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h - h. Obesity & OSA in Kids. Sherri Katz, MD, CM, FRCPC Pediatric Respirologist Assistant Professor Children’s Hospital of Eastern Ontario University of Ottawa. Objectives. Understand the pathophysiologic mechanisms of obstructive sleep apnea in obese children

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  1. h - h Obesity & OSA in Kids Sherri Katz, MD, CM, FRCPC Pediatric Respirologist Assistant Professor Children’s Hospital of Eastern Ontario University of Ottawa

  2. Objectives • Understand the pathophysiologic mechanisms of obstructive sleep apnea in obese children • Recognize associated co-morbidities of obesity and concurrent OSA in childhood • Review alternative treatment strategies for children with obesity and obstructive sleep apnea

  3. A growing problem… • OSA has a prevalence of 1-3% in children • Prevalence of sleep disordered breathing in obese children is 13-66% - 10-20 x  • Obesity is a rising epidemic in pediatrics • 5-fold increase in the past 15 years • Prevalence of 10% Ali, 1994, Gislason, 1995, Brunetti, 2001; Mallory, 1989; Silvestri, 1993;Chay, 2000; Marcus, 1996, Wing, 2003; Shields, 2009; Willms, 2003;

  4. A growing problem… As OSA is strongly linked to obesity, this means more kids with OSA!

  5. What is OSA? • Partial (hypopnea) or complete (apnea) upper airway obstruction during sleep associated with: • Sleep disruption • Hypoxemia • Hypercapnia • Daytime symptoms • Continued chest and abdominal motion in the absence of airflow during sleep • Apnea-Hypopnea Index: # of events/hour • Used to categorize severity of condition

  6. Why does OSA occur? • We don’t breathe as deeply while sleeping as when awake • blunting of hypoxic / hypercapnic drive • 25% ¯ tidal volume • arterial pCO2­ 3-4 mmHg • arterial pO2¯ 5-10 mmHg

  7. Why does OSA occur? • Upper airway tone is decreased during sleep, especially in REM • Collapse/obstruction of the upper airway during sleep causes obstruction & apnea

  8. Why does OSA occur? • Adenotonsillar hypertrophy • Most common cause of OSA in children • Between 3-6 yrs, tonsils & adenoids are largest relative to size of airway  peak incidence of OSA

  9. Why does OSA occur? Large tonsils and adenoids BUT No direct correlation between airway or adenotonsillar size & OSA Upper airway is narrower and more collapsible in children with OSA Airway patency is maintained by increased neuromuscular activity THEREFORE Combination of structural abnormalities & neuromotor tone abnormalities must be present for OSA to occur • Isono, AJRCCM, 1998, Marcus, Respiration Physiology, 1999

  10. Why do Obese Kids get OSA? • Older kids & teens • Increased fat mass around the neck & trunk, resulting in: • Reduction in thoracic cage compliance • Mass loading of the respiratory muscles • Increased pharyngeal resistance • May be obstructive initially, but resetting of chemoreceptor sensitivity  hypoventilation Mallory, J Peds, 1989

  11. What are the consequences? • Health Care Utilization • Inflammation • Metabolic • Cardiovascular • Neurobehavioural • Quality of life

  12. Health Care Burden • Economic burden of untreated OSA alone is comparable to that of diabetes • Children with OSA have 226%  health care utilization • Treating OSA in children health care costs by 1/3 • In adults, PAP therapy is as effective as cholesterol-lowering agents in preventing cardiovascular disease AlGhanim, 2008; Reuveni, 2002; Tarasiuk, 2004&2007

  13. Common Pathophysiology Obesity OSA Changes in renin-angiotensin-aldosterone system &  renal sympathetic activity Hypoxia and micro-arousals Oxidative stress Sympathetic Nervous System Activation Systemic inflammation

  14. Inflammation • C-reactive protein is released during systemic inflammatory processes • Can assess risk of heart disease using hs-CRP assay • Hs-CRP levels  in OSA and correlate with severity • Hs-CRP  following OSA treatment with T&A Goldbart, 2008; Bassuk, 2004;Li, 2008; Kheirandish-Gozal, 2006;

  15. Insulin Resistance • Consequence of both childhood obesity + OSA Hypoxia and micro-arousals activate sympathetic nervous system Pro-inflammatory state Insulin resistance Kheirandish-Gozal, Sleep Med, 2010; Gozal, AJRCCM, 2008; Waters, J Sleep Res, 2007; Li, Ped Pulm, 2008; Esler, J Appl Physiol, 2006; Sinha, NEJM, 2002; Vgontzas, J Intern Med, 2003; Somers, J Clin Invest 1995

  16. Insulin Resistance • Precursor of type 2 diabetes and cardiovascular disease • Elevated insulin levels in childhood persist into adulthood & are predictive of cardiovascular disease risk • Severity of insulin resistance is α OSA (independent of BMI) Combo of OSA & Obesity = Greater risk of endocrine dysfunction

  17. Insulin Resistance • In obese and non-obese adults, PAP treatment for severe OSA improved insulin sensitivity within 2 days and sustained effect over 3 months • Improvements more rapid in non-obese subjects • Suggests obesity is contributing to insulin resistance • Treating OSA alone, independent of body composition, improves insulin resistance Harsch, AJRCCM. 2004

  18. Insulin Resistance • 4 Pediatric studies of effect of T&A for OSA on insulin resistance showed improvement • Small sample size, young children, mostly non-obese • PAP therapy for OSA in obese kids with pre-existing insulin resistance: • Improved fasting glucose & insulin levels without change in BMI • Not statistically significant, small sample size Nakra, Pediatrics, 2008; Gozal, AJRCCM, 2008; Apostolidou, Ped Pulm, 2008; Waters, AJRCCM, 2006; Kaditis, Ped Pulm 2005; Reinehr, Pediatrics 2004

  19. Cardiovascular Disease • Hypertension is a well-described consequence of both OSA and obesity • Common mechanism: sympathetic nervous system activation & endothelial dysfunction • Children with OSA lose normal nocturnal dip in BP, eventually get daytime hypertension • Best assessed with 24 hour ambulatory BP monitoring Bhattacharjee, 2009; Gozal. 2008; Kheirandish-Gozal, 2010

  20. Neurobehavioral • Neurobehavioral & learning deficits common and reversible • Young children who snore frequently & loudly are at risk of lower grades in school several years after OSA is resolved Ali, Eur J Peds, 1996, Suratt, Pediatrics, 2006, Kaemingk (tuCASA), J Int Neuropsychol Soc., 2003 ; Gozal, Peds, 1998

  21. Neurobehavioral • Magnitude of impairment in cognitive function attributable to sleep-disordered breathing, is profound • Similar in magnitude to the effects of lead exposure in children Suratt, Pediatrics, 2006

  22. Quality of Life • Improves with OSA treatment

  23. Treatment Options for OSA with Obesity

  24. Treatments • Adenotonsillectomy (T&A): • First-line therapy for younger children with OSA • In obese children, cure rates are much lower: ineffective in 70-80% • Weight loss: • Improves obesity-related OSA • Difficult to achieve & sustain • Positive Airway Pressure (PAP) Shine, 2006; Amin, 2008

  25. PAP Treatment • 86% success rate in kids to improve OSA with CPAP • In 10 children using CPAP/BIPAP AHI decreased from 20 to 1 and lowest oxygen saturation increased from 76% to 90% Marcus, J Pediatr, 1995; Padman, Clin Pediatr, 2002

  26. PAP Treatment • CPAP used initially • If needing CPAP > 10 cmH2O, or evidence of hypoventilation, use Bi-level

  27. Future Directions • Emerging evidence that PAP for OSA improves obesity-related conditions: • Insulin resistance • Hypertension • Quality of life ** Unfortunately does not assist weight loss in adults! Redenius, 2008

  28. Future Directions • Long-term outcomes of PAP therapy for OSA in obese children not yet studied in long-term prospective manner • CIHR funded study now ongoing in Canada INSULIN RESISTANCE INSULIN RESISTANCE PAP

  29. Thank you

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