Snoring - Learn the Facts

Snoring results from the pharyngeal airway collapsing during inspiration. Snoring
can disrupt sleep, cause a variety of important but nonspecific symptoms, and suggest
the presence of the obstructive sleep apnea syndrome, which can lead to cor pulmonale
and sudden death. Therefore, the review of systems for a child at any age should
include questions regarding snoring and breathing during sleep. Most normal children
snore at one time or another, and many, particularly those who have nasal allergies,
snore almost nightly.

Physiologic Sources of the Problem
Snoring and obstructive sleep apnea do not represent structural upper
airway narrowing alone, but rather an imbalance between the degree of airway
narrowing and the ability of the respiratory centers in the brainstem to use
the muscles of the pharynx and tongue to maintain airway patency. For each
child who has tonsillar hypertrophy and who snores, there are many who have
larger tonsils who do not snore because they use their pharyngeal muscles to
keep the airway open during sleep. Conversely, children who have little or no
structural airway narrowing may have severe obstructive sleep apnea solely
because of a dramatic loss of pharyngeal muscle tone during sleep. In this light, it is not
surprising that many children who have obstructive sleep
apnea (the absence of airflow despite inspiratory efforts) also have central
apneas (respiratory pauses of >15 seconds without airway obstruction) as
another manifestation of respiratory center dysfunction, and that snoring and
obstructive sleep apnea are particularly common in children who have
underlying neurologic problems or hypotonia (eg, trisomy 21). Obstructive
sleep apnea is overlooked easily in children who have neurologic deficits because they
often have noisy breathing at baseline and other reasons to explain the nonspecific
symptoms of sleep disruption.

Pathologic Progression
In most children who snore, increased respiratory effort successfully compensates for airway narrowing, and both gas exchange and sleep are
unaffected. With more severe obstruction, compensation is compromised by
increased inspiratory effort tending to collapse the pharynx further and to
exacerbate the obstruction. The earliest pathologic consequence of increasing
obstruction is disruption of the normal structure and organization of sleep.
For reasons that are poorly understood, disordered sleep (even in the absence
of apnea or hypoxemia) can cause growth failure, daytime hypersomnolence,
enuresis, systemic hypertension, headaches, school failure, and a host of
other nonspecific symptoms. As obstruction becomes extreme, completely
obstructed breaths and repetitive episodes of hypoxemia, with or without
central apneas, result in cor pulmonale. Although obstructive sleep apnea does not
seem to be a cause of the sudden infant death syndrome, infants and
children who have severe obstructive sleep apnea are at a much increased risk
of sudden death during sleep, particularly when airway patency is compromised
by an upper respiratory infection. Pediatricians should identify patients who
have pathologic snoring before severe obstructive sleep apnea has developed.

Ascertaining the Need for Further Evaluation
Snoring that is regular, is not interrupted by totally obstructed breaths or central
apneas, is not associated with dramatic intercostal or substernal
retractions, and that does not lead the child to assume unusual postures
during sleep or to sweat profusely is unlikely to be pathologic. In the
absence of potentially related signs or symptoms (eg, growth failure,
enuresis, school failure), further evaluation of such children rarely is
indicated. If parental concerns or uncertainty about the extent of snoring
persist, the easiest next step is to ask the parents to record several minutes of the child’s
“worst” snoring on audio or, preferably, audio/video tape.
Review of a video tape or direct observation of a sleeping child is worth a
thousand words. Age is not a critical factor in the diagnosis of pathologic
snoring, but it is important to remember that young children who snore are
likely to develop increasing obstruction as lymphoid tissue hypertrophies.
If respiratory compromise is not obvious from direct observation, but
snoring is severe or the child has a nonspecific symptom that could be related to this
problem, the next step is to evaluate oxygenation during sleep. This can be done easily and reliably on most pediatric units by correlating transcutaneous oximetry and direct observation. If done at home, a video recording, which includes the oximeter reading and the child simultaneously, helps to confirm that desaturations are related to disordered breathing rather than being technical artifacts. Recurrent episodes of desaturation (SaO2
<90%) during sleep is an indication for tonsillectomy, adenoidectomy, or another
procedure. Evidence of right ventricular hypertrophy on
electrocardiogram or echocardiogram, polycythemia, and elevated bicarbonate
suggest hypoxemia or hypoventilation and also are indications for surgery.
However, these are late signs and may be absent even in children who have
severe problems.
Polysomnography
A difficult diagnostic problem is posed by children who do not have
completely obstructed breaths, obvious sleep disorganization, or recurrent hypoxemia
but who snore chronically or recurrently and have one or more
nonspecific symptoms (enuresis, school failure, etc) that might be related to
disordered sleep. Polysomnography (recordings of oximetry, respiratory
airflow, snoring, respiratory effort, electrocardiogram, electroencephalogram,
end-tidal CO2, or other parameters during sleep) can help identify which
children deserve surgery or further evaluation. A tracing of respiratory effort and heart rate (pneumogram) is not helpful because completely obstructed breaths
can be missed unless a parameter sensitive to airflow is
recorded simultaneously. Many tertiary care centers have sleep laboratories
and consultants familiar with the evaluation of sleep and respiratory
disorders who can help the pediatrician decide which children might benefit
from such “high-tech” assessments. Consultants also may identify children who
would benefit from nasal constant positive airway pressure during sleep rather
than surgery and can help manage children in whom surgery has not helped resolve
symptoms.

Treatment for Pathologic Snoring
Although respiratory stimulants and tricyclic antidepressants have been used to treat obstructive sleep apnea, it rarely is possible to improve
pharyngeal muscle tone and function significantly with drug therapy.
Therefore, symptomatic snoring and obstructive sleep apnea usually are managed
by enlarging the airway (tonsillectomy or adenoidectomy, pharnygoplasty, nasal
reconstruction, or other procedures), bypassing the airway (tracheostomy), or supporting
the airway during inspiration (nasal constant positive airway
pressure). Although the pharyngeal airway may be narrowed by adipose tissue
in the neck and pharynx (obesity, obstructive sleep apnea, and cor pulmonale
comprise the Pickwickian syndrome), hypertrophy of the tonsils and adenoids is
by far the most common cause of airway narrowing, snoring, and obstructive
sleep apnea in children. Tonsillectomy or adenoidectomy often eliminates or
ameliorates this problem, even in children whose tonsils and adenoids are not massively
enlarged, and may be a reasonable first step in children who have
other reasons for airway narrowing. This is particularly true when correction
of the underlying abnormality (obesity, micrognathia, macroglossia, or other
maxillofacial abnormalities) is difficult or must be delayed. Nevertheless,
tonsillectomy or adenoidectomy is not indicated for the vast majority of
snoring children, and just because this procedure may decrease snoring does
not justify its widespread use in children who are otherwise normal.

Obstructive Sleep Apnea
The hallmark of obstructive sleep apnea is completely obstructed breaths
in which the pharynx collapses completely and air flow (and snoring) cease
despite continued inspiratory efforts. Flow then is reestablished with a loud
snorting breath. Most parents of children who have obstructive sleep apnea
can describe this distinctive respiratory pattern. Full-blown obstructive
sleep apnea, with its characteristic snoring, hypoxemia, daytime hypersomnolence, and
cor pulmonale, usually is recognized easily by history, video tape, or direct observation.
In such cases, it is worthwhile to obtain a baseline electrocardiogram or
echocardiogram and a measurement of the serum bicarbonate level to assess
hypoxemia and hypoventilation. When the diagnosis is straightforward, early
surgery with careful anesthesia and postoperative monitoring is appropriate,
and further evaluation is unnecessary. Administering oxygen to correct hypoxemia
during sleep in such children carries the risk of acute hypoventilation. The aim of therapy should be to establish and maintain a patent airway during sleep as soon as
possible. Tonsillectomy, adenoidectomy, or other procedure to enlarge the airway also
is justified when a tape or direct observation confirms frequent, completely obstructed
breaths or grossly disturbed or irregular breathing during much of the night.
Many affected children assume unusual postures during sleep to help maintain
airway patency. After surgery, it is appropriate to document by
history or repeat studies that the problem has been resolved.

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