Very severe childhood OSA: target cardiac work-up to obese teenagers with an AHI above 50

Design

Retrospective single-centre review, 2018–2024

Population

144 children aged 2–18 with AHI ≥25 having adenotonsillectomy (38 with cardiac work-up)

Primary outcome

Yield of preoperative cardiac work-up

Effect

3 of 38 abnormal (7.9%), all obese adolescents with AHI >50; no change in management

Children with very severe obstructive sleep apnoea are often sent for echocardiography or cardiology review before adenotonsillectomy, to look for pulmonary hypertension or ventricular strain. A US centre reviewed 144 children aged 2 to 18 with an AHI of 25 or more who had adenotonsillectomy between 2018 and 2024.

Thirty-eight had a preoperative cardiac work-up, and three had abnormal findings. All three were obese adolescents aged 13 to 16 with an AHI above 50. None needed further tests or was started on CPAP before surgery, and having a cardiac work-up was not linked to how much the AHI improved. Length of stay was longer in younger children and those with higher AHI.

The authors suggest a selective approach: target cardiac evaluation to obese adolescents with the most severe OSA, and avoid delaying surgery for everyone else. This is a small retrospective series in which only a quarter of children were tested, so it cannot exclude occasional important findings in others. It is a reason to review local protocols rather than to abandon cardiac assessment.

• Consider limiting routine preoperative echocardiography in very severe childhood OSA to obese adolescents and those with an AHI above 50.
• Keep a low threshold for cardiac assessment in any child with signs of heart failure, syncope or known cardiac disease.
• Avoid delaying adenotonsillectomy for cardiac work-up in younger, non-obese children without clinical concerns.
• Plan monitored overnight care for younger children and those with the highest AHI, who stayed longest.

Why it matters

Blanket cardiac testing can delay surgery for children whose OSA is itself the risk.

Don't overread it

With 38 children tested and three abnormal results, this cannot show that skipping cardiac work-up is safe for all.

The statistics, in plain English

Three abnormal results in 38 tests is 7.9%. With so few events, the true rate could be noticeably higher or lower, and the children who were tested may not represent those who were not.

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