University of Michigan
Department of Pediatrics
Evidence-Based Pediatrics Web Site

Question

• Will nasal corticosteroids decrease severity of symptoms of obstructive sleep apnea in children?

Clinical Bottom Lines

1. Use nasal corticosteroid spray in pediatric patients with obstructive sleep apnea syndrome (OSAS) to help improve symptoms.
2. Nasal steroids are especially useful in patients who do not have symptoms severe enough to warrant surgery, for those awaiting adenotonsillectomy, or for those who cannot undergo surgical treatment.
3. NNT to improve Apnea/hypopnea index (AHI) is 2. NNT to prevent one patient from undergoing adenotonsillectomy is 4.

Summary of Key Evidence

1. Randomized, triple-blind, placebo-controlled, parallel-group trial of nasal fluticasone for the treatment of obstructive sleep apnea in 25 children aged 1-10 years.¹
2. Inclusion criteria included (1) Adenoidal hypertrophy (2) Signs and symptoms of OSA (3) AHI > 1 on polysomnography (PSG).
3. Patients excluded if any of the following were present: craniofacial abnormalities, genetic abnormalities, Down's syndrome, neurologic disease, acute URI, severe OSA requiring urgent surgery, 4+ tonsillar hypertrophy, exposure to varicella, use of systemic steroids or antibiotics within last 3 weeks.
4. 278 underwent PSG, 44 eligible for study, only 25 (57%) completed study.
5. Patients in treatment group received fluticasone propionate 1 spray per nostril twice daily for 6 weeks.
6. All patients underwent PSG before and after treatment/placebo.
7. Treatment group had decrease in AHI from 10.7 ± 2.6 to 5.8 ± 2.2 compared with placebo, who went from10.9 ± 2.3 to13.1 ± 3.6 (p=0.04).
8. Frequency of desaturations decreased by 4/hr (p=0.03) and arousals/movements decreased by 3.5/hr (p=0.05).
9. 46% of patients in treatment group went on to adenotonsillectomy compared to 75% of those patients in placebo group.
10. Size of tonsils and adenoids did not decrease with treatment.
11. Symptoms score did not improve with treatment.
12. Study was valid in that it was randomized and triple-blinded. Groups were treated equally. However, differences in the baseline characteristics of the two different groups were significant.
    

Additional Comments

• Mechanisms of OSAS include airflow obstruction and pharyngeal muscles and airway dilator muscles relax during sleep (especially REM). In most children obstruction to flow is caused by adenotonsillar hypertrophy (ATH). Thus, any therapy that will decrease ATH should improve symptoms.
• It has been commonly thought that corticosteroids are not useful in the treatment of children with OSAS.²
• A prior study showed reduction in adenoidal size and improved symptoms of airway obstruction when nasal steroids given for 24weeks.³
• AAP clinical guideline statement: Adenotonsillectomy is first-line therapy for most children with OSAS, and CPAP is option for those who are not surgical candidates.⁴
• Limitations include small sample size, lack of data on long-term effects of therapy (will symptoms recur after steroids stopped?), AHI after treatment still meets criteria for OSAS despite 50% improvement, and significant number/variety of patients excluded.
  

Citation

1. Brouillette RT, Manoukian JJ, Ducharme FM, et al. Efficacy of fluticasone nasal spray for pediatric obstructive sleep apnea. J Pediatr 2001; 138:838-844.
2. Marcus CL, Management of Obstructive Sleep Apnea in Childhood. Curr Opin Pulm Med 1997; 3:464-469.
3. Demain JG, Goetz DW. Pediatric adenoidal hypertrophy and nasal airway obstruction: reduction with aqueous nasal beclomethasone. Pediatrics 1995; 95:355-364.
4. AAP Clinical Practice Guideline: Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2002; 109:704-712.
   

CAT Author: Martin L. Bocks, MD

CAT Appraisers: Alex Kemper, MD

Date appraised: July 31, 2002