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Polysomnography: When? Why?

Polysomnography: When? Why?. Zeynep Seda Uyan, MD Marmara University Division of Paediatric Pulmonology Istanbul - Turkey. The Importance of Sleep.

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Polysomnography: When? Why?

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  1. Polysomnography: When? Why? Zeynep Seda Uyan, MD Marmara University Division of Paediatric Pulmonology Istanbul - Turkey

  2. The Importance of Sleep “Our whole economy and social structure is organized around the astonishing fact that we must slumber helplessly once in each rotation of the planet.” Arthur Winfree, Purdue University

  3. The Purpose of Sleep • The Restorative Theory: Sleep is for relief of bodily or cerebral deficits caused by waking activity. • Sleep is for energy conservation. Less energy is used during sleep than in quiet restfulness.

  4. Sleep Deprivation • Sleep deprived rats: Weight loss, skin lesions, increased energy expenditure, fall in body temperature, and excessive heat loss. Death occurs in 2-3 weeks. (Rechtschaffen, 1989) • Fatal familial insomnia: Progressive inability to sleep resulting in death in 1-3 yrs. (autosomal dominant prion disease)

  5. Percentiles for total sleep duration per 24 hours from infancy to adolescence Iglowstein, I. et al. Pediatrics 2003;111:302-307

  6. Outline • Classification of sleep disorders • Sleep-related breathing disorders • Obstructive sleep apnea syndrome • Definition, athophysiology, epidemiology • Clinical features • Sequelae • Diagnostic tests • Treatment options

  7. International Classification of Sleep Disorders Version 2 (ISCD-2) • Insomnias • Sleep-Related Breathing Disorders • Hypersomnias Not Due to a Sleep-Related Breathing Disorder • Circadian Rhythm Sleep Disorders • Parasomnias • Sleep-Related Movement Disorders • Other Sleep Disorders

  8. Sleep-Related Breathing Disorders • Central Sleep Apnea Syndromes • Primary Central Sleep Apnea • Central Sleep Apnea Due to Cheyne Stokes Breathing Pattern • Central Sleep Apnea Due to High-Altitude Periodic Breathing • Central Sleep Apnea Due to Medical Condition Not Cheyne Stokes • Central Sleep Apnea Due to Drug or Substance • Obstructive Sleep Apnea Syndromes • Obstructive Sleep Apnea • Sleep-Related Hypoventilation / Hypoxemic Syndromes • Sleep-Related Non-Obstructive Alveolar Hypoventilation, Idiopathic • Congenital Central Alveolar Hypoventilation Syndrome • Sleep-Related Hypoventilation / Hypoxemia due to Lower Airways Obstruction • Sleep-Related Hypoventilation / Hypoxemia due to Neuromuscular and Chest Wall Disorders • Sleep-Related Hypoventilation / Hypoxemia due to Pulmonary Parenchymal or Vascular Pathology • Other Sleep-Related Breathing Disorder • Sleep Apnea / Sleep Related Breathing Disorder, unspecified

  9. Outline • Classification of sleep disorders • Sleep-related breathing disorders • Obstructive sleep apnea syndrome • Definition, pathophysiology, epidemiology • Clinical features, sequelae • Diagnostic tests • Treatment options

  10. Obstructive Sleep Apnea Syndrome OSAS is a 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. Schechter MS, Pediatrics 2002;109:e69

  11. Pathophysiology of OSAS Upper Airway Skeletal Muscle Tone Upper Airway Size Inspiratory Force Airway Occlusion Airway Patency

  12. Pathophysiology of OSAS

  13. Pathophysiology of OSAS Marcus CL, Respiration Physiology 2000;119:143-54

  14. Sleep and Upper Airway Resistance Increased UAW resistance sufficient to elevate PaCO2 or lower SpO2 IncreasedUAW resistance causing only noisy breathing (snoring) IncreasedUAW resistance sufficient to degrade sleep quality Increased UAW resistance leading to intermittent complete UAW obstruction Normal UAW resistance (no snoring) Upper airway resistance syndrome Obstructive hypoventilation or obstructive hypopnea Normal Primary snoring OSAS

  15. 40 35 30 25 % Habitual Snorers 20 15 10 5 0 UK/1993 UK/1996 Italy/1989 Italy/2001 USA/2002 USA/2003 Italy/2003 Spain/2001 Island/1995 Turkey/2005 France/1992 France/1992 Austria/2001 Sweden/1995 Sweden/1999 Portugal/2000 Thailand/2001 Germany/2003 Prevalence of Habitual Snoring (HS)

  16. Prevalence of OSAS % OSAS UK 1993 USA 1999 USA 1999 Tahiland 2001 Iceland 1993 Italy 2001 Italy 2003 Turkey 2005

  17. Outline • Classification of sleep disorders • Sleep-related breathing disorders • Obstructive sleep apnea syndrome • Definition, pathophysiology, epidemiology • Clinical features, sequelae • Diagnostic tests • Treatment options

  18. Nighttime Symptoms in SDB • Loud intermittent snoring (not obligatory!) • Observed apneas during sleep • Struggling to breathe, prompting parents to intervene • Open mouth during sleep, hyperextended neck • Unusual sleep positions (sitting, knee-elbow position) • Profuse sweating • Restless sleep, rhythmic movements, frequent awakenings • Bed wetting (>3y), nightmares

  19. Morning/Daytime Symptoms in SDB • Morning fatigue • Slow to waken, resistance to getting up • Bad mood • Dry mouth • Morning headache • Hyponasal voice • Concentration deficits, hyperactivity • Poor school performance

  20. Outline • Classification of sleep disorders • Sleep-related breathing disorders • Obstructive sleep apnea syndrome • Definition, pathophysiology, epidemiology • Clinical features • sequelae • Diagnostic tests • Treatment options

  21. Sequelae of OSAS Growth failure Neurocognitive function Cardiovascular problems

  22. Sequelae of OSAS 22 children with OSAS • 55% had cor pulmonale • 27% had failure to thrive • 9% had permanent brain damage BrouilletteRT, J Pediatr 1982;100:31-40

  23. Growth in Children with OSAS after T&A • Relieving airway obstruction resulted in catch-up growth in all six children with failure to thrive(Brouillette, J Pediatr 1982). • Average sleeping energy expenditure decreased and mean weight z score increased after T&A in children with OSAS(Marcus, J Pediatr 1994) • There was statistically significant increase in weight and IGF-1 levels in children with OSAS 18 months after adenotonsillectomy(Nieminen, Pediatrics 2002)

  24. Neurobehavioural Dysfunction Halbower, Sleep Med Rev2006;10:97-107

  25. Gozal D, J Sleep Res2002;11:1-16

  26. OSA-CV disease-PathogenesisQuan and Gersh. Circulation 2004;109:951 Obstructive Apnea-Hypopnea ΔIntrathoracic Pressure Hypoxia Arousals Oxidative stress ↑ Sympathetic tone Δ in cardiac structure-function Endothelial dysfunction-↓arterial distensibility Inflammation- metabolic disturbances BP abnormalities

  27. Left Ventricular Hypertrophy and Abnormal Ventricular Geometry in Children with OSA Amin RS, Am J Respir Crit Care Med2002;165:1395-99

  28. Outline • Classification of sleep disorders • Sleep-related breathing disorders • Obstructive sleep apnea syndrome • Definition, pathogenesis, epidemiology • Clinical features, sequelae • Diagnostic tests • Treatment options

  29. Questionnaires Eleven of the twelve papers concluded that history and/or physical examination cannot reliably diagnose obstructive apnea-hypopnea syndrome in children compared to polysomnography Brietzke, Otolaryngol HNS2004;131:827-32

  30. Audiotaping and Videotaping The use of home audiotaping and videotaping has been inadequately investigated. Although these techniques may have promise, the discrepancies in results indicate that additional study is necessary.

  31. Home Pulse Oximetry: Desaturation Cluster 20 min.

  32. Pulse Oximetry in Diagnosing SDB • Easy to perform, automatic analysis possible • Inexpensive, good acceptance with parents • Diagnostic if positive result • Low sensitivity: neg. result does not exclude SDB • Not useful in 1st year of life (periodic apnea) • No differentiation between central/obstructive SDB

  33. Comparison of nap and overnight PSG in children • 1-hr daytime nap PSG compared to ON PSG in 40 children with SDB • Sensitivity 74% Specificity 100% Positive predictive value 100% Negative predictive value 17% • Nap PSG may be an effective screening method • If nap study is inconclusive ON PSG should be performed Marcus, Pediatr Pulmonol2000;13:16-21

  34. Screening Tests in Pediatric SDB • History/Questionnaires • Otolaryngological examination • Audiotapes of snoring • Videotapes • Nap PSG • Nocturnal oximetry • None useful in identifying pediatric SDB Low sensitivity Low specificity Low sensitivity High specifictiy Marcus, Am J Respir Crit Care Med 2001;164:16-30 Schechter, Pediatrics 2002;109:e69

  35. Home Polysomnography Moss, Pediatr Res 2005; 58: 958-965

  36. Role of Home PSG in Diagnosing SDB • Well accepted by both children and parents • Relatively easy to perform; comparatively low cost • (probably) less influenced by first-night-effect • 10% failure rate • No commercial system offers ET/Tc CO2 (hypovent.?) • Technician must be available in the evening • Reliability/validity yet unclear

  37. Polysomnography To determine diagnosis and severity

  38. Recording Montages: In-Laboratory

  39. Central Apnea Airflow Rib cage Abdomen Time

  40. Obstructive Apnea Airflow Rib cage Abdomen SpO2 Time

  41. Overnight Polysomnography TcpCO2 TcpO2 EEG EOG EMG EKG RC ABD FLOW PetCO2 SpO2 Snoring TIME (sec)

  42. Polysomnographic characteristics in normal preschool and early school-aged children Montgomery-Downs. Pediatrics 2006;117:741

  43. Outline • Classification of sleep disorders • Sleep-related breathing disorders • Obstructive sleep apnea syndrome • Definition, pathogenesis, epidemiology • Clinical features, sequelae • Diagnostic tests • Treatment options

  44. Treatment Options • Surgical management • Adenotonsillectomy-most common surgical option in children • Tracheostomy-less common with advent of mask positive pressure • Soft tissue procedures • Skeletal procedures

  45. Adenotonsillectomy 13.92 event/hour 82.9% Brietzke, S.E. et al. Otolaryngol Head Neck Surg 2006;134:979-84

  46. Tracheostomy

  47. Treatment Options Medical management • Nasopharyngeal airway • Weight loss for obese patients • Pharmacological therapy • Mask positive airway pressure-continuous or bilevel

  48. Nazopharyngeal Airway

  49. Weight Loss

  50. Non-invasive Ventilation

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