Presentation on theme: "D ANIEL E RICHSEN, MD Pediatric Sleep Apnea. I NTRODUCTION D EFINITIONS S IGNIFICANCE D IAGNOSIS E PIDEMIOLOGY R ISK F ACTORS P ATHOPHYSIOLOGY M ANAGEMENT."— Presentation transcript:
I NTRODUCTION D EFINITIONS S IGNIFICANCE D IAGNOSIS E PIDEMIOLOGY R ISK F ACTORS P ATHOPHYSIOLOGY M ANAGEMENT S PECIAL P ATIENTS WITH S LEEP A PNEA S EVERE OSA C ONCLUSIONS D ISCUSSION Objectives
“ THE FAT BOY RETURNED, SLUMBERING AS PEACEABLY IN HIS DICKEY, OVER THE STONES, AS IF IT HAD BEEN A DOWN BED ON WATCH SPRINGS. B Y SOME EXTRAORDINARY MIRACLE HE AWOKE OF HIS OWN ACCORD, WHEN THE COACH STOPPED, AND GIVING HIMSELF A GOOD SHAKE TO STIR UP HIS FACULTIES, WENT UPSTAIRS TO EXECUTE HIS COMMISSION.” --C HARLES D ICKENS Introduction
Definitions Sleep-disordered breathing (SDB) refers to the clinical spectrum of repetitive episodes of complete or partial obstruction of the airway during sleep. Primary Snoring (PS) Snoring without obstructive apnea, frequent arousals from sleep, or gas exchange abnormalities. Obstructive Hypoventilation Syndrome (OHS) Persistent partial upper airway obstruction associated with gas exchange abnormalities, rather than discrete, cyclic apneas. Upper Airway Resistance Syndrome (UARS) Increasingly negative intrathoracic pressures during inspiration that lead to arousals and sleep fragmentation. Obstructive sleep apnea (OSA) Disorder of breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction. Disrupts normal ventilation. Disrupts normal sleep patterns.
Significance Daytime somnolence Motor Vehicle Accidents Cognitive dysfunction Behavioral problems ADHD Impaired work performance Impaired school performance Metabolic effects Insulin resistance Type II diabetes Metabolic Syndrome Cardiovascular morbidity Pulmonary Hypertension Cor Pulmonale Systemic Hypertension Stroke Failure to Thrive Rarely a presenting symptom now Death Hypothesized to be involved with SIDS/SUNDS
Diagnosis History & Physical Sleep history screening for snoring should be part of routine health care visits. OSA unlikely in absence of snoring. If snoring history elicited should obtain more detailed sleep history. Including: labored breathing, apneas, diaphoresis, enuresis, cyanosis, behavior/learning problems. Audio taping/Video taping Discrepancies from different centers make this method unreliable. Abbreviated (Nap) Polysomnography High PPV but Low NPV. Useful if results are positive. False positive results in patients with coexistent medical problems (obesity, asthma). Polysomnogram (PSG) “Gold Standard.” Can assess severity of SDB. Includes EEG, EKG, EOG, EMG, saturation monitor, respiratory effort and airflow monitor.
Diagnosis Apnea Any pause in respiration. Versus at least 10 s in adults. Hypopnea Reduction of airflow by 50% for two respiratory cycles accompanied by reduction of saturation by 3% or arousal from sleep. AHI Sum of Apneas and Hypopneas per hour of sleep. RDI Sum of Apneas, Hypopneas, and respiratory event-related arousals per hour of sleep. AHI or RDI of 1 to 5 events per hour is most often used to identify children with OSA. Versus > 5 events in adults.
Epidemiology Most studies showed 0.2% to 4.0% prevalence of parent- reported apnea. Depending on threshold of AHI to diagnose, the prevalence of pediatric OSA ranges from 1% to 4% in most studies. Children with abnormal PSG that go untreated will continue to have abnormal findings. A significant proportion of patients with primary snoring will have resolution of this symptom. Only a small proportion of patients that do not snore will develop this habit. Meta-analysis of 48 studies evaluating the frequency of snoring, OSA and SDB in various pediatric cohorts.
Epidemiology Pediatric OSA Adult OSA AgePreschoolElderly GenderEqualM>F EtiologyAdenoid/ Tonsil hypertrophy Obesity WeightFTT, normal, or obese Obese BehavioralHyperactiveSomnolent Sleep architecture NormalDecreased delta and REM sleep Surgical RxT&AUPPP Medical RxCPAP (rarely)CPAP Review article that focuses on the difference between pediatric and adult OSA from a physiological development perspective.
Risk Factors Cohort of 399 pediatric patients in the greater Cleveland area aged 2-18 years investigated by home-PSG.
Pathophysiology Review article from describing the mechanisms of airway resistance during sleep in children with OSA.
Pathophysiology Large pediatric cohort of the Louisville, Kentucky Jefferson County Public School system of children aged 5-7 years. 378 randomly of those that snored underwent PSG.
Pathophysiology Cohort of children from kindergarten to 5 th grade of the Dauphin County public school system in Hershey, Pennsylvania that underwent overnight PSG.
Pathophysiology Study from Cincinnati of 92 patients undergoing adenotonsillectomy that underwent noninvasive measurements of cerebral oxygenation during sleep and wake periods.
“T O KNOW EVEN ONE LIFE HAS BREATHED EASIER BECAUSE YOU LIVED. T HIS IS TO HAVE S UCCEEDED.” --R ALPH W ALDO EMERSON Management
Medical Management Results AHI tx 3.7 -> 1.3 (p<0.001) AHI placebo 2.9-> 4.0 (p<0.04) 62 children with mild OSA (AHI 2-5). Double- blind, randomized, crossover trial of intranasal budesonide or placebo for 6 -> 2 week wash out - > 6-week treatment in the alternative treatment arm.
Adenotonsillectomy Exclusion Criteria Children with BMI > 95 th percentile. Children with developmental delay or neuromuscular disease. Children with craniofacial syndromes or asthma. All children showed improvement in respiratory parameters after surgery. 82% of children had resolution of OSA (to AHI <5). Prospective Cohort Study of 79 patients that underwent adenotonsillectomy followed by PSG 3-6 months postoperatively.
Adenotonsillectomy Prospective Cohort Study of 79 patients that underwent adenotonsillectomy w/ monopolar cautery and suction ablation followed by PSG 3-6 months postoperatively.
Adenotonsillectomy Efficacy AHI Quality of life Cognition Pediatric Sleep Questionnaire IQ Test Cardiovascular Parameters Cerebral blood flow Hemoglobin Saturation Pulse Rate Pulse variability School performance Significant improvement in grades from 1 st to 2 nd grade in cohort that underwent adenotonsillectomy. No significant change in control group and group that chose not to have adenotonsillectomy. All patients started in lowest 10 th percentile of class. Enuresis/Incontinence Children with OSA have increased risk for enuresis. Possibly related to increased levels of BNP? Significant decrease in nocturnal enuresis and voids/day after adenotonsillectomy.
Positive Pressure Ventilation Advantages Avoids perioperative complications of adenotonsillectomy. But does have localized/temporary effects from equipment such as nasal irritation, skin breakdown. May serve as a “bridge” preoperatively until surgery to reduce morbidity. Can be used postoperatively for residual OSA. Useful in obese and complex patients. High flow nasal cannula recently shown to also be effective. Disadvantages Poor compliance >3-4h of use per night is considered good compliance. Estimated at only 50-60%. Children require more sleep than adults; therefore such limited use may not be adequate. Requires training for parents as well as patients. Lifelong use required. Risk for aspiration of stomach contents. Very young. Significant GERD. Neuromuscular weakness.
Severe OSA Introduction Children with severe OSA are more likely to have respiratory compromise after adenotonsillectomy. Overnight observation is recommended after adenotonsillectomy in patients with severe OSA. This study did not have a control group of patients with severe OSA that did not under go adenotonsillectomy. This study did not assess long- term efficacy of adenotonsillectomy in severe OSA. Study on 29 children 1-18 years of age with RDIs > 30 that underwent adenotonsillectomy followed by PSG 6 months postoperatively.
Severe OSA Study on 29 children 1-18 years of age with RDIs > 30 that underwent adenotonsillectomy followed by PSG 6 months postoperatively.
Severe OSA Summary Children with severe OSA show a significant improvement in RDI and quality of life. OSA does not resolve in the majority of these patients. Postoperative PSG is recommended for all children with severe OSA. To identify those who may require further therapy. Study on 29 children 1-18 years of age with RDIs > 30 that underwent adenotonsillectomy followed by PSG 6 months postoperatively.
Down Syndrome Introduction DS occurs in approximately 1.5 of 1000 births. 10% of mentally retarded persons. DS children commonly have otolaryngologic problems. Frequent URIs, COM, HL and hypothyroidism. They also fall into the group of children with craniofacial and neurologic anomalies which predispose them to OSA. Small midface and cranium Relatively narrow nasopharynx Marcroglossia Hypotonia Tendency for obesity Relatively small larynx In addition, given their congenital heart defects, they are already predisposed to cor pulmonale. Known complication of prolonged OSA (part of the Pickwickian syndrome). Because of these factors, the incidence of OSA in patients with DS has been estimated to be from 54% to 100%. A retrospective review of patients with a diagnosis of Down syndrome who underwent tonsillectomy and/or adenoidectomy.
Down Syndrome Summary T&A is successful in the majority of patients with Down Syndrome (69%). More aggressive intervention such as UPPP, CPAP, tracheostomy are necessary in some patients Preoperative evaluation should include assessment for cardiac, thyroid, and cervical abnormalities. Surgical planning should be based on the severity of disease. Follow up sleep studies are indicated to evaluate for the need for more aggressive treatment in patients with persistent symptoms. DS patients should be admitted post- operatively as persistent OSA and other complications are common. ICU monitoring is often necessary. A retrospective review of patients with a diagnosis of Down syndrome who underwent tonsillectomy and/or adenoidectomy.
P EDIATRIC OSA IS BECOMING AN INCREASINGLY SIGNIFICANT DISORDER. P RE - OP SCREENING COST - EFFICACY NEEDS TO BE ASSESSED. A DENOTONSILLECTOMY IS EFFECTIVE IN TREATING PEDIATRIC OSA. A LGORITHMS FOR TREATING PATIENTS WITH SEVERE OSA AND SPECIAL PATIENT POPULATIONS ARE STILL BEING OPTIMIZED. P OST - OP PSG I NDICATIONS WILL CONTINUE TO BE A TOPIC OF INVESTIGATION AND CONTROVERSY. Conclusions
References 1.Standards and indications for cardiopulmonary sleep studies in children. American Thoracic Society. Am J Respir Crit Care Med. 1996;153(2):866-78. 2.Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2002;109(4):704-12. 3.Alkhalil M, Schulman ES, Getsy J. Obstructive sleep apnea syndrome and asthma: the role of continuous positive airway pressure treatment. Ann Allergy Asthma Immunol. 2008;101(4):350-7. 4.Baldassari CM, Mitchell RB, Schubert C, Rudnick EF. Pediatric obstructive sleep apnea and quality of life: a meta-analysis. Otolaryngol Head Neck Surg. 2008;138(3):265-273. 5.Basha S, Bialowas C, Ende K, Szeremeta W. Effectiveness of adenotonsillectomy in the resolution of nocturnal enuresis secondary to obstructive sleep apnea. Laryngoscope. 2005;115(6):1101-3. 6.Bent JP, April MM, Ward RF, Sorin A, Reilly B, Weiss G. Ambulatory powered intracapsular tonsillectomy and adenoidectomy in children younger than 3 years. Arch Otolaryngol Head Neck Surg. 2004;130(10):1197-200. 7.Bixler EO, Vgontzas AN, Lin HM, et al. Blood Pressure Associated With Sleep-Disordered Breathing in a Population Sample of Children. Hypertension. 2008. 8.Bluestone C. Pediatric Otolaryngology. 4th ed Philadelphia, Pennsylvania: Saunders; 2003. 9.Bower CM, Richmond D. Tonsillectomy and adenoidectomy in patients with Down syndrome. Int J Pediatr Otorhinolaryngol. 1995;33(2):141-8. 10.Brooks LJ, Topol HI. Enuresis in children with sleep apnea. J Pediatr. 2003;142(5):515-8. 11.Cakirer B, Hans MG, Graham G, Aylor J, Tishler PV, Redline S. The relationship between craniofacial morphology and obstructive sleep apnea in whites and in African-Americans. Am J Respir Crit Care Med. 2001;163(4):947-50. 12.Carroll JL, McColley SA, Marcus CL, Curtis S, Loughlin GM. Inability of clinical history to distinguish primary snoring from obstructive sleep apnea syndrome in children. Chest. 1995;108(3):610- 8. 13.Castorena-Maldonado A, Torre-Bouscoulet L, Meza-Vargas S, Vazquez-Garcia JC, Lopez-Escarcega E, Perez-Padilla R. Preoperative continuous positive airway pressure compliance in children with obstructive sleep apnea syndrome: Assessed by a simplified approach. Int J Pediatr Otorhinolaryngol. 2008. 14.Cohen MS, Getz AE, Isaacson G, Gaughan J, Szeremeta W. Intracapsular vs. extracapsular tonsillectomy: a comparison of pain. Laryngoscope. 2007;117(10):1855-8. 15.Cohen SR, Simms C, Burstein FD, Thomsen J. Alternatives to tracheostomy in infants and children with obstructive sleep apnea. J Pediatr Surg. 1999;34(1):182-6; discussion 187. 16.Cohen SR, Suzman K, Simms C, Burstein FD, Riski J, Montgomery G. Sleep apnea surgery versus tracheostomy in children: an exploratory study of the comparative effects on quality of life. Plast Reconstr Surg. 1998;102(6):1855-64. 17.Colen TY, Seidman C, Weedon J, Goldstein NA. Effect of intracapsular tonsillectomy on quality of life for children with obstructive sleep-disordered breathing. Arch Otolaryngol Head Neck Surg. 2008;134(2):124-7. 18.Constantin E, McGregor CD, Cote V, Brouillette RT. Pulse rate and pulse rate variability decrease after adenotonsillectomy for obstructive sleep apnea. Pediatr Pulmonol. 2008;43(5):498-504. 19.Darrow DH. Surgery for pediatric sleep apnea. Otolaryngol Clin North Am. 2007;40(4):855-75. 20.Derkay CS, Darrow DH, Welch C, Sinacori JT. Post-tonsillectomy morbidity and quality of life in pediatric patients with obstructive tonsils and adenoid: microdebrider vs electrocautery. Otolaryngol Head Neck Surg. 2006;134(1):114-20. 21.Dickens C. The Pickwick Papers; 1836-1837. 22.Firoozi F, Batniji R, Aslan AR, Longhurst PA, Kogan BA. Resolution of diurnal incontinence and nocturnal enuresis after adenotonsillectomy in children. J Urol. 2006;175(5):1885-8; discussion 1888. 23.Friedman M, Lin HC, Gurpinar B, Joseph NJ. Minimally invasive single-stage multilevel treatment for obstructive sleep apnea/hypopnea syndrome. Laryngoscope. 2007;117(10):1859-63. 24.Friedman M, Tanyeri H, La Rosa M, et al. Clinical predictors of obstructive sleep apnea. Laryngoscope. 1999;109(12):1901-7. 25.Garetz SL. Behavior, cognition, and quality of life after adenotonsillectomy for pediatric sleep-disordered breathing: summary of the literature. Otolaryngol Head Neck Surg. 2008;138(1 Suppl):S19-26. 26.Goodwin JL, Kaemingk KL, Fregosi RF, et al. Clinical outcomes associated with sleep-disordered breathing in Caucasian and Hispanic children--the Tucson Children's Assessment of Sleep Apnea study (TuCASA). Sleep. 2003;26(5):587-91. 27.Gozal D. Sleep-disordered breathing and school performance in children. Pediatrics. 1998;102(3 Pt 1):616-20. 28.Gozal D. Matters of the heart: the brain in pediatric sleep apnea. Am J Respir Crit Care Med. 2008;178(8):785-6. 29.Halbower AC, McGinley BM, Smith PL. Treatment alternatives for sleep-disordered breathing in the pediatric population. Curr Opin Pulm Med. 2008;14(6):551-8. 30.Hogan AM, Hill CM, Harrison D, Kirkham FJ. Cerebral blood flow velocity and cognition in children before and after adenotonsillectomy. Pediatrics. 2008;122(1):75-82. 31.Katz ES, D'Ambrosio CM. Pathophysiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc. 2008;5(2):253-62. 32.Khadra MA, McConnell K, VanDyke R, et al. Determinants of regional cerebral oxygenation in children with sleep-disordered breathing. Am J Respir Crit Care Med. 2008;178(8):870-5. 33.Koltai PJ, Solares CA, Mascha EJ, Xu M. Intracapsular partial tonsillectomy for tonsillar hypertrophy in children. Laryngoscope. 2002;112(8 Pt 2 Suppl 100):17-9. 34.Kosko JR, Derkay CS. Uvulopalatopharyngoplasty: treatment of obstructive sleep apnea in neurologically impaired pediatric patients. Int J Pediatr Otorhinolaryngol. 1995;32(3):241-6. 35.Lam YY, Chan EY, Ng DK, et al. The correlation among obesity, apnea-hypopnea index, and tonsil size in children. Chest. 2006;130(6):1751-6. 36.Lin SY, Halbower AC, Tunkel DE, Vanderkolk C. Relief of upper airway obstruction with mandibular distraction surgery: Long-term quantitative results in young children. Arch Otolaryngol Head Neck Surg. 2006;132(4):437-41. 37.Lumeng JC, Chervin RD. Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc. 2008;5(2):242-52.
References 38.Mansour KF, Rowley JA, Badr MS. Measurement of pharyngeal cross-sectional area by finite element analysis. J Appl Physiol. 2006;100(1):294-303. 39.Marcus CL. Sleep-disordered breathing in children. Am J Respir Crit Care Med. 2001;164(1):16-30. 40.Marcus CL, Omlin KJ, Basinki DJ, et al. Normal polysomnographic values for children and adolescents. Am Rev Respir Dis. 1992;146(5 Pt 1):1235-9. 41.Martinho FL, Zonato AI, Bittencourt LR, et al. Obese obstructive sleep apnea patients with tonsil hypertrophy submitted to tonsillectomy. Braz J Med Biol Res. 2006;39(8):1137-42. 42.Matsumoto E, Tanaka E, Tabe H, et al. Sleep architecture and the apnoea-hypopnoea index in children with obstructive-sleep apnoea syndrome. J Oral Rehabil. 2007;34(2):112-20. 43.McGinley BM, Patil SP, Kirkness JP, Smith PL, Schwartz AR, Schneider H. A nasal cannula can be used to treat obstructive sleep apnea. Am J Respir Crit Care Med. 2007;176(2):194-200. 44.Messner AH, Pelayo R. Pediatric sleep-related breathing disorders. Am J Otolaryngol. 2000;21(2):98-107. 45.Mitchell RB. Adenotonsillectomy for obstructive sleep apnea in children: outcome evaluated by pre- and postoperative polysomnography. Laryngoscope. 2007;117(10):1844-54. 46.Mitchell RB, Kelly J. Outcome of adenotonsillectomy for severe obstructive sleep apnea in children. Int J Pediatr Otorhinolaryngol. 2004;68(11):1375-9. 47.Mitchell RB, Kelly J. Quality of life after adenotonsillectomy for SDB in children. Otolaryngol Head Neck Surg. 2005;133(4):569-72. 48.Muntz H, Wilson M, Park A, Smith M, Grimmer JF. Sleep disordered breathing and obstructive sleep apnea in the cleft population. Laryngoscope. 2008;118(2):348-53. 49.Nakata S, Noda A, Yanagi E, Suzuki K, Yamamoto H, Nakashima T. Tonsil size and body mass index are important factors for efficacy of simple tonsillectomy in obstructive sleep apnoea syndrome. Clin Otolaryngol. 2006;31(1):41-5. 50.Okubo M, Suzuki M, Horiuchi A, et al. Morphologic analyses of mandible and upper airway soft tissue by MRI of patients with obstructive sleep apnea hypopnea syndrome. Sleep. 2006;29(7):909-15. 51.Ow AT, Cheung LK. Meta-analysis of mandibular distraction osteogenesis: clinical applications and functional outcomes. Plast Reconstr Surg. 2008;121(3):54e-69e. 52.Pagel JF. The burden of obstructive sleep apnea and associated excessive sleepiness. J Fam Pract. 2008;57(8 Suppl):S3-8. 53.Potsic WP. Assessment and treatment of adenotonsillar hypertrophy in children. Am J Otolaryngol. 1992;13(5):259-64. 54.Punjabi NM. The epidemiology of adult obstructive sleep apnea. Proc Am Thorac Soc. 2008;5(2):136-43. 55.Redline S, Tishler PV, Hans MG, Tosteson TD, Strohl KP, Spry K. Racial differences in sleep-disordered breathing in African-Americans and Caucasians. Am J Respir Crit Care Med. 1997;155(1):186-92. 56.Redline S, Tishler PV, Schluchter M, Aylor J, Clark K, Graham G. Risk factors for sleep-disordered breathing in children. Associations with obesity, race, and respiratory problems. Am J Respir Crit Care Med. 1999;159(5 Pt 1):1527-32. 57.Ross AT, Kazahaya K, Tom LW. Revisiting outpatient tonsillectomy in young children. Otolaryngol Head Neck Surg. 2003;128(3):326-31. 58.Rudnick EF, Walsh JS, Hampton MC, Mitchell RB. Prevalence and ethnicity of sleep-disordered breathing and obesity in children. Otolaryngol Head Neck Surg. 2007;137(6):878-82. 59.Sans Capdevila O, Crabtree VM, Kheirandish-Gozal L, Gozal D. Increased morning brain natriuretic peptide levels in children with nocturnal enuresis and sleep-disordered breathing: a community-based study. Pediatrics. 2008;121(5):e1208-14. 60.Schmidt R, Herzog A, Cook S, O'Reilly R, Deutsch E, Reilly J. Complications of tonsillectomy: a comparison of techniques. Arch Otolaryngol Head Neck Surg. 2007;133(9):925-8. 61.Schwartz AR, Patil SP, Laffan AM, Polotsky V, Schneider H, Smith PL. Obesity and obstructive sleep apnea: pathogenic mechanisms and therapeutic approaches. Proc Am Thorac Soc. 2008;5(2):185-92. 62.Sobol SE, Wetmore RF, Marsh RR, Stow J, Jacobs IN. Postoperative recovery after microdebrider intracapsular or monopolar electrocautery tonsillectomy: a prospective, randomized, single-blinded study. Arch Otolaryngol Head Neck Surg. 2006;132(3):270-4. 63.Solares CA, Koempel JA, Hirose K, et al. Safety and efficacy of powered intracapsular tonsillectomy in children: a multi-center retrospective case series. Int J Pediatr Otorhinolaryngol. 2005;69(1):21-6. 64.Stewart MG, Glaze DG, Friedman EM, Smith EO, Bautista M. Quality of life and sleep study findings after adenotonsillectomy in children with obstructive sleep apnea. Arch Otolaryngol Head Neck Surg. 2005;131(4):308-14. 65.Tran KD, Nguyen CD, Weedon J, Goldstein NA. Child behavior and quality of life in pediatric obstructive sleep apnea. Arch Otolaryngol Head Neck Surg. 2005;131(1):52-7. 66.Tunkel DE, Hotchkiss KS, Carson KA, Sterni LM. Efficacy of powered intracapsular tonsillectomy and adenoidectomy. Laryngoscope. 2008;118(7):1295-302. 67.Wiet GJ, Bower C, Seibert R, Griebel M. Surgical correction of obstructive sleep apnea in the complicated pediatric patient documented by polysomnography. Int J Pediatr Otorhinolaryngol. 1997;41(2):133-43. 68.Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med. 2005;353(19):2034-41.
Your consent to our cookies if you continue to use this website.