Red Cross War Memorial Childrens Hospital University of Cape Town - - PowerPoint PPT Presentation

Marco Zampoli Paediatric Pulmonology Red Cross War Memorial Children’s Hospital University of Cape Town

No conflicts of interest; permission for all photos

 Aetiology and prevalence  Complications  Pathophysiology  Diagnosis and its challenges  Medical interventions  Indications and role of surgery  Perioperative risks  Management approach algorithm

“Apnea “ Chest wall indrawing “effort” Abdominal effort

+Snoring + Arousals

With permission from the parents....

Prevalence(%) (95% CI) of habitual snoring reported across 41 studies reporting questionnaire data for snoring prevalence Lumeng et al Proc of ATS Feb 2008 Age distribution of children investigate for SDB in large US centre Tassig and Landau. Pediatric Resp Medicine

Prevalence %

Age in years

Nose Nasopharynx Oropharynx Larynx Extrathoracic trachea

Diaphragm

Increased upstream airway resistance eg adenoidal hypertrophy Increased inspiratory effort; “suction pressure” Downstream airway collapse and

• cclusion, worse

during REM sleep Arousal, hypoxia, hypercarbia, sleep fragmentation

Airway/luminal

• bstruction

Neuromuscular defects Skeletal abnormalities Adenoidal/tonsillar hypertrophy (ATH) Obesity Allergic rhinitis/Asthma Foreign body Deviated septum Retropharyngeal abscess Congenital mass/tumour/cysts

Neuromuscular diseases (congenital or acquired) Cerebral palsy Central hypoventilation Spinal cord defects Micrognathia e.g. Pierre Robin Craniofacial syndromes Down’s syndrome Other syndromes Prader Willi Other medical conditions E.g. sickle cell

Airway stability Arousal threshold

Central Ventilatory control

Neuromuscular

activation Anatomical factors



Intermittent hypoxia, hypercapnea, repeated intrathoracic pressure swings, sleep fragmentation, systemic inflammation , individual genetic susceptibilty, environmental factors e.g. passive smoking, nutrition all contribute to adverse consequences of OSA

Growth impairment Excessive daytime sleepiness Impaired concentration Poor Quality of Life Neurobehavioral consequences Cardiovascular consequences Metabolic consequences

 Inattention, poor scholastic

performance, developmental delay are well known effects of OSA.

 Hyperactivity, aggressive

behaviour and ADHD increasingly recognised as associated with OSA

 Enuresis and polydipsia

“ wild child ”

Cor pulmonale

Apnea Hyponea Index (AHI)

 AHI< 1 normal  AHI 1-5: mild OSA  AHI 5-10 : mod OSA  AHI> 10 : severe

 Technically challenging

in children; need

• vernight supervision by

skilled technologist.

 Need sleep lab facility, or

in-patient bed with suitable equipment and software

 Suitably trained

technologist s to perform, analyse and report studies PSG (2-4 hrs per study !

 Relatively “invasive “

investigation

 The bedside observation  Screening

questionnaires and scores

 Overnight oximetry  Combining screening

questionnaires and

• ximetry

 Home polygraphy and

portable devices

 New technologies  Urinary biomarkers

The bedside “sleep study”

• Simple; cheap; portable;

widely available

• Requirements:
• Oximeter with memory.
• 2-3 sec Sats and HR

averaging ability.

• Sensor that eliminates

motion artefact.

• Download serial cable.
• Compatible download and

analysis software.....problem in SA!!

 median SpO2 >95%  <4 desats / h of >4%  no abnormal clusters

• f desats:

>4 / 0.5h of >4%

• n = 349 snorers – mean age 4.5y [Montreal]
• Sensitivity (90/210) = 43%
• Specificity (136/139) = 98%
• Positive predictive value (90/93) = 97%
• Negative predictive value (120/256) = 47%

PSG +ve PSG -ve Oximetry +ve 90 3 93 Oximetry -ve 120 136 256 210 139

Brouillette et al. Pediatrics 2000

McGill Score No. desats < 90 % No. desats < 85% No desats< 80% No of desats clusters

1 < 3 <3 2 ≥ 3 ≤ 3 ≥ 3 3 ≥ 3 > 3 ≤ 3 ≥ 3 4 ≥ 3 > 3 > 3 ≥ 3

No /mild OSA Moderate OSA severe OSA Very severe OSA * Nixon et al, Pediatrics 2004

LIMITATIONS

 Cannot distinguish the

cause(s) of hypoxia.

 Cannot distinguish central

from obstructive events.

 Sleep/awake states not

established.

 Motion artefacts.  Normal oximetry does not

exclude OSA, will miss those with mild OSA without desaturations

ADVANTAGES

 Quick and simple  Cheap  Picks up severe spectrum

OSA accurately

 Excludes severe spectrum

OSA accurately

 Identifies those at high risk

• f perioperative

complications (nadir SaO2)

• Multichannel devices gaining popularity but few have yet been validated in

children; validated and accepted now as “gold standard” in adults.

• Channels: Oximeter, HR, nasal flow, snore, effort (single chest/abdominal

band)

• Evidence if limited but home polygraphy seems to perform reasonably well

compared to laboratory PSG ( Sensitvity 76%, specificty 77%)

• Underperforms with diagnosis of mild –moderate OSA (AHI >1 and < 10)

Tan et al , CHEST Dec 2015

Combination of urinary biomarkers had sensitivity of 100% and specificity of 95% for predicting PSG-confirmed OSA compared to habitual snorers and healthy controls

 Andenotonsillectomy : is it indicated for mild-

mod OSA ?

 Evidence for anti-inflammatory medications

for OSA

 Oromotor exercises for OSA (myofunctional

therapy

Excluded children with severe OSA (AHI> 20 or desats < 90% for 2% of Sleep time)

Attention and executive functions Behaviour Quality of life scores PSG score

 Nearly half of watchful waiting group had normalisation of PSG

findings after 7 months., however less in Black and Obese children

 Risk vs benefits of adeno-tonisillectomy (asphyxia, brain injury and

death) must be considered

 Intranasal fluticasone vs placebo improved

OSA by AHI criteria

 Intranasal budesonide vs placebo improved

AHI

 Monteleukast vs placebo improved OSA in

children 2-10 years ( Kherandish-Gozal et al Ann Am

Thorac Soc- Epub July 2016)

 Monteleukast vs intranasal steroids : trial

results pending….

2011

ORTHODONTIC INTERVENTIONS

MYOFUNCTIONAL THERAPY

25 paediatric patients: 62% reduction in AHI

Airway/luminal

• bstruction:

AT hypertrophy Allergy Infections Obesity

Neuromuscular defects Skeletal abnormalities

Anti-inflammatories Decongestants/nasal washes Antihistamines Adenotonsillectomy Weight loss Myofunctional therapy CPAP Bi-level NIV Orthodontic treatment Orthodontic surgery CPAP Bi-level NIV Tracheostomy

 Young children < 2  Syndromes, multifactorial OSA  Neuromuscular conditions  Obesity  Severe OSA AHI> 10  Nadir desaturation < 80%

Suspect OSA

Documented severe/life threatening OSA (bedside observation/monitoring

• r cell phone recording) with or without

associated life-threatening complications e.g. Cor pulmonale

Urgent intervention: CPAP, CIPP, Surgery Non-severe

• Snoring most

nights

• Difficulty

breathing some nights

• no concerning

complications

Severe OSA

• Snoring every night
• Difficulty breathing and witnessed

apneas every night

• Parents shake child awake or re-

position to prevent apnoea's

• Complications eg PHT, enuresis,

systemic HPT, growth faltering

• Worrying cell phone recording

Underlying high risk disorders

• Young age < 2 years
• Craniofacial and other syndromes
• Neuromuscular disorders
• Morbid obesity

Optimise medical treatment

• Intranasal

steroids

• Montelukast
• Request cell

phone recording

Review 3-6 months Sleep study: Oximetry / PSG Severe OSA Mild-mod OSA

Watchful waiting Continue medical treatment

Symptom improvement ?

No Symptom improvement > 6 months or young child

surgery

 Childhood snoring and OSA is a common but under recognised

public health problem in SA.

 Persistent snoring and mild OSA is not harmless and requires

• intervention. A history of snoring should be a routinely obtained.

 Watchful waiting and anti-inflammatory therapy should be

initiated in all children with habitual snoring and mild-moderate OSA before surgical interventions are considered or while awaiting PSG/sleep study

 Tools other than PSG/ Laboratory studies need to be developed

and implemented for use in resource-poor settings. Portable devises and oximetry should become routine on SA setting

 Awareness and greater access to home CPAP , orthodontic and

• ther interventions is needed as adjunctive treatments for OSA in

children