Pediatric Obstructive Sleep Apnea Ford Shippey MD 10/10/13 Center for Pediatric Sleep Medicine http://www.ghschildrens.org/pediatric- sleep-medicine.php
Disclosures • I have nothing to disclose about any ongoing relationships
Objectives Recognize and diagnose sleep apnea List the complications of untreated sleep apnea Understand the treatment of sleep apnea
Changes in breathing during sleep Shallower and slower Decreased oxygen and increased carbon dioxide Muscle Atonia(not diaphragm) Decreased Arousal
Sleep Architecture- REM Sleep • Rapid Eye Movement • May play role in concentration and memory • 20-25% of total sleep time • Altered response to changes in oxygen and carbon dioxide • Irregular heart rate and breathing
NREM Sleep •60 -80% of TST •Stage 1 Light sleep (transitional) •Stage 2 Deep sleep (increases with age) •Stage 3 Deeper sleep (restoration)
Pediatric Obstructive Sleep (OSA) • Sleep disordered breathing due to airway resistance/obstruction leading to impaired gas exchange • Occurs in children of all ages • Prevalence 2% (snoring 10%) • Mean interval between onset of symptoms and treatment - 3.3 years, suspect this is getting better
Definitions • Apnea Hypopnea Index (AHI) – average number of apneas/hypopneas per hours during sleep • Obstructive Apnea Hypopnea Index (OAHI)- excludes central apneas • Respiratory Disturbance Index (RDI) – AHI + respiratory event related arousals per hour • Obstructive Apnea • Central Apnea • Mixed Apnea
Trisomy 21- Down’s Syndrome
Down Syndrome Facts • Occurs when individuals have 3 instead of 2 copies of chromosome 21 (Trisomy 21) • 1 in every 691 babies born with this in US • Over 400,000 people with Down syndrome in US • Life expectancy used to be 25 (1983), currently up to 60 years today • Have unique health issues www.ndss.org National Down Syndrome Society
Medical Problems Common in Down Syndrome • • Hearing Problems 75% Seizures 1-13% • • Vision Problems 60% Blood Problems 1-10% • • Cataracts 15% Celiac Disease 5% • • Refractive Errors 50% Neck instability 1-2% • Autism 1% • Obstructive Sleep Apnea 50-75% • Ear Infections 50-70% • Congenital Heart Disease 40- 50% • Delayed dental eruption 23% • GI problems 12% • Thyroid Disease 4-18% 2011 AAP Guidelines for Health Supervision for Children with Down Syndrome
Sleep issues are common • Recommend discussing sleep issues by 6 months of age and at every well child check thereafter • Ask about symptoms of snoring, uncommon sleeping positions, frequent night awakenings, pauses in breathing or irregular breathing, daytime sleepiness, behavior problems • Recommend all children with Down syndrome have a sleep study by age 4 2011 AAP Guidelines for Health Supervision for Children with Down Syndrome
Recent medical studies • Some infants with Down syndrome spontaneously outgrow their obstructive sleep apnea (3/16) Clin Pediatr 2010 Nov • Body Mass Index (BMI) is predictive of OSA in patients with Down syndrome Int J Pediatr Otorhinolaryngol 2010 Jul • Down syndrome children have higher risk of persistent OSA after adenotonsillectomy Int J Pediatr Otorhinolaryngol 2010 Mar • Children with Down syndrome and OSA do not necessarily snore Arch Dis Child 2007
Patient Case • 5yo child with mild to moderate obstructive sleep apnea was subsequently found to have severe hypothyroidism. • After 3 months of medical treatment, she had complete resolution of sleep apnea. • TSH (thyroid studies) need to be done annually in children with Down syndrome Clin Pediatr 2010 Apr
Pediatric Obstructive Sleep Apnea (OSA) AAP recommends all children should be screened for snoring, which is the best clinical indicator of OSA in children Very different clinically from adult/adolescent OSA
Upper airway resistance syndrome (UARS) Snoring AND partial upper airway obstruction that leads to arousals and sleep fragmentation. NO evidence of apnea, hypopnea, or gas exchange abnormality during sleep study UARS may result in symptoms similar to those in children with OSA
Primary Snoring Occurs without associated apnea, gas exchange abnormalities, or excessive arousals Prevalence varies between 3 and 12 percent Clinical evaluation alone CANNOT be used to diagnose OSA, nor to differentiate between OSA and primary snoring Mounting evidence that chronic snoring alone can lead to neurobehavioral disturbances
OSA Evaluation-History • AAP recommends that all children be screened for snoring at routine health care visits • If snoring is present, additional history should look for: -Growth/Devolopment (5% of OSA assoc w/ Failure to Thrive) -Family history of OSA -Nightime/daytime symptoms
Snorers…..OSA’ers? Observed apnea or gasping by caretakers Nighttime sweating Restless/agitated sleep Unusual sleep positions, extended neck Parasomnias may be exacerbated Nocturnal enuresis (Bedwetting)-has been associated with OSA, and appears to improve after adenotonsillectomy
What about Daytime Symptoms? Mouth breathing Nasal obstruction Hyponasal speech Morning headache Child may be difficult to awaken Excessive Daytime sleepiness (13-20%, confirmed by MSLT) Poor academic performance Association with learning and behavior disorders including ADHD
AAP Practice Guideline 2012 1. All children/adolescents should be screened for snoring. 2. Polysomnography should be performed in children/adolescents with snoring and symptoms/signs of OSA 3. Adenotonsillectomy is recommended as the first line treatment of patient’s with adenotonsillar hypertrophy 4. High risk patient should be monitored as inpatients postoperatively
AAP Practice Guideline 2012(cont) 5. Patient should be reevaluated postoperatively to determine whether further treatment is required 6. Continuous positive airway pressure is recommended as treatment if adenotonsillectomy is not performed or if OSA persists postoperatively 7. Weight loss is recommended in addition to other therapy in patients who are overweight or obese. 8. Intranasal corticosteroids is an option for children with mild OSA in whom adenotonsillectomy is contraindicated or for mild postoperative OSA
Who’s at risk for OSA? • Adenotonsillar hypertrophy • African American (but many kids have 3+ tonsils • Allergic Rhinitis without OSA) • • Obesity Asthma • Cerebral Palsy • Micrognathia • Down Syndrome • Macroglossia • Craniofacial anomalies • Myelomeningocele • Nasal septal obstruction • Neuromuscular Disorders • Achondroplasia (Muscular Dystrophy, SMA, • Mucopolysaccharidoses (Hunter/Hurler) etc.) • Sickle Cell Disease • Tumors (vascular hemangioma • Prematurity • Hx of cleft palate repair
OSA Clinical Features Infants: • More subtle, less snoring, increased work of breathing, lethargy, failure to thrive • worse with upper respiratory tract infections Children : • Naps beyond age 5, daytime sleepiness unusual • Mouth breathing, difficulty swallowing, speech problems, nocturnal enuresis • Difficulty waking child in am
OSA Evaluation-Physical Exam Look for craniofacial abnormalities Signs of allergic disease (allergic shiners, transverse nasal crease) Thorough nasal exam (septal deformity, mass, mucosal/turbinate swelling) Normal exam does not exclude OSA
OSA- Physical Exam (con’t) Oropharyngeal exam (pharyngeal dimensions, palate shape/size, tongue size, bifid uvula) Assessment of pharyngeal/laryngeal tone Tonsil size/symmetry Thorough cardiac exam listening for signs of pulmonary hypertension
Labs/Other studies • Labs rarely needed in otherwise healthy children • Lateral neck radiograph optional • Polycythemia/compensated metabolic alkalosis rarely present in children • Definative diagnosis made by overnight polysomnography (sleep study) • Multiple studies have shown that OSA and primary snoring cannot reliably be differentiated on the basis of history and physical exam alone
Sleep Study (Polysomnogram)
Overnight Polysomnography 1) Respiratory effort (abdominal and chest wall movement) 2) Airflow at nose and mouth 3) Arterial O2 saturation and End expiratory CO2 4) ECG rhythm strip 5) Electromyography in anterior tibialis region to detect excessive leg movement 6) EEG/electrooculography/electromyographic measurements (submental, ant tibialis) to detect sleep staging and leg movement 7) Body position sensor 8) Snoring Recorder 9) Audio/Video recording
Polysomnography Must be long enough to examine sleep architecture, and should have at least one REM period Can show sleep efficiency and frequency of arousals, especially in relation to respiratory events Avoid use of sedatives or sleep deprivation prior to study
PSG-Interpretation • Adult/adolescent criteria not applicable to children • Adult/adolescent apnea defined as >10sec, but in children definition is >2 regular breaths (often shorter than 10sec) • Apnea-Hypopnea Index >1.5 (more than 1.5 events per hour) is abnormal • Guidelines not well established…. AHI>10 per hour associated with increased risk of respiratory compromise after adenotonsillectomy
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