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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.

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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:

1 D ANIEL E RICHSEN, MD Pediatric Sleep Apnea

2 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

3 “ 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

4 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.

5 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

6 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.

7 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.

8 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.

9 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.

10 Risk Factors Cohort of 399 pediatric patients in the greater Cleveland area aged 2-18 years investigated by home-PSG.

11 Pathophysiology Review article from describing the mechanisms of airway resistance during sleep in children with OSA.

12 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.

13 Pathophysiology Cohort of children from kindergarten to 5 th grade of the Dauphin County public school system in Hershey, Pennsylvania that underwent overnight PSG.

14 Pathophysiology Study from Cincinnati of 92 patients undergoing adenotonsillectomy that underwent noninvasive measurements of cerebral oxygenation during sleep and wake periods.

15 “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

16 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.

17 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.

18 Adenotonsillectomy Prospective Cohort Study of 79 patients that underwent adenotonsillectomy w/ monopolar cautery and suction ablation followed by PSG 3-6 months postoperatively.

19 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.

20 Colin Sullivan, MD

21 Positive Pressure Ventilation Review of the literature of 5 prospective trials of CPAP for OSA and explores mechanisms of its beneficial effects.

22 Positive Pressure Ventilation Effects  Local and Systemic Anti- inflammatory effects.  Restore sleep pattern.  Promote weight loss.  Suppress leptin secretion in adipose tissue.  Improve cardiac function.  Suppress acid reflux.  Decrease airway hyper- responsiveness.

23 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.

24 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.

25 Severe OSA Study on 29 children 1-18 years of age with RDIs > 30 that underwent adenotonsillectomy followed by PSG 6 months postoperatively.

26 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.

27 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.

28 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.

29 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

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