Presentation on theme: "Pediatric Obstructive Sleep Apnea Syndrome: Kids are not simply little adults Ronald J. Green, MD, FCCP Diplomate, American Board of Sleep Medicine Sleep."— Presentation transcript:
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
Pediatric OSAS Risk Factors Adenotonsillar hypertrophy Craniofacial anomalies Down Syndrome Obesity Neurological disorders Family History
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
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
Pediatrics: Clinical Consequences Obstructive Sleep Apnea Syndrome Attention and hyperactivity problems Sleep fragmentation, Hypoxia / Hypercapnia In very severe cases, cor pulmonale and hypertension MorbidityMortality
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
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.
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
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
Adult Physical Examination Guilleminault C et al. Sleep Apnea Syndromes. New York: Alan R. Liss, 1978.
Pediatric diagnosis: Physical Examination Tonsillar hypertrophy Nasal obstruction Overbite Morbid obesity Behavior in exam room Note: PE often is normal
Exam: Tonsillar Hypertrophy Shepard JW Jr et al. Mayo Clin Proc 1990;65.
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)
Diagnosis of Sleep Apnea In-laboratory polysomnography –Gold standard –Assess severity –Initiate treatment –Look for other sleep disorders
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
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
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
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
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.
Adult OSAS treatment: Adenotonsillectomy Adenotonsillectomy by itself does not work in adults
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
Uvulopalatopharyngoplasty (UPPP) Usually eliminates snoring 41% chance of achieving AHI < 20 No accurate method to predict surgical success Follow-up sleep study required
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
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