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Pediatric Obstructive Sleep Apnea Syndrome: Kids are not simply little adults

Pediatric Obstructive Sleep Apnea Syndrome: Kids are not simply little adults. Ronald J. Green, MD, FCCP Diplomate, American Board of Sleep Medicine Sleep Disorders & Pulmonary Disease, The Everett Clinic Medical Director North Puget Sound Center for Sleep Disorders Everett, WA

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Pediatric Obstructive Sleep Apnea Syndrome: Kids are not simply little adults

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  1. Pediatric Obstructive Sleep Apnea Syndrome:Kids are not simply little adults Ronald J. Green, MD, FCCP Diplomate, American Board of Sleep Medicine Sleep Disorders & Pulmonary Disease, The Everett Clinic Medical Director North Puget Sound Center for Sleep Disorders Everett, WA 425-339-5410; www.ilikesleep.com

  2. Obstructive Sleep Apnea Syndrome • Common • Dangerous • Easily recognized • Treatable

  3. Obstructive Mixed Central Airflow Respiratory effort Apnea Patterns

  4. Measures of Sleep Apnea Frequency • Apnea Index • # apneas per hour of sleep • Apnea / Hypopnea Index (AHI) • # apneas + hypopneas per hour of sleep

  5. Pediatric OSAS Epidemiology • 7% to 20% of children snore frequently • 1% to 3% of preschool age children have OSAS • Peak age is two to five years

  6. Pathophysiology of Obstructive Apnea

  7. Awake: Small airway + neuromuscular compensation Loss of neuromuscular compensation Sleep Onset Hyperventilate: correct hypoxia & hypercapnia + Decreased pharyngeal muscle activity Airway opens Airway collapses Pharyngeal muscle activity restored Apnea Arousal from sleep Hypoxia & Hypercapnia Increased ventilatory effort Pathophysiology of OSAS

  8. Adult OSAS Risk Factors • Obesity • Increasing age • Male gender • Anatomic abnormalities of upper airway • Family history • Alcohol or sedative use • Smoking

  9. Adult OSAS Risk Factors, cont’d • Hypothyriodism • Acromegaly • Amyloidosis • Vocal cord paralysis • Marfan syndrome • Down syndrome • Neuromuscular disorders

  10. Pediatric OSAS Risk Factors • Adenotonsillar hypertrophy • Craniofacial anomalies • Down Syndrome • Obesity • Neurological disorders • Family History

  11. Odds Ratio (Adjusted forage, race, sex, BMI) 1 2 3 Relative Relatives Relatives Risk Factor: Family History Likelihood of Sleep Apnea as Function of Family Prevalence Adapted from Redline S et al. Am J Resp Crit Care Med 1995;151.

  12. Adults: Clinical Consequences Obstructive Sleep Apnea Syndrome Sleep fragmentation, Hypoxia / Hypercapnia Excessive daytime sleepiness Cardiovascular Complications Morbidity Mortality

  13. Adult OSAS consequences • Excessive daytime sleepiness • Increased motor vehicle crashes & work-related accidents • Poor job performance • Poor memory and concentrating ability • Family discord from loud snoring and above symptoms • Chronic headaches • Hypertension • Increased incidence of depression • Decreased quality of life

  14. Pediatrics: Clinical Consequences Obstructive Sleep Apnea Syndrome Sleep fragmentation, Hypoxia / Hypercapnia In very severe cases, cor pulmonale and hypertension Attention and hyperactivity problems Morbidity Mortality

  15. Pediatric OSAS consequences • Behavioral problems at home and at school • Hyperactivity and inattention (ADHD symptoms) • Discipline problems at school • Poor school performance • Irritability • Difficulties with memory and concentrating ability • Morning headaches • Failure to thrive • Decreased quality of life • Uncommon symptom in pediatrics: Excessive daytime sleepiness

  16. Adult OSAS Diagnosis: History • Loud snoring (not all snore) • Nocturnal gasping and choking • Ask bed partner (witnessed apneas) • Automobile or work related accidents • Personality changes or cognitive problems • Risk factors • Excessive daytime sleepiness (often not recognized by patient) • Frequent nocturia Sleep Apnea: Is Your Patient at Risk? NIH Publication, No 95-3803.

  17. Pediatric OSAS Diagnosis: History • Loud snoring (almost all snore loudly) • Snorting/gasping/choking • Observed apneic pauses (often not seen) • Restless sleep • Diaphoresis • Abnormal sleeping position • Paradoxical chest wall movement • Secondary enuresis

  18. Pediatric OSAS Diagnosis: History, cont’d • Attention deficit and hyperactivity symptoms • Behavioral problems • Poor school performance • Difficulty awakening in AM • Morning headaches • Uncommon symptom in pediatrics: daytime somnolence • Symptoms from adenotonsillar hypertrophy

  19. Adult diagnosis: Physical Examination • Obvious airway abnormality • Upper body obesity / thick neck > 17” males > 16” females • Hypertension

  20. Adult Physical Exam: Oropharynx

  21. Adult Physical Examination Guilleminault C et al. Sleep Apnea Syndromes. New York: Alan R. Liss, 1978.

  22. Pediatric diagnosis: Physical Examination • Tonsillar hypertrophy • Nasal obstruction • Overbite • Morbid obesity • Behavior in exam room Note: PE often is normal

  23. Exam: Tonsillar Hypertrophy Shepard JW Jr et al. Mayo Clin Proc 1990;65.

  24. Why Get a Sleep Study? • Signs and symptoms poorly predict disease severity • Appropriate therapy dependent on severity • Failure to treat leads to: • Increased morbidity and mortality • Motor vehicle crashes and job-related accidents in adults • Other sleep disorders can cause same symptoms (especially restless legs syndrome in both pediatrics and adults)

  25. Diagnosis of Sleep Apnea • In-laboratory polysomnography • Gold standard • Assess severity • Initiate treatment • Look for other sleep disorders

  26. Polysomnography

  27. Nocturnal Polysomnogram

  28. Nocturnal Polysomnography In contrast to adults, children have: • Fewer obstructive apneas • Desaturation with shorter events • Higher respiratory rate • Lower functional residual capacity • Smaller oxygen stores

  29. Pediatric OSAS treatment • Surgery • Adenotonsillectomy (treatment of choice) • Turbinate reduction if indicated • Maxillofacial surgery • Tracheostomy (very rarely) • Weight loss if obese • Nasal Continuous Positive Airway Pressure (CPAP)----Will discuss in more detail under adult treatment options

  30. Pediatric OSAS treatment:Adenotonsillectomy • Usually highly effective in children with adenotonsillar hypertrophy, even in the presence of other underlying conditions • Children with severe pre-operative OSAS should have post-op PSG to confirm complete remission of OSA

  31. Pediatric groups at high risk for postoperative T&A complications • Age less than two • Severe OSAS by nocturnal polysomnography • Associated medical conditions • Craniofacial anomalies • Hypotonia • Severe obesity • Complications of OSAS already present • Failure to thrive • Cor pulmonale

  32. Postoperative monitoring of high risk pediatric patients Postoperatively, high risk patients should be observed overnight in a facility where appropriate monitoring and care are available.

  33. Adult OSAS treatment:Adenotonsillectomy Adenotonsillectomy by itself does not work in adults

  34. Adult OSAS treatment • Risk counseling • Motor vehicle crashes • Job-related hazards • Judgment impairment • Apnea and comorbidity treatment • Behavioral • Medical (non-surgical) • Surgical

  35. The High-Risk Driver • Educate patient • Document warning • Resolve apnea quickly • Follow-up • Effectiveness • Compliance

  36. Adults: Behavioral Interventions • Encourage patients to: • Lose weight • Avoid alcohol and sedatives • Avoid sleep deprivation • Avoid supine sleep position • Stop smoking

  37. Adults and kids: Weight loss • Should be prescribed for all obese patients • Can be curative but has low success rate • Other treatment is required until optimal weight loss is achieved

  38. Medical Interventions • Positive airway pressure • Continuous positive airway pressure (CPAP) • Bi-level positive airway pressure • Oral appliances • Other (limited role) • Medications---don’t work • Oxygen

  39. Positive Airway Pressure

  40. Positive Airway Pressure

  41. Special considerations for CPAP in children • Not FDA approved • Need wide variety of mask sizes and styles to fit children • Compliance may be enhanced by behavioral techniques • Empowerment • Positive reinforcement • Desensitization • Role modeling

  42. Positive Airway Pressure: Problems

  43. Positive Airway Pressure: Problems

  44. CPAP Compliance • Patient report: 75% • Objectively measured use > 4 hrs for > 5 nights / week: 46% • Asthma-medicine compliance: 30%

  45. Strategies to Improve Compliance • Improve nasal patency--THIS IS THE KEY • Machine-patient interfaces • Masks • Nasal pillows • Chin straps • Humidifiers • Ramp • Desensitization • Bi-level pressure

  46. Oral Appliances

  47. Uvulopalatopharyngoplasty (UPPP)

  48. Surgical alternatives in adults • Reconstruct upper airway • Uvulopalatopharyngoplasty (UPPP) • Laser-assisted uvulopalatopharyngoplasty (LAUP) • Radiofrequency tissue volume reduction • Genioglossal advancement • Nasal reconstruction • Tonsillectomy • Bypass upper airway • Tracheostomy

  49. Uvulopalatopharyngoplasty (UPPP) • Usually eliminates snoring • 41% chance of achieving AHI < 20 • No accurate method to predict surgical success • Follow-up sleep study required

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