TuCASA questionnaire for assessment of children with obstructive sleep apnea: validation

Highlights

• The TuCASA validation for Brazilian children is a reliable and consistent version.

• The TuCASA questionnaire is a valuable tool for symptoms of sleep-disordered breathing.

• The validated instrument is important for sleep evaluation in children.

Abstract

Objective

The aim of the present study was to validate The Tucson Children's Assessment of Sleep Apnea Study (TuCASA) questionnaire for use in the Brazilian population.

Methods

Of the total 62 children who participated in the present study (27 girls), aged 4 to 11 years, 45 (72.6%) had sleep-disordered breathing (SDB) diagnosed by polysomnography, while 17 (27.4%) had no sleep disorders. Translation, back-translation, and pretesting were previously performed. The final Portuguese-language version of TuCASA was administered to the participants from May 2012 to August 2013. The interviewer was blinded to presence or absence of SDB. Cronbach's alpha for the overall scale (with 95% CI) and the effect of excluding any items were evaluated.

Results

There was no difference among TuCASA items/score and the presence of SDB with either age or gender. The TuCASA had a Cronbach's alpha coefficient of 0.726 (95% CI 0.614 to 0.817), which denotes satisfactory internal consistency – a finding reinforced by evaluation of the effect of item exclusion on the questionnaire. Convergent validity was also satisfactory, in as much as most correlations were positive and significant.

Conclusion

The translated version of the TuCASA questionnaire was validated for Brazilian populations and proved to be a reliable, validated instrument that can be used in clinical practice for evaluation of children with symptoms of SDB.

Introduction

The term sleep-disordered breathing (SDB) describes the clinical spectrum of a condition that includes primary snoring, upper airway resistance syndrome (UARS), and obstructive sleep apnea syndrome (OSAS) [1]. The prevalence of OSAS in children is estimated to range between 1% and 3%, with equal distribution between the genders and peak prevalence in preschoolers [2], [3], [4], [5], [6].

Unlike adults, children with SDB do not have excessive daytime sleepiness, but rather have symptoms such as: behavioral changes, cognitive dysfunction [3], [4], impulsivity [7], impaired balance [8], impaired concentration and learning difficulties, facial growth abnormalities, growth retardation, and hyperactivity [9], [10], [11], [12], [13]. Thus, pediatric SDB may lead to major complications such as delayed growth and development, mental retardation, and pulmonary heart disease (cor pulmonale).

The pathophysiology of SDB in childhood is not yet understood, although adenotonsillar hypertrophy, obesity, muscle weakness, and craniofacial dismorphism are factors that may contribute [12], [13], [14].

Polysomnography (PSG), the standard for the diagnosis of SDB, is the most accurate method for determining its presence and severity, but is costly and has limited availability [12], [15]. In Brazil, the demand for PSG in children far exceeds the number of facilities qualified to perform it, which forces the children and their parents to seek care at major centers, where they are usually placed on a waiting list [13]. The need for expert technicians is a further hindrance to wider access to this diagnostic test.

Questionnaires are very useful tools for the assessment of sleep in children; however, these instruments must be clear, simple, brief, and easy to understand and administer. Several different questionnaires may be used for diagnostic purposes in routine clinical practice. Most instruments used for this purpose in Brazil were developed in other countries, and few have been adapted and validated for Portuguese-speaking populations; therefore, it is believed that misinterpretations and certain cultural aspects may influence the specificity and sensitivity of these methods. The need for visual adaptation of instruments should also be taken into account [16]. The use of questionnaires as evaluation parameters is useful, because they can allow standardization, consistency, and reproducibility of the proposed measures. When translating a questionnaire, its measurement properties need to be tested and validated in a pilot group, to enable later use in population studies. Thus, established methods for translation and cross-cultural adaptation allow instruments to be used in a given language and culture.

The Tucson Children's Assessment of Sleep Apnea Study (TuCASA) questionnaire is intended for children aged 4 years to 11 years and comprises 13 items about the symptoms of SBD [12]. This questionnaire has proven to be relevant and reproducible, as demonstrated in several studies [12], [17], [18], [19], [20], is easy to administer in a clinical setting, and can help determine the symptoms of SDB in Brazilian children. The aim of the present study was to validate a version of the TuCASA questionnaire that had been translated and adapted for use in Brazil [21].