Sleep-disordered breathing in children with asthma: a systematic review on the impact of treatment

Figures & data

Figure 1 Study selection process of the included/excluded studies.

Table 1 Association of asthma and SDB

Author (year)	Country	N	Male	Mean age (years)	Asthma diagnosis	SDB diagnosis	Prevalence of asthma (%)	Prevalence of SDB (%)
Lu et al (2003)^Citation21	Australia	974	516	Not given	Questionnaire	Snoring for +4 nights/week	28	10.5
Valery et al (2004)^Citation27	Australia	1,650	Not given	8.5	ISAAC questions	Snoring	15.6	14.2
Sulit et al (2005)^Citation25	USA	788	393	9.5	History or spirometry	Portable polygraphy AHI >5	13.3	20.1
Desager et al (2005)^Citation16	Belgium	1,234	Not given	9.6	ISAAC questions, spirometry	Snoring	8.8	28
Verhulst et al (2007)^Citation28	Sri Lanka	652	432	8.4	ISAAC questions	Snoring	14	32.6
Ramagopal et al (2008)^Citation24	USA	236	147	7.2	History	PSG AHI >2	31.4	41.1
Ramagopal et al (2009)^Citation34	USA	50	32	9.3	ISAAC questions + spirometry	PSG AHI >2	44	100
Kaditis et al (2010)^Citation10	Greece	442	241	7.6	History	Habitual snoring	47.5	28.5
Bhattacharjee et al (2010)^Citation9	USA	578	355	6.9	History	PSG	29.6	100
Ross et al (2012)^Citation35	USA	108	73	9.1	History	Snoring for + 3 nights/week + ≥3 desaturations >3%/hour	100	29.6
Greenfeld et al (2013)^Citation30	Israel	2,178	1,415	4.9	History	PSG OAHI >1	18	100
Gutierrez et al (2013)^Citation31	USA	141	85	6.1	History	PSG OAHI >1.5	43.9	100
Goldstein et al (2015)^Citation29	USA	529	298	5.8	Previous diagnosis	PSQ >0.33	50	18.2
Teng et al (2014)^Citation37	Taiwan	102	56	9.4	History + methacholine test	PSG AHI >5	50	50
Li et al (2015)^Citation32	People’s Republic of China	22,478	10,227	9	History	CSHQ	3.5	12
Mean prevalence							33.2	41.8

Abbreviations: SDB, sleep-disordered breathing; ISAAC, International Study on Asthma and Allergies in Childhood; AHI, apnea–hypopnea index; PSG, polysomnography; OAHI, obstructive apnea–hypopnea index; PSQ, Pediatric Sleep Questionnaire; CSHQ, Children’s Sleep Habits Questionnaire.

Table 2 Prevalence of SDB and asthma as a risk factor

Author (year)	Country	N	Male	Mean age (years)	Asthma diagnosis	SDB diagnosis	SDB prevalence (%) – asthma vs controls	OR (95% CI)
Redline et al (1999)^Citation41	USA	399	194	10.9	History + spirometry	PSG AHI>10	11.8 vs 28	3.83 (1.39–10.55)
Corbo et al (2001)^Citation15	Italy	2,209	722	12.5	Previous diagnosis or questionnaire	Snoring “often”	12.2 vs 7.6	1.79 (0.97–3.33)
Chng et al (2004)^Citation14	Singapore	11,114	5,212	5.8	Questionnaire	Snoring for > 3 nights/week	8.6 vs 5.1	1.83 (1.50–2.24)
Urschitz (2004)^Citation26	Germany	1,144	585	9.6	History	“Frequently” or “always” snoring	7.1 vs 9.8	0.68 (0.24–1.94)
Ersu et al (2004)^Citation17	Turkey	2,147	1,074	8.5	History, questionnaire	“Often” or “always” snoring	9.1 vs 7.6	1.25 (0.75–2.09)
Bidad et al (2006)^Citation13	Iran	2,900	1,200	14	ISAAC questions	Snoring for ≥ 3 nights/week	10.7 vs 7.1	1.64 (1.05–2.58)
Marshall et al (2007)^Citation22	USA	219	107	5	ISAAC questions, spirometry	Snoring for ≥ 3 nights/week	29.1 vs 16.9	2.71 (1.42–5.16)
Li et al (2010)^Citation20	People’s Republic of China	20,152	9,890	9	Previous diagnosis	“Frequently” or “almost always” snoring	17.8 vs 10.5	2.09 (1.72–2.54)
Kheirandish-Gozal et al (2011)^Citation40	USA	92	49	6.6	History	PSG AHI 5/hour TST	63.0 vs 4.0	40.9 (12.9–144.1)
Fadzil et al (2012)^Citation18	Malaysia	550	285	8.5	Questionnaire	PSQ >0.33	29.2 vs 13.5	2.62 (1.34–5.15)
Ng et al (2014)^Citation33	People’s Republic of China	2,005	1,173	15.3	Questionnaire	Snoring for ≥ 6 nights/week	17.9 vs 9.7	2.18 (1.25–3.71)

Abbreviations: SDB, sleep-disordered breathing; OR, odds ratio; CI, confidence interval; PSG, polysomnography; AHI, apnea–hypopnea index; ISAAC, International Study on Asthma and Allergies in Childhood; TST, total sleep time; PSQ, Pediatric Sleep Questionnaire.

Table 3 Studies on impact of treatment of SDB and asthma

Author (year)	Country	N	Male	Mean age (years)	Asthma diagnosis	SDB diagnosis	Type of study	Main results
Bhattacharjee et al (2010)^Citation9	USA	578	355	6.9	History	PSG	Retrospective study: 578 children with OSA undergoing AT studied with PSG preoperatively and postoperatively	AT resulted in a significant AHI reduction from 18.2±21.4 to 4.1±6.4/hour total sleep time. 27.2% had complete resolution of OSA; asthma was a modest contributing factor for post-AT AHI
Bhattacharjee et al (2014)^Citation38	USA	40,518	22,320	7.7	ICD-9-CM	ICD-9-CM	Retrospective study: 13,506 children with asthma with AT compared to 27,012 matched children with asthma without AT	AT associated with reductions in AAE (30.2%), ASA (37.9%), ARERs (25.6%), ARHs (35.8%), bronchodilators (16.7%), inhaled corticosteroids (21.5%), leukotriene receptor antagonists (13.4%), and systemic corticosteroids (23.7%)
Busino et al (2010)^Citation39	USA	465	263	5.9	Clinical history	Previous diagnosis	Retrospective study: 465 children with AT, 16.6% asthmatics	AT associated with reductions of asthma therapies (eg, corticosteroids) and improvements in ACT scores
Kheirandish-Gozal et al (2011)^Citation40	USA	92	49	6.6	Clinical history	PSG AHI >5/hour TST	Prospective study: 92 children with poorly controlled asthma, 63% with OSA and AT	AT associated with reduction in AAE (4.1±1.3 to 1.8±1.4/year), β-agonist rescue use (4.3±1.8 to 2.1±1.5/week), and ACT scores (3.1±1.9 to 1.9±1.7)
Levin et al (2014)^Citation42	USA	130	55	6.1	Clinical history	Previous diagnosis	Longitudinal observational study: 130 children with AT (66 asthmatics and 64 controls)	AT associated in children with asthma with improvement in ACT scores (22–25) and decrease in emergency department/urgent care visits (1.88–0.4), oral corticosteroid courses (1.11–0.21), missed school days due to asthma (3.86–2.0), total missed parental work days due to illness (2.79–1.13), and circulating chitinase activity (0.4 nmol/L/mL/h)

Abbreviations: SDB, sleep-disordered breathing; PSG, polysomnography; OSA, obstructive sleep apnea; AT, adenotonsillectomy; AHI, apnea–hypopnea index; ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification; AAE, acute asthmatic exacerbation; ASA, acute status asthmaticus; ARERs, asthma-related emergency room visits; ARHs, asthma-related hospitalizations; ACT, asthma control test; TST total sleep time.

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