Pediatric Obstructive Sleep Apnea

1. Pediatric Obstructive Sleep Apnea Lisa Musso, ARNP Seattle Children’s Hospital Pulmonary/Sleep Division Ronna Smith, ARNP Seattle Children’s Hospital Otolaryngology Division

2. Primary Snoring OSAS Sleep Disordered Breathing (SDB) • Dynamic imbalance between airway patency and collapse during sleep leading to recurrent airways obstruction (partial or complete) resulting in: • Gas exchange abnormalities • Cortical arousals leading to sleep fragmentation • Autonomic arousals leading to systemic fragmentation • Diagnosed by presenting symptoms (night and day) and sleep study • Naturally occurring model of sleep fragmentation UARS

3. Notes about SDB in children • Breathing worse in sleep, especially REM • Less cortical input overall • Smaller lung volumes • Low muscle tone  upper airway collapse, decreased amount of air exchange • Relative immaturity of the respiratory system particularly in infants • Blunted hypoxic and hypercapnic responses • Smallest airway to pharyngeal structure ratio is during childhood (3-6 years of age) • Craniofacial abnormalities most impactful in infancy

4. Case Study Pete is a 9 month old baby with a nearly lifetime history of nasal congestion. He is described as a ‘poor sleeper’ by mom. He wakes up at least twice per night. He snores every night, sometimes it is loud. Mom is not sure if he has apneic spells. He has trouble drinking from a bottle, was a difficult breast feeder. Mom says he pulls off the nipple often to breathe.

5. BEARS • B: bedtime problems • Has to be rocked to sleep or have a bottle? • No consistent routine? • E: excessive sleepiness/dysfunction • Fussy, no nap/sleep routine? • Essentially difficult to assess in an infant • A: awake after sleep onset? • Night time awakenings • R: sleep routine • Really non-existent • S: snoring • Quality/quantity/frequency/positional/witnessed apnea

6. Physical Exam • Pete has clear rhinitis which mom says is ‘constant.’ He has loud nasal breathing or mouth breathing throughout the visit. His nares are normal to exam. His tonsils are 1-2+. The rest of the physical exam is normal.

7. What next? • Would you refer? • Would you get any imaging? • Sleep clinic or OTO?

8. How OSAS can present in infants • Slam dunk • Otherwise healthy • Loud, obstructive snoring • BIG tonsils and/or adenoids • Abnormal sleep study • History/exam don’t really match: snoring, but no tonsil hyperplasia • Neuromuscular abnormalities/syndromes

9. Adenoid film

10. Case Study Lily is a 3 year old with mild global developmental delay. She walked at 18 months and has a moderate speech delay. She was born at 32 weeks gestation. Other medical problems include GERD and asthma. She snores most nights and is a restless sleeper. She will sleep for 11 or 12 hours and still appears tired in the morning. She takes long naps during the day.

11. BEARS • B: falls asleep easily on her own. Sleeps in her own bed, does not awaken at night. • E: hard to get her up for preschool, very moody if nap is missed. Multiple behavior concerns, parents have attributed this to her global DD. • A: does not awaken at night. • R: sleep times predictable • S: snores every night, described as ‘scary’ when she is sick.

12. Physical Exam Lily is height/weight appropriate, her tonsils are 2+. She has a high arched palate and a narrow oropharynx. The remainder of the exam is normal.

13. What next? • Would you refer? • Would you get any imaging? • Sleep clinic or OTO?

14. How OSAS presents in toddlers/preschoolers • Slam dunk • Otherwise healthy • Loud, obstructive snoring • BIG tonsils and/or adenoids • Abnormal sleep study • Behavior concerns: moody, emotionally labile • Fatigue, daytime lethargy OR hyperactivity • Cognitive impairment-concentration focus, attention

15. Case Study Jose is a 10 year old who was recently evaluated for ADHD. He has had a long history of behavior problems. He also has a speech articulation difficulty and has been getting speech therapy at school.

16. BEARS • B: has a TV in his room. Typically sleeps 7-8 hours per night. Somewhat difficult to awaken in the morning. • E: parents deny sleepiness, but Jose says he is tired. Parents describe him as ‘very busy.’ Teachers say he lacks focus and attention. He is impulsive and gets in trouble at school. • A: doesn’t awaken at night, often wets the bed. • R: occasionally irregular bedtime, but typically predictable • S: parents say he snores ‘sometimes’ but are not concerned about it. They deny any history of pausing, gasping or dyspnea in sleep.

17. Physical Exam Jose is in your office for a well child exam. He has no history of recent illness. On exam, you see 3+ tonsils that nearly meet in the midline. You notice that he keeps his mouth open throughout the entire visit. When you ask him to breathe through his nose, he is unable to. He seems to be cooperative, able to follow instructions and is engaging in an age appropriate manner.

18. What next? • Would you refer? • Would you get any imaging? • Sleep clinic or OTO?

19. How OSAS presents in school aged kids • Slam dunk • Otherwise healthy • Loud, obstructive snoring • BIG tonsils and/or adenoids • Abnormal sleep study • Behavior concerns: moody, emotionally labile, impulsivity, non-compliance • Fatigue, daytime lethargy OR hyperactivity • Cognitive impairment-concentration focus, attention, memory concerns, symptoms of ADHD, problem solving skills • School problems: tardiness, behavior, academic problems, falling asleep in school or on the bus

20. SDB: Clinical Presentations • “Classic” or Type 1 • 3-6 year old • Adenotonsillar hypertrophy or other obvious craniofacial malformation • Open mouth breathing, adenoidal facies • Normal BMI  Thin or even FTT • Tend to be inattentive and hyperactive; if they are overtly sleepy it’s pretty severe • 80-90% “cured” with T & A • Clinically resolved SDB • Oftentimes sleep studies still with residual abnormalities

21. Case Study Shayla is a 17 year old obese girl who comes to clinic with a complaint of ‘sleepiness.’ She says she is having trouble getting up in the morning for school and has fallen asleep in class. She wonders if she has ‘mono.’ Parents say she is getting very good grades but recently is having trouble with tardiness and they think she is not getting enough sleep.

22. BEARS • B: Shayla often stays up late studying. She is often on her phone texting with friends until late at night. She stays up very late on weekends. • E: Often naps after school. • A: wakes up in the middle of the night and is sometimes unable to go back to sleep. • R: No predictable schedule. • S: Snores loudly every night and has since early childhood. Parents have not perceived this as a problem because she doesn’t snore as ‘bad as dad’ and she has always been very highly functional.

23. Physical Exam Shayla’s BMI is 25. Her tonsils are 3+ with no signs of infection. She has no signs of acute illness. Her turbinates are very enlarged and obstructive, she tends to mouth breathe. She has acanthosis nigricans around her neck. She is her own historian and disagrees with some of her parents’ version of the history. She denies any ‘sleep problem’ and is convinced she has mono. She thinks that because her grades are fine and her schedule has not changed, her sleep can’t be the problem.

24. What Next? • Would you refer? • Would you get any imaging? • Sleep clinic or OTO?

25. How OSAS presents in adolescents • Slam dunk • Otherwise healthy • Loud, obstructive snoring • BIG tonsils and/or adenoids • Abnormal sleep study • Moodiness, irritability, emotionally labile, anger, depression, impulsivity, non-compliance • Fatigue, daytime lethargy, somatic complaints (HA, muscle aches) • Cognitive impairments, memory, attention, concentration, decision making, problem solving • Risk taking behaviors • Use of stimulants, e.g. caffeine, borrowed Ritalin, etc • School failure

26. SDB: Clinical Presentations • “New” (but the old Pickwickian model), Type II • adolescents • Obesity with variable, even minimal adenotonsillar hypertrophy • Early metabolic syndrome (borderline HTN, acanthosis) • Tend to be sleepy and inattentive as opposed to hyper and distractable • <50% cured with T & A although usually improved in severity, many need PAP • Most studies heavily confounded by obesity

27. SDB: Referral – when to order a sleep study? • What the AAP says • Every child should be screened for snoring by their pediatricians at well child checks • For those who do snore, and there is suspicion of OSA, a sleep study is recommended to qualify and quantify severity to determine if it is truly OSA vs. primary snoring • Treatment for OSA is adenotonsillectomy, and CPAP for those who are not surgical candidates or non-responders. • High risk/complex patients should be referred to a specialist monitored in-patient post-operatively • All patients should undergo clinical re-evaluation, and high-risk patients should have repeat sleep studies • Pediatrics, 2002

28. Polysomnogram (sleep study) • What we actually monitor: • EEG • EOG (eye movements) to determine REM sleep • EMG (chin, leg) • ECG • Oral and nasal airflow via thermistor and nasal cannula • Snore microphone to evaluate for audible and non-audible snoring • Pulse oximetry, end-tidal CO2, transcutaneous CO2 • Thoracic and Abdominal Movements • Video recording: for everything!

29. Questions……