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h - h. Obesity & OSA in Kids. Sherri Katz, MD, CM, FRCPC Pediatric Respirologist Assistant Professor Children’s Hospital of Eastern Ontario University of Ottawa. Objectives. Understand the pathophysiologic mechanisms of obstructive sleep apnea in obese children

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h - h

Obesity & OSA in Kids

Sherri Katz, MD, CM, FRCPC

Pediatric Respirologist

Assistant Professor

Children’s Hospital of Eastern Ontario

University of Ottawa

objectives
Objectives
  • Understand the pathophysiologic mechanisms of obstructive sleep apnea in obese children
  • Recognize associated co-morbidities of obesity and concurrent OSA in childhood
  • Review alternative treatment strategies for children with obesity and obstructive sleep apnea
a growing problem
A growing problem…
  • OSA has a prevalence of 1-3% in children
  • Prevalence of sleep disordered breathing in obese children is 13-66% - 10-20 x 
  • Obesity is a rising epidemic in pediatrics
    • 5-fold increase in the past 15 years
    • Prevalence of 10%

Ali, 1994, Gislason, 1995, Brunetti, 2001; Mallory, 1989; Silvestri, 1993;Chay, 2000; Marcus, 1996, Wing, 2003; Shields, 2009; Willms, 2003;

a growing problem1
A growing problem…

As OSA is strongly linked to obesity, this means more kids with OSA!

what is osa
What is OSA?
  • Partial (hypopnea) or complete (apnea) upper airway obstruction during sleep associated with:
    • Sleep disruption
    • Hypoxemia
    • Hypercapnia
    • Daytime symptoms
  • Continued chest and abdominal motion in the absence of airflow during sleep
  • Apnea-Hypopnea Index: # of events/hour
      • Used to categorize severity of condition
why does osa occur
Why does OSA occur?
  • We don’t breathe as deeply while sleeping as when awake
    • blunting of hypoxic / hypercapnic drive
    • 25% ¯ tidal volume
    • arterial pCO2­ 3-4 mmHg
    • arterial pO2¯ 5-10 mmHg
why does osa occur1
Why does OSA occur?
  • Upper airway tone is decreased during sleep, especially in REM
  • Collapse/obstruction of the upper airway during sleep causes obstruction & apnea
why does osa occur2
Why does OSA occur?
  • Adenotonsillar hypertrophy
    • Most common cause of OSA in children
    • Between 3-6 yrs, tonsils & adenoids are largest relative to size of airway  peak incidence of OSA
why does osa occur3
Why does OSA occur?

Large tonsils and adenoids

BUT

No direct correlation between airway or adenotonsillar size & OSA

Upper airway is narrower and more collapsible in children with OSA

Airway patency is maintained by increased neuromuscular activity

THEREFORE

Combination of structural abnormalities & neuromotor tone abnormalities must be present for OSA to occur

  • Isono, AJRCCM, 1998, Marcus, Respiration Physiology, 1999
why do obese kids get osa
Why do Obese Kids get OSA?
  • Older kids & teens
  • Increased fat mass around the neck & trunk, resulting in:
    • Reduction in thoracic cage compliance
    • Mass loading of the respiratory muscles
    • Increased pharyngeal resistance
  • May be obstructive initially, but resetting of chemoreceptor sensitivity  hypoventilation

Mallory, J Peds, 1989

what are the consequences
What are the consequences?
  • Health Care Utilization
  • Inflammation
  • Metabolic
  • Cardiovascular
  • Neurobehavioural
  • Quality of life
health care burden
Health Care Burden
  • Economic burden of untreated OSA alone is comparable to that of diabetes
  • Children with OSA have 226%  health care utilization
  • Treating OSA in children health care costs by 1/3
  • In adults, PAP therapy is as effective as cholesterol-lowering agents in preventing cardiovascular disease

AlGhanim, 2008; Reuveni, 2002; Tarasiuk, 2004&2007

common pathophysiology
Common Pathophysiology

Obesity

OSA

Changes in renin-angiotensin-aldosterone system &  renal sympathetic activity

Hypoxia and micro-arousals

Oxidative stress

Sympathetic Nervous System Activation

Systemic inflammation

inflammation
Inflammation
  • C-reactive protein is released during systemic inflammatory processes
  • Can assess risk of heart disease using hs-CRP assay
  • Hs-CRP levels  in OSA and correlate with severity
  • Hs-CRP  following OSA treatment with T&A

Goldbart, 2008; Bassuk, 2004;Li, 2008; Kheirandish-Gozal, 2006;

insulin resistance
Insulin Resistance
  • Consequence of both childhood obesity + OSA

Hypoxia and micro-arousals activate sympathetic nervous system

Pro-inflammatory state

Insulin resistance

Kheirandish-Gozal, Sleep Med, 2010; Gozal, AJRCCM, 2008; Waters, J Sleep Res, 2007; Li, Ped Pulm, 2008; Esler, J Appl Physiol, 2006; Sinha, NEJM, 2002; Vgontzas, J Intern Med, 2003; Somers, J Clin Invest 1995

insulin resistance1
Insulin Resistance
  • Precursor of type 2 diabetes and cardiovascular disease
  • Elevated insulin levels in childhood persist into adulthood & are predictive of cardiovascular disease risk
  • Severity of insulin resistance is α OSA (independent of BMI)

Combo of OSA & Obesity = Greater risk of endocrine dysfunction

insulin resistance2
Insulin Resistance
  • In obese and non-obese adults, PAP treatment for severe OSA improved insulin sensitivity within 2 days and sustained effect over 3 months
    • Improvements more rapid in non-obese subjects
    • Suggests obesity is contributing to insulin resistance
    • Treating OSA alone, independent of body composition, improves insulin resistance

Harsch, AJRCCM. 2004

insulin resistance3
Insulin Resistance
  • 4 Pediatric studies of effect of T&A for OSA on insulin resistance showed improvement
    • Small sample size, young children, mostly non-obese
  • PAP therapy for OSA in obese kids with pre-existing insulin resistance:
    • Improved fasting glucose & insulin levels without change in BMI
    • Not statistically significant, small sample size

Nakra, Pediatrics, 2008; Gozal, AJRCCM, 2008; Apostolidou, Ped Pulm, 2008; Waters, AJRCCM, 2006; Kaditis, Ped Pulm 2005; Reinehr, Pediatrics 2004

cardiovascular disease
Cardiovascular Disease
  • Hypertension is a well-described consequence of both OSA and obesity
  • Common mechanism: sympathetic nervous system activation & endothelial dysfunction
  • Children with OSA lose normal nocturnal dip in BP, eventually get daytime hypertension
  • Best assessed with 24 hour ambulatory BP monitoring

Bhattacharjee, 2009; Gozal. 2008; Kheirandish-Gozal, 2010

neurobehavioral
Neurobehavioral
  • Neurobehavioral & learning deficits common and reversible
  • Young children who snore frequently & loudly are at risk of lower grades in school several years after OSA is resolved

Ali, Eur J Peds, 1996, Suratt, Pediatrics, 2006, Kaemingk (tuCASA), J Int Neuropsychol Soc., 2003 ; Gozal, Peds, 1998

neurobehavioral1
Neurobehavioral
  • Magnitude of impairment in cognitive function attributable to sleep-disordered breathing, is profound
    • Similar in magnitude to the effects of lead exposure in children

Suratt, Pediatrics, 2006

quality of life
Quality of Life
  • Improves with OSA treatment
treatments
Treatments
  • Adenotonsillectomy (T&A):
    • First-line therapy for younger children with OSA
    • In obese children, cure rates are much lower: ineffective in 70-80%
  • Weight loss:
    • Improves obesity-related OSA
    • Difficult to achieve & sustain
  • Positive Airway Pressure (PAP)

Shine, 2006; Amin, 2008

pap treatment
PAP Treatment
  • 86% success rate in kids to improve OSA with CPAP
  • In 10 children using CPAP/BIPAP AHI decreased from 20 to 1 and lowest oxygen saturation increased from 76% to 90%

Marcus, J Pediatr, 1995; Padman, Clin Pediatr, 2002

pap treatment1
PAP Treatment
  • CPAP used initially
  • If needing CPAP > 10 cmH2O, or evidence of hypoventilation, use Bi-level
future directions
Future Directions
  • Emerging evidence that PAP for OSA improves obesity-related conditions:
    • Insulin resistance
    • Hypertension
    • Quality of life

** Unfortunately does not assist weight loss in adults!

Redenius, 2008

future directions1
Future Directions
  • Long-term outcomes of PAP therapy for OSA in obese children not yet studied in long-term prospective manner
    • CIHR funded study now ongoing in Canada

INSULIN RESISTANCE

INSULIN RESISTANCE

PAP