© 2006 American Thoracic Society
Assessing the Role of Antiinflammatory Medications in Children with Mild Sleep-disordered BreathingTo The Editor:We read with interest the article by Goldbart and colleagues reporting improvement in polysomnography indices and decrease of adenoidal size after a course of montelukast was administered to children with mild sleep-disordered breathing (1). As was emphasized in the accompanying editorial (2), obstructive sleep apnea in children may have an immunologic/inflammatory component. Thus, antiinflammatory medications could be useful in children with mild forms of the disorder for whom adenotonsillectomy is not indicated. At least one other report supports the previous concept (3). In an open-label study, 27 children with snoring and an apnea–hypopnea index (AHI) of 1 to 10 episodes per hour were treated with nasal budesonide for 4 weeks. Mean AHI decreased from 5.2 (± 2.2) to 3.2 (± 1.5) in Alexopoulos and colleagues' study (3) as compared with a decrease from 3.0 (± 0.22) to 2.0 (± 0.3) episodes per hour in the montelukast trial (1). Twelve of 14 children with an AHI of more than 5 at baseline had an index of less than 5 episodes per hour post-treatment. Respiratory movement/arousal index and oxygenation indices improved significantly. According to the perceptions of the children's parents, their child's breathing was better after treatment in 23 of 27 subjects. A decrease in frequency of snoring and difficulty breathing was maintained for 9 months after the budesonide course. In the paper by Goldbart and colleagues (1), novel and interesting data are presented supporting increased leukotriene receptor expression and higher levels of leukotrienes in adenotonsillar tissue from children with sleep-disordered breathing than from those with recurrent tonsilitis. It should be recognized that the authors undertook a more challenging task compared with the goal of the study by Alexopoulos and colleagues (3). Participants in the montelukast study had a more narrow range of AHI (1–5 episodes/h) than subjects in the budesonide trial (1–10 episodes/h) (1, 3). It is somewhat difficult to appreciate the clinical significance of a decrease in the mean AHI from 3 to 2 episodes per hour, especially without concomitant improvement in oxygenation indices (1). Additional outcome measures such as frequency of symptoms, parents' perception about their child's breathing during sleep, or parameters associated with work of breathing (e.g., paradoxical breathing) could have further clarified the clinical significance of the authors' important and thought-provoking findings. Future studies, using changes in cognitive function (4), school performance (5), or even indices of inflammation (e.g., C-reactive protein) (6) as outcome variables, could assess the role of antiinflammatory medications in reducing morbidity associated with sleep apnea in children.
University of Thessaly School of Medicine, Larissa, Greece FOOTNOTES Conflict of Interest Statement: None of the authors have a financial relationship with a commercial entity that has an interest in the subject of this manuscript. REFERENCES
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