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Obstructive Sleep Apnea in Growing Patients: Separating Fact from Fiction

11/16/2016

3 Comments

 
PictureCBCT of the same airway with the patient supine (left) and upright (right). Van Holsbeke et al 2014
BY TUNG T. NGUYEN

Approximately 20% of adults and 2-10% of children suffer from obstructive sleep apnea (OSA).  The potential impact to health includes: diabetes, stroke, heart attack, lack of concentration, fatigue, among other symptoms.(1) The financial impact of OSA is estimated at $60 billion dollars annually.  These numbers alone might inspire you to embrace the growing trend of “Airway Friendly Orthodontics,” but what do those words really mean? With the potential for truly significant health impacts, it is easy to sensationalize treatment designed to improve the symptoms of OSA in children. What does current evidence suggest?

In order to separate fact from fiction, when it comes to OSA in growing patients, the well-informed orthodontist must first understand three basic anatomic and physiological principles regarding airway. 

1. Airway volume and cross-sectional area are influenced by head position, consciousness and inhalation/ exhalation state during image capture.  The majority of CBCT studies published in orthodontic journals are captured in the upright or sitting position.  Yet, airway studies have shown that minimum cross-sectional area decreases by as much as 70% from the upright to supine position.(2)  In addition, airway volume and cross-sectional area decrease in unconscious breathing compared to conscious breathing. A single snapshot of the airway captured using CBCT is an anatomic image with limitations: the patient is almost never lying down or asleep. Correctly interpreting data collected in such a fashion means understanding that the true physiologic problem (OSA) might be diminished or amplified relative to the CBCT volume.

PictureThe airway changes with growth. cbctortho.com
2. Airway volume and minimum cross-sectional area both increase from birth to age 20 years, then stabilize until to the 50s, after which they slowly dcrease.(3)  That means that any case report or study in growing patients needs to have untreated controls to separate treatment effect from growth alone. If appliance “X” reportedly increases the airway volume or minimum cross-sectional area in 10-12 year olds, then ideally, that statement should be made based on comparison to a control group.




3. There is often a remission of OSA from middle childhood to late adolescence.  A recent longitudinal study reported only 8.7% of children diagnosed with OSA at ages 8-11 y had OSA at 16-19 years(4)  They hypothesized that normal growth of the airway self-corrects the problem.  This begs the question “Are we taking credit for fixing something that growth takes care of anyway?”  In addition, this study found that snoring alone is not a predictor of OSA for middle-childhood patients.

What is the take-home message? 
  • Anatomic changes may or may not translate into change in the physiologic process of breathing. One should be cautious when listening to airway presentations at meetings or when reading articles that claim to cure OSA by increasing airway volume or minimum cross-sectional area alone. Often such claims are made using CBCT only.
  • Airway changes with growth. Any device or intervention claiming to improve airway in growing patients must be evaluated with this observation in mind. Data suggest that up to 91% of children diagnosed with OSA at 8-11 years old go into remission by the time they are 16-19 years old.  
 
References:
1. Lumeng J and Chervin R. Epidemiology of Pediatric Obstructive Sleep Apnea. Proc Am Thorac Soc. 2008; 5: 242–252.
2.  Van Holsbeke CS, Verhulst SL, Vos WG, De Backer JW, Vinchurkar SC, Verdonck PR et al. Change in upper airway geometry between upright and supine position during tidal nasal breathing. J Aerosol Med Pulm Drug Deliv. 2014; 27:51–7.
3.  Schendel SA, Jacobson R, Khalessi S. Airway growth and development: a computerized 3-dimensional analysis. J Oral Maxillofac Surg. 2012 2012-09-01;70(9):2174–83.
4.  Spilsbury, J.C., Storfer-Isser, A., Rosen, C.L. et al, Remission and incidence of obstructive sleep apnea from middle childhood to late adolescence. Sleep. 2015;38:23–29.


3 Comments
Andrew Thompson link
7/2/2018 09:40:48 am

Very sensible and well articulated arguments. Thankyou.

Reply
Sal Taiym
7/2/2018 10:32:04 pm

Dr. Nguyen, thank you for your blog post.

I would like to make a few brief comments regarding the three basic anatomic and physiological principles regarding airway you had mentioned.

1. You are correct about the assessment of airway volume using CBCT is not a great indicator of obstructive sleep apnea (OSA), but I do not know anyone currently that is experienced on the topics of OSA and oral appliance therapy trying to diagnose OSA from a CBCT. It may be used as a record, like an intra-oral photo would be used in an orthodontic evaluation. The vast majority of dentists and sleep physicians treating patients with OSA understand a large volumetric airway on a CBCT means absolutely nothing. What is important is the collapsibility during sleep of the oro-pharyngeal structures. There is also no mention of where the ultimate diagnoses of OSA comes from, which is from a polysomnography (PST).

2. Airway volume increase into adulthood is inderstood. We want to focus away from airway volume because it does not indicate whether an individual may have OSA. The real test should be a PST to assess whether a patient has a sleep disorder such as OSA. The slide that shows the 2-year difference and the substantial increase of the airway from infant to toddler tells us nothing about whether the patient is more susceptible to a diagnosis of OSA. The only way to know is through a PST.

3. Remission from OSA from childhood to adolescents is known among pediatric sleep physicians. But, a child who is diagnosed with pediatric OSA at 8 years old is experiencing apnea and hypopnea episodes throughout the night, meaning he/she is essentially depriving his/her brain and other tissues valuable oxygen. Not to mention the micro arousals and sleep deprivation. That child needs to be treated to prevent the known complications of pediatric OSA. Whether it is with a CPAP or some type of functional or fixed appliance such as an expander, herbst or reverse pull headgear. Even if we know he/she “will grow out of it,” waiting 6-10 years for that is not recommended.

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    Think Pieces are longer-form editorials on selected topics.

    Curated by:

    Tate H. Jackson, DDS, MS
    with
    William R. Proffit, DDS, PhD
    Tung T. Nguyen, DMD, MS

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