1. 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

2. Obstructive Sleep Apnea Syndrome Obstructive Sleep Apnea Syndrome  Common  Dangerous  Easily recognized  Treatable

3. Apnea Patterns Obstructive Mixed MixedCentral Airflow Airflow Respiratoryeffort

4. Measures of Sleep Apnea Frequency  Apnea Index –# apneas per hour of sleep  Apnea / Hypopnea Index (AHI) –# apneas + hypopneas per hour of sleep

5. 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

6. Pathophysiology of Obstructive Apnea

7. 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 +

8. Adult OSAS Risk Factors  Obesity  Increasing age  Male gender  Anatomic abnormalities of upper airway  Family history  Alcohol or sedative use  Smoking

9. Adult OSAS Risk Factors, cont’d  Hypothyriodism  Acromegaly  Amyloidosis  Vocal cord paralysis  Marfan syndrome  Down syndrome  Neuromuscular disorders

10. Pediatric OSAS Risk Factors  Adenotonsillar hypertrophy  Craniofacial anomalies  Down Syndrome  Obesity  Neurological disorders  Family History

11. Adapted from Redline S et al. Am J Resp Crit Care Med 1995;151. Likelihood of Sleep Apnea as Function of Family Prevalence Risk Factor: Family History (Adjusted for age, race, sex, BMI) Odds Ratio 1 2 3 1 2 3 Relative Relatives Relatives Relative Relatives Relatives

12. Adults: Clinical Consequences Obstructive Sleep Apnea Syndrome Excessive daytime sleepiness Sleep fragmentation, Hypoxia / Hypercapnia Cardiovascular Complications MorbidityMortality

13. 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

14. Pediatrics: Clinical Consequences Obstructive Sleep Apnea Syndrome Attention and hyperactivity problems Sleep fragmentation, Hypoxia / Hypercapnia In very severe cases, cor pulmonale and hypertension MorbidityMortality

15. 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

16. 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.

17. 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

18. 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

19. Adult diagnosis: Physical Examination  Obvious airway abnormality  Upper body obesity / thick neck > 17” males > 16” females  Hypertension

20. Adult Physical Exam: Oropharynx

21. Adult Physical Examination Guilleminault C et al. Sleep Apnea Syndromes. New York: Alan R. Liss, 1978.

22. Pediatric diagnosis: Physical Examination  Tonsillar hypertrophy  Nasal obstruction  Overbite  Morbid obesity  Behavior in exam room Note: PE often is normal

23. Exam: Tonsillar Hypertrophy Shepard JW Jr et al. Mayo Clin Proc 1990;65.

24. 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)

25. Diagnosis of Sleep Apnea  In-laboratory polysomnography –Gold standard –Assess severity –Initiate treatment –Look for other sleep disorders

26. Polysomnography

27. Nocturnal Polysomnogram

28. 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

29. 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

30. 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

31. 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

32. Postoperative monitoring of high risk pediatric patients Postoperatively, high risk patients should be observed overnight in a facility where appropriate monitoring and care are available.

33. Adult OSAS treatment: Adenotonsillectomy Adenotonsillectomy by itself does not work in adults

34. Adult OSAS treatment  Risk counseling –Motor vehicle crashes –Job-related hazards –Judgment impairment  Apnea and comorbidity treatment –Behavioral –Medical (non-surgical) –Surgical

35. The High-Risk Driver  Educate patient  Document warning  Resolve apnea quickly  Follow-up –Effectiveness –Compliance

36. Adults: Behavioral Interventions  Encourage patients to: –Lose weight –Avoid alcohol and sedatives –Avoid sleep deprivation –Avoid supine sleep position –Stop smoking

37. Adults and kids: Weight loss  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

38. Medical Interventions  Positive airway pressure –Continuous positive airway pressure (CPAP) –Bi-level positive airway pressure  Oral appliances  Other (limited role) –Medications---don’t work –Oxygen

39. Positive Airway Pressure

42. Special considerations for CPAP in children  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

43. Positive Airway Pressure: Problems

45. CPAP Compliance  Patient report: 75%  Objectively measured use > 4 hrs for > 5 nights / week: 46%  Asthma-medicine compliance: 30%

46. Strategies to Improve Compliance  Improve nasal patency--THIS IS THE KEY  Machine-patient interfaces –Masks –Nasal pillows –Chin straps  Humidifiers  Ramp  Desensitization  Bi-level pressure

47. Oral Appliances

48. Uvulopalatopharyngoplasty (UPPP)

49. Surgical alternatives in adults  Reconstruct upper airway –Uvulopalatopharyngoplasty (UPPP) –Laser-assisted uvulopalatopharyngoplasty (LAUP) –Radiofrequency tissue volume reduction –Genioglossal advancement –Nasal reconstruction –Tonsillectomy  Bypass upper airway –Tracheostomy

50. Uvulopalatopharyngoplasty (UPPP)  Usually eliminates snoring  41% chance of achieving AHI < 20  No accurate method to predict surgical success  Follow-up sleep study required

51. Summary: Pediatric and Adult OSAS  Dangerous  Common  ADHD symptoms in kids vs. sleepiness in adults  Treatment: T&A in most kids vs. CPAP in most adults

52. Summary: Pediatric 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