Obstructive sleep apnoea in children — branching viva

Station opening

Examiner: "Define obstructive sleep apnoea in children and grade its severity." [1]

Strong candidate (must-hit)

• Defines OSA as recurrent partial or complete upper-airway obstruction during sleep with continued respiratory effort, disturbing gas exchange and sleep, and places it at the severe end of the sleep-disordered breathing spectrum that begins with primary snoring; grades severity on the obstructive apnoea-hypopnoea index using paediatric thresholds (mild 1-5, moderate 5-10, severe >10 events per hour) and notes these are lower than adult cut-offs because children are harmed at lower event rates. [1] [4]

Weak candidate

• "It is when children stop breathing at night; I would use the adult apnoea thresholds." [1]

Branch A — The 4-year-old with snoring and faltering growth

Examiner: "A 4-year-old snores loudly with witnessed apnoeas and has dropped growth centiles. How do you investigate and treat him?" [3] [7]

Strong

• Recognises probable OSA from adenotonsillar hypertrophy; confirms and grades with overnight polysomnography as the gold standard, or nocturnal oximetry if unavailable (a positive clustered-desaturation trace rules in, a normal result does not exclude); treats with adenotonsillectomy first-line, citing the CHAT trial's benefit on behaviour, quality of life and polysomnography; and explains that the faltering growth reflects OSA and should show catch-up after treatment. [3] [7]

Weak

• "Reassure the parents it is just snoring and review in a year." [1]

Branch B — The 3-year-old with Down syndrome and severe OSA for surgery

Examiner: "A 3-year-old with Down syndrome and severe OSA is listed for adenotonsillectomy. What are your peri-operative concerns?" [1] [4]

Strong

• Identifies a high-risk peri-operative airway because of young age, severe OSA and Down syndrome (midface hypoplasia, macroglossia, hypotonia); arranges monitored surgery and overnight admission in a centre able to manage the paediatric airway; uses opioids cautiously because the OSA airway is unusually sensitive to respiratory depressants; assesses for pulmonary hypertension beforehand; and warns the family that residual OSA is common so a post-operative sleep study and possible CPAP may be needed. [1] [4]

Weak

• "Book him as a routine day case and discharge him the same afternoon." [1]

Branch C — The obese 14-year-old with residual symptoms after surgery

Examiner: "An obese 14-year-old still has symptoms and a moderate AHI 6 months after adenotonsillectomy. What now?" [6] [10]

Strong

• Explains that residual OSA is expected in the obese child because obesity narrows the airway and adds a restrictive load surgery does not address (Bhattacharjee); moves to CPAP as next-line while naming adherence as the central problem and describing structured support to improve it (Marcus); adds genuine weight management, treatment of nasal allergy, adjuncts such as intranasal corticosteroid or montelukast, and ongoing sleep and metabolic follow-up. [6] [10]

Weak

• "The tonsils are out, so the OSA must be cured; nothing more to do." [6]

Branch D — The remote family without ready access to a sleep study

Examiner: "A family from a remote community cannot easily access polysomnography. How do you manage the snoring child?" [4] [7]

Strong

• Uses a structured sleep history and validated questionnaire to triage, recognises that clinical assessment cannot grade severity, and uses nocturnal oximetry as a pragmatic rule-in test given limited sleep-laboratory capacity; expedites referral for adenotonsillectomy when the picture and a positive oximetry fit; uses telehealth for follow-up; and acknowledges the higher burden of respiratory disease and access barriers among Indigenous and remote families as an equity issue. [4] [7]

Weak

• "Do nothing until a full sleep study can be arranged, however long that takes." [7]

Close

Examiner: "Summarise your approach to the snoring child in one sentence." [1] [3]

Strong

• "I take a structured sleep history, confirm and grade OSA with polysomnography or nocturnal oximetry where studies are scarce, treat the child with adenotonsillar hypertrophy with adenotonsillectomy first-line on the strength of the CHAT trial, reserve monitored surgery and overnight admission for the high-risk airway, use CPAP with adherence support and adjuncts for residual disease and children without a surgical target, and re-study the obese, severe or syndromic child who often has residual OSA." [1] [3]