Traitement médical des troubles respiratoires obstructifs du sommeil de l’enfant et de l’adolescent

Introduction : Chez l’enfant et l’adolescent, les troubles respiratoires obstructifs du sommeil (TROS) nécessitent un traitement précoce pour éviter leurs complications. Matériel et méthodes : Un bilan pluridisciplinaire réalisé par un pneumo-pédiatre, un médecin du sommeil, un orthodontiste, un ORL, un rééducateur myofacial permet de déterminer les prises en charge thérapeutiques, chirurgicales et médicales, adaptées à chaque enfant. Seuls les traitements médicaux font l’objet de cet article. Résultats : La revue de la littérature montre que le traitement de première intention est l’adéno-amygdalectomie. Toutefois, des thérapeutiques médicales peuvent jouer un rôle fondamental, en première ligne ou en complément de la chirurgie. Le surpoids et l’obésité, fréquents à l’adolescence, aggravent les TROS et favorisent leur persistance après adéno-amygdalectomie ; ils nécessitent une prise en charge par un régime alimentaire adapté, un renforcement de l’activité physique, un soutien psychologique et une bonne hygiène du rythme veille-sommeil. L’inflammation pourra être traitée, dans les formes modérées de TROS, par des anti-inflammatoires (corticoïdes ou antagonistes des récepteurs aux leucotriènes). De nombreux enfants atteints de TROS ont des anomalies maxillo- faciales qui, selon leur type, bénéficieront d’une disjonction maxillaire rapide ou d’un dispositif de type activateur en complément de l’adéno-amygdalectomie. L’utilisation d’un appareil de ventilation par pression positive continue (PPC) est rarement nécessaire chez l’enfant et est réservée aux TROS graves persistant après chirurgie. Enfin, la thérapie myofonctionnelle, active ou passive, est pour certains auteurs indispensable pour éviter les récidives du syndrome d’apnées obstructives du sommeil (SAOS) après chirurgie. Conclusion : Ces traitements médicaux personnalisés sont mis en place soit parallèlement à l’adéno-amygdalectomie, soit dans un ordre hiérarchique

Sleep and its relation to cognition and behaviour in preschool-aged children of the general population: a systematic review

International audienceBackground: While the relations between sleep, cognition and behavior have been extensively studied in adolescents and school-aged children, very little attention has been given to preschoolers. Objective: In this systematic review, our aim was to survey articles that address the link between sleep and both cognition and behavior in preschoolers (24 to 72 months old). Methods: Four electronic databases were searched, namely Medline, Web of Science, PsycINFO and ERIC, completed by forward and backward citation search. Results: Among the 1590 articles identified (minus duplicates), 26 met the inclusion criteria. Globally, studies with the largest sample sizes (N=13) found that a greater quantity or quality of sleep was associated with better behavioral and cognitive outcomes, while the others were less consistent. Conclusion: Although the current literature seems to indicate that sleep is related to behavioral and cognitive development as early as preschool years, the strength of the associations (i.e. effect sizes) was relatively small. In addition to taking stock of the available data, this systematic review identifies potential sources of improvement for future research

Objective evaluation of excessive daytime sleepiness

International audienceExcessive daytime sleepiness (EDS) is multifactorial. It combines, among other things, an excessive propensity to fall asleep ("physiological sleepiness") and a continuous nonimperative sleepiness (or drowsiness/hypo-arousal) leading to difficulties remaining awake and maintaining sustained attention and vigilance over the long term ("manifest sleepiness"). There is no stand-alone biological measure of EDS. EDS measures can either capture the severity of physiological sleepiness, which corresponds to the propensity to fall asleep, or the severity of manifest sleepiness, which corresponds to behavioral consequences of sleepiness and reduced vigilance. Neuropsychological tests (The psychomotor vigilance task (PVT), Oxford Sleep Resistance Test (OSLeR), Sustained Attention to Response Task (SART)) explore manifest sleepiness through several sustained attention tests but the lack of normative values and standardized protocols make the results difficult to interpret and use in clinical practice.Neurophysiological tests explore the two main aspects of EDS, i.e. the propensity to fall asleep (Multiple sleep latency test, MSLT) and the capacity to remain awake (Maintenance of wakefulness test, MWT). The MSLT and the MWT are widely used in clinical practice. The MSLT is recognized as the "gold standard" test for measuring the severity of the propensity to fall asleep and it is a diagnostic criterion for narcolepsy. The MWT measures the ability to stay awake. The MWT is not a diagnostic test as it is recommended only to evaluate the evolution of EDS and efficacy of EDS treatment. Even if some efforts to standardize the protocols for administration of these tests have been ongoing, MSLT and MWT have numerous limitations: age effect, floor or ceiling effects, binding protocol, no normal or cutoff value (or determined in small samples), and no or low test-retest values in some pathologies. Moreover, the recommended electrophysiological set-up and the determination of sleep onset using the 30-sec epochs scoring rule show some limitations. New, more precise neurophysiological techniques should aim to detect very brief periods of physiological sleepiness and, in the future, the brain local phenomenon of sleepiness likely to underpin drowsiness, which could be called "physiological drowsiness".</div

Étude d’une orthèse d’avancée mandibulaire dans le traitement du syndrome d’apnées obstructives du sommeil

Introduction Le but de cette étude était d’évaluer l’efficacité et la tolérance d’une orthèse mandibulaire en traction de type optimisation de la retenue mandibulaire (orthèse type ORM) dans le traitement des syndromes d’apnées obstructives du sommeil (SAOS) modérés à sévères avec une prise en charge ambulatoire simple n’imposant pas de protocole de titration de l’avancée. Matériel et méthodes 40 patients, 10 présentant un SAOS sévère en échec ou refus de PPC avec un indice d’apnée-hypopnée (IAH) ≥ g0, et 30 un SAOS modéré (15 ≤ gAH < 30) ont été inclus dans 4 centres. Une polygraphie respiratoire nocturne, des questionnaires de qualité de vie et de qualité du sommeil ont été utilisés pour évaluer l’effet du traitement après 45 jours. Résultats 35 patients ont terminé l’étude. La fréquence des événements respiratoires, la somnolence diurne, la qualité du sommeil évaluée par le patient, le questionnaire SF-36 de qualité de vie, et l’index de qualité du sommeil du questionnaire de Pittsburgh (PSQI) ont été significativement améliorés avec l’orthèse. 60 % des patients étaient répondeurs au traitement avec une diminution de l’IAH d’au moins 50 %. L’observance du traitement était élevée (80 % des patients ont porté leur orthèse toutes les nuits). Les effets indésirables ont été mineurs et transitoires. Discussion L’efficacité sur les paramètres respiratoires et la somnolence de cette orthèse mandibulaire en retenue a été validée avec un taux de réponse similaire à celui publié dans la littérature. Cette étude montre une amélioration constante des paramètres de qualité de vie et de qualité du sommeil sous orthèse. Le traitement par l’orthèse type ORM dans le cadre d’une prise en charge ambulatoire simple sans titration systématique avec contrôle rapide par polygraphie ventilatoire est approprié pour la prise en charge des patients porteurs d’un SAOS, particulièrement si ce SAOS est modéré

Electroencephalography in premature and full-term infants. Developmental features and glossary.: Electroencephalography in premature and full-term infants

International audienceFollowing the pioneering work of C. Dreyfus-Brisac and N. Monod, research into neonatal electroencephalography (EEG) has developed tremendously in France. French neurophysiologists who had been trained in Paris (France) collaborated on a joint project on the introduction, development, and currently available neonatal EEG recording techniques. They assessed the analytical criteria for the different maturational stages and standardized neonatal EEG terminology on the basis of the large amount of data available in the French and the English literature. The results of their work were presented in 1999. Since the first edition, technology has moved towards the widespread use of digitized recordings. Although the data obtained with analog recordings can be applied to digitized EEG tracings, the present edition, including new published data, is illustrated with digitized recordings. Herein, the reader can find a comprehensive description of EEG features and neonatal behavioural states at different gestational ages, and also a definition of the main aspects and patterns of both pathological and normal EEGs, presented in glossary form. In both sections, numerous illustrations have been provided. This precise neonatal EEG terminology should improve homogeneity in the analysis of neonatal EEG recordings, and facilitate the setting up of multicentric studies on certain aspects of normal EEG recordings and various pathological patterns

Mandibular advancement device use in obstructive sleep apnea: ORCADES study 5-year follow-up data

International audienceStudy Objectives: Mandibular advancement devices (MADs) are an alternative to continuous positive airway pressure for the management of obstructive sleep apnea (OSA). The ORthèse d'avanCée mAndibulaire dans le traitement en DEuxi ème intention du SAHOS sév ère (ORCADES) study is investigating the long-term effectiveness of MAD therapy in patients with OSA who refused or were intolerant of continuous positive airway pressure. Five-year follow-up data are presented. Methods: Data were available in 172 of 331 patients treated with a custom-made computer-aided design/computer-aided manufacturing biblock MAD (Narval CC; ResMed, Saint-Priest, France). The primary end point was treatment success (≥50% decrease in apnea-hypopnea index from baseline). Results: Five-year treatment success rates were 52% overall and 25%, 52%, and 63%, respectively, in patients with mild, moderate, or severe OSA. This reflects a decline over time vs 3-6 months (79% overall) and 2 years (68%). Rates declined in all patient subgroups but to the greatest extent in patients with mild OSA. The slight worsening of respiratory parameters over time was not associated with any relevant changes in sleepiness and symptoms. Moderate or severe OSA at baseline, treatment success at 3-6 months, and no previous continuous positive airway pressure use were significant independent predictors of 5-year treatment success on multivariate analysis. No new safety signals emerged during long-term follow-up. The proportion of patients using their MAD for ≥4 h/night on ≥4 days/wk was 93.3%; 91.3% of patients reported device use of ≥6 h/night at 5 years. At 5-year follow-up, 96.5% of patients reported that they wanted to continue MAD therapy. Conclusions: Long-term MAD therapy remained effective after 5 years in >50% of patients, with good levels of patient satisfaction and adherence

Efficacy and tolerability of a custom-made Narval mandibular repositioning device for the treatment of obstructive sleep apnea: ORCADES study 2-year follow-up data

International audienceObjective/BackgroundMandibular repositioning device (MRD) therapy is an alternative to continuous positive airway pressure (CPAP). The ORCADES study is assessing the long-term efficacy and tolerability of MRD therapy in OSAS; 2-year follow-up data are presented.Patients/MethodsOSAS patients who refused or were noncompliant with CPAP were fitted with a custom-made computer-aided design/computer-aided manufacturing (CAD/CAM) bi-block MRD (ResMed, Narval CC™); mandibular advancement was individually titrated. Sleep and respiratory parameters were determined at baseline, 3–6 months, and two years. The primary endpoint was treatment success (percentage of patients achieving a ≥50% reduction in the apnoea-hypopnoea index [AHI]).ResultsOf 315 enrolled patients, 237 remained on MRD treatment at two years, and 197 had follow-up data. The treatment success rate at two years was 67%; AHI <5/h, <10/h and <15/h was achieved in 30%, 56% and 72% of patients, respectively. On multivariate analysis, ≥50% decrease in AHI at 3–6 months and absence of nocturia at 3–6 months were significant predictors of MRD treatment continuation. Adverse events were generally mild, and the majority occurred in the first year of treatment.ConclusionsTwo years’ treatment with an MRD was effective and well tolerated in patients with mild to severe OSAS who refused or were intolerant of CPAP