Pediatric obstructive sleep apnea syndrome kids are not simply little adults
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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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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


Obstructive sleep apnea syndrome

Obstructive Sleep Apnea Syndrome

  • Common

  • Dangerous

  • Easily recognized

  • Treatable

Apnea patterns







Apnea Patterns

Measures of sleep apnea frequency

Measures of Sleep Apnea Frequency

  • Apnea Index

    • # apneas per hour of sleep

  • Apnea / Hypopnea Index (AHI)

    • # apneas + hypopneas per hour of sleep

Pediatric osas epidemiology

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

Pathophysiology of obstructive apnea

Pathophysiology of Obstructive Apnea

Pathophysiology of osas

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


Arousal from sleep

Hypoxia & Hypercapnia

Increased ventilatory effort

Pathophysiology of OSAS

Adult osas risk factors

Adult OSAS Risk Factors

  • Obesity

  • Increasing age

  • Male gender

  • Anatomic abnormalities of upper airway

  • Family history

  • Alcohol or sedative use

  • Smoking

Adult osas risk factors cont d

Adult OSAS Risk Factors, cont’d

  • Hypothyriodism

  • Acromegaly

  • Amyloidosis

  • Vocal cord paralysis

  • Marfan syndrome

  • Down syndrome

  • Neuromuscular disorders

Pediatric osas risk factors

Pediatric OSAS Risk Factors

  • Adenotonsillar hypertrophy

  • Craniofacial anomalies

  • Down Syndrome

  • Obesity

  • Neurological disorders

  • Family History

Risk factor family history

Odds Ratio

(Adjusted forage, race, sex,


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.

Adults clinical consequences

Adults: Clinical Consequences

Obstructive Sleep Apnea Syndrome

Sleep fragmentation, Hypoxia / Hypercapnia

Excessive daytime sleepiness

Cardiovascular Complications



Adult osas consequences

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

Pediatrics clinical consequences

Pediatrics: Clinical Consequences

Obstructive Sleep Apnea Syndrome

Sleep fragmentation, Hypoxia / Hypercapnia

In very severe cases, cor pulmonale and hypertension

Attention and hyperactivity problems



Pediatric osas consequences

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

Adult osas diagnosis history

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.

Pediatric osas diagnosis history

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

Pediatric osas diagnosis history cont d

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

Adult diagnosis physical examination

Adult diagnosis: Physical Examination

  • Obvious airway abnormality

  • Upper body obesity / thick neck

    > 17” males

    > 16” females

  • Hypertension

Adult physical exam oropharynx

Adult Physical Exam: Oropharynx

Adult physical examination

Adult Physical Examination

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

Pediatric diagnosis physical examination

Pediatric diagnosis: Physical Examination

  • Tonsillar hypertrophy

  • Nasal obstruction

  • Overbite

  • Morbid obesity

  • Behavior in exam room

    Note: PE often is normal

Exam tonsillar hypertrophy

Exam: Tonsillar Hypertrophy

Shepard JW Jr et al. Mayo Clin Proc 1990;65.

Why get a sleep study

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)

Diagnosis of sleep apnea

Diagnosis of Sleep Apnea

  • In-laboratory polysomnography

    • Gold standard

    • Assess severity

    • Initiate treatment

    • Look for other sleep disorders



Nocturnal polysomnogram

Nocturnal Polysomnogram

Nocturnal polysomnography

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

Pediatric osas treatment

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

Pediatric osas treatment adenotonsillectomy

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

Pediatric groups at high risk for postoperative t a complications

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

Postoperative monitoring of high risk pediatric patients

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.

Adult osas treatment adenotonsillectomy

Adult OSAS treatment:Adenotonsillectomy

Adenotonsillectomy by itself does not work in adults

Adult osas treatment

Adult OSAS treatment

  • Risk counseling

    • Motor vehicle crashes

    • Job-related hazards

    • Judgment impairment

  • Apnea and comorbidity treatment

    • Behavioral

    • Medical (non-surgical)

    • Surgical

The high risk driver

The High-Risk Driver

  • Educate patient

  • Document warning

  • Resolve apnea quickly

  • Follow-up

    • Effectiveness

    • Compliance

Adults behavioral interventions

Adults: Behavioral Interventions

  • Encourage patients to:

    • Lose weight

    • Avoid alcohol and sedatives

    • Avoid sleep deprivation

    • Avoid supine sleep position

    • Stop smoking

Adults and kids weight loss

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

Medical interventions

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

Positive airway pressure

Positive Airway Pressure

Positive airway pressure1

Positive Airway Pressure

Special considerations for cpap in children

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

Positive airway pressure problems

Positive Airway Pressure: Problems

Positive airway pressure problems1

Positive Airway Pressure: Problems

Cpap compliance

CPAP Compliance

  • Patient report: 75%

  • Objectively measured use

    > 4 hrs for > 5 nights / week: 46%

  • Asthma-medicine compliance: 30%

Strategies to improve compliance

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

Oral appliances

Oral Appliances

Uvulopalatopharyngoplasty uppp

Uvulopalatopharyngoplasty (UPPP)

Surgical alternatives in adults

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

Uvulopalatopharyngoplasty uppp1

Uvulopalatopharyngoplasty (UPPP)

  • Usually eliminates snoring

  • 41% chance of achieving AHI < 20

  • No accurate method to predict surgical success

  • Follow-up sleep study required

Summary pediatric and adult osas

Summary:Pediatric and Adult OSAS

  • Dangerous

  • Common

  • ADHD symptoms in kids vs. sleepiness in adults

  • Treatment: T&A in most kids vs. CPAP in most adults

Summary pediatric osas

Summary:Pediatric OSAS

  • Not all kids with ADD or ADHD symptoms need OSAS evaluation

  • Think about OSAS in kids with ADHD symptoms then ask about loud snoring, poor/disrupted sleep and look for adenotonsillar hypertrophy

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