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Pediatric Obstructive Sleep Apnea Stuart Morgenstein, D.O.

Pediatric Obstructive Sleep Apnea Stuart Morgenstein, D.O. Goals. Upper airway anatomy Causes of Obstructive Sleep Apnea Diagnosis Treatment New 2011 Tonsillectomy Guidelines Tonsillectomy Techniques. American Academy of Pediatrics Practice Guidelines April, 2002.

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Pediatric Obstructive Sleep Apnea Stuart Morgenstein, D.O.

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  1. Pediatric Obstructive Sleep ApneaStuart Morgenstein, D.O.

  2. Goals • Upper airway anatomy • Causes of Obstructive Sleep Apnea • Diagnosis • Treatment • New 2011 Tonsillectomy Guidelines • Tonsillectomy Techniques

  3. American Academy of PediatricsPractice Guidelines April, 2002 • All children should be screened for snoring • Sleep hx for snoring should be a part of routine health care hx

  4. Introduction • Prevalence OSAS 2% Children • 3-12% “ Primary Snoring” • Peak incidence Preschoolers (4-6yo) (tonsils/adenoids largest in relation to airway size overall) • 25-30% snoring children have OSAS

  5. Risk Factors • African-American 4 X risk • Obesity – prepubertal 5 x teens • Hx Prematurity - 3 X risk • ?? Prior T&A • Positive Family Hx • Cerebral Palsy / Syndromes

  6. Definition Primary Snoring • Snoring without obstructive sleep apnea , frequent arousals from sleep, or gas exchange abnormalities • Healthy, thriving kids. Rested in AM. Active. Growing. Reasonable behavior.

  7. Definition OSA • “Disorder of breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction that disrupts normal ventilation during sleep and normal sleep patterns” . Pediatrics Vol 109 No.4 April 2002

  8. OSA Definition in Children • Challenging to define with the same precision as adults • Normal variability of sleep patterns • Lack of widely available and Reproducible sleep lab measurements • Brief apneas may be physiologic : infants/prematurity • Brief cessation of oronasal air flow is normal with end of a breath cycle

  9. Definition • Apneas common but disconcerting to parents: gasping for air, waking up “mini-arousals” • What constitutes apnea/hyponea unclear , not well defined, varies with age

  10. Sleep Requirements • School age: 10+ hrs. • High School/College: 9+ • Average: 7 hrs/ sleep deprivation • (cell phones, MP3”s, computers ) • Impact: MVA, risk taking behavior, school dysfunction, poor dietary choices, disciplinary problems

  11. Morbidity OSA • Behavioral/ Mood Disturbances/ ? ADHD • Inattention/ Poor Memory/Hyperactivity • School Problems : Low IQ • Family Disruption • Reduced quality of life • Pulmonary Hypertension/Elevated Diastolic /Increase left Ventricular wall thickness • Increased healthy expenses

  12. Neurobehavioral Consequences • Deficits in learning, memory , vocabulary • IQ loss of 5 points or more • Apneic events inversely related to memory and learning performance • Treatment of OSA liley improves behavior, attention, quality of life, neurocognitive functioning.

  13. Metabolic Consequences • Incidence: type 2 Diabetes 30% OSA patient vs. 18 % no OSA • Increase glucose intolerance and insulin resistance

  14. Causes • Craniofacial Abnormalities ie:Choanal Atresia/Cleft Palate • Hypertrophic Tonsils and/or Adenoids (Most common) • Obesity • GERD (Laryngeal/pharyngeal edema) • Neuromuscular Disorders : MD • Achondroplasia • Mucopolysaccharidosis • Nasal Polyps (CF)

  15. Craniofacial Disorders • Down syndrome • Crouzon • Aperts • Treacher-Collins • Pierre-Robin sequence • Nager’s Syndrome • Goldenhar’s Syndrome • Choanal Atresia

  16. Pierre Robin Sequence • Micrognathia/Mandibular Hypoplasia • Glossoptosis • Cleft Palate

  17. OSA and OBESITY • Narrowing Upper airway • Increase pharyngeal floppiness • Limitation diaphragm movement – restrictive effect • Increased abdominal and chest wall mass – decrease lung volume

  18. OBESITY and INFLAMMATION • Tumor necrosis factor • Interleukin (IL) 6 • Leptin

  19. Diagnosis OSA • Caregiver Obervations • Sleep Study Required to confirm Dx (Exam findings limited correlation ) • Limited consensus what is “abnormal: • Sleep centers use different scoring criteria • Adult OSA criteria not applicable to children • Must use age related criteria for OSA:

  20. Caregiver Observations • Snoring/ Arousals/ Agitated sleep • Labored breathing • Neck Hyperextension • Excessive daytime sleepiness/ naps • Hyperactivity or aggressive behavior • Enuresis

  21. Diagnosis:Sleep Study (Polysomnogram)”Gold –Standard” • Oxygen saturation • Volume/frequency of oronasal air flow • Spirometry volumes/flow rates • Respiratory muscle (ie: chest) excursion • End-Tidal pCO2 • ECG • Cortical activity EEG

  22. Sleep Study (Polysomnogram) • Apnea: Cessation of breathing 10+sec • Hypopnea: (hypoventilation) O2 desaturation 3- 4% 10sec or more • AHI: apnea/hypopnea index: • #apnea + # hypopnea = AHI • RDI: #apnea + #hypopnea / total sleep time

  23. Diagnosis OSA: Sleep Study • End-tidal pCO2 50-55m Hg 10% TST) ?? • End-tidal pCO2 45mm Hg or greater 60% of total sleep time ?? • AHI/ RDI ??? Abnormal : No validated severity scales available: > 1 ? > 5 etc • CAUTION: Be careful comparing sleep studies from different labs. Controversy exists: which respiratory events in children are significant enough to be recorded ?

  24. American Academy of Oto/Hd & Neck surgery • Clinical Practice Guideline: Polysomnography for Sleep- DisorderedBreathing Prior to Tonsillectomy in Children • July, 2011

  25. # 1 Complex Medical Conditions: Obesity, Down Syndrome, Mucopolysaccharidoses, Craniofacial Abnormalitites, Neuromuscular disorders, Sickle cell dz,

  26. # 2 No comorbidities listed in #1 and need for OR is uncertain or there is discordance between tonsil size on exam and reported severity of OSA

  27. #3 : In children for whom Sleep Study (PSG) is indicated, clinicians should obtain laboratory –based (attended) study when available vs. Portable (Home) Monitoring (PM)

  28. Sleep Studies • Inconvenient • Expensive • ?? Unavailable

  29. When To Do Sleep Study??? • Family concerns ie: reassurance • Physician concerns ie: confirmation

  30. Treatment • Weight loss/ ? Bariatric Surgery: Major Risks • CPAP – use will increase in future: obese teens • T&A (? 10-20% residual OSAS) • Mandibular Advancement • Distraction Osteogenesis • Tracheostomy • Repair Choanal Atresia • Tongue Reduction • Hyoid Advancement • Uvulopalatopharyngoplasty (UPPP)

  31. Weight Loss • ie: weight loss 18 kg over 20 weeks, AHI decrease 14 to 2 / Hr. • Bariatric surgery : 58 kg loss over 5 months AHI decrease 9 to 0.7 / hr.

  32. Difficulties with CPAP Tx • Difficulty wearing • Skin breakdown • Nasal congestion • Midface hypoplasia • Reserve for complex cases

  33. Repair Choanal Atresia • Transnasal/Endoscopic • Transpalatal

  34. Treatment Pierre Robin Sequence • Prone position (70% Successful) • vs. SIDS • Nasopharyngeal airway (“trumpet”) • Tonque/lip adhesion procedure • Mandibular distraction • Tracheostomy • ?T&A (Abnormal nasal speech post-op)

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