Letter Regarding “A Commentary on Broader Use of Preoperative Polysomnography in Pediatric Patients With Obstructive Sleep Apnea”

This is the authors' abstract. We don't add key points for this paper.

Garg et al advocates for broader use of preoperative polysomnography (PSG) among pediatric patients with obstructive sleep apnea (OSA).1 They suggest that additional PSG results would improve assessment of OSA and outcomes after intervention, thus enhancing decision-making. While this may be the case in the ideal state with unlimited resources. However, in current, we believe this would create an enormous barrier to access of care, surgical consultation, and ultimately delay or even prevent the diagnosis and treatment of sleep disorders in children. First and foremost, the focus of this letter is on pediatric OSA, and we ask the reader to keep in mind that in-lab PSGs with pediatric expertise are a very limited resource that are not exclusively for OSA. Unnecessary use of in-lab PSG for OSA decreases availability of PSG for children who need evaluation for other sleep disorders, many of which may have as much adverse impact if left untreated on a child and family's health and function. Optimization of PSG utilization for children with any and all sleep disorders, not just OSA, must be a priority for all. In regard specifically for OSA, PSGs should be targeted for those who would benefit the most, that is, the patients in whom a PSG would alter the course of the OSA treatment. These include the complex cases with high suspicion of concomitant sleep disorders, other medical comorbidities, and high risk for perioperative respiratory complications.2 PSG's are much more helpful at the two ends of the OSA severity spectrum—(1) Using PSG to determine who needs an intensive care unit bed postoperatively and those with extremely severe OSA that would be unlikely cured by a gold-standard adenotonsillectomy alone; and (2) to determine who would not benefit from surgery at all. PSGs need to go to those at highest risk/benefit profiles. Though the (outdated) American Academy of Pediatrics guidelines suggest a PSG is needed for all with snoring, the reality is that many healthy children in a pediatric setting who have large tonsils and have a clinical presentation consistent with OSA may not benefit from pre-operative PSGs.3 Empiric (adeno)tonsillectomy is well tolerated and leads to symptom resolution in many.4 Apnea hypopnea index (AHI) is only one of multiple indices on a sleep study, and one that has proven not to be a reliable indicator for clinical symptomatology or outcome. The AHI alone should not be the single driver for treating pediatric OSA but is often the only index used to determine operative need, perhaps incorrectly. Garg et al reported a wait time as long as 4 to 5 months for in-lab PSG and suggest a solution of more home sleep apnea tests (HSATs). In our institution and in underserved areas, the wait times may be much longer, up to 6 to 12 months. The authors suggest that the flood of the PSG market could be offset with utilization of HSATs. However, HSATs have been clearly not recommended for children for multiple reasons. The American Academy of Sleep Medicine published a position paper on the use of HSAT in children,5 which is not recent, though is more recent than the studies currently listing in their supportive evidence. The reason pediatric PSG differs from adult PSG is the use of CO2 monitoring, which is not included in HSATs. Thus, pediatric PSGs and HSATs cannot be interchanged as in the adult OSA population. HSATs may have a role in the future with certain pediatric populations, but currently cannot be considered standard of care given the dearth of evidence. Lastly, we would argue the quoted cost of a PSG ($793.57) to be on the lower end of the spectrum. We would challenge the calculation of PSG cost and would estimate roughly 8 to 10 times higher in charge for most in practice. With this discrepancy, the final calculations for cost savings will ultimately become cost spending, with low impact on the decision for surgery for a majority of patients with OSA. Allison K. Ikeda, design, literature review, manuscript preparation, editing; Maida L. Chen, design, literature review, manuscript preparation, editing. None. None.