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
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


Obstructive sleep apnea syndrome
Obstructive Sleep Apnea Syndrome

  • Common

  • Dangerous

  • Easily recognized

  • Treatable


Apnea patterns

Obstructive

Mixed

Central

Airflow

Respiratory

effort

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 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

Apnea

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,

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.


Adults clinical consequences
Adults: Clinical Consequences

Obstructive Sleep Apnea Syndrome

Sleep fragmentation, Hypoxia / Hypercapnia

Excessive daytime sleepiness

Cardiovascular Complications

Morbidity

Mortality


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

Morbidity

Mortality


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 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 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 complications

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: complicationsAdenotonsillectomy

Adenotonsillectomy by itself does not work in adults


Adult osas treatment
Adult OSAS treatment complications

  • 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 complications

  • Educate patient

  • Document warning

  • Resolve apnea quickly

  • Follow-up

    • Effectiveness

    • Compliance


Adults behavioral interventions
Adults: Behavioral Interventions complications

  • 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 complications

  • 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 complications

  • Positive airway pressure

    • Continuous positive airway pressure (CPAP)

    • Bi-level positive airway pressure

  • Oral appliances

  • Other (limited role)

    • Medications---don’t work

    • Oxygen




Special considerations for cpap in children
Special considerations for CPAP in children complications

  • 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




Cpap compliance
CPAP Compliance complications

  • 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 complications

  • 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 complications



Surgical alternatives in adults
Surgical alternatives in adults complications

  • 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) complications

  • 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: complicationsPediatric 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: complicationsPediatric 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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