Obstructive sleep apnoea syndrome | Anales de Pediatría

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] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Neumología, Complejo Hospitalario Universitario de Albacete, Albacete, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Pediatría, Complejo Hospitalario Universitario de Albacete, Albacete, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Atención Primaria de la Gerencia de Atención Integrada de Albacete, Albacete, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome de apneas-hipopneas durante el sueño" ] ] "textoCompleto" => "IntroductionObstructive sleep apnoea (OSA) is characterised by repetitive episodes of cessation or significant decrease in airflow (apnoea or hypopnoea, respectively) during sleep due to anatomical or functional abnormalities in the upper airway that lead to its collapse and may be accompanied by oxygen desaturation and multiple unconscious arousals (microawakenings), all of which results in nonrestorative sleep. It may be associated with excessive daytime sleepiness (EDS) and neuropsychiatric, respiratory, endocrine/metabolic or cardiovascular diseases.<a class="elsevierStyleCrossRef" href="#bib0185">1</a> Although one-fourth of the population experiences some episodes of apnoea or hypopnoea, OSA is only diagnosed when these episodes are very frequent and cause health problems.<a class="elsevierStyleCrossRef" href="#bib0190">2</a>Obstructive sleep apnoea affects 4–6% of middle-aged men and 2–4% of middle-aged women,<a class="elsevierStyleCrossRefs" href="#bib0195">3,4</a> and its frequency increases with age.<a class="elsevierStyleCrossRef" href="#bib0205">5</a> It is a public health problem of utmost importance.<a class="elsevierStyleCrossRef" href="#bib0210">6</a> However, only 5–9% of the 1200000–2150000 individuals estimated to have the disease in Spain have received a diagnosis or been treated for it.<a class="elsevierStyleCrossRef" href="#bib0215">7</a>Obstructive sleep apnoea can also occur in children, in whom it presents with specific manifestations. Children differ from adults on account of developmental peculiarities in the anatomy and function of the upper airway and of the neurophysiology of sleep. Paediatric OSA is a distinct entity with significant differences in aetiology, clinical presentation and treatment. The clinical manifestations and physical, cognitive and developmental outcomes of OSA in children are different compared to adults.<a class="elsevierStyleCrossRef" href="#bib0190">2</a> Thus, the American Academy of Sleep Medicine differentiates between these two entities and includes them as separate categories in its classification of sleep disorders.<a class="elsevierStyleCrossRef" href="#bib0220">8</a>The Consensus Document on Obstructive Sleep Apnoea in Children was published in 2011.<a class="elsevierStyleCrossRef" href="#bib0225">9</a> It defines paediatric OSA as a disorder of breathing during sleep characterised by prolonged partial upper airway obstruction and/or intermittent complete obstruction that disrupts normal ventilation during sleep and normal sleep patterns. It presents with symptoms such as snoring, sleep disturbances and/or behavioural or learning problems.<a class="elsevierStyleCrossRef" href="#bib0230">10</a> Severe cases may cause faltering weight, neurocognitive impairment and cor pulmonale. Several risk factors for OSA have been identified,<a class="elsevierStyleCrossRef" href="#bib0235">11</a> the most frequent of which is adenotonsillar hypertrophy, followed by obesity, which has been emerging as an aetiological factor in children in recent years. Other factors include craniofacial anomalies, neurologic diseases such as cerebral palsy, neuromuscular disorders and gastroesophageal reflux.<a class="elsevierStyleCrossRef" href="#bib0225">9</a>The prevalence of OSA in children is high. It affects 2–4% of children aged 2–6 years,<a class="elsevierStyleCrossRef" href="#bib0230">10</a> and its incidence peaks between 2 and 5 years. It is most commonly found in preschool- and school-age children, but it may also manifest in the first months of life. There are no differences in prevalence between the sexes.<a class="elsevierStyleCrossRef" href="#bib0190">2</a> Obstructive sleep apnoea is a child health priority due to its high prevalence, because it often appears in association with different chronic diseases, is associated with less favourable outcomes of these comorbidities, and has a negative impact on the quality of life of children and their caregivers.<a class="elsevierStyleCrossRef" href="#bib0225">9</a>Our unit has been performing sleep studies in children since 1999. The number of these studies has been increasing in recent years. Patients are mainly referred due to clinical suspicion of OSA or for preoperative evaluation of patients eligible for adenotonsillectomy. The primary objective of our study was to determine the clinical and polysomnographic features of OSA in children aged less than 14 years in our region, and the secondary objective was to find the treatments used most frequently and their outcomes in terms of clinical manifestations and weight.Patients and methodsWe conducted a retrospective descriptive study, including 234 consecutive sleep studies performed in children aged less than 14 years between October 1999 and August 2012 in the Sleep Unit of the Department of Pulmonology of the Complejo Hospitalario Universitario de Albacete.We collected data on the following variables: sex, age, indication for sleep study, comorbidities, clinical presentation, weight, height, BMI, type of sleep study, polysomnographic/polygraphic variables, diagnosis, severity, treatment and clinical and weight outcomes.We retrieved the data by actively searching the hospital records of each patient included in the study. The presence or absence of snoring, apnoea and EDS had been documented in every case.We considered that the patient had comorbidities and/or adenotonsillar hypertrophy when such conditions were entered in the hospital records by a paediatrician or otorhinolaryngology specialist.We defined obesity as a BMI at or above the 95th percentile (95P) and overweight as a BMI above the 85th percentile (85P) and below the 95P.<a class="elsevierStyleCrossRefs" href="#bib0240">12,13</a>Polysomnography (PSG) and respiratory polygraphy (RP) were always performed in our unit, and their results were analysed and interpreted by the same pulmonologist. The chief of the unit decided which type of test should be applied based on available resources and the current indications at the time of the study.The polysomnographic/polygraphic variables included: apnoea–hypopnoea index (AHI)/respiratory disturbance index (RDI); baseline, average and lowest SatO2; percentage of total sleep time spent with SatO2<90% (T90); oxygen desaturation index of 3% or lower per hour of sleep/recording; percentage of sleep time/recording in the supine position; percentage of respiratory events in the supine position.In its Consensus Document on OSA, the Grupo Español de Sueño (Spanish Group on Sleep) established an AHI of 1–3 as the limit of normal.<a class="elsevierStyleCrossRef" href="#bib0190">2</a> Thus, an AHI/RDI of less than 3 was not considered abnormal. When it came to severity, OSA was classified as mild if the AHI/RDI was less than 5, moderate if it was between 5 and 10, and severe if it was greater than 10.<a class="elsevierStyleCrossRef" href="#bib0225">9</a>Patients were treated in adherence with current indications and recommendations, in the otorhinolaryngology department if they presented with adenotonsillar hypertrophy, and otherwise in the paediatrics and/or pulmonology department.We classified weight and clinical outcomes as improved, unchanged or worse. We categorised outcomes based on the information entered in the hospital records of patients during follow-up visits at least 6 months after initiation of treatment. Symptoms were considered to have improved if family members reported decreased snoring and frequency of apnoea, to be unchanged if they remained the same, and to be worse if they had increased in frequency or intensity, all of which were subjective assessments. Weight was considered improved if the BMI changed to a lower category (from ≥95P to 86P-94P or ≤85P, or from 86P-94P to ≤85P), unchanged if it remained in the same category, and worse if it had changed to a higher category (from ≤85P to 86P-94P and from 86P-94P to ≥95P).The descriptive analysis consisted in the calculation of proportions for qualitative variables and of measures of central tendency and dispersion for quantitative variables. We summarised quantitative variables with the mean and standard deviation if they were normally distributed, or otherwise with the median and interquartile range (IQR).We performed the statistical analyses and generated all charts and tables using the software SPSS version 19.0 for Windows.ResultsA total of 234 sleep studies were performed, 148 (63.2%) in boys, and the median patient age was 5 years (IQR, 3–8.25). The reason for the study was to evaluate the need for surgery for treatment of adenotonsillar hypertrophy in 112 children (47.9%), clinical suspicion of OSA in 108 (46.2%), and other reasons in 14 (6%).Of the 234 children under study, 168 (71.8%) had an AHI/RDI of 3 or more events per hour, which led to diagnosis of OSA. In the OSA group, 102 (60.7%) were male; the median age was 5 years (IQR, 3–8), with 82 preschool-age patients (48.8%) and 49 school-age patients (29.2%). Thus, a total of 131 patients with OSA (78%) were preschool- or school-age children.Most of the children that received a diagnosis of OSA had no significant comorbidities. The most frequent comorbidities were diseases of the lower respiratory tract, found in 35 patients (20.8%), most commonly bronchial asthma, found in 24 patients (14.3%). However, we did not find a statistically significant association between lower respiratory disease and OSA (20.8% vs 21.2%; P=.949) or between asthma in particular and OSA (14.3% vs 15.2%; P=.866).Of the children with OSA, 157 (93.4%) presented with snoring, 142 (84.5%) had a history of witnessed apnoeic episodes, and 9 (5.4%) had EDS. Seventy-four (44%) had excess weight, 100 (59.5%) adenotonsillar hypertrophy, and 35 (20.8%) had both.The diagnosis was made by PSG in 23 patients and by RP in 145. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarises the relevant findings of the sleep tests.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Obstructive sleep apnoea was mild in 22 patients (13.1%), moderate in 71 (42.3%) and severe in 75 (44.6%).In the 168 children with OSA, treatment consisted in adenotonsillectomy in 72 (42.9%), lifestyle and dietary measures (weight loss/dieting, measures to control snoring, sleep hygiene measures) in 49 (29.2%), CPAP in 10 (6%) and other treatments (such as observation and followup, topical anti-inflammatory treatment, use of a chin strap, dental devices or orthodontic intervention) in 37 (22%).After treatment initiation, of the 157 children with a history of snoring and/or witnessed apnoeic episodes, 109 (69.4%) experienced improvement in these symptoms, 47 (29.9%) experienced no changes and 1 (0.6%) worsening of symptoms. The weight status of the 74 children with a diagnosis of OSA associated with overweight or obesity improved in 24 (32.4%) remained unchanged in 36 (48.6%) and got worse in 14 (18.9%).We also assessed the characteristics of 2 subsets of patients with OSA classified according to the indication for the sleep study: clinical suspicion of OSA (subset I) or evaluation of need of surgery in patients with adenotonsillar hypertrophy (subset II). <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> presents the results of the descriptive and comparative analysis of these two groups.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>DiscussionPaediatric sleep disorders are growing in importance in our region (a total of 90 children had been assessed in our unit until 2009, while the number of children assessed in 2012 was as high as 234). In recent years, OSA was clinically significant in up to 90% of children, and treatment achieved symptom control in most.The prevalence of OSA in children is high, and the literature estimates its incidence at 2–4% of the paediatric population.<a class="elsevierStyleCrossRef" href="#bib0230">10</a>In our area, the onset of OSA peaked between age 2 and 5 years, closely followed in frequency by school-age children. In the reviewed literature, as in our study, onset occurred most frequently in preschool- and school-age children, with no difference in prevalence between sexes.<a class="elsevierStyleCrossRef" href="#bib0190">2</a>Adenotonsillar hypertrophy and obesity are the main risk factors for OSA in otherwise healthy children. As our study demonstrates, the most frequent cause of OSA in the paediatric population is enlargement of the tonsils and/or adenoids, and adenotonsillar hypertrophy was found in 59.5% of the patients in our sample that received an OSA diagnosis.Obstructive sleep apnoea may also be associated with obesity, anatomical anomalies or neurologic, metabolic or muscular abnormalities.<a class="elsevierStyleCrossRefs" href="#bib0190">2,9</a> Individual susceptibility, environmental factors and lifestyle (physical and cognitive activity, diet, etc.) play an important role in phenotypic variation. Therefore, and considering the lifestyle and dietary changes that have occurred in the paediatric age group in recent years, with an increase in obesity and sedentary habits, the classic phenotype is gradually being replaced by a pattern that is more similar to the form of OSA found in adults.In our study, 74 (44%) of the patients with OSA had overweight or obesity. This excess weight was the most likely cause of OSA in 39 (23.2%), as they did not present with adenotonsillar hypertrophy. In a study of 37 obese adolescents (BMI>97th percentile), Hannon et al. found that 45% had OSA based on the findings of PSG (OSA defined as AHI>1.5).<a class="elsevierStyleCrossRef" href="#bib0250">14</a> Other studies have found that 47% of obese children have moderate to severe OSA, and 39% mild OSA.<a class="elsevierStyleCrossRefs" href="#bib0255">15,16</a> Redline et al. found that obesity was the strongest risk for OSA, with an OR of 4.59 (95% CI, 1.58–13.33).<a class="elsevierStyleCrossRef" href="#bib0265">17</a> In a review of 27 studies,<a class="elsevierStyleCrossRef" href="#bib0270">18</a> the authors found that one-third found a statistically significant association between obesity and OSA in children younger than 10 years. In fact, a literature review by Ng et al. concluded that the severity of OSA was positively correlated to the degree of obesity.<a class="elsevierStyleCrossRef" href="#bib0275">19</a> There is variability between studies in the proportion of children with OSA reported to have obesity, which ranges between 10% and 50.6%.<a class="elsevierStyleCrossRefs" href="#bib0280">20–23</a> However, different criteria are used to define obesity, and overweight is usually not included in the analysis. A more recent study in 197 patients aged less than 18 years with sleep-associated breathing disorders found that 45.1% of them had overweight or obesity. Of these patients, 34 did not have tonsillar hypertrophy, and therefore excess weight was the main risk factor in 17.2% of the total sample.<a class="elsevierStyleCrossRef" href="#bib0300">24</a>In our sample, 93.4% of children with OSA presented with snoring, and 84.5% had a history of apnoeic episodes witnessed by the parents. The 3 symptoms that were the strongest predictors of OSA were snoring, laboured breathing and pauses in breathing during sleep. Multiple retrospective studies have demonstrated that OSA cannot be discriminated from primary snoring based on the history and physical examination alone.<a class="elsevierStyleCrossRef" href="#bib0305">25</a> A history of intense snoring is not sensitive enough to be an indication for surgery in children.<a class="elsevierStyleCrossRef" href="#bib0235">11</a> Similarly, the specificity of the combination of a clinical assessment and evaluation of home video<a class="elsevierStyleCrossRef" href="#bib0310">26</a> or audio<a class="elsevierStyleCrossRef" href="#bib0315">27</a> recordings of a child's sleep is not high enough to confirm the diagnosis of OSA. A systematic literature review found that the positive predictive value of clinical evaluation was approximately 55% using overnight PSG as the reference test; furthermore, none of the reviewed studies found any component of the clinical evaluation to have a sensitivity and specificity greater than 65%.<a class="elsevierStyleCrossRef" href="#bib0320">28</a> For these reasons, the American Thoracic Society<a class="elsevierStyleCrossRef" href="#bib0235">11</a> and the American Academy of Pediatrics<a class="elsevierStyleCrossRef" href="#bib0230">10</a> recommend PSG for assessment of paediatric OSA prior to surgery.In our study, 5.4% of children with OSA reported EDS. The main clinical difference relative to adults is that children with sleep-associated breathing disorders usually do not experience obvious EDS and, when EDS is present, it is not predictive of OSA in young children.<a class="elsevierStyleCrossRef" href="#bib0325">29</a>In our series, RP was the diagnostic tool used in 208 children and PSG the one used in 26. Overnight PSG is the gold standard for the detection and assessment of severity of OSA in children. However, RP could be used in the large population of children that could have OSA and thus reduce underdiagnosis, reserving PSG for children with comorbidities referred on an urgent basis for a sleep study or cases where the diagnosis is unclear or sleep disorders other than OSA are suspected.<a class="elsevierStyleCrossRef" href="#bib0225">9</a> In uncomplicated cases, RP may correlate strongly to the findings of PSG. Several authors have noted that the combination of a clinical evaluation, a thorough examination of the upper airway, a home audio-visual recording and a RP recording performed with certified equipment offers an adequate alternative for confirmation of diagnosis in children with suspected OSA.<a class="elsevierStyleCrossRefs" href="#bib0330">30,31</a> There are few paediatric studies on the use of RP, and most have been conducted in populations at high risk of OSA, had small sample sizes and did not involve performance of PSG at the time of testing to compare the findings of both tests, leading to inconsistent results.<a class="elsevierStyleCrossRef" href="#bib0340">32</a> A study conducted in Spain that compared both techniques concluded that RP performed in the sleep laboratory setting is a valid method for diagnosis of OSA in children.<a class="elsevierStyleCrossRef" href="#bib0345">33</a>Resection of the tonsils and adenoids is usually the treatment of choice in children with confirmed OSA and adenotonsillar hypertrophy. In our study, adenotonsillectomy was the most frequent treatment and led to clinical improvement in 68 (94.4%) of the 72 patients treated surgically. However, this improvement was self-reported and not corroborated by performance of a new sleep study after surgery, which is a limitation in our study, as we do not know the actual number of patients that had residual OSA and therefore eligible for other interventions. Based on the current literature, adenotonsillectomy is effective in approximately 78% of cases of OSA in children,<a class="elsevierStyleCrossRefs" href="#bib0190">2,10,34,35</a> although this figure varies between sources. A Cochrane review published in 2009<a class="elsevierStyleCrossRef" href="#bib0355">35</a> remarked on the absence of double-blind studies on the treatment of paediatric OSA and concluded that the current evidence on the effectiveness of adenotonsillectomy in paediatric OSA has methodological problems, including lack of randomisation and controls and variability in the definitions and variables taken into account. A retrospective multicentre study conducted in 2010<a class="elsevierStyleCrossRef" href="#bib0290">22</a> found a cure rate of 27.2% applying a definition of cure as an AHI of less than 1 event per hour. However, the success rate rose to 78.4% if cure was defined as an AHI equal or less than 5. The authors concluded that adenotonsillectomy was associated with significant improvement in most children. However, until data from prospective multicentre studies become available, children at higher risk of residual OSA, including those aged more than 7 years, with obesity or without obesity but with asthma or severe OSA, should undergo sleep tests before and after surgery.In our sample, CPAP was used to treat 10 patients, all of them with overweight or obesity. Patients treated with CPAP were managed at the outpatient pulmonology sleep clinic, and symptoms improved in 9 of them (90%). Continuous positive airway pressure is the second-line treatment for children with OSA,<a class="elsevierStyleCrossRef" href="#bib0360">36</a> as most of these patients improve after undergoing adenotonsillectomy, with only a small percentage left requiring additional treatment or in who CPAP is the first-line treatment. The latter are usually children with obesity, craniofacial anomalies or neuromuscular disorders associated with adenotonsillar hypertrophy or without adenotonsillar hypertrophy.<a class="elsevierStyleCrossRef" href="#bib0230">10</a>In addition to the limitation mentioned above, we also must remain aware of those that result from the retrospective design of the study, the predominant use of RP for diagnosis, and not having included certain symptoms that may be relevant in paediatric OSA in the analysis.To conclude, most children that underwent a sleep study in our unit had an abnormal AHI, and a high percentage received a diagnosis of moderate or severe OSA. Nearly half of the children with OSA had overweight or obesity. The treatment prescribed most frequently was adenotonsillectomy. The clinical outcomes of treatment were favourable in nearly 70% of children with OSA, while less than one third of patients with OSA associated with excess weight succeeded in improving their weight status.Conflict of interestThe authors have no conflicts of interest to declare" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1021204" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec979444" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1021205" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec979445" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Patients and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-12-19" "fechaAceptado" => "2017-07-08" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec979444" "palabras" => array:4 [ 0 => "Obstructive sleep apnoea syndrome" 1 => "Child" 2 => "Polysomnography" 3 => "Tonsillectomy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec979445" "palabras" => array:4 [ 0 => "Síndrome de apnea obstructiva del sueño" 1 => "Niño" 2 => "Polisomnografía" 3 => "Amigdalectomía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionObstructive sleep apnoea (OSA) is highly prevalent in children and a major public health problem. An attempt is made to determine the clinical and polysomnographic presentation of paediatric OSA in our area. Patients and methodsRetrospective descriptive study of sleep tests conducted on children up to 14 years old from 1999 to 2012 in the Sleep Unit of the University Hospital of Albacete. Age, gender, anthropometric, clinical data, indication and variables of sleep study, treatment, and outcomes were collected. ResultsThe study included 234 children. OSA was found in 71.8%, with 42.3% moderate and 44.6% severe. The majority were male (60.7%) and the mean age was 5 years, of whom 78% were pre-school or school age. There was overweight/obesity in 44%, with 93.4% snoring, apnoea 84.5%, and 5.4% daytime sleepiness. There were 23 polysomnographies and 145 polygraphies, with a median apnoea/hypopnoea index (AHI) of 10, SatO2 minimum 84%, desaturation index 8, and mean sleep supine 53.65% and supine events 57.61%. Treatment was lifestyle modifications 29.2%, CPAP 6%, and surgery 42.9%. Improved snoring and/or apnoea 69.4%, and weight 32.4% of overweight/obesity children. ConclusionsMost of the studied children had a pathological AHI. Almost half were overweight/obese, and a high percentage had moderate-severe OSA. Most frequent treatment was surgery. The clinical outcome was favourable in almost 70%. Less than a third with OSA and overweight/obesity improved weight." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónEl síndrome de apneas-hipopneas del sueño (SAHS) es altamente prevalente en la edad pediátrica y un problema importante de salud pública. Se pretende conocer la presentación clínica y polisomnográfica del SAHS infantil en nuestro medio. Pacientes y métodosEstudio descriptivo retrospectivo de los estudios del sueño realizados a menores de 14 años desde 1999 hasta 2012 en la Unidad del Sueño del Complejo Hospitalario Universitario de Albacete. Se recogen edad, sexo, datos antropométricos, clínicos, indicación y variables del estudio del sueño, tratamiento y evolución. ResultadosDoscientos treinta y cuatro niños. SAHS el 71,8%: moderado 42,3% y grave 44,6%. 60,7% varones y mediana de edad 5 años; el 78% en edad preescolar o escolar. Presentaban sobrepeso/obesidad 44%, ronquidos 93,4%, apneas 84,5% y somnolencia diurna 5,4%; 23 polisomnografías y 145 poligrafías: mediana de índice de apneas-hipopneas (IAH) 10, de SatO2 mínima 84% y de índice de desaturaciones 8, y media de sueño en supino 53,65% y de eventos en supino 57,61%. El tratamiento fue medidas higiénico-dietéticas en el 29,2%, CPAP el 6% y cirugía el 42,9%. Mejoraron los ronquidos y/o apneas el 69,4% y el peso el 32,4% de los niños con sobrepeso/obesidad. ConclusionesLa mayoría de los niños estudiados tenían un IAH patológico. Casi la mitad presentaban sobrepeso/obesidad y un alto porcentaje tenía SAHS moderado-grave. El tratamiento más indicado fue la cirugía. La evolución clínica fue favorable en casi el 70%. Menos de un tercio con SAHS y sobrepeso/obesidad mejoraron el peso." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: García Castillo S, Hoyos Vázquez MP, Coloma Navarro R, Cruz Ruiz J, Callejas González FJ, Godoy Mayoral R, et al. Síndrome de apneas-hipopneas durante el sueño. An Pediatr (Barc). 2018;88:266–272." ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "Previous presentation: This study was presented the 48 Congreso Nacional SEPAR, June 5–8, 2015; Gran Canaria, Spain." ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "AHI, apnoea-hypopnoea index; RDI, respiratory disturbance index; IQR, interquartile range; SaO2, oxygen saturation; T90, percentage of sleep time/recording with oxygen saturation<90%." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Result \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">AHI/RDI (median number of events per hour) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 (IQR 6–15) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Baseline SaO2 (median) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">97% (IQR 97–98) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Average SatO2 (median) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">95% (IQR 94–96) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lowest SatO2 (median) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">84% (IQR 74–88) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T90 (median) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0% (IQR 0–2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Events of desaturation≥3% per hour of sleep/recording (median) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (IQR 4–14) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Time spent supine during sleep/recording (mean) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">53.65±30.94% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Events while in supine position (mean) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">57.61±30.94% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1735036.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Results of the analysis of the sleep variables under study." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "AHI, apnoea-hypopnoea index; CPAP, continuous positive airway pressure; EDS, excessive daytime sleepiness; ENT, ear–nose–throat; IQR, interquartile range; ODI, oxygen desaturation index (SaO2≥3%); PSG, polysomnography; RP, respiratory polygraphy; SaO2, oxygen saturation; T90, percentage of sleep time with oxygen saturation<90%." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Subgroup I \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Subgroup II \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sex (male/female) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">34/25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">64/35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.379 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (IQR 3–11) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (IQR 3–6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lower respiratory disease (yes/no) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13/46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18/81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.555 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Asthma (yes/no) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8/51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15/84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.784 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Snoring (yes/no) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">59/0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">97/2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.529 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Apnoeic episodes (yes/no) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">51/8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">98/1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.793 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">EDS (yes/no) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8/51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1/98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Overweight or obesity (yes/no) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">36/22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35/58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.006 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Test (PSG/RP) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13/46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6/93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.003 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">AHI (n/h) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (IQR 7–15) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 (5–14) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.583 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Baseline SaO2 (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">97 (IQR 97–97) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">96 (IQR 97–98) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.021 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SatO2 media (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">95 (IQR 94–96) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">96 (IQR 95–96) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.034 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Minimum SaO2 (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">81 (IQR 76–87) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">85 (IQR 81–88) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.018 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T90 (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (IQR 0–2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 (IQR 0–2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.465 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ODI (n.°/h) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 (IQR 5–13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (IQR 4–15) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.644 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">% supine position \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">55.8±32.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">51.9±29.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.437 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">% events in supine position \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">59.3±31.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">55.9±29.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.504 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">OSA severity (mild/moderate/severe) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3/31/25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16/39/44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.072 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Treatment (sleep hygiene-dietary measures/ENT surgery/CPAP/other) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">34/1/8/16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9/70/2/18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Snoring and apnoea outcomes (improved/unchanged/worse) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9/19/8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13/16/6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Weight outcome (improved/unchanged/worse) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25/34/0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">81/12/1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.534 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1735037.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Differences between the 2 subgroups." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:36 [ 0 => array:3 [ "identificador" => "bib0185" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tratamiento del síndrome de las apneas-hipopneas durante el sueño" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J. 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Original Article

Obstructive sleep apnoea syndrome

Síndrome de apneas-hipopneas durante el sueño

Sergio García Castilloa,

Corresponding author

sgarciac@sescam.jccm.es
sgc82@hotmail.com

Corresponding author.

, María del Perpetuo Socorro Hoyos Vázquezb, Ramón Coloma Navarroa, Javier Cruz Ruiza, Francisco Javier Callejas Gonzáleza, Raúl Godoy Mayorala, Pedro Juan Tárraga Lópezc, José Antonio Rodríguez Montesd

a Servicio de Neumología, Complejo Hospitalario Universitario de Albacete, Albacete, Spain

b Servicio de Pediatría, Complejo Hospitalario Universitario de Albacete, Albacete, Spain

c Atención Primaria de la Gerencia de Atención Integrada de Albacete, Albacete, Spain

d Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario La Paz, Madrid, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Obstructive sleep apnoea &#40;OSA&#41; is characterised by repetitive episodes of cessation or significant decrease in airflow &#40;apnoea or hypopnoea&#44; respectively&#41; during sleep due to anatomical or functional abnormalities in the upper airway that lead to its collapse and may be accompanied by oxygen desaturation and multiple unconscious arousals &#40;microawakenings&#41;&#44; all of which results in nonrestorative sleep&#46; It may be associated with excessive daytime sleepiness &#40;EDS&#41; and neuropsychiatric&#44; respiratory&#44; endocrine&#47;metabolic or cardiovascular diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">1</span></a> Although one-fourth of the population experiences some episodes of apnoea or hypopnoea&#44; OSA is only diagnosed when these episodes are very frequent and cause health problems&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Obstructive sleep apnoea affects 4&#8211;6&#37; of middle-aged men and 2&#8211;4&#37; of middle-aged women&#44;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">3&#44;4</span></a> and its frequency increases with age&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">5</span></a> It is a public health problem of utmost importance&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">6</span></a> However&#44; only 5&#8211;9&#37; of the 1<span class="elsevierStyleHsp" style=""></span>200<span class="elsevierStyleHsp" style=""></span>000&#8211;2<span class="elsevierStyleHsp" style=""></span>150<span class="elsevierStyleHsp" style=""></span>000 individuals estimated to have the disease in Spain have received a diagnosis or been treated for it&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Obstructive sleep apnoea can also occur in children&#44; in whom it presents with specific manifestations&#46; Children differ from adults on account of developmental peculiarities in the anatomy and function of the upper airway and of the neurophysiology of sleep&#46; Paediatric OSA is a distinct entity with significant differences in aetiology&#44; clinical presentation and treatment&#46; The clinical manifestations and physical&#44; cognitive and developmental outcomes of OSA in children are different compared to adults&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">2</span></a> Thus&#44; the American Academy of Sleep Medicine differentiates between these two entities and includes them as separate categories in its classification of sleep disorders&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The Consensus Document on Obstructive Sleep Apnoea in Children was published in 2011&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">9</span></a> It defines paediatric OSA as a disorder of breathing during sleep characterised by prolonged partial upper airway obstruction and&#47;or intermittent complete obstruction that disrupts normal ventilation during sleep and normal sleep patterns&#46; It presents with symptoms such as snoring&#44; sleep disturbances and&#47;or behavioural or learning problems&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">10</span></a> Severe cases may cause faltering weight&#44; neurocognitive impairment and <span class="elsevierStyleItalic">cor pulmonale</span>&#46; Several risk factors for OSA have been identified&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">11</span></a> the most frequent of which is adenotonsillar hypertrophy&#44; followed by obesity&#44; which has been emerging as an aetiological factor in children in recent years&#46; Other factors include craniofacial anomalies&#44; neurologic diseases such as cerebral palsy&#44; neuromuscular disorders and gastroesophageal reflux&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The prevalence of OSA in children is high&#46; It affects 2&#8211;4&#37; of children aged 2&#8211;6 years&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">10</span></a> and its incidence peaks between 2 and 5 years&#46; It is most commonly found in preschool- and school-age children&#44; but it may also manifest in the first months of life&#46; There are no differences in prevalence between the sexes&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">2</span></a> Obstructive sleep apnoea is a child health priority due to its high prevalence&#44; because it often appears in association with different chronic diseases&#44; is associated with less favourable outcomes of these comorbidities&#44; and has a negative impact on the quality of life of children and their caregivers&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Our unit has been performing sleep studies in children since 1999&#46; The number of these studies has been increasing in recent years&#46; Patients are mainly referred due to clinical suspicion of OSA or for preoperative evaluation of patients eligible for adenotonsillectomy&#46; The primary objective of our study was to determine the clinical and polysomnographic features of OSA in children aged less than 14 years in our region&#44; and the secondary objective was to find the treatments used most frequently and their outcomes in terms of clinical manifestations and weight&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">We conducted a retrospective descriptive study&#44; including 234 consecutive sleep studies performed in children aged less than 14 years between October 1999 and August 2012 in the Sleep Unit of the Department of Pulmonology of the Complejo Hospitalario Universitario de Albacete&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">We collected data on the following variables&#58; sex&#44; age&#44; indication for sleep study&#44; comorbidities&#44; clinical presentation&#44; weight&#44; height&#44; BMI&#44; type of sleep study&#44; polysomnographic&#47;polygraphic variables&#44; diagnosis&#44; severity&#44; treatment and clinical and weight outcomes&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">We retrieved the data by actively searching the hospital records of each patient included in the study&#46; The presence or absence of snoring&#44; apnoea and EDS had been documented in every case&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">We considered that the patient had comorbidities and&#47;or adenotonsillar hypertrophy when such conditions were entered in the hospital records by a paediatrician or otorhinolaryngology specialist&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">We defined obesity as a BMI at or above the 95th percentile &#40;95P&#41; and overweight as a BMI above the 85th percentile &#40;85P&#41; and below the 95P&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">12&#44;13</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Polysomnography &#40;PSG&#41; and respiratory polygraphy &#40;RP&#41; were always performed in our unit&#44; and their results were analysed and interpreted by the same pulmonologist&#46; The chief of the unit decided which type of test should be applied based on available resources and the current indications at the time of the study&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The polysomnographic&#47;polygraphic variables included&#58; apnoea&#8211;hypopnoea index &#40;AHI&#41;&#47;respiratory disturbance index &#40;RDI&#41;&#59; baseline&#44; average and lowest SatO<span class="elsevierStyleInf">2</span>&#59; percentage of total sleep time spent with SatO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>90&#37; &#40;<span class="elsevierStyleItalic">T</span><span class="elsevierStyleInf">90</span>&#41;&#59; oxygen desaturation index of 3&#37; or lower per hour of sleep&#47;recording&#59; percentage of sleep time&#47;recording in the supine position&#59; percentage of respiratory events in the supine position&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In its Consensus Document on OSA&#44; the Grupo Espa&#241;ol de Sue&#241;o &#40;Spanish Group on Sleep&#41; established an AHI of 1&#8211;3 as the limit of normal&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">2</span></a> Thus&#44; an AHI&#47;RDI of less than 3 was not considered abnormal&#46; When it came to severity&#44; OSA was classified as mild if the AHI&#47;RDI was less than 5&#44; moderate if it was between 5 and 10&#44; and severe if it was greater than 10&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">9</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Patients were treated in adherence with current indications and recommendations&#44; in the otorhinolaryngology department if they presented with adenotonsillar hypertrophy&#44; and otherwise in the paediatrics and&#47;or pulmonology department&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">We classified weight and clinical outcomes as improved&#44; unchanged or worse&#46; We categorised outcomes based on the information entered in the hospital records of patients during follow-up visits at least 6 months after initiation of treatment&#46; Symptoms were considered to have improved if family members reported decreased snoring and frequency of apnoea&#44; to be unchanged if they remained the same&#44; and to be worse if they had increased in frequency or intensity&#44; all of which were subjective assessments&#46; Weight was considered improved if the BMI changed to a lower category &#40;from &#8805;95P to 86P-94P or &#8804;85P&#44; or from 86P-94P to &#8804;85P&#41;&#44; unchanged if it remained in the same category&#44; and worse if it had changed to a higher category &#40;from &#8804;85P to 86P-94P and from 86P-94P to &#8805;95P&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The descriptive analysis consisted in the calculation of proportions for qualitative variables and of measures of central tendency and dispersion for quantitative variables&#46; We summarised quantitative variables with the mean and standard deviation if they were normally distributed&#44; or otherwise with the median and interquartile range &#40;IQR&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">We performed the statistical analyses and generated all charts and tables using the software SPSS version 19&#46;0 for Windows&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0095" class="elsevierStylePara elsevierViewall">A total of 234 sleep studies were performed&#44; 148 &#40;63&#46;2&#37;&#41; in boys&#44; and the median patient age was 5 years &#40;IQR&#44; 3&#8211;8&#46;25&#41;&#46; The reason for the study was to evaluate the need for surgery for treatment of adenotonsillar hypertrophy in 112 children &#40;47&#46;9&#37;&#41;&#44; clinical suspicion of OSA in 108 &#40;46&#46;2&#37;&#41;&#44; and other reasons in 14 &#40;6&#37;&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Of the 234 children under study&#44; 168 &#40;71&#46;8&#37;&#41; had an AHI&#47;RDI of 3 or more events per hour&#44; which led to diagnosis of OSA&#46; In the OSA group&#44; 102 &#40;60&#46;7&#37;&#41; were male&#59; the median age was 5 years &#40;IQR&#44; 3&#8211;8&#41;&#44; with 82 preschool-age patients &#40;48&#46;8&#37;&#41; and 49 school-age patients &#40;29&#46;2&#37;&#41;&#46; Thus&#44; a total of 131 patients with OSA &#40;78&#37;&#41; were preschool- or school-age children&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Most of the children that received a diagnosis of OSA had no significant comorbidities&#46; The most frequent comorbidities were diseases of the lower respiratory tract&#44; found in 35 patients &#40;20&#46;8&#37;&#41;&#44; most commonly bronchial asthma&#44; found in 24 patients &#40;14&#46;3&#37;&#41;&#46; However&#44; we did not find a statistically significant association between lower respiratory disease and OSA &#40;20&#46;8&#37; vs 21&#46;2&#37;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;949&#41; or between asthma in particular and OSA &#40;14&#46;3&#37; vs 15&#46;2&#37;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;866&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Of the children with OSA&#44; 157 &#40;93&#46;4&#37;&#41; presented with snoring&#44; 142 &#40;84&#46;5&#37;&#41; had a history of witnessed apnoeic episodes&#44; and 9 &#40;5&#46;4&#37;&#41; had EDS&#46; Seventy-four &#40;44&#37;&#41; had excess weight&#44; 100 &#40;59&#46;5&#37;&#41; adenotonsillar hypertrophy&#44; and 35 &#40;20&#46;8&#37;&#41; had both&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The diagnosis was made by PSG in 23 patients and by RP in 145&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarises the relevant findings of the sleep tests&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">Obstructive sleep apnoea was mild in 22 patients &#40;13&#46;1&#37;&#41;&#44; moderate in 71 &#40;42&#46;3&#37;&#41; and severe in 75 &#40;44&#46;6&#37;&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In the 168 children with OSA&#44; treatment consisted in adenotonsillectomy in 72 &#40;42&#46;9&#37;&#41;&#44; lifestyle and dietary measures &#40;weight loss&#47;dieting&#44; measures to control snoring&#44; sleep hygiene measures&#41; in 49 &#40;29&#46;2&#37;&#41;&#44; CPAP in 10 &#40;6&#37;&#41; and other treatments &#40;such as observation and followup&#44; topical anti-inflammatory treatment&#44; use of a chin strap&#44; dental devices or orthodontic intervention&#41; in 37 &#40;22&#37;&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">After treatment initiation&#44; of the 157 children with a history of snoring and&#47;or witnessed apnoeic episodes&#44; 109 &#40;69&#46;4&#37;&#41; experienced improvement in these symptoms&#44; 47 &#40;29&#46;9&#37;&#41; experienced no changes and 1 &#40;0&#46;6&#37;&#41; worsening of symptoms&#46; The weight status of the 74 children with a diagnosis of OSA associated with overweight or obesity improved in 24 &#40;32&#46;4&#37;&#41; remained unchanged in 36 &#40;48&#46;6&#37;&#41; and got worse in 14 &#40;18&#46;9&#37;&#41;&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">We also assessed the characteristics of 2 subsets of patients with OSA classified according to the indication for the sleep study&#58; clinical suspicion of OSA &#40;subset I&#41; or evaluation of need of surgery in patients with adenotonsillar hypertrophy &#40;subset II&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> presents the results of the descriptive and comparative analysis of these two groups&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0140" class="elsevierStylePara elsevierViewall">Paediatric sleep disorders are growing in importance in our region &#40;a total of 90 children had been assessed in our unit until 2009&#44; while the number of children assessed in 2012 was as high as 234&#41;&#46; In recent years&#44; OSA was clinically significant in up to 90&#37; of children&#44; and treatment achieved symptom control in most&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The prevalence of OSA in children is high&#44; and the literature estimates its incidence at 2&#8211;4&#37; of the paediatric population&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">10</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">In our area&#44; the onset of OSA peaked between age 2 and 5 years&#44; closely followed in frequency by school-age children&#46; In the reviewed literature&#44; as in our study&#44; onset occurred most frequently in preschool- and school-age children&#44; with no difference in prevalence between sexes&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">2</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Adenotonsillar hypertrophy and obesity are the main risk factors for OSA in otherwise healthy children&#46; As our study demonstrates&#44; the most frequent cause of OSA in the paediatric population is enlargement of the tonsils and&#47;or adenoids&#44; and adenotonsillar hypertrophy was found in 59&#46;5&#37; of the patients in our sample that received an OSA diagnosis&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Obstructive sleep apnoea may also be associated with obesity&#44; anatomical anomalies or neurologic&#44; metabolic or muscular abnormalities&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">2&#44;9</span></a> Individual susceptibility&#44; environmental factors and lifestyle &#40;physical and cognitive activity&#44; diet&#44; etc&#46;&#41; play an important role in phenotypic variation&#46; Therefore&#44; and considering the lifestyle and dietary changes that have occurred in the paediatric age group in recent years&#44; with an increase in obesity and sedentary habits&#44; the classic phenotype is gradually being replaced by a pattern that is more similar to the form of OSA found in adults&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In our study&#44; 74 &#40;44&#37;&#41; of the patients with OSA had overweight or obesity&#46; This excess weight was the most likely cause of OSA in 39 &#40;23&#46;2&#37;&#41;&#44; as they did not present with adenotonsillar hypertrophy&#46; In a study of 37 obese adolescents &#40;BMI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>97th percentile&#41;&#44; Hannon et al&#46; found that 45&#37; had OSA based on the findings of PSG &#40;OSA defined as AHI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1&#46;5&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">14</span></a> Other studies have found that 47&#37; of obese children have moderate to severe OSA&#44; and 39&#37; mild OSA&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">15&#44;16</span></a> Redline et al&#46; found that obesity was the strongest risk for OSA&#44; with an OR of 4&#46;59 &#40;95&#37; CI&#44; 1&#46;58&#8211;13&#46;33&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">17</span></a> In a review of 27 studies&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">18</span></a> the authors found that one-third found a statistically significant association between obesity and OSA in children younger than 10 years&#46; In fact&#44; a literature review by Ng et al&#46; concluded that the severity of OSA was positively correlated to the degree of obesity&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">19</span></a> There is variability between studies in the proportion of children with OSA reported to have obesity&#44; which ranges between 10&#37; and 50&#46;6&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">20&#8211;23</span></a> However&#44; different criteria are used to define obesity&#44; and overweight is usually not included in the analysis&#46; A more recent study in 197 patients aged less than 18 years with sleep-associated breathing disorders found that 45&#46;1&#37; of them had overweight or obesity&#46; Of these patients&#44; 34 did not have tonsillar hypertrophy&#44; and therefore excess weight was the main risk factor in 17&#46;2&#37; of the total sample&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">24</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">In our sample&#44; 93&#46;4&#37; of children with OSA presented with snoring&#44; and 84&#46;5&#37; had a history of apnoeic episodes witnessed by the parents&#46; The 3 symptoms that were the strongest predictors of OSA were snoring&#44; laboured breathing and pauses in breathing during sleep&#46; Multiple retrospective studies have demonstrated that OSA cannot be discriminated from primary snoring based on the history and physical examination alone&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">25</span></a> A history of intense snoring is not sensitive enough to be an indication for surgery in children&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">11</span></a> Similarly&#44; the specificity of the combination of a clinical assessment and evaluation of home video<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">26</span></a> or audio<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">27</span></a> recordings of a child&#39;s sleep is not high enough to confirm the diagnosis of OSA&#46; A systematic literature review found that the positive predictive value of clinical evaluation was approximately 55&#37; using overnight PSG as the reference test&#59; furthermore&#44; none of the reviewed studies found any component of the clinical evaluation to have a sensitivity and specificity greater than 65&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">28</span></a> For these reasons&#44; the American Thoracic Society<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">11</span></a> and the American Academy of Pediatrics<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">10</span></a> recommend PSG for assessment of paediatric OSA prior to surgery&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">In our study&#44; 5&#46;4&#37; of children with OSA reported EDS&#46; The main clinical difference relative to adults is that children with sleep-associated breathing disorders usually do not experience obvious EDS and&#44; when EDS is present&#44; it is not predictive of OSA in young children&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">29</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">In our series&#44; RP was the diagnostic tool used in 208 children and PSG the one used in 26&#46; Overnight PSG is the gold standard for the detection and assessment of severity of OSA in children&#46; However&#44; RP could be used in the large population of children that could have OSA and thus reduce underdiagnosis&#44; reserving PSG for children with comorbidities referred on an urgent basis for a sleep study or cases where the diagnosis is unclear or sleep disorders other than OSA are suspected&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">9</span></a> In uncomplicated cases&#44; RP may correlate strongly to the findings of PSG&#46; Several authors have noted that the combination of a clinical evaluation&#44; a thorough examination of the upper airway&#44; a home audio-visual recording and a RP recording performed with certified equipment offers an adequate alternative for confirmation of diagnosis in children with suspected OSA&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">30&#44;31</span></a> There are few paediatric studies on the use of RP&#44; and most have been conducted in populations at high risk of OSA&#44; had small sample sizes and did not involve performance of PSG at the time of testing to compare the findings of both tests&#44; leading to inconsistent results&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">32</span></a> A study conducted in Spain that compared both techniques concluded that RP performed in the sleep laboratory setting is a valid method for diagnosis of OSA in children&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">33</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Resection of the tonsils and adenoids is usually the treatment of choice in children with confirmed OSA and adenotonsillar hypertrophy&#46; In our study&#44; adenotonsillectomy was the most frequent treatment and led to clinical improvement in 68 &#40;94&#46;4&#37;&#41; of the 72 patients treated surgically&#46; However&#44; this improvement was self-reported and not corroborated by performance of a new sleep study after surgery&#44; which is a limitation in our study&#44; as we do not know the actual number of patients that had residual OSA and therefore eligible for other interventions&#46; Based on the current literature&#44; adenotonsillectomy is effective in approximately 78&#37; of cases of OSA in children&#44;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">2&#44;10&#44;34&#44;35</span></a> although this figure varies between sources&#46; A Cochrane review published in 2009<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">35</span></a> remarked on the absence of double-blind studies on the treatment of paediatric OSA and concluded that the current evidence on the effectiveness of adenotonsillectomy in paediatric OSA has methodological problems&#44; including lack of randomisation and controls and variability in the definitions and variables taken into account&#46; A retrospective multicentre study conducted in 2010<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">22</span></a> found a cure rate of 27&#46;2&#37; applying a definition of cure as an AHI of less than 1 event per hour&#46; However&#44; the success rate rose to 78&#46;4&#37; if cure was defined as an AHI equal or less than 5&#46; The authors concluded that adenotonsillectomy was associated with significant improvement in most children&#46; However&#44; until data from prospective multicentre studies become available&#44; children at higher risk of residual OSA&#44; including those aged more than 7 years&#44; with obesity or without obesity but with asthma or severe OSA&#44; should undergo sleep tests before and after surgery&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">In our sample&#44; CPAP was used to treat 10 patients&#44; all of them with overweight or obesity&#46; Patients treated with CPAP were managed at the outpatient pulmonology sleep clinic&#44; and symptoms improved in 9 of them &#40;90&#37;&#41;&#46; Continuous positive airway pressure is the second-line treatment for children with OSA&#44;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">36</span></a> as most of these patients improve after undergoing adenotonsillectomy&#44; with only a small percentage left requiring additional treatment or in who CPAP is the first-line treatment&#46; The latter are usually children with obesity&#44; craniofacial anomalies or neuromuscular disorders associated with adenotonsillar hypertrophy or without adenotonsillar hypertrophy&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">10</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">In addition to the limitation mentioned above&#44; we also must remain aware of those that result from the retrospective design of the study&#44; the predominant use of RP for diagnosis&#44; and not having included certain symptoms that may be relevant in paediatric OSA in the analysis&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">To conclude&#44; most children that underwent a sleep study in our unit had an abnormal AHI&#44; and a high percentage received a diagnosis of moderate or severe OSA&#46; Nearly half of the children with OSA had overweight or obesity&#46; The treatment prescribed most frequently was adenotonsillectomy&#46; The clinical outcomes of treatment were favourable in nearly 70&#37; of children with OSA&#44; while less than one third of patients with OSA associated with excess weight succeeded in improving their weight status&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interest</span><p id="par0205" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare</p></span></span>"
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          "titulo" => "Abstract"
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              "identificador" => "abst0005"
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              "titulo" => "Patients and methods"
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              "titulo" => "Results"
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    "fechaRecibido" => "2016-12-19"
    "fechaAceptado" => "2017-07-08"
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          "clase" => "keyword"
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          "palabras" => array:4 [
            0 => "Obstructive sleep apnoea syndrome"
            1 => "Child"
            2 => "Polysomnography"
            3 => "Tonsillectomy"
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:4 [
            0 => "S&#237;ndrome de apnea obstructiva del sue&#241;o"
            1 => "Ni&#241;o"
            2 => "Polisomnograf&#237;a"
            3 => "Amigdalectom&#237;a"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Obstructive sleep apnoea &#40;OSA&#41; is highly prevalent in children and a major public health problem&#46; An attempt is made to determine the clinical and polysomnographic presentation of paediatric OSA in our area&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Retrospective descriptive study of sleep tests conducted on children up to 14 years old from 1999 to 2012 in the Sleep Unit of the University Hospital of Albacete&#46; Age&#44; gender&#44; anthropometric&#44; clinical data&#44; indication and variables of sleep study&#44; treatment&#44; and outcomes were collected&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The study included 234 children&#46; OSA was found in 71&#46;8&#37;&#44; with 42&#46;3&#37; moderate and 44&#46;6&#37; severe&#46; The majority were male &#40;60&#46;7&#37;&#41; and the mean age was 5 years&#44; of whom 78&#37; were pre-school or school age&#46; There was overweight&#47;obesity in 44&#37;&#44; with 93&#46;4&#37; snoring&#44; apnoea 84&#46;5&#37;&#44; and 5&#46;4&#37; daytime sleepiness&#46; There were 23 polysomnographies and 145 polygraphies&#44; with a median apnoea&#47;hypopnoea index &#40;AHI&#41; of 10&#44; SatO<span class="elsevierStyleInf">2</span> minimum 84&#37;&#44; desaturation index 8&#44; and mean sleep supine 53&#46;65&#37; and supine events 57&#46;61&#37;&#46; Treatment was lifestyle modifications 29&#46;2&#37;&#44; CPAP 6&#37;&#44; and surgery 42&#46;9&#37;&#46; Improved snoring and&#47;or apnoea 69&#46;4&#37;&#44; and weight 32&#46;4&#37; of overweight&#47;obesity children&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Most of the studied children had a pathological AHI&#46; Almost half were overweight&#47;obese&#44; and a high percentage had moderate-severe OSA&#46; Most frequent treatment was surgery&#46; The clinical outcome was favourable in almost 70&#37;&#46; Less than a third with OSA and overweight&#47;obesity improved weight&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0005"
            "titulo" => "Introduction"
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            "identificador" => "abst0010"
            "titulo" => "Patients and methods"
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            "titulo" => "Results"
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            "titulo" => "Conclusions"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El s&#237;ndrome de apneas-hipopneas del sue&#241;o &#40;SAHS&#41; es altamente prevalente en la edad pedi&#225;trica y un problema importante de salud p&#250;blica&#46; Se pretende conocer la presentaci&#243;n cl&#237;nica y polisomnogr&#225;fica del SAHS infantil en nuestro medio&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio descriptivo retrospectivo de los estudios del sue&#241;o realizados a menores de 14 a&#241;os desde 1999 hasta 2012 en la Unidad del Sue&#241;o del Complejo Hospitalario Universitario de Albacete&#46; Se recogen edad&#44; sexo&#44; datos antropom&#233;tricos&#44; cl&#237;nicos&#44; indicaci&#243;n y variables del estudio del sue&#241;o&#44; tratamiento y evoluci&#243;n&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Doscientos treinta y cuatro ni&#241;os&#46; SAHS el 71&#44;8&#37;&#58; moderado 42&#44;3&#37; y grave 44&#44;6&#37;&#46; 60&#44;7&#37; varones y mediana de edad 5 a&#241;os&#59; el 78&#37; en edad preescolar o escolar&#46; Presentaban sobrepeso&#47;obesidad 44&#37;&#44; ronquidos 93&#44;4&#37;&#44; apneas 84&#44;5&#37; y somnolencia diurna 5&#44;4&#37;&#59; 23 polisomnograf&#237;as y 145 poligraf&#237;as&#58; mediana de &#237;ndice de apneas-hipopneas &#40;IAH&#41; 10&#44; de SatO2 m&#237;nima 84&#37; y de &#237;ndice de desaturaciones 8&#44; y media de sue&#241;o en supino 53&#44;65&#37; y de eventos en supino 57&#44;61&#37;&#46; El tratamiento fue medidas higi&#233;nico-diet&#233;ticas en el 29&#44;2&#37;&#44; CPAP el 6&#37; y cirug&#237;a el 42&#44;9&#37;&#46; Mejoraron los ronquidos y&#47;o apneas el 69&#44;4&#37; y el peso el 32&#44;4&#37; de los ni&#241;os con sobrepeso&#47;obesidad&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La mayor&#237;a de los ni&#241;os estudiados ten&#237;an un IAH patol&#243;gico&#46; Casi la mitad presentaban sobrepeso&#47;obesidad y un alto porcentaje ten&#237;a SAHS moderado-grave&#46; El tratamiento m&#225;s indicado fue la cirug&#237;a&#46; La evoluci&#243;n cl&#237;nica fue favorable en casi el 70&#37;&#46; Menos de un tercio con SAHS y sobrepeso&#47;obesidad mejoraron el peso&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Garc&#237;a Castillo S&#44; Hoyos V&#225;zquez MP&#44; Coloma Navarro R&#44; Cruz Ruiz J&#44; Callejas Gonz&#225;lez FJ&#44; Godoy Mayoral R&#44; et al&#46; S&#237;ndrome de apneas-hipopneas durante el sue&#241;o&#46; An Pediatr &#40;Barc&#41;&#46; 2018&#59;88&#58;266&#8211;272&#46;</p>"
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      1 => array:2 [
        "etiqueta" => "&#9734;&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Previous presentation&#58; This study was presented the 48 Congreso Nacional SEPAR&#44; June 5&#8211;8&#44; 2015&#59; Gran Canaria&#44; Spain&#46;</p>"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">AHI&#44; apnoea-hypopnoea index&#59; RDI&#44; respiratory disturbance index&#59; IQR&#44; interquartile range&#59; SaO<span class="elsevierStyleInf">2</span>&#44; oxygen saturation&#59; <span class="elsevierStyleItalic">T</span><span class="elsevierStyleInf">90</span>&#44; percentage of sleep time&#47;recording with oxygen saturation<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>90&#37;&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Result&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">AHI&#47;RDI &#40;median number of events per hour&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 &#40;IQR 6&#8211;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Baseline SaO<span class="elsevierStyleInf">2</span> &#40;median&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">97&#37; &#40;IQR 97&#8211;98&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Average SatO<span class="elsevierStyleInf">2</span> &#40;median&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">95&#37; &#40;IQR 94&#8211;96&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lowest SatO<span class="elsevierStyleInf">2</span> &#40;median&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">84&#37; &#40;IQR 74&#8211;88&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T90 &#40;median&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#37; &#40;IQR 0&#8211;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Events of desaturation<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>3&#37; per hour of sleep&#47;recording &#40;median&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 &#40;IQR 4&#8211;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Time spent supine during sleep&#47;recording &#40;mean&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">53&#46;65<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>30&#46;94&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Events while in supine position &#40;mean&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57&#46;61<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>30&#46;94&#37;&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">AHI&#44; apnoea-hypopnoea index&#59; CPAP&#44; continuous positive airway pressure&#59; EDS&#44; excessive daytime sleepiness&#59; ENT&#44; ear&#8211;nose&#8211;throat&#59; IQR&#44; interquartile range&#59; ODI&#44; oxygen desaturation index &#40;SaO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>3&#37;&#41;&#59; PSG&#44; polysomnography&#59; RP&#44; respiratory polygraphy&#59; SaO<span class="elsevierStyleInf">2</span>&#44; oxygen saturation&#59; <span class="elsevierStyleItalic">T</span><span class="elsevierStyleInf">90</span>&#44; percentage of sleep time with oxygen saturation<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>90&#37;&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Subgroup I&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">99&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sex &#40;male&#47;female&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">34&#47;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">64&#47;35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;379&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;IQR 3&#8211;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lower respiratory disease &#40;yes&#47;no&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&#47;46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&#47;81&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;555&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Asthma &#40;yes&#47;no&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#47;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#47;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;784&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Snoring &#40;yes&#47;no&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">59&#47;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">97&#47;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;529&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Apnoeic episodes &#40;yes&#47;no&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">51&#47;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">98&#47;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;793&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">EDS &#40;yes&#47;no&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#47;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#47;98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">36&#47;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&#47;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;006&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&#47;46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#47;93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;003&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;IQR 7&#8211;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 &#40;5&#8211;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;583&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">96 &#40;IQR 97&#8211;98&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;021&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SatO<span class="elsevierStyleInf">2</span> media &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">96 &#40;IQR 95&#8211;96&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;034&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Minimum SaO<span class="elsevierStyleInf">2</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">81 &#40;IQR 76&#8211;87&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">85 &#40;IQR 81&#8211;88&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;018&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;IQR 0&#8211;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;465&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 &#40;IQR 4&#8211;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;644&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">51&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>29&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;437&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#37; events in supine position&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">59&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>31&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">55&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>29&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;504&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#47;31&#47;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#47;39&#47;44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;072&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#47;70&#47;2&#47;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#47;19&#47;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&#47;16&#47;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Weight outcome &#40;improved&#47;unchanged&#47;worse&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#47;34&#47;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">81&#47;12&#47;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;534&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Differences between the 2 subgroups&#46;</p>"
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                          "etal" => false
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                      "titulo" => "El s&#237;ndrome de apneas-hipopneas durante el sue&#241;o en Espa&#241;a&#46; Disponibilidad de recursos para su diagn&#243;stico y tratamiento en los hospitales del Estado espa&#241;ol"
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                      "Libro" => array:4 [
                        "edicion" => "2nd ed&#46;"
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                        "editorialLocalizacion" => "Westchester&#44; IL"
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                      "titulo" => "Documento de consenso del s&#237;ndrome de apneas-hipopneas durante el sue&#241;o en ni&#241;os &#40;versi&#243;n completa&#41;"
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                            2 => "M&#46; Cubell Alarco"
                            3 => "E&#46; Estivill"
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                      "doi" => "10.1016/S0300-2896(11)70028-X"
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Article information

ISSN: 23412879
Original language: English

DOI:10.1016/j.anpede.2017.07.003

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Year/Month	Html	Pdf	Total

2024 November	3	4	7
2024 October	56	33	89
2024 September	61	34	95
2024 August	62	80	142
2024 July	51	23	74
2024 June	59	23	82
2024 May	54	34	88
2024 April	49	32	81
2024 March	47	24	71
2024 February	52	23	75
2024 January	34	22	56
2023 December	60	17	77
2023 November	53	22	75
2023 October	49	35	84
2023 September	39	25	64
2023 August	42	21	63
2023 July	44	21	65
2023 June	53	27	80
2023 May	50	21	71
2023 April	26	19	45
2023 March	59	25	84
2023 February	49	20	69
2023 January	19	22	41
2022 December	67	30	97
2022 November	95	49	144
2022 October	124	48	172
2022 September	74	36	110
2022 August	64	48	112
2022 July	47	37	84
2022 June	40	47	87
2022 May	51	39	90
2022 April	47	37	84
2022 March	78	66	144
2022 February	54	36	90
2022 January	53	48	101
2021 December	51	51	102
2021 November	76	55	131
2021 October	79	101	180
2021 September	84	56	140
2021 August	65	36	101
2021 July	92	29	121
2021 June	68	35	103
2021 May	93	50	143
2021 April	123	75	198
2021 March	83	64	147
2021 February	58	23	81
2021 January	75	29	104
2020 December	64	20	84
2020 November	86	27	113
2020 October	55	19	74
2020 September	63	25	88
2020 August	70	14	84
2020 July	73	18	91
2020 June	83	19	102
2020 May	79	34	113
2020 April	63	26	89
2020 March	59	30	89
2020 February	55	26	81
2020 January	48	13	61
2019 December	64	21	85
2019 November	66	20	86
2019 October	85	17	102
2019 September	63	16	79
2019 August	72	24	96
2019 July	49	37	86
2019 June	47	50	97
2019 May	62	16	78
2019 April	61	30	91
2019 March	49	22	71
2019 February	44	15	59
2019 January	39	21	60
2018 December	55	23	78
2018 November	107	33	140
2018 October	167	15	182
2018 September	154	19	173
2018 August	9	0	9
2018 July	5	0	5
2018 June	3	0	3
2018 May	0	1	1
2018 April	0	24	24

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