Effect of upper airway obstruction on pulmonary arterial pressure in children

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Summary

Objective

Our aim was to examine the elevation of pulmonary arterial pressure in children with upper airway obstruction caused by adenotonsillar hypertrophy according to their disease severity assessed with symptom scoring and to demonstrate the profit for echocardiographic monitorization of the children with adenotonsillar hypertrophy regardless of their clinical status.

Methods

Thirty-nine children with a diagnosis of upper airway obstruction caused by adenotonsillar hypertrophy were included for the study. There were 16 female and 23 male patients. Ages of the children were between 3 and 10 years with a mean age of 5.78 ± 1.98. Twenty children composed the control group with a similar age and sex distribution but without any sign and symptom of upper airway obstruction. Mean pulmonary arterial pressures were measured by Doppler echocardiography preoperatively and 6 months postoperatively. Symptom scores were calculated for each patient in the study group to assess their disease severity. The significances of changes and relations between pressure levels and symptom scores were calculated by statistical package for social sciences (SSPS) computer program in terms of Student's test, χ2-test and Mc Nemar's test.

Results

Mean pulmonary arterial pressure were 26.26 ± 5.40 (14–36) preoperatively, 16,61 ± 2.68 (10.15–22.3) postoperatively and 16.54 ± 2.63 (10.5–21.7) in the control group. There were a statistically significant decrease at pressure levels postoperatively and a significant difference from the levels in the control group (Student's t-test, p < 0.01). We found no correlation between the pressure levels and disease severity assessed in terms of symptom scoring.

Conclusion

This study showed that upper airway obstruction caused by adenotonsillar hypertrophy causes significant elevation of pulmonary arterial pressures and adenotonsilectomy is an absolute therapeutic method in these children. Every child with adenotonsillar hypertrophy has some probability of having pulmonary hypertension regardless of his or her disease severity. Therefore, performing echocardiographic examination to all children with adenotonsillar hypertrophy is beneficial for assessing the cardiopulmonary status of the patient and may be useful at decision making for adenotonsilectomy.

Introduction

Upper airway obstruction (UAO) is known as the cause of various systemic abnormalities in children. It can have detrimental effects on the quality of life in children. There are some reports in the literature declaring these effects on somatic growth [1], [2], [3], poor school performance [4], [5], [6], [7], hyperactivity [8] and cardiopulmonary system [9], [10], [11], [12], [13], [14], [15]. Cardiovascular deterioration is the most important one among these disorders which may lead to cor pulmonale and congestive heart failure. Although cardiopulmonary sequelae of UAO had been mentioned by anecdotal reports [16], [17], [18] in the literature, importance of this problem is best understood when considering the incidence of adenotonsillar hypertrophy (ATH) which is the most common cause of upper airway obstruction and obstructive sleep apnea in children.

Elevation of the pulmonary arterial pressure is the first step of the sequelae leading to cor pulmonale and congestive heart failure. Because of the absence of cardiovascular system-related symptoms in this period, changes at the pulmonary arterial pressure do not draw attention. At clinical practice, Doppler echocardiographic examination is not employed routinely unless severe obstructive sleep apnea (OSA) disease settles down and cardiovascular deterioration becomes established. Therefore, the following question arises. Should echocardiographic examination be done to all children with ATH and do the children with ATH but having milder symptoms are also under risk of pulmonary hypertension? Accurate diagnosis of OSA is made with polysomnography (PSG) but it is not easily employed, expensive and usually not possible at office practice. Because of these disadvantages of PSG, decision of referring the child to a cardiologist for echocardiographic examination and the decision of adenotonsilectomy is commonly made according to symptom questionnaire and physical examination findings by otolaryngologists.

Purpose of this study is to examine the relationship between UAO-related symptoms and pulmonary hypertension in order to have an idea about the answers of the questions asked above. The effect of adenotonsilectomy on pulmonary arterial pressure in children with ATH is also examined.

Section snippets

Materials and methods

The study group was selected among children who were admitted to ENT outpatient clinic of Haydarpasa Numune Education and Research Hospital with the complaint of recurrent adenotonsillar infection between March 2005 and November 2007. After getting approval from the ethic committee of our hospital, we obtained a written informed consent from the parents of the children. All children underwent a complete otolaryngologic examination including oropharyngal examination, otoscopy, anterior

Results

The mean age of the children in the study group was 5.78 ± 1.98 years (3–10 years). Sixteen (41%) of them were female whereas 23 (59%) of the were male. The mean pulmonary arterial pressure levels and symptom scores of the children in the study group preoperatively and postoperatively are shown in Table 1.

Preoperative mPAP levels were found to be very significantly higher than the mPAP levels of the children postoperatively and the children in the control group (Student's t-test, p = 0.01). But,

Discussion

It is well known that ATH is the most common cause of upper airway obstruction in children. This obstruction becomes more pronounced during sleep when the oropharyngeal musculature is relaxed. Sleep-related UAO in children may manifest as obstructive apnea or obstructive hypoventilation. Obstructive hypoventilation results from continuous partial upper airway obstruction, which leads to paradoxical respiratory efforts, hypercarbia and often hypoxemia. Hypoxemia and hypercarbia induced

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