Pediatric Obstructive Sleep Apnea Ford Shippey MD 10/10/13 Center - - PowerPoint PPT Presentation

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
• ngoing 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
• f 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%

• Vision Problems

60%

• Cataracts

15%

• Refractive Errors

50%

• 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%

• Seizures

1-13%

• Blood Problems

1-10%

• Celiac Disease

5%

• Neck instability

1-2%

• Autism

1%

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
• f 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

• bstruction 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

(but many kids have 3+ tonsils without OSA)

• Obesity
• Cerebral Palsy
• Down Syndrome
• Craniofacial anomalies
• Nasal septal obstruction
• Achondroplasia
• Mucopolysaccharidoses

(Hunter/Hurler)

• Sickle Cell Disease
• Prematurity
• African American
• Allergic Rhinitis
• Asthma
• Micrognathia
• Macroglossia
• Myelomeningocele
• Neuromuscular Disorders

(Muscular Dystrophy, SMA, etc.)

• Tumors (vascular hemangioma
• 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

• f 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

• n 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

Polysomnography-Middle Class Man’s sleep study

 Nap PSG-if positive correlates well with

• vernight study, but if negative cannot exclude

OSA; often will not get a REM period  Home PSG- gaining more popularity as less expensive and more convenient for the family (still not widely available or widely accepted, but likely will see more studies in future looking at reliability)

OSA-Sequelae

• Abnormal growth
• related to increased work of breathing
• improved growth often occurs after treatment
• Pulmonary hypertension
• can lead to cor pulmonale
• one study of 27 children with OSAH, 25 of which had no clinical

evidence of cardiac involvement, 10 had reduced right ventricular ejection fraction

• Neurocognitive effects
• Systematic reviews of cross sectional data suggest that there is

increased risk of behavior problems and neurocognitive abnormalities

Cardiovascular Sequelae

• Alteration on sympathetic tone due to sleep

disruption/poor gas exchange

• Leads to vascular remodeling, suspect causative

link to high blood pressure even in children

• One study demonstrated significantly higher

arterial blood pressure in peds pt w/ OSA vs. Snoring

• Treatment of OSA w/ CPAP in adults showed

improvement in RV remodeling and pulmonary vascular resistance

• We need more studies in children

Further Sequelae

• OSA felt to be a low grade inflammatory

disorder (increased CRP, Leptin, TNF alpha, IL-6, IL-1, Adipokines)

• OSA has been shown to promote a

procoagulant state in adults

• Association with Weight Gain (increased

ghrelin, decreased Leptin)

• Insulin resistance

OSA-Treatment

• Weight loss (for obesity)
• Surgery (various options including

adenotonsillectomy, mandibular advancement, tongue reduction, uvulopalatoplasty)

• CPAP/BiPAP
• Intranasal steroids
• Monteluekast
• Orthodontics???

CPAP (Continuous Positive Airway Pressure)

What to do with Mild OSA (AHI 1.5 to <5)?

• ? Is the child symptomatic
• ? Degree of sleep fragmentation/sleep

architecture distortion

• ? Degree of hypercarbia/hypoxia
• If no treatment, when should they be

reevaluated?

Does every child with snoring need a sleep study before having a adenotonsillectomy?

• Age older than 3
• Large tonsils on exam with nightly snoring
• Symptomatic
• No risk factors for severe disease
• Low preop surgical risk

Tonsillectomy & Adenoidectomy

• Approx 500,000 performed in USA annually
• Many ENT surgeons refer prior to surgery, cut off

criteria is AHI>5, abnormal is AHI>1.5

• Uncomplicated cases do not need followup PSG
• Red Flags: obesity, neuromuscular disease,

trisomy 21, craniofacial syndromes, severe OSA defined as AHI>15

• One meta analysis suggest cure rate of 85% in

all comers

• Symptoms can recur as patient ages

Summary

 OSA is a common pediatric problem  Sequelae of OSA include abnormal growth and development, enuresis, learning and behavior problems, pulmonary and systemic hypertension  Polysomnography (sleep study) is the gold standard and is required to assess severity  Application of adult criteria for scoring and interpretation of pediatric sleep studies may result in misdiagnosis and mismanagement of children, make sure they have end tidal CO2 detectors

Indications for ordering a PSG

• Suspected OSA
• Behavior problems
• Suspected Narcolepsy (need f/u Multiple

Sleep Latency Test)

• Nocturnal Seizures
• Periodic Limb Movement (Restless Leg

Syndrome)

• NOT pure insomnia

What to tell the family…

• Avoid caffeine the day of the study
• Arrive around 7-9pm, will be done usually by

6am

• Only one adult can accompany each child
• Private rooms with private bathrooms
• Technician will be there all night (usually 1:1

ratio) to ensure study runs well

• Results usually available 2 weeks after study

GMH Lab (2 beds, seven nights a week)

• Greenville Memorial Pediatric Sleep Lab

701 Grove Road 5th Floor, Room 5206 Greenville, SC 29607

• Daytime Hours: 8:00am - 4:00pm

Phone: (864)286-7530 Fax: (864)286-7531

• Nighttime Hours 8:00pm - 6:30am

(864)455-8494

Verdae Sleep Lab (3 beds, 4 nights a week)

• Verdae Pediatric Sleep Lab

1025 Verdae Boulevard, Suite D Greenville, SC 29609

• Daytime Hours: 8:00am - 4:00pm

Phone: (864)286-7530 Fax: (864)286-7531

• Nighttime Hours 8:00pm - 6:30am

(864)286-7533

Questions?

Helpful Websites, References

• Diagnosis and Management of Childhood Obstructive Sleep Apnea

Syndrome, Marcus et al., Pediatrics, 2010;130;pp 576-584, August 27 2012

• Clinical Practice Guideline: Diagnosis and Management of Childhood

Obstructive Sleep Apnea Syndrome; Pediatrics 2002; 109; pp 707-712

• www.entnet.org/HealthInformation/Could-Child-Have-Sleep-Apnea.cfm
• series/en/resources/sleep-apnea-children.pdf
• www.ghschildrens.org/pediatric-sleep-medicine.php
• http://www.apneasupport.org/pediatric-sleep-apnea-f14.html