCLA Appropriateness Method.
3.2.4 Polysomnography is indicated when there is clinical
evidence of a sleep related breathing disorder in infants who have
experienced an apparent life-threatening event (ALTE). [Review
Sections 4.2.4.4, 4.2.4.6] (Guideline)
Four Level 2,52,107-109 8 Level 3,22,110-116 and 3 Level 4 studies35,117,118
[4.2.4.4, 4.2.4.6] showed subtle, nonspecific PSG
abnormalities in some infants who had experienced an ALTE.
The PSG findings were not predictive of recurrence of ALTE.
Studies of infants who eventually succumbed to sudden infant
death syndrome (SIDS) (4 Level 3)22,111,113,114 demonstrated PSG
abnormalities that were neither sufficiently distinctive nor predictive
to support routine use of PSG for children at risk for
SIDS. Finally, 2 low level studies109,116showed that infants who
had experienced an ALTE may be at increased risk to develop
SRBD. These infants, however, had other risk factors for
SRBD, such as a family history of SRBD or facial dysmorphology.
Clinical suspicion of SRBD in a patient with ALTE should
prompt consideration of PSG.
3.3 Indications for Preoperative Polysomnography
3.3.1 Polysomnography is indicated in children being considered
for adenotonsillectomy to treat obstructive sleep apnea syndrome.
[Review Section 4.2.3] (Guideline)
Adenotonsillectomy (AT) is commonly performed as a firstline
treatment of OSAS in children, yet the diagnosis of OSAS
is often based on clinical parameters alone.119 The task force
reviewed the literature to determine the clinical utility of PSG
to confirm the diagnosis of OSAS prior to AT. Whether or not
a PSG prior to AT has clinical utility is important for some of
the following issues (see review paper for a more complete
discussion):
(1) AT is a surgical procedure with a small risk of hemorrhage,
infection, upper airway compromise, and pain, and
should only be performed if necessary.
expected direction after a therapeutic intervention for OSAS,
was robust as demonstrated in all 45 studies [4.2.1.1.10].
Convergent validity, or whether PSG and an independent
measure both change consistently in the presence of OSAS,
was extensively evaluated, including objective [4.2.1.1.4.2]
and subjective sleepiness [4.2.1.1.4.1], radiographic evaluation
[4.2.1.1.6], neurocognitive and psychological evaluation
[4.2.1.1.7], blood pressure [4.2.1.1.8], and quality of life measures
[4.2.1.1.9]. Some, but not all, of these measures demonstrated
convergent validity with PSG.
Additionally, there was clinical consensus by experts that
the PSG is necessary to diagnose congenital central alveolar
hypoventilation syndrome, sleep related hypoventilation due
to chest wall disorders, and sleep related hypoventilations due
to neuromuscular disorder, for which there was also low level
evidence.55-63 There was also clinical consensus by experts that
PSG is necessary in selected cases to diagnose primary sleep
apnea of infancy when other medical disorders have been ruled
out. Patients with CCHS and primary sleep apnea of infancy
often present as neonates in the Neonatal Intensive Care Unit,
where PSG may not be available. These recommendations are
consistent with the recommendations outlined in the ICSD-2
Manual.64
Lastly, the task force identified certain conditions associated
with an elevated prevalence of SRBD including OSAS. The
clinician should consider PSG in children with the following
conditions if there is even the slightest suspicion of SRBD. A
high prevalence of SRBD has been reported in children with
obesity13,65-71 (13%67 to 78%65) [4.2.2.1], Down syndrome37,72-74
(57%37 to 100%74) ([4.2.2.8.1.1], Prader-Willi syndrome75-80
(93%75) [4.2.2.8.1.2], neuromuscular disorders55-63 (53% in
one study of children with Duchenne Muscular Dystrophy56)
[4.2.2.8.4], Chiari malformations and myelomeningocele81-84
(60% in one series of children with CM84) [4.2.2.8.4], and craniofacial
anomalies that obstruct the upper airway32,38,85-87 (48%
in children with achondroplasia,85 76% in a group of infants
with Pierre Robin sequence,86 and 50% to 91% in 2 small series
of craniofacial dysostoses32,87) [4.2.2.8.2]. Obesity was identified
as an independent risk factor for having SRBD. Furthermore,
SRBD was identified as an independent risk factor for
hypertension,20,88-96 suggesting that the clinician should evaluate
children who present with hypertension for the possibility of
underlying SRBD.
Children in the following categories have an intermediate
level of risk for OSAS: those with history of prematurity25,97-99
(prevalence of OSAS of 7.3%)97 [4.2.2.2], African American
race34,100-102 (conflicting data) [4.2.2.3], family history of
SRBD102,103 (sparse data) [4.2.2.4], and allergic rhinitis101,102,104
(not well defined) [4.2.2.5]. Children in these intermediate risk
groups ought to be queried for signs or symptoms of SRBDs,
and should undergo PSG if present.
Overall, the above data on SRBD prevalence and disease
associations included 1 Level 1,65 6 Level 2,13,86,88-90,100 17
Level 3,20,57,60,61,66,67,70,76,84,85,91-93,95,97,98,102 and 32 Level 4 studies.
25,32,34,37,38,55,56,58,59,62,63,68,69,71-75,77-83,87,94,96,99,101,103,104
In summary, high quality data demonstrate that PSG is indicated
for the diagnosis of OSAS in children both because clinical
parameters alone lack reliability to correctly classify disease
and because PSG is a valid and reliable clinical tool. PSG is
SLEEP, Vol. 34, No. 3, 2011 383 Practice Parameters—Aurora et al
lowing AT are better when PSG is routinely performed prior to
AT. The evidence taken as an aggregate indicates that preoperative
PSG has strong clinical utility prior to AT for treatment of
OSAS.
3.4 Indications for Polysomnography to Assess Response to
Treatment
3.4.1 Children with mild obstructive sleep apnea syndrome
preoperatively should have clinical evaluation following
adenotonsillectomy to assess for residual symptoms. If there
are residual symptoms of obstructive sleep apnea syndrome,
polysomnography should be performed. [Review Section 4.2.3]
(Standard)
This recommendation is a logical extension of parameter
3.2.1. There are Level 2 and 3 studies documenting a high
prevalence of residual OSAS after AT. In 1 Level 2 study, residual
OSAS was detected in as many as 75% of non-obese
children,131 and in 1 Level 3 study,132 75% of a combined obese
and non-obese pediatric population had residual OSAS following
AT for OSAS. Although many patients had some degree
of residual obstruction, most had a considerable reduction in
the severity of the OSAS (postoperative results in the 2 studies
above showed 90%131 and 71%132 of the children had a postoperative
OAHI < 5). In 1 Level 2 study,130 which excluded
obese children, the rate of residual polysomnographic evidence
of OSAS was 10% to 28% (depending on the criteria used). Another
Level 2 study found that OSAS can recur 1 year postoperatively,
so patients should be reevaluated periodically.129 Given
the high prevalence of residual obstruction, clinicians should
evaluate children postoperatively for symptoms of OSAS and if
present, a PSG should be performed.
3.4.2 Polysomnography is indicated following adenotonsillectomy
to assess for residual sleep related breathing disorder in children
with preoperative evidence for moderate to severe OSAS, obesity,
craniofacial anomalies that obstruct the upper airway, and
neurologic disorders (e.g., Down syndrome, Prader-Willi syndrome,
and myelomeningocele). [Review Section 4.2.3] (Standard)
Incomplete resolution of OSAS was more common in children
with high preoperative AHI (exact cut-off not established
as norms and statistical methods varied from study to study)
(2 Level 2,129,130 1 Level 3132), obesity (2 Level 2,129,130 1 Level
3,132 3 Level 4101,133,134), craniofacial anomalies that obstruct the
upper airway (1 Level 3135 and 1 Level 438), and neurologic disorders
such as myelomeningocele (1 level 481) and Down syndrome
(1 Level 442), while absence of obesity and craniofacial
abnormalities (2 Level 3,132,136 1 Level 4137) and lower AHI (2
Level 2,129,130 1 Level 3132) favored a good outcome. Children
with neuromuscular disorders can have a mix of both obstructive
and central sleep apnea and require PSG following AT to
determine the need for CPAP or NIPPV as demonstrated in 2
level 481,83 studies. This recommendation is a logical extension
of 3.2.1. These populations are at increased risk for having residual
SRBD and are often difficult to reliably evaluate clinically.
3.4.3 Polysomnography is indicated after treatment of children for
obstructive sleep apnea syndrome with rapid maxillary expansion
(2) Clinical parameters may be unreliable for predicting
OSAS.
(3) Children with certain medical disorders are at higher surgical
risk (e.g., sickle cell anemia, HIV, coagulopathies, congenital
heart disease).
(4) Children with severe OSAS have a higher risk for certain
postoperative complications including respiratory compromise.
The task force identified 30 papers pertaining to the clinical
utility of PSG prior to AT. Twenty-three of these papers were
referenced previously as they demonstrated test-retest validity
of PSG in the setting of AT.
First the task force reviewed the literature to determine
whether PSG prior to AT correlated with symptoms or physical
features of SRBD. As detailed above, history and physical
examination were not always reliable predictors of SRBD in
children [4.2.1.1.1, 4.2.1.1.3, 4.2.1.1.4.1, 4.2.1.1.3, 4.2.1.1.5].
Three Level 3 papers18,23,43 showed the limitations of history and
physical examination for diagnosing OSAS in children specifically
scheduled for AT. In 1 Level 211 and 2 Level 426,41 studies,
the authors concluded that a negative PSG did not rule out
clinically significant SRBD that may respond to AT; however,
all 3 demonstrate that as one changes the cut-off of a polysomnographic
definition of OSAS to be more in-line with the recommendation
in the ICSD-2, the percentage of PSG-positive
subjects increases, improving the clinical utility of PSG.
To further establish clinical utility of PSG prior to AT, the
task force reviewed the literature to determine whether PSG
identified those children likely to develop perioperative complications.
Ten papers addressed the clinical utility of PSG for
assessment of perioperative risk of respiratory complications
related to AT in children. One Level 2,120 1 Level 3,121 and 4
Level 4 studies122-125 showed a positive correlation between
PSG measures of OSAS severity and postoperative respiratory
complications. In 1 study, respiratory complications occurred
as late as the first postoperative night124 and in another, as long
as 14 hours125after surgery. In 2 Level 4 studies,126,127 children
without significant comorbid diseases who had no or mild abnormalities
on preoperative PSG were likely to have an uncomplicated
postoperative course. Although in 2 Level 4 studies30,128
preoperative PSG did not identify those who later developed
perioperative complications, the majority of the evidence supports
the clinical utility of preoperative PSG for predicting
which children are at risk for postoperative respiratory compromise
or prolonged stay and will need postoperative monitoring.
Lastly, to establish clinical utility of PSG prior to AT the task
force examined whether the PSG could predict which children
were more likely to have residual OSAS following surgery.
Two Level 2 studies129,130 demonstrated that children with higher
preoperative AHIs had a greater likelihood of residual OSAS
following AT.
In summary, as delineated in practice parameter 3.2.1, PSG
is indicated for the diagnosis of SRBD in children. Logically
it follows that PSG is indicated to diagnose OSAS prior to AT
when OSAS is the primary indication for AT. There are data
indicating that history and physical examination alone have
limitations for predicting OSAS and that the preoperative AHI
can guide the physician in perioperative and postoperative
management. At this time, the task force was unable to identify
prospective studies addressing whether clinical outcomes folSLEEP,
Vol. 34, No. 3, 2011 384 Practice Parameters—Aurora et al
determine the timing and frequency of follow-up PSG. This
recommendation is a generally accepted patient care strategy.
3.4.8 Children treated with mechanical ventilation may benefit from
periodic evaluation with polysomnography to adjust ventilator
settings. [Review Section 4.4.5] (Option)
PSG is useful for assessing optimal ventilator settings since
respiration worsens during sleep and wake ventilator settings
may not be adequate for sleep. There were no studies addressing
the use of PSG in the management of ventilator settings that met
inclusion criteria. This recommendation is based on consensus
expert opinion using the Rand/UCLA Appropriateness Method.
3.4.9 Children considered for treatment with supplemental oxygen
do not routinely require polysomnography for management of
oxygen therapy. [Review Section 4.4.6] (Option)
Nocturnal oximetry is generally sufficient to assess adequate
oxygenation. However, PSG can be useful for titrating supplemental
oxygen in patients who may hypoventilate and may be
at risk for developing central apneas or hypercarbia with supplemental
oxygen. There were no studies addressing this topic
that met inclusion criteria. This recommendation is based on
consensus expert opinion using the Rand/UCLA Appropriateness
Method.
3.4.10 Children treated with tracheostomy for sleep related
breathing disorders benefit from polysomnography as part of
the evaluation prior to decannulation. These children should be
followed clinically after decannulation to assess for recurrence of
symptoms of sleep related breathing disorders. [Review Section
4.4.4] (Option)
One Level 3 study147 demonstrated clinical usefulness of
PSG as part of the evaluation to assess readiness for decannulation
in children with long-term tracheostomy [4.4.4]. This
recommendation is based on this study and on consensus expert
opinion using the Rand/UCLA Appropriateness Method.
3.5 Indications for Polysomnography in Respiratory Diseases
3.5.1 Polysomnography is indicated in the following respiratory
disorders only if there is a clinical suspicion for an accompanying
sleep related breathing disorder: chronic asthma, cystic fibrosis,
pulmonary hypertension, bronchopulmonary dysplasia, or chest
wall abnormality such as kyphoscoliosis. [Review Sections 4.3.1.1
and 4.3.1.2] (Option)
In children with asthma, prevalence studies showed conflicting
low level evidence for increased risk of SRBD
([4.3.1.1]102,148). The data were too sparse to assess the clinical
utility of PSG in children with cystic fibrosis, although 1 Level
4 study149 demonstrated clinical utility of PSG to initiate and
titrate noninvasive ventilation [4.3.1.2]. There were no studies
addressing the clinical utility of PSG in children with unexplained
pulmonary hypertension [4.2.2.7] or bronchopulmonary
dysplasia [4.3.1.3]. Finally, a low level study150 of children
with kyphoscoliosis who could not undergo PFTs did not find
statistically significant evidence that preoperative polysomnography
could predict those at risk for prolonged postoperative
ventilation after scoliosis repair [4.3.2.1]. As with all children,
those with asthma, cystic fibrosis, unexplained pulmonary hyto
assess for the level of residual disease and to determine whether
additional treatment is necessary. [Review Section 4.4.3] (Option)
This is a rarely performed treatment for OSAS in children
with only limited data regarding efficacy. Two low level studies
evaluated children following rapid maxillary expansion
(RME). Significant residual disease remained after RME in 1
Level 3138 and 1 Level 4 study139 [4.4.3]. PSG was useful to
establish residual disease and the efficacy of staged treatment.
Given the paucity of evidence demonstrating the efficacy for
this new procedure, it is recommended that children treated
with rapid maxillary expansion have follow-up PSG. This recommendation
is based on consensus expert opinion using the
Rand/UCLA Appropriateness Method.
3.4.4 Children with OSAS treated with an oral appliance should
have clinical follow-up and polysomnography to assess response
to treatment. [Review Section 4.4.3] (Option)
This is a relatively new treatment for OSAS in children with
limited studies available. One Level 286 and 1 Level 4 study40
used PSG to demonstrate clinical efficacy of dental devices in
children [4.4.3]. Given the paucity of evidence demonstrating
the efficacy for this new procedure, it is recommended that children
treated with a dental device have follow-up PSG. This recommendation
is based on consensus expert opinion using the
Rand/UCLA Appropriateness Method.
3.4.5 Polysomnography is indicated for positive airway pressure
(PAP) titration in children with obstructive sleep apnea syndrome
(Standard)
3.4.6 Polysomnography is indicated for noninvasive positive
pressure ventilation (NIPPV) titration in children with other sleep
related breathing disorders. [Review Section 4.4.1] (Option)
PSG was shown to be a valid measure to assess response to
therapy for SRBD. There were insufficient data on autotitration
PAP (APAP) in children to assess this mode of therapy. Four
papers (1 Level 2,140 3 Level 4141-143) demonstrated that PSG was
useful to determine optimal PAP settings in children and infants.
It was particularly important for children at risk for multiple
types of SRBD, such as those with neurologic disorders.
Five studies (1 Level 357 and 4 Level 456,144-146) evaluated or described
the use of PSG for titration of nocturnal intermittent
positive pressure ventilation (NIPPV) in children with SRBD
and neuromuscular disorders. These studies demonstrated either
clinical or physiologic improvement with NIPPV that was
titrated using PSG.
3.4.7 Follow-up PSG in children on chronic PAP support is indicated
to determine whether pressure requirements have changed as a
result of the child’s growth and development, if symptoms recur
while on PAP, or if additional or alternate treatment is instituted.
[Review Section 4.4.2] (Guideline)
Growth and development should be considered in children
on chronic PAP treatment as symptoms may resolve or worsen
with significant changes in the child’s morphology. One Level 4
study146 [4.4.2] demonstrated that many children required pressure
changes (66%) in PAP level, even in the absence of interventions,
suggesting that PAP requirements might change with
growth and development. Clinical judgment should be used to
SLEEP, Vol. 34, No. 3, 2011 385 Practice Parameters—Aurora et al
participated in research supported by Sepracor and participated
in a speaking engagement for Forest Pharmaceuticals. Dr. Karippot
has received research support from Wyeth and is Medical
Director of Akane Sleep Solutions, Inc., a sleep disorders clinic
and laboratory. The other authors have indicated no financial
conflicts of interest.
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pertension, bronchopulmonary dysplasia, kyphoscoliosis, or
chest wall deformity for whom there is a clinical suspicion of a
SRBD should undergo PSG.
4.0 FUTURE RESEARCH
Improvement in diagnostic accuracy and clinical utility of
PSG for evaluation of SRBD in children will require investigations
that address a wide range of pediatric populations using
adequate sample sizes and standardized methodology. Study
designs should account for changes in respiratory physiology
by age and maturation and should avoid bias through inclusion
of a broad spectrum of subjects with a range of severity from
normal to severe disease. Development of definitive and wellvalidated
normative and pathological respiratory PSG values
will help refine diagnosis and possibly treatment options in
children with SRBD. Improved research design and methodology
will also improve understanding of the earliest forms of
SRBD and the natural history of SRBD in children.
There is an urgent need for research clarifying the clinical utility
of polysomnography. For example, comparison of validated
and relevant outcomes in patients managed with and without
PSG would provide the most compelling evidence to evaluate
the value of PSG in managing children with suspected SRBDs.
Findings indicate that PSG may be particularly useful in the
evaluation of children with chronic health conditions such as obesity,
metabolic syndrome, overt or evolving hypertension, and
other conditions associated with cardiovascular risk. There is a
need for further investigation of SRBD in children with neurodevelopmental
and neuromuscular disorders, sickle cell anemia,
craniofacial disorders, and certain infants who experience ALTEs.
The clinical utility and cost effectiveness of testing outside
the sleep laboratory for certain groups of children with suspected
SRBD needs further investigation. Preliminary evidence
suggests that efforts to make the sleep laboratory experience
more child-friendly will improve the quality of data collected
as well as patient and family satisfaction.
Pediatric sleep medicine is a complex, dynamic, and multidisciplinary
field, and the sleep specialist involved with evaluation
and management of children faces an evolving landscape.
The medical literature regarding pediatric PSG is expanding
exponentially, and recording techniques and methods for digital
analysis are changing at a rapid pace. Superimposed on these
dynamic changes is the challenge of characterizing respiratory
sleep disorders and the impact of SRBD on behavior and cognition
in the developing child. Performance of PSG using standardized
and developmentally appropriate methods has strong
clinical utility in the diagnosis and management of SRBD in
children. Accurate diagnosis and management of SRBD in children
is best accomplished through careful integration of polysomnographic
findings with the clinical evaluation.
ACKNOWLEDGMENTS
The committee would like to thank Sharon Tracy, PhD and
Christine Stepanski, MS for their efforts in the development of
this manuscript.
DISCLOSURE STATEMENT
This was not an industry supported study. Dr. Morgenthaler
has received research support from ResMed. Dr. Auerbach has
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