Treatment of Pediatric OSA

1. Treatment of Pediatric OSA Dr Meir Kryger

2. Introduction: Why this is important • State of alertness affects a child's ability to • Concentrate • Focus • Learn • Succeed • Sleepiness can ruin a child’s life • Disorders causing sleepiness such as OSA can be treated

3. Objectives • Recognize the faces of sleepiness • Understand the causes of sleepiness • What to do with a sleepy child suspected of OSA

4. Overview • Sleep breathing disorders in children are common • They can cause children to fail • The symptoms can be easily recognized • The disorders can be treated • Once treated performance can be normal

5. Important principles in dealing with pediatric sleep problems • Children almost never bring a sleep problem to anyone’s attention • The medical encounter is started by a parent or a teacher • What is the problem? • Whose problem is it?

6. How do children with apnea present? • Behavioral symptoms • Manifestations of sleepiness • Observations of their sleep • What does the parent see?

7. The faces of the sleepy child • Falling asleep • Difficulty concentrating • Memory lapses • Loss of energy • Lack of initiative • Emotional lability • Hyperactivity

8. The differential diagnosis of sleepiness • Reduced quantity of sleep • Deprivation, abnormal body clock • Reduced quality of sleep • Sleep disruption • Primary Sleep Disorder • Sleep apnea • Narcolepsy

9. Almost all students are sleep deprived!

10. Diary of a night owl Sunday Saturday Friday Thursday Wednesday Tuesday Monday 0 2 4 6 8 10 12 14 16 18 20 22 24 Time

11. What the parent observes • Noisy breather • Snoring, snorting • Gasping • Stopping breathing • Restless • Moves a lot • Sweats

12. The HPI will cover • Behavioral symptoms • Manifestations of sleepiness • Observations of their sleep • What does the parent see? • Medications • Other illnesses

13. What illnesses? • Congenital • Skeletal structures • Control of breathing • Acquired

14. Patient Normal Central canal Spinal cord Spinal Cord Congenital: Syringomyelia

15. Congenital: KlippelFeil

16. Congenital: Down syndrome

17. Congenital: Mucopolysaccharidosis

19. Infiltration of airway

20. Congenital: mysteries

21. Acquired: enlarged tonsils

22. Acquired: enlarged tonsils

23. Acquired: enlarged tonsils

24. Acquired: (from parent) Small lower jaw

25. Acquired: obesity in toddler

26. Acquired: obesity in teen

27. Confirming the diagnosis

28. Confirming the diagnosis • What you end up doing depends on • Beliefs of parents • Beliefs of referring clinician • Beliefs of insurance companies • Whether long term treatment will be needed • Most of the times you’ll end up doing PSG

29. Nitty gritty of PSG in children • Show child bedroom before they come in • Have them bring in whatever they use to fall asleep (blankets, teddy bears) • Parent/guardian in room • One tech per patient– need experienced tech • Don’t do split in child

30. Pediatric PSG Synchronized video End tidal PCO2

31. Pediatric PSG

32. Pediatric PSG: may be classic

33. Pediatric PSG: may be classic with surprises

34. Pediatric PSG: with more surprises

35. Pediatric PSG: yet more surprises

36. What is observed: may be subtle

37. What is observed sped up

38. Restless sleep and apnea

39. Mask fitting in child may be difficult

40. 3 case studies • Presentation • What is the problem? Whose problem is it? • Assessment • What data is needed to find cause of problem? • Analysis • How is data used to find cause of problem? • Solution • What was done

41. Case 1: Falling asleep in class • Presentation • 12 year old female student who dropped out of school 3 months before because of “depression”; on antidepressants • Fell asleep repeatedly in class for about a year • Referred for diagnosis of sleep disorder • Assessment • Analysis • Solution

42. Case 1: Falling asleep in class • Presentation • Assessment • Explore typical sleep wake pattern • Explore daytime performance • Explore symptoms of sleep disorders • Explore development of problem • Analysis • Solution

43. Case 1: Falling asleep in class • Presentation • Assessment • Explore typical sleep wake pattern • Falls asleep whenever in low stimulus situation • Never feels refreshed • Analysis • Solution

44. Case 1: Falling asleep in class • Presentation • Assessment • Explore daytime performance • School performance has been poor for 2 years • Frequently absent • Daydreams or falls asleep in class • Analysis • Solution

45. Case 1: Falling asleep in class • Presentation • Assessment • Explore symptoms of common sleep disorders • Loud snoring and stops breathing • Overweight • Large tonsils; large overbite (small jaw) • No dream related symptoms • Analysis • Solution

46. Case 1: Falling asleep in class • Presentation • Assessment • Analysis • Classic sleep apnea • Confirmed by sleep test • Solution

47. Case 1: Falling asleep in class • Presentation • Assessment • Analysis • Solution • Referral to surgeon for possible tonsillectomy • May require orthodontic evaluation • Weight loss program

48. Case 1: Falling asleep in class Take home messages • Sleep apnea occurs in children • History of snoring • Often have big tonsils, obesity or overbite • Check bite during health exam • Usually cured with treatment • Remember the orthodontic window

49. Case 2: Hyperactive child • Presentation • 5 year old boy who was expelled from kindergarten because of “hyperactivity”; small for age • “Crashes” during the midafternoons • Referred for diagnosis of sleep disorder • Assessment • Analysis • Solution

50. Case 2: Hyperactive child • Presentation • Assessment • Explore typical sleep wake pattern • Explore daytime performance • Explore symptoms of sleep disorders • Snoring and restless sleep • Explore development of problem • Analysis • Solution