Safety and Efficacy of a Novel Approach to Pulmonary Vein Isolation Using Prolonged Apneic Oxygenation.

BACKGROUND: Improved ablation catheter-tissue contact results in more effective ablation lesions. Respiratory motion causes catheter instability, which impacts durable pulmonary vein isolation (PVI). OBJECTIVES: This study sought to evaluate the safety and efficacy of a novel ablation strategy involving prolonged periods of apneic oxygenation during PVI. METHODS: We conducted a multicenter, prospective controlled study of 128 patients (mean age 63 ± 11 years; 37% women) with paroxysmal atrial fibrillation undergoing PVI. Patients underwent PVI under general anesthesia using serial 4-minute runs of apneic oxygenation (apnea group; n = 64) or using standard ventilation settings (control group; n = 64). Procedural data, arterial blood gas samples, catheter position coordinates, and ablation lesion characteristics were collected. RESULTS: Baseline characteristics between the 2 groups were similar. Catheter stability was significantly improved in the apnea group, as reflected by a decreased mean catheter displacement (1.55 ± 0.97 mm vs 2.25 ± 1.13 mm; P < 0.001) and contact force SD (4.9 ± 1.1 g vs 5.2 ± 1.5 g; P = 0.046). The percentage of lesions with a mean catheter displacement >2 mm was significantly lower in the apnea group (22% vs 44%; P < 0.001). Compared with the control group, the total ablation time to achieve PVI was reduced in the apnea group (18.8 ± 6.9 minutes vs 23.4 ± 7.8 minutes; P = 0.001). There were similar rates of first-pass PVI, acute PV reconnections and dormant PV reconnections between the two groups. CONCLUSIONS: A novel strategy of performing complete PVI during apneic oxygenation results in improved catheter stability and decreased ablation times without adverse events. (Radiofrequency Ablation of Atrial Fibrillation Under Apnea; NCT04170894).

Microlaryngeal Laser Surgery Using High-flow Nasal Ventilation at Two Oxygen Concentration Deliveries.

OBJECTIVES: Ventilation using 100% oxygenation creates a risk of fire during laser microlaryngeal surgery (MLS). The purpose of this study is to describe the technique of transnasal high-flow ventilation using laser safe (30%) oxygen conditions, measure the intraoperative real-time laryngeal oxygen concentration, and examine patient saturation status using this technique. METHODS: Prospective IRB approved study of patients undergoing tubeless laser MLS using high-flow nasal oxygenation. Delivered oxygen concentration was reduced from 100% to 30% before lasering using an oxygen-air blender then increased to 100% post-laser procedure. Outcome measures included time for laryngeal oxygen concentration to equalize to laser safe levels; time to, methods of and duration of rescue ventilation; and desaturation rates and apnoeic times at both 100% and 30% oxygen deliveries. RESULTS: Fifty patients were recruited (mean age = 47.4 years). Mean laryngeal oxygen concentration (%) at 100% and 30% deliveries was 98.46 and 31.45, respectively. Mean (SD) of laryngeal oxygen concentration equalization time to 30% (seconds) was 9.4 (3.69). At 30% oxygen delivery desaturation rate was faster and apneic time shorter compared with 100%. Eighteen patients required rescue (jet) ventilation and they had a faster apneic desaturation rate (%/minute) than patients not requiring rescue. Mean (SD) apneic time (minutes) at 30% delivery was 4.56 (2.25) and 4.41 (2.18) in rescue versus non-rescue groups respectively. BMI was the only significant predictor of desaturation rate at 30% oxygen delivery. CONCLUSION: It is possible to achieve a safe time window for use of laser during MLS using transnasal humidified high-flow ventilation by delivering 30% oxygen concentration. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:634-639, 2023.

The effect of head rotation on efficiency of face mask ventilation in anaesthetised apnoeic adults: A randomised, crossover study.

BACKGROUND: Upper airway obstruction occurs commonly after induction of general anaesthesia. It is the major cause of difficult mask ventilation. OBJECTIVES: The aim of this study was to determine whether head rotation improves the efficiency of mask ventilation of anaesthetised apnoeic adults. DESIGN: A randomised, crossover study. SETTING: Single university teaching hospital. PATIENTS: Forty patients, aged 18 to 75 years with a BMI 18.5 to 35.0 kg m requiring general anaesthesia for elective surgery were recruited and randomised into two groups. INTERVENTIONS: Once apnoeic after induction of general anaesthesia, face mask ventilation began with pressure controlled ventilation, at a peak inspiratory pressure of 15 cmH2O. Each patient was ventilated for three 1-min intervals with the head position alternated every minute: group A, mask ventilation was performed with a neutral head position for 1 min, followed by an axial head position rotated 45° to the right for 1 min and then returned to the neutral position for another 1 min. In group B, the sequence of head positioning was rotated → neutral → rotated. MAIN OUTCOME MEASURES: Expiratory tidal volume, measured with a respiratory inductive plethysmograph. RESULTS: Two patients were excluded due to protocol violation; thus, data from 38 patients were analysed. The mean expiratory tidal volume was significantly higher in the rotated head position than in the neutral position (612.6 vs. 544.0 ml: difference [95% confidence interval], 68.6 [46.8 to 90.4] ml, P < 0.0001). CONCLUSION: Head rotation of 45° in anaesthetised apnoeic adults significantly increases the efficiency of mask ventilation compared with the neutral head position. Head rotation is an effective alternative to improve mask ventilation if airway obstruction is encountered. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02755077.

Developmental and genetic perspectives on Pierre Robin sequence.

Pierre Robin sequence (PRS) is a craniofacial anomaly comprising mandibular hypoplasia, cleft secondary palate and glossoptosis leading to life-threatening obstructive apnea and feeding difficulties during the neonatal period. The respiratory issues require careful management and in severe cases may require extended stays in neonatal intensive care units and surgical intervention such as lengthening the lower jaw or tracheotomy to relieve airway obstruction. These feeding and respiratory complications frequently continue well into childhood, affecting not only growth and development but also impacting on long term educational attainment. The diagnosis of PRS depends on readily recognizable clinical features but the phenotypic similarity of many PRS individuals conceals considerable etiological heterogeneity. Defects in the growth of the mandible sit at the core of PRS and the natural history of PRS can be classified into two major streams: primary defects of mandibular outgrowth and elongation and issues that are external to the mandibular skeleton but that secondarily impact on its growth. These altered developmental trajectories appear to be driven by a range of influences including defects in cartilage growth, neuromuscular function and fetal constraint. Various genetic and cytogenetic associations have been made with PRS and the diversity of these associations highlights the fact that there are numerous ways to arrive at this common phenotypic endpoint.

Immediate mandibular distraction in mandibular hypoplasia and upper airway obstruction.

Distraction osteogenesis of the mandible has become an alternative to tracheostomy in infants and children who present with upper airway obstruction due to micrognathia. To avoid prolonged intubation during distraction, we have implemented a protocol of immediate distraction at the time of distractor placement, which results in acute airway improvement. Over 2 years, 22 patients with micrognathia and severe airway obstruction have undergone mandibular distractor placement. Indications for surgery were apnea and desaturations with feeding. Resorbable distraction devices were placed bilaterally and activated to 5 to 8 mm. Recombinant human bone morphogenetic protein 2 was placed in the gap. Distraction was implemented at postoperative day 2 at 2 mm/d. Forty-four distraction devices were placed in 22 patients (68% male, 32% female) with a mean age of 24.1 months (range, 3 days to 5.5 years). The average distance of distraction performed in the operating room was 5 mm. The average total distraction was 24 mm performed over 12 days. Overall, 89% of patients were extubated after distractor placement in the operating room. Two patients with difficult intubations were extubated 7 days later in the operating room with otolaryngology. Of the 4 tracheostomy patients, 1 patient was decannulated, whereas 3 patients are pending postoperative sleep studies. One patient had a minor wound complication. Tracheostomy and prolonged intubation in patients with mandibular hypoplasia have significant morbidity and mortality. We have implemented a successful protocol of immediate distraction in the operating room with placement of bone morphogenetic protein. Immediate distraction appears to be an effective method of avoiding postoperative intubation and tracheostomy.

Decision analysis using decision trees for a simple clinical decision.

OBJECTIVE: To illustrate the use of decision trees with a utility index in clinical decision making. METHODS: A decision tree was created related to whether or not to perform a tonsillectomy. Data from the literature were applied to a common hypothetical clinical scenario. RESULTS: A decision tree graphically represents the typical decision-making process that many clinicians use. The addition of utility functions permitted consideration of the adverse or beneficial effects of outcomes, altering the treatment decision. CONCLUSION: Quantitative tools such as decision trees may quantify outcome preferences and aid in clinical decision making, but the proper tool and background data are essential.

[The study on AHI, LSaO2 and ET-1 in patients with obstructive sleep apnea-hypopnea syndrome after H-UPPP].

OBJECTIVE: To explore the treatment effect of H-UPPP on patients with obstructive sleep apnea hypopnea syndrome (OSAHS). METHOD: Seventy-nine patients were enrolled in our study. Among which 49 patients were done with H-UPPP, and the other 30 patients were done with UPPP. AHI and LSaO2 were monitored by polysomnography and plasma endothelins-1 were tested with enzyme linked immunosorbent assay (ELISA) before and after operation. RESULT: Forty-one patients were improved with reduced snoring and daytime sleepiness one year after operation in H-UPPP group,and the overall efficiency was 83.7%. Twenty-six patients were improved with reduced snoring and daytime sleepiness one year after operation in UPPP group, and the overall efficiency was 86.7%. There were significant differences of AHI, LSaO2 and ET-1 before and after operation between the two groups. Negative correlation was showed between AHI and LSaO2, also between LSaO2 and ET-1. CONCLUSION: Both H-UPPP and UPPP were proved to be effective to patients with OSAHS. The perioperative complications with H-UPPP was less than UPPP.

Subjective outcomes of maxillomandibular advancement surgery for treatment of obstructive sleep apnea syndrome.

PURPOSE: To evaluate subjective outcomes and use of continuous positive airway pressure (CPAP) after maxillomandibular advancement surgery for treatment of obstructive sleep apnea syndrome (OSAS). PATIENTS AND METHODS: A self-administered questionnaire was completed pre- and postoperatively by 116 patients who underwent maxillomandibular advancement surgery for treatment of OSAS from February 2000 through September 2010. The questionnaire included the Epworth Sleepiness Scale (ESS) for assessment of daytime somnolence and questions regarding snoring, witnessed apneas, CPAP use, and overall satisfaction. RESULTS: Preoperatively, 40% of patients were very sleepy (ESS ≥16), 32% were sleepy (ESS 10 to 16), and 28% were not sleepy (ESS ≤10). Postoperatively, only 1 patient (<1%) was very sleepy, 9% were sleepy, and 90% were not sleepy (McNemar test, P < .001). The mean ESS score for the very sleepy, sleepy, and not-sleepy groups decreased from 18.3 to 5.9, 12.9 to 4.4, and 7.3 to 4.5, respectively (P < .001). Surgery decreased snoring by 83%, witnessed apneas by 94%, and CPAP use by 96% (P < .001). The surgery was judged to be worthwhile by 89% of patients, and 95% of patients said they would recommend the treatment to other patients with OSAS. CONCLUSIONS: Maxillomandibular advancement surgery for treatment of OSAS is very effective at improving excessive daytime sleepiness, snoring, and witnessed apneas. Most patients in this study were able to discontinue the use of CPAP after surgery. Overall, patients reported the treatment to be worthwhile and would recommend it to others.

[Mandibular distraction osteogenesis in patients with craniofacial malformation]. / Distracción mandibular osteogénica en pacientes con malformaciones craneofaciales.

Craniofacial malformations (Pierre-Robin sequence, Treacher-Collins syndrome, Nager syndrome, etc.) are frequently associated to severe mandibular hypoplasia, which can cause upper airway obstruction by retroposition of the base of the tongue in the posterior pharyngeal space. Most of the patients respond to postural treatment. In prone decubitus position, it may be necessary to monitor oxygen saturation, insert a nasopharyngeal tube and even an endotracheal one. In more severe cases with prolonged and frequent pauses of apnea, tracheostomy may be necessary, but it is associated with high morbidity and sometimes mortality. In the last two years, in the Multidisciplinary Cleft Lip and Palate Unit of the Hospital Virgen de las Nieves, 4 children with severe obstructive apnea secondary to severe mandibular hypoplasia have been treated with mandibular distraction osteogenesis, this procedure being effective in the resolution of the condition. It has avoided tracheostomy, it has lengthened the jaw in a period of 2-3 weeks. During this time, the obstructive respiratory problems and also swallowing problems have disappeared. The esthetic results were excellent and the complications, for the moment, minimum.

[Simultaneous multiple plane operations in treating severe obstructive sleep apnea-hypopnea syndrome].

OBJECTIVE: To investigate the effect and clinical value of simultaneous multiple plane operations in treating severe OSAHS. METHOD: The clinical data of 93 patients with severe OSAHS were retrospectively analyzed. According to different obstruction plane, all the patients were performed different multiple planes of operations. Operations were finished in the same term. All patients underwent PSG examination before operation and 6-month, 1 year after surgical treatment separately. RESULT: No severe complication occurred. According to the assessment guidelines, the response rate was 100% in 6-month and 91.40% in 1-year respectively. CONCLUSION: Most OSAHS have multi-level obstructions in upper airway caliber, such as nasal, nasopharyngeal, velo-pharyngeal and tongue-pharyngeal obstruction. Simultaneous multiple plane operations which based on multiple plane obstruction can improve curative effect.

[A study of modified lateral pharyngoplasty for the treatment of obstructive sleep apnea hypopnea syndrome: primary outcomes analysis].

OBJECTIVE: To describe a modified lateral pharyngoplasty with partial transsection of levator veli palatine muscle in patients with obstructive sleep apnea hypopnea syndrome (OSAHS) and report the primary outcomes. METHOD: Retrospective review was performed in sixty patients with OSAHS. All the patients underwent modified surgical procedures, including partial transsection of levator veli palatine muscle and high soft palatoplasty. RESULT: The patients with a reduction of the AHI at least 50% were 6 (6/60, 10%). The patients with a reduction of the AHI at least 50% and a postoperative AHI < 20 were 44 (44/60, 73.3%). The patients with a postoperative AHI < 5 were 10 (10/60, 16.7%). Postoperative complications were postoperative bleeding in two cases (3.3%) and short-term velopharyngeal insufficiency in 10 cases (16.7%). CONCLUSION: Lateral pharyngoplasty with partial transsection of levator veli palatine muscle provides a safe and effective procedure for selected OSAHS patients with oropharyngeal collapse as the main site.

[Comparison of H-uvulopalatopharyngoplasty and plasma-assisted H-uvulopalatopharyngoplasty in the treatment of obstructive sleep apnea hypopnea syndrome].

OBJECTIVE: To compare the clinic effectiveness on OSAHS operated respectively by H-UPPP and plasma-assisted H-UPPP procedures,and to explore a utility operation procedure. METHOD: Thirty-five cases operated by H-UPPP and 29 cases by plasma-assisted H-UPPP, 6-36 months followed-up, the effectiveness analyzed and compared. RESULT: The difference of polysomnogram results between preoperative and postoperative in the two operation procedures were significantly(P < 0.05). But the total effectiveness of H-UPPP and plasma-assisted H-UPPP procedures were found to be similar (P > 0.05), nevertheless plasma-assisted H-UPPP procedure has a higher curing and excellence rate (P < 0.05). CONCLUSION: The two operation procedures were in effect, the plasma-assisted H-UPPP procedure was more ascendant in extending the left and right diameter on pharyngeal cavity, increasing tension on soft palate.

Why do palatine tonsils grow back after partial tonsillectomy in children?

Within the last decade, adenoidectomy with partial tonsillectomy has been revived in children with obstructive sleep-disordered breathing caused by adenotonsillar hyperplasia, generating debate about remaining tonsillar tissue regrowth. The study examined potential risk factors of the regrowth. Prospective, nonrandomised, case series feasibility study of children meeting the criteria for palatine tonsils regrowth after partial tonsillectomy performed in patients with obstructive sleep-related breathing disorder was carried out. Out of 793 operated children, 294 after adenoidectomy and 373 after adenotonsillotomy were followed up for 4 years in 12-month intervals. In 27 children after adenotonsillotomy, regrowth of tonsillar tissue was observed. In 22 individuals after adenoidectomy alone, hyperplasia of palatine tonsils was noted. The children had bacterial cultures of pharyngeal smears and blood samples tested for anti-streptolysin O, C-reactive protein and total IgE. Caregivers completed a questionnaire reporting on: their child's breathing after surgery; frequency, severity and treatment of upper respiratory tract infections; diet; family history of adenoidal and/or tonsillar hyperplasia; and history of allergy. As controls, 272 participants after adenoidectomy alone and 346 after adenotonsillotomy were examined. The amount of sugar in the diet and the incidence of upper respiratory tract infections after surgery differed between the groups of patients and controls. Other differences were insignificant. The tonsillar tissue remaining after partial tonsillectomy in children has a remarkable tendency to grow back, related to a diet abundant in sugar and numerous upper respiratory tract infections. Tonsillar regrowth was age related and occurred most frequently in individuals older than 7 years.

Palatal Pillar implants for the treatment of simple snoring.

OBJECTIVES: In this study the efficacy of palatal implants for treatment of snoring was evaluated. PATIENTS AND METHODS: Seventeen patients (10 males, 7 females; mean age 49.2+/-7.8 years; range 31 to 66 years) with primary snoring and an apnea-hypopnea index of less than 15 were treated with palatal implants after clinical and endoscopic examination. Snoring-related symptoms were evaluated at baseline and 90 days after surgery and polysomnography was performed. Patients and their spouses completed questionnaires and visual analog scales (VAS) evaluating snoring, apneas, and the intensity, duration, and social effects of daytime sleepiness at baseline and 90 days after surgery. Pre- and postoperative assessment results were compared. RESULTS: Epworth sleepiness scale score was significantly decreased in the postoperative period (p<0.05). Postoperative mean VAS snoring, apnea, and daytime sleepiness scores were also significantly improved (p<0.01). No patients reported worsening of apnea, 5.9% of patients reported no change in apnea, and 94.1% of patients reported a marked decrease in apneas. In the postoperative period, 76.4% of patients reported reduced snoring, and 88.3% of patients reported reduced daytime sleepiness. CONCLUSION: Palatal implants have been demonstrated to be a safe and effective treatment for snoring with minimal patient discomfort. Establishing realistic pretreatment expectations can maximize patient satisfaction.

[Effective evaluation of multiple level surgery in obstructive sleep apnea-hypopnea syndrome].

OBJECTIVE: To investigate the therapeutic effects of multiple level surgery in treating obstructive sleep apnea-hypopnea syndrome (OSAHS). METHODS: One hundred ninety two patients with OSAHS diagnosed by polysomnography were treated through uvulopalatopharyngoplasty (UPPP). Thirty patients were combined with sub-mucous resection of the nasal septum. Forty four patients received sub-mucous resection of the nasal septum and partial inferior turbinectomy. Two patients received sub-mucous resection of the nasal septum and partial resection of the tongue base. Two patients received genioglossus advancement and partial resection of the tongue base. Three patients received partial resection of the tongue base. In addition, the patients with the nasal disease and/or the lingual fat, AHI > 40 times/h, LSaO(2) < 0.64 and/or BMI > 30 kg/m(2) received tracheotomy before general anaesthesia. RESULTS: One hundred ninety two patients were treated through UPPP. One hundred ninety one patients were successful, one patient died of pneumothorax and cardiac arrest during the incision of the trachea. All patients were followed-up for 6-37 months, among them, 132 patients showed therapeutic effect, with the effective rate as 68.7%. Fifty five patients were cured (AHI < 5 times/h); 39 patients had significant effect (AHI < 20 times/h and decreased > or = 50%); 38 patients were effective (AHI decreased > or = 50%). However, 60 patients did not have any therapeutic effect, with the ineffective rate as 31.3%. Fifty four patients had palatopharyngeal and nasal cavity emphasis, 24 patients had palatopharyngeal and oropharyngeal emphasis, 96 patients had palatopharyngeal and nasal cavity and oropharyngeal emphasis. Some patients were treated with UPPP, which made effective rate as 15 (68.2%), 12 (63.2%), 29 (55.8%). The others were treated with multiple level operations, which made effective rate as 25 (78.1%), 5 (5/5), 33 (75.0%). The effective rate was 60.2% (56/93) by simple UPPP and it was 77.8% (63/81) by multiple level treatment in patients with multiple level obstruction. There was statistical significance between them (chi(2) = 6.2, P = 0.01). CONCLUSIONS: The effective rate was improved through multiple level operations in OSAHS patients. The serious complications could be prevented through tracheotomy before general anaesthesia in patients with severe OSAHS who needed multiple level surgery.

Apnea and macrocephaly-cutis marmorata telangiectatica congenita.

The authors report a case of an infant girl with macrocephaly-cutis marmorata telangiectatica congenita (Macrocephaly-CMTC). This patient presented with developmental delay, mild subcostal retractions, and occasional apneic spells. An MRI demonstrated mild to moderate lateral ventricle hydrocephalus, left hemi-megalencephaly, and left cerebellar tonsillar herniation with full occlusion of the cisterna magna. Her foramen magnum was narrowed, measuring 17.5mm in transverse diameter. This value was significantly below the 50th percentile for age, which is 23.5mm. Together, these findings were suggestive of cervicomedullary cord compression, concerning for sudden death. The patient underwent posterior fossa decompression by suboccipital craniectomy and cervical laminectomy. Initially due to hypertrophy and paralysis of the left true and false vocal cords, endotracheal intubation was not achieved, requiring tracheostomy tube placement. To our knowledge this is the first report of apnea in a patient diagnosed with M-CMTC, likely due to cervicomedullary cord compression and perhaps exacerbated by unilateral laryngeal hypertrophy. M-CMTC is a newly-described hemi-hypertrophy syndrome affecting the neurodevelopment of affected children. The authors emphasize airway obstruction secondary to unilateral hypertrophy of the vocal cords in addition to brainstem compromise as a consideration for the etiology of apnea in M-CMTC patients presenting with signs and symptoms of cervicomedullary cord compression.

Congenital atresia of the left coronary artery--myocardial revascularization in two children.

Two patients with congenital atresia of the left coronary artery ostium underwent myocardial revascularization at the age of three years and three months, respectively. The patients were admitted to the hospital with a clinical history of sudden chest pain or short apnea not necessitating resuscitation. Non-invasive examinations and hemodynamic studies revealed dysfunction of the left ventricle and ostial atresia of the left coronary artery. Surgical revascularization-bypass grafts were performed using the left internal mammary artery and saphenous vein graft in the first case and the left internal mammary artery in the second child. Both patients survived surgery and good patency of the grafts was confirmed by coronary angiograms during hospital stay. These cases are interesting because of their rarity and diagnostic and therapeutic difficulties.

[Effectiveness and related factors of Z-palatopharyngoplasty for treating obstructive sleep apnea hypopnea syndrome].

OBJECTIVE: To investigate the efficacy and related factors of Z-palatopharyngoplasty for treating severe obstructive sleep apnea hypopnea syndrome (OSAHS). METHODS: Thirty four OSAHS patients with graded 1-3 tonsil, posterior airway space (PAS) > or = mm , Friedman II and III oropharyngeal airway were included in this study, all cases had Z-palatopharyngoplasty. The follow up was at least 6 months postoperatively. Measurement parameters of responders and nonresponders were analyzed. RESULTS: According to related criterion of China, cure rate was 35.3%, accumulative total excellence rate 64.7% and accumulative valid rate 70. 6%. The cured and excellence patients were considered as responders, the other as nonresponders. The lowest oxygen saturation (LSaO2), percentage of time with oxyhemoglobin saturation below 0.90 (CT90), mandibular plane angle (MPA), mandibular body length, position of tongue and Friedman clinical stage are statistically significant between responder and nonresponder. The best cut points of LSaO2, CT90 and MPA were 0.72, 22.80% and 29.40 degrees respectively. The logistic regression showed that Friedman stage and MPA entered into equation, which was Y = ln [P/(1-P)] = -122.85 + 31.57X1 + 1.01X2, if setting X1 as Friedman stage, and X2 as MPA. CONCLUSIONS: Z-palatopharyngoplasty is effective surgical approach for OSAHS patients with posterior airway space (PAS) > or = 11 mm. The affective factors of Z-palatopharyngoplasty included LSaO2, CT90, MPA, mandibular body length, position of tongue and Friedman clinical stage. Among them, the mandibular plane angle and Friedman clinical stage were predominant factors.

Cyanotic breath-holding spells in children respond to adenotonsillectomy for sleep-disordered breathing.

Children with breath-holding (BH) spells may demonstrate sleep-disordered breathing (SDB) during polysomnography. We studied five young children with cyanotic spells retrospectively and found both SDB and a response to adenotonsillectomy. We therefore proceeded with a prospective investigation of treatment for SDB in children with comorbid cyanotic spells. Nineteen children with cyanotic BH spells were identified and enrolled in the prospective study. Parents chose either treatment or observation. Fourteen children underwent complete SDB evaluation and treatment trials while five selected observation only (control group). Sleep and sleep-surgery specialist evaluation and polysomnography revealed the presence of a narrow upper-airway and an abnormal respiratory disturbance index in all 14 children. Nasal CPAP was not successful, but adenotonsillectomy performed near 14 months of age eliminated SDB. BH spells were eliminated 1 month after surgery, while they persisted to the end of the study (24 months of age) in the control group. In conclusion, the presence of cyanotic BH should prompt investigation and polysomnography for possible SDB. Independent treatment of SDB may hasten resolution of BH spells in these cases.