Decuzzi Julianna, Redline Susan, Isaiah Amal
University of Maryland Medical Center, Department of Otorhinolaryngology-Head and Neck Surgery, Baltimore.
Division of Sleep Medicine and Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
JAMA Otolaryngol Head Neck Surg. 2022 Aug 1;148(8):779-784. doi: 10.1001/jamaoto.2022.1330.
Adenotonsillectomy, performed for approximately 500 000 children annually in the US alone, is the first line of treatment of pediatric obstructive sleep apnea (OSA). The Childhood Adenotonsillectomy Trial (CHAT), the first randomized clinical trial to test the efficacy of adenotonsillectomy, compared the management of pediatric nonsevere OSA by early adenotonsillectomy (eAT) vs watchful waiting with supportive care. Since the publication of the primary article in 2013, the CHAT study data set were made available via the National Sleep Research Resource, which allowed researchers to address a range of additional clinical questions relevant to the care of children with OSA. This review focuses on secondary analyses associated with the CHAT data set as grouped by the outcome of interest.
The results of most secondary analyses suggest that children who underwent eAT experienced the greatest improvements in symptom burden, sleepiness, parent-reported behavior, and quality of life. Changes in other domains, such as cognition, cardiovascular physiology, and metabolic indicators, were modest and selective. The associations between most treatment outcomes and polysomnographic parameters were weak. Symptoms were poor predictors of OSA severity. The results from these secondary analyses benefitted from the rigor of multicenter design and centralized polysomnography interpretation in CHAT. However, the exclusion of younger preschool-aged children and children with primary snoring limited the generalizability of findings. In addition, because caregivers were not masked, some of the parent-reported outcomes may have been inflated.
The results of this narrative review suggest that CHAT provides a model for future OSA-related studies in children for design, conduct, and subsequent reuse of the study data set, and its findings have advanced our understanding of the pathophysiology and management of pediatric nonsevere OSA. Directions for future research include whether the findings from this landmark study are generalizable to younger children and children with primary snoring and severe OSA. Similar studies may help address practice variability associated with pediatric OSA and help identify children who are most likely to benefit from undergoing eAT.
仅在美国，每年就有约50万名儿童接受腺样体扁桃体切除术，这是小儿阻塞性睡眠呼吸暂停（OSA）的一线治疗方法。儿童腺样体扁桃体切除术试验（CHAT）是第一项测试腺样体扁桃体切除术疗效的随机临床试验，比较了早期腺样体扁桃体切除术（eAT）与观察等待及支持性护理对小儿非重度OSA的治疗效果。自2013年发表主要文章以来，CHAT研究数据集可通过国家睡眠研究资源获取，这使研究人员能够解决一系列与OSA儿童护理相关的其他临床问题。本综述重点关注与CHAT数据集相关的次要分析，这些分析按感兴趣的结果进行分组。
大多数次要分析结果表明，接受eAT的儿童在症状负担、嗜睡、家长报告的行为和生活质量方面改善最大。其他领域的变化，如认知、心血管生理学和代谢指标，变化较小且具有选择性。大多数治疗结果与多导睡眠图参数之间的关联较弱。症状对OSA严重程度的预测能力较差。这些次要分析的结果得益于CHAT多中心设计的严谨性和集中的多导睡眠图解读。然而，排除年龄较小的学龄前儿童和原发性打鼾儿童限制了研究结果的普遍性。此外，由于护理人员未设盲，一些家长报告的结果可能被夸大。
本叙述性综述结果表明，CHAT为未来儿童OSA相关研究的设计、实施及后续研究数据集的再利用提供了一个模型，其研究结果增进了我们对小儿非重度OSA病理生理学和治疗的理解。未来研究方向包括这项具有里程碑意义的研究结果是否适用于年龄更小的儿童以及原发性打鼾和重度OSA儿童。类似研究可能有助于解决与小儿OSA相关的实践差异问题，并有助于确定最有可能从接受eAT中获益的儿童。
