1. Obstructive Sleep Apnea in Children
Alyssa Brzenski

2. Case
A 31 month old term 17kg girl presents for Tonsillectomy and Adenoidectomy as an outpatient. She has a history of frequent ear infections, which have resolved since ear tubes were placed. According to her mom she snores loudly and is much more active than the other children her age. Mom doesn’t think that she stops breathing at night but notices that she always breathes through her mouth and always seems to have bad breath. She has no other past medical history. On exam you observe an overweight female with grade III tonsils but an otherwise unremarkable airway, heart and lung exam.

3. Tonsillectomy and Adenoidectomy
T&A remains the most commonly performed ambulatory procedure in the pediatric population with over 500,000 performed yearly. This surgery likely is performed so frequently due to the increasing rates of OSA, as T&A is largely considered to be curative in the pediatric population.

4. Indications for T&A
In fact, when we look at the indications for T&A in one county obstructive etiology comprises over 75% of the given reasons for T&A surgery.

5. Tonsil Size
A quick review, the ENT surgeons will frequently grade the size of Tonsils which may have implications for you as an anesthesiologist. These sizes are graded on a 1 to 4 scale.

6. What is OSA in kids?
OSA is a “disorder of breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction (obstructive apnea) that disrupts normal ventilation during sleep and normal sleep patterns.”
In kids this commonly occurs in REM.
Obstructions worsen throughout the sleep period.
OSA is a disorder characterized by repeated, partial or complete obstruction of the upper airway during sleep. It is found in 1-3% of the population. Unlike in adults where these events can occur in both REM and non-REM sleep, in kids these event occur during REM sleep. In addition, there is no significant muscle fatigue seen in kids, unlike in adults, but the obstructions do typically worsen through out the night.

7. OSA in kids
AAF guidelines

8. OSA in Kids
Given that most OSA in children is due to increased upper airway resistance from airway narrowing, OSA is associated with certain features in pediatric patients. See above.

9. Syndromes associated with OSA
OSA in children can also be seen with certain congenital syndromes, most notably syndromes with midface and mandibular hypoplasia, enlarged(macroglossia) posteriorly positioned (glossoptosis) tongues, disordered neural control of airway caliber or decreased pharyngeal tone.

10. OSA Differences- Peds vs Adults
There are two peaks of OSA in the pediatric population, 2-6 years of age and years of age. There are numerous differences between OSA in the pediatric and adult populations. One of the most notable differences between the two populations is the presentation of OSA. Often adults will present with daytime somnolence. However, younger kids less commonly have daytime somnolence. Rather young children may have normal weight or failure to thrive and behavioral issues such as hyperactivity, attention problem and enuresis. In addition, surgical treatment can often be curative in the pediatric population which is not always true in the adult population.

11. How should we screen for OSA in our patients?
“Does your child snore?”
Should be referred for evaluation by a specialist or with a sleep study if
snores more than 3 times a week
1 or more associated signs or symptoms
The American Academy of Pediatrics currently recommends that all providers routinely screen for OSA by asking parents is their child snores. This is a sensitive question but not specific as 10-27% of children have primary snoring but only 1-3% of children have OSA. Is grade B recommendations that children be referred for a sleep study if the kids snore at least 3 days a week and have 1 or more associated signs or symptoms.

12. Screening with Polysomnography
Sleep studies are the gold standard in diagnosing OSA in children, just as it is in the adult population. However, there are differences in the diagnosis in children and adults. There is a concern that there is a limited number of facilities that can adequate perform and interpret pediatric sleep studies as well as the cost associated with screening these large number of kids with sleep studies.

13. Pediatric Sleep Studies
Unlike in adults where a AHI of 5 is positive for OSA, a child with more than 1 apnea-hypopnea event would be defined as having OSA. Any child with an AHI greater than 10 is considered to have severe OSA. This does not take into account the duration or severity of the apnic or hypopnic events. Thus there are other criteria grading the severity of OSA based on the oxygen saturation nadir. This is called the McGill Oximetry Score which stratifies OSA into 2, 3,4 based on Oxygen saturation nadir of <90%, 85%, and <80% respectively.

14. What should we be asking?
Although the recommendation is for primary care physicians to screen all children this may not happen prior to surgery. We should do our own screening of patients prior to taking them to the operating room. In the operating room we should be observing how our patient responds to predict the likelihood of postoperative difficulties. Infants (<1 year old) is a special subgroup that is not well studied. Evaluating for snoring, apnea, failure to thrive, developmental delay and recurrent respiratory infections may be helpful in identifying at risk patients.

15. Treatment of OSA in Children
Tonsillectomy and adenoidectomy is the treatment of choice for children in OSA who have enlarged tonsils and adenoids. This procedure should “cure” 75% of pediatric patients as can be seen in the sleep studies above. However, certain subsets of patients, notable those with obesity, severe OSA, and syndromic children with abnormal craniofacial anatomy or abnormal pharyngeal tone, are at risk to have persistent OSA despite T&A surgery. These patients may require further surgery such as UPP, tongue reduction, craniofacial advancements, orthodontic treatments(palate expanders) or non-invasive positive-pressure ventilation. Nasal CPAP and BiPAP can be used in children and typically has good results. However, there is the risk of midface hypoplasia through the use of Nasal NIPPV and the devices should be re-evaluated yearly to ensure for proper fit and settings.

16. Should kids with OSA stay overnight after anesthesia?
There are no current guidelines that delineate which patients should remain in a monitored bed post-operatively. However, children with OSA have rate of complications ranging from %, mostly oxygen desaturations, increased work of breathing, edema and atelectasis. In addition, children with OSA have an increased sensitivity to opioids, requiring less for the same pain relief as children who do not have OSA. Children who are less than 3 years of age with OSA have twice the rate of complications than children who are 3-6 years of age. In addition, children with severe OSA (AHI>10 or Sat Nadir<80) should remain in the hospital. Other factors, such as patient co-morbidities, excessive pain, poor oral intake, or awake Saturation less than 95% on Room Air should also be considered possible reasons for post-operative admissions. If an OSA patient is a candidate for outpatient surgery, they should remain in the PACU for at least 2 hours to ensure that there are not any apnic events.

17. What anesthetic should be used?
No standard anesthetic recommended
Reduce the use of narcotics
Use a balanced technique, maximizing non-opioid strategies and regional anesthesia

18. Increased Sensitivity to Narcotics
OSA Kids with younger age and lower preoperative O2 Nadir correlates with increased narcotic sensitivity
Avoid Codeine products
There have been both animal and human studies which suggest that patients with younger age and more severe OSA have a sensitivity to narcotics, requiring less to obtain the same pain control. It has been postulated that during recurrent hypoxemia there is an upregulation of the mu opioid receptors leading to increased response of these medications. Of note, codeine products including loratab should be avoided in any pediatric patients but most specifically the OSA patients. Codeine is metabolized by CYP2D6 to morphine which exerts its pain reliving effects. There are individual mutations that may affect a patient’s response to codeine. Some patients have decreased activity of CYP2D6 leading to decreased pain relief. More worisome in this population is the rapid metabolizer which leads to more rapid metabolism of codeine to morphine with ultimately higher blood levels. In the OSA patient this can be deadly. There have been reports of pediatric patients who have been prescribed codeine for pain relief and then are found dead postoperatively. Some of these patient have been found to have this CYP2D mutation for rapid metabolism. For this reason, we typically prescribe oxycodone for pediatric patients.

19. Sources
Schwengel D, Sterni LM, Tunkel DE, Heitmiller E. Perioperative Management of Children with Obstructive Sleep Apnea. Anesthesia and Analgesia. 2009; 109:
Marcus CL, et al. Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome. Pediatrics ; 130: e