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PPC Interdisciplinary Case: Obstructive Sleep Apnea in an Obese Child

PPC Interdisciplinary Case: Obstructive Sleep Apnea in an Obese Child. LaKiesha Bonham, CRT, MAE Trainee Patrick Maeng , MD, Pulmonary Fellow Casey Mathews, BS, MSW/MPH Trainee. Outline. Rationale Multiple medical, respiratory care, and social work issues

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PPC Interdisciplinary Case: Obstructive Sleep Apnea in an Obese Child

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  1. PPC Interdisciplinary Case:Obstructive Sleep Apnea in an Obese Child LaKiesha Bonham, CRT, MAE Trainee Patrick Maeng, MD, Pulmonary Fellow Casey Mathews, BS, MSW/MPH Trainee

  2. Outline • Rationale • Multiple medical, respiratory care, and social work issues • Severity and complexity of each factor requires an interdisciplinary approach for optimal management • Medical overview • Morbid obesity • Severe obstructive sleep apnea • Respiratory insufficiency • Non-medical barriers to care • Family resources • Social history • Psychosocial factors related to obesity • Group discussion • What is her optimal medical therapy? • How do we overcome her barriers to care? • How can we improve adherence?!?!

  3. Case Presentation • CW is an 18 y/o morbidly obese AAF • Referred for overnight polysomnogram from the Children’s Center for Weight Management • Sleep study • Severe obstructive sleep apnea (OSA) • Apnea/hypopnea index (AHI) 50.8 • Significant oxygen desaturations • Hospital admission • Titration of significant BiPAP settings • 23/12 cm H2O with rate 20 • 2-3 LPM oxygen • Assessment of respiratory and other healthcare issues • PMH • Obesity • OSA • Insulin resistance syndrome • Polycystic ovarian disease

  4. Case Presentation • Meds • Metformin • Ibuprofen PRN pain • ROS • Gen: obese with recent weight gain • CV: diminished exercise tolerance, sleeps with head elevated, occasional chest pain and tenderness • Resp: SOB at rest, daytime sleepiness, snoring with pauses in breathing • GI: abd pain related to menstruation • MSK: joint, back pain and tenderness, moderate joint swelling • GU: regular menstrual cycles • Neuro: headache related to sleep patterns

  5. Further History • FH • Obesity • Type 2 diabetes • Cardiovascular disease • Thyroid disease • SH • Lives in public housing apartment with mother and other extended family • Dropped out of high school

  6. Physical Examination • Vitals: • T 98 P 97 BP 130/66 (119/74 thigh cuff) R 20 SaO2 95% RA • Wt 180.3 kg Ht 166 cm • BMI (wt kg/ht m2) = 65.5 (BMI% = 99.7%) • Gen: obese, alert, interactive, appropriate, NAD • HEENT: NCAT, no LAD • Resp: distant breath sounds, CTA • CV: distant heart sounds, no murmurs, pulses 2+ • Abd: soft, NT, no organomegaly appreciated due body habitus • Ext: no joint swelling or tenderness, edema, digital clubbing

  7. Clinical Course • Assessment • Morbid obesity with insulin resistance • Severe OSA • Respiratory insufficiency • Nocturnal hypoxia • Hypercarbia • BiPAP • Difficulty obtaining BiPAP machine • Multiple strategies to improve tolerance of high settings • Mother to manually titrate from low pressures to goal • Repeat PSG • Goal home settings: 25/13 with rate of 20 and 3 LPM oxygen • Follow-up • Sleep clinic – 4 weeks, seen by interdisciplinary team • Weight management clinic – seen by interdisciplinary and multidisciplinary teams

  8. The Pediatric Obesity Epidemic • Obese = BMI > 95th percentile (BMI ~30) • Severe obesity = BMI 35-40 • Morbid obesity = 40-45 or 50 • Super obesity = >45 or 50 • US during the last 30 yrs (2007-2008 NHANES) • Increase from 5 to 10.4% in 2-5 year olds • 6.5 to 19.6% in 6-11 year olds • 5 to 18.1% in 12-19 year olds • Biggest risk factors for adult obesity • Obese as a child • Parent(s) with obesity • Adverse effects • Psychological, neurological, endocrine, cardiovascular, respiratory, GI, orthopedic • Metabolic syndrome • Dyslipidemia, hypertension, insulin-resistant diabetes, prothrombotic and inflammatory states • Independent role in the development of OSAS

  9. Obstructive Sleep Apnea Syndrome (OSAS) • Prolonged, intermittent complete or partial obstruction (obstructive apnea or hypopnea) • May occur with obstructive hypoventilation • Arterial oxygen desaturation • Hypercarbia • Movement, autonomic, or cortical arousals from sleep • Associated sx • Hypoxemia, hypercarbia • Adenotonsillar hypertrophy • Excessive daytime sleepiness • Snoring +/- pauses and gasps • Movements or arousal from sleep • Paradoxical breathing, retractions • Sleep in unusual positions • Diaphoresis • Morning headaches • Parental concern, sleep with their child, shake to awaken to terminate apnea International Classification of Sleep Disorders, 2nd Edition, 2005, American Academy of Sleep Medicine

  10. OSAS • Demographics • 2% of children • Boys = girls • Increased prevalence in African-American children • Predisposing Factors • Larger tonsils and adenoids • Size of adenotonsillar tissue does not predict disease • Obesity • Craniofacial abnormalities • Down Syndrome, Pierre Robin Sequence • Hypotonia/neuromuscular disorders • Infants with GERD • Familial patterns • Complications • Growth failure • Increase in height and weight following treatment in all weight categories, including obese patients • Cognitive and behavioral • Developmental delay • Poor school performance • ADHD • Aggressive behavior • Severe • Asphyxial brain damage, seizures • Pulmonary htn, cor pulmonale, systemic htn • Pathophysiology • Combination of upper airway narrowing and hypotonia • Narrowing • Adenotonsillar hypertrophy • Obesity • Hypotonia • Pharyngeal dilating muscles (naturally decreases with sleep onset) International Classification of Sleep Disorders, 2nd Edition, 2005, American Academy of Sleep Medicine

  11. Childhood Obesity and OSA • Obesity may increase risk of OSA four-fold • 10% of those with OSA were obese • 20-50% of obese children have evidence of OSA • Pathophysiology of OSA in obese children • Anatomic factors • Adenotonsillar hypertrophy (45%) • Hormonal changes • Inflammatory changes • Soft tissue obstruction • Fat pads, soft palate, lateral pharyngeal wall, tongue • Functional factors • Higher critical airway pressure needed by dilator muscles to prevent airway collapse • Chest wall mechanics • Increased chest wall mass effect • Decreased lung compliance • Decreased FRC from abdominal visceral fat • Decreased lung volumes leading to decreased tethering of trachea and easier collapse • Ventilatory drive • Decreased ventilatory responses to hypoxia and hypercapnea Arens and Muzumdar, J Appl Physiol. 2010

  12. Approach to the Obese Child with OSAS Arens and Muzumdar, J Appl Physiol. 2010

  13. Treatment of OSA in the Obese Child • T&A • Treatment of choice when there is adenotonsillar hypertrophy • Resolves OSA in ~50% • Can resolve or decrease severity of OSA in 75% • Much less effective in obese adults • Oral appliances • Expand upper airway • Mild OSA or do not tolerate CPAP • Efficacy in children not well established • Positional therapy • Promotes lateral, prone, or upright position • Uvulopalatopharyngoplasty • Trim lateral pharygeal pillars, excise uvula and posterior palate • Improves mild to moderate OSA in 40-50% • Significant complications Arens and Muzumdar, J Appl Physiol. 2010

  14. Treatment of OSA in the Obese Child • Weight loss • Greater degrees of weight loss associated with significant reductions in OSA • Most have residual OSAS • Decreased CPAP requirements • Dieting alone successful in adults 5-15% of the time over the first 8 years of treatment (Kohler 2009) • Bariatric surgery • Unclear benefits in obese children after 10 years • Rao et al. (2009) showed 50% resolution of OSA following lap band surgery with loss of 20 kg excess weight • Adult studies show resolution of OSA after gastric bypass in 25-75% of cases (Fritscher et al. 2007; Peluso and Vanek 2007) • Reasonable candidates for surgery: • Morbidly obese • Skeletally mature • Failed organized attempts at weight loss Arens and Muzumdar, J Appl Physiol. 2010

  15. CW • 18 year old African American female diagnosed with Morbid Obesity • Initial sleep study was performed at the age of 12 • Apnea/hypopnea index (AHI) of 23 • Started on CPAP and titrated to a pressure of 8 cm H2O

  16. Hospital • Repeat sleep study 9/16/10 revealed an AHI of 50 • Pt was started on CPAP 14 and found to be inadequate • Pt was then placed on BiPAP 14/6 and titrated up to 22/12 with a rate of 20

  17. Hospital • Supplemental oxygen was titrated from 1 lpmto 3 lpm • Sleep study performed prior to discharge revealed optimal settings of 25/13 with a rate of 20

  18. Home • Pt didn’t tolerate IPAP pressure of 22 • Mother started at a low setting of 12/6 increasing her dial throughout the night • Max level achieved was 18/8 • Target goal 22/13 (highest level on machine)

  19. CPAP vs. BiPAP • Continuous positive airway pressure (CPAP) delivers a set pressure to lungs • Bi-level positive airway pressure (BiPAP) helps deliver pressure to the lungs at higher levels

  20. Comparison • Flow generator (delivery mechanism) • Hose (linkage between interface/generator) • Interface (facial or nasal mask)

  21. Contrast (CPAP) • CPAP delivers a set pressure (4-20 cm H2O) • Works by releasing the amount of compressed air through the hose to the interface (mask) and keeps the upper airway opened under continuous air pressure • Increases the oxygen flow by keeping airway opened

  22. Contrast (BIPAP) • Delivers two levels of pressure (IPAP/EPAP) • IPAP (20-30 cm H2O) • EPAP (4-20 cm H2O) • Preferred over CPAP to treat CSA or OSA and heart diseases • BIPAP has a set rate

  23. Comparison • Side effects: • Headache • Skin irritation • Abdominal bloating • Nasal congestion • Runny nose

  24. What is BiPAP? • Pushes air into the lungs • Holds the lungs open to allow more oxygen to enter into it

  25. Qualifications for BiPAP • Initial ventilatory crisis and avoid intubation and ventilation • Home ventilation for patients with neuromuscular dysfunction, obstructive sleep apnea, and other conditions resulting in hypoventilation

  26. BiPAP Settings • IPAP • Once inspiration begins, a preset Inspiratory Positive Airway Pressure (IPAP) is reached • EPAP • Expiratory Positive Airway Pressure (EPAP) is preset to maintain airway patency and oxygenation • Frequency • Determines the timed breath rate and is adjustable • Synchronizes to patients own breaths

  27. Criteria for BiPAP • Stable hemodynamics • Cooperative patient • Minimal airway secretions

  28. Goals for CW’s BiPAP Use • Adherence • Better fitting mask for comfort • Auto titration • Incentives (gift card) • Achievement of optimal pressure settings • New BiPAP machine (25/13)

  29. Adolescent Obesity • Under age 19, obesity is determined by BMI percentile • Obese = >95th percentile • 16.8% of girls ages 12-19 are obese • 29.2% of black adolescent girls • 19.3% of boys ages 12-19 are obese • Risk factors for adolescent obesity • Low SES • Minority race/ethnicity • Obese family member • 80% of obese adolescents with an obese parent will become obese adults Centers for Disease Control (2010). Childhood obesity. http://www.cdc.gov/HealthyYouth/obesity/

  30. Psychosocial Effects of Obesity “There is no doubt that obesity is an undesirable state of existence for a child. It is even more undesirable for an adolescent, for whom being overweight acts as a damaging barrier in a society obsessed with slimness.” – Hilde Bruch

  31. Psychosocial Effects of Adolescent Obesity • Higher prevalence of depressive symptoms and lower self-esteem than non-overweight peers • Associated with adverse social and economic status in adulthood • Particularly strong association in women • Report fewer reciprocal friendships than non-overweight peers • Reported more hours of television viewing per day • Less involvement in formal activities Strauss, Pollack (2003). Social marginalization of overweight children. Pediatric and adolescent medicine 157. p 746-752.

  32. Family Composition/History • Lives with mother, two siblings, aunt, cousin • Public housing apartment • Father passed away 1 year ago • Obesity-related complications • Long family history of obesity • Mom – diabetes • PGF – gastric bypass surgery

  33. School History • Dropped out at age 16 as an eighth grader • Reasons for dropping out • Teasing • Not feeling well • Bad grades • Embarrassment about weight • Currently attending GED classes • Both parents graduated from high school

  34. Economic Factors • Sources of income • Mother’s unemployment • Food Stamps • Father’s death worsened financial burden of the family • Significant decrease in income • Family moved into public housing • Mother lost her job shortly after his death

  35. Funding for Medical Care • Medicaid • Receives Oxygen through Pediatric Services of America • Medicaid is not funding her BiPap machine • PSA donated an old machine

  36. Mental Health • Denies suicidal ideation or intent • She perceives that she has been left out of activities because of her weight • Has lost most of her friends as she has become more overweight • Teased by siblings, adult family members, and other children at school • Expresses that she intensely dislikes herself and her body

  37. Adherence to Treatment • Has a history of non-adherence with CPap • States that there is a “50/50” chance that she will wear the BiPap at home • States that she does enjoy the activities in Weight Management Clinic • Fun exercises to do at home • Weight Management Clinical Nutrition Assessment • Low adherence predicted

  38. Adherence • Strategies to encourage adherence • Gift card incentives • If mask is irritating the patient at night, encourage her to wear it while watching television during the day • Reinforce how serious her OSA is, and the consequences that will likely come if she does not use BiPap regularly • Lead the patient to articulate for herself reasons that the BiPap is good for her and ways that it helps her • Help her formulate her own realistic goals for her health, then teach her what is required to reach them

  39. Barriers to Care • Transportation issues • Rely on public transportation • Frequent doctor’s appointments, Weight Management appointments • Stigma of wearing BiPap at age 18 • Related teasing from family members, siblings • Financial burden • Out of pocket expenses for medical care • Increased cost of eating fresh food

  40. Barriers to Care • Culture of neighborhood • Convenient foods are fatty foods • “Food Desert” • Lack of safe opportunities for exercise • Family culture • Obesity is the norm • Traditional southern cooking

  41. Sleep Clinic Follow-Up • Seen by interdisciplinary team • 2-3+ Adenotonsillar hypertrophy • Admits to poor adherence • Using BiPAP ~2-3x/week • Takes off BiPAP after a few hours due discomfort from high pressures • Intermittent discomfort due to mask • Embarrassment due to teasing • Old Respironics ST BiPAP machine • Mother manually titrating from 12/6 to 18/8 • Maximum IPAP 22 cm H2O

  42. Sleep Clinic Follow-Up • Plan • New BiPAP • Start at low settings 12/5 • Autotitrate to goal 25/13 rate 20, with 3 LPM oxygen • Download usage at next f/u to gauge adherence • Attempt different mask fitting (ResMed Quattro, small) • Refer to otolaryngology for T&A • Repeat sleep study 6 weeks post-op • Anesthesia risk • Ongoing psychosocial support • Strongly recommend continued weight management clinic follow-up

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