When should a patient be referred for polysomnography (poly sonography)?

When to Refer for Polysomnography

Refer children with sleep-disordered breathing for polysomnography if they are under age 2, have high-risk comorbidities (obesity, Down syndrome, craniofacial abnormalities, neuromuscular disorders, sickle cell disease, or mucopolysaccharidoses), or when clinical uncertainty exists about the need for intervention. 1

Pediatric Indications (Ages 2-18 Years)

Mandatory Referral Criteria

• Age < 2 years with any signs of obstructive sleep-disordered breathing 1
• High-risk comorbidities in children with sleep-disordered breathing: 1
  • Obesity
  • Down syndrome
  • Craniofacial abnormalities
  • Neuromuscular disorders
  • Sickle cell disease
  • Mucopolysaccharidoses

Clinical Uncertainty Situations

• Discordance between physical examination and reported symptom severity - when tonsillar size doesn't match the severity of reported sleep-disordered breathing 1
• Uncertain surgical indication - when the need for tonsillectomy is not clear despite symptoms 1
• Documented obstructive sleep apnea requiring severity assessment before surgical planning 1

Pre-Surgical Assessment Requirements

Polysomnography results must be communicated to the anesthesiologist before tonsillectomy in any child with sleep-disordered breathing, as this impacts perioperative risk stratification. 1 Children with severe OSA (apnea-hypopnea index ≥10 events/hour or oxygen saturation nadir <80%) require inpatient overnight monitoring post-tonsillectomy. 1

Adult Indications

Suspected Obstructive Sleep Apnea

Polysomnography is indicated when OSA is clinically suspected, particularly if CPAP or surgical therapy is being considered. 2 The gold standard remains laboratory-based polysomnography for diagnosis and CPAP titration. 2, 3

Pulmonary Arterial Hypertension

In patients with PAH, polysomnography is recommended when OSA is suspected as the etiology, when screening tests are positive, or when high clinical suspicion exists. 1 This is a Grade E/B recommendation despite limited evidence, as nocturnal desaturation is common in PAH (77% of patients) and may exacerbate pulmonary hypertension through hypoxia-induced vasoconstriction. 1

Severely Obese Surgical Candidates

When symptoms of obstructive sleep apnea or hypercapnia are identified in severely obese patients undergoing surgery (particularly bariatric procedures), polysomnography should be performed. 1 This population has substantially higher cardiac complication rates (6.8-15.3 per 1000 patients) compared to general surgery. 1

Type of Study Recommended

Laboratory-based polysomnography is preferred over home testing when indicated for children with sleep-disordered breathing prior to tonsillectomy. 1 Laboratory PSG provides comprehensive monitoring including EEG, electro-oculography, electromyography, respiratory effort, airflow, oxygen saturation, and body position. 4, 3

Common Pitfalls to Avoid

• Do not rely on clinical diagnosis alone - clinical assessment is a poor predictor of OSA severity in children, and physical examination often underestimates cardiac pathology in obese adults 1
• Do not assume tonsillar hypertrophy correlates with OSA severity - discordance is common and warrants objective testing 1
• Do not use arbitrary AHI cutoffs without clinical context - various thresholds (>5, >10, >15) are used, but their clinical importance varies by patient population 2
• Recognize obesity as a confounder - up to 75% of OSA patients are obese, and weight loss significantly improves or resolves OSA in 85.7% of cases, suggesting obesity may be the primary driver rather than OSA causing other comorbidities 2