obstructive sleep apnea syndrome dr. amir bar, bnei-zion medical center, haifa
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Obstructive Sleep Apnea Syndrome
Dr. Amir Bar,
Bnei-Zion Medical Center,
Haifa
A “new syndrome”
“PubMed” search (Sleep Apnea; 0-18y):– 1960’ 11
– 1970’ 82
– 1980’ 689
– 1990’ 1012
A common syndrome Has significant complications w/o Tx Can be efficiently treated in the majority of cases
>>Awareness and early diagnosis and Tx
EEG Non-REM Sleep Stages
EEGREM sleep
Sleep physiology
REM
EOG M. Tone
WakeRapidNormal
St 1Slow+/-
St 2NoneRelaxation
St 3-4
“SWS”
NoneRelaxationMetabolism , GH secretionPara-sympathetic predominance NoneRelaxation
REMRapidAtoniaDreams, Mental, Memory Sympathetic predominance (MI)Penile- erection REM-Related OSA
Classification
Apnea: a Greek word - “want of breath”– Obstructive – Central – Mixed
m/p the Greeks describe obstructive type
Classification
Respiratory Disturbance Index (RDI)– Normal value <1-2 per hour of sleep
1. Apnea: complete airflow cessation (2 respiratory
cycles) 2. Hypopnea: airflow reduction (2 respiratory cycles) 3. Respiratory Effort Related Arousal (RERA):
prolonged flow limitation with associated arousal (Upper Airways Resistance Syndrome)
• Normal oxygen saturation
Epidemiology
Prevalence: – OSAS: 1-3%– Primary snoring (PS): 3-12%
Gender: – M/F ratio 1:1 (Adults: male predominance)
Age: – From neonates to adolescents – Commonest in preschool children (2-5y)
• (Peak incidence of adenotonsillar hypertrophy)
Race: – More common in African-American children ??
Nocturnal presentation
ApneaDyspneaSnoringMouth breathingRestless sleep
Pathophysiology
Closed AW
Opened AW
Insp. Neg. pressure
•Anatomical factors
Pharyngeal dilators
•Muscle relaxation (Sleep)•Muscle atonia (REM)•Neuromuscular dis
Upper Airways
Anatomical Factors
Anatomical Factors
Neuromuscular Factors
Pathophysiology
Vast majority of cases are associated with adeno-tonsillar hypertrophy (AT-Ht)
Obesity in children is a risk factor for OSAS, and the severity of OSAS is proportional to the degree of obesity– In contrast to adults, most OSAS
children are not obese (may have FTT)
Pathophysiology
Although strongly associated with AT-Ht, childhood OSAS is not caused by AT-Ht alone:
– No obstruction during wakefulness– Adenotonsillar size and OSAS are not correlated
– Deficit in arousal mechanisms • Elevated arousal thresholds in response to
hypercapnia and increased UA resistance
– Abnormal centrally mediated activation of UA muscles
Complications
CVS – systemic and pulmonary HTN
Neurocognitive/behavioral problems
FTTEnuresis
OSAS: PSG screen
Chin EMG
ECG
Airflow
Peripheral Pulse Volume
BP
Leg Mt.
Oximetry
EEG
Complications: CVS
Cor-pulmonale - used to be a common presentation, but is currently rare – When it does develop-can be reversed by
Tx
Tal, Pediatr Pulmonol, 1988:Ventriculography in children who had
abnormal questionnaire for OSAS:– 37% had Rt. ventricular EF – 67% had abnormal wall motion– All of the 11 pt who had a repeat evaluation
after T&A showed improvement
Complications: CVS
Shiomi, Chest, 1993:Pulsus-paradoxus and leftward
shift of the inter-ventricular septum in 3/6 children with OSAS– Correlated with negative esophageal
pressures but not with oxygen desaturation, reversed with CPAP
Complications: CVS
Am J Respir Crit Care Med. 2004 Apr 24 h ambulatory BP in children with sleep-disordered breathing
Background: OSAS causes intermittent elevation of systemic BP during sleep
Objective: to determine whether obstructive apnea in children has a tonic effect on diurnal BP
Conclusion: OSA in children is associated with 24 h BP dysregulation
Complications: CVS
AAPThe Fourth Report on the Diagnosis,
Evaluation, and Treatment of High Blood Pressure in Children and Adolescents
National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents
PEDIATRICS Vol. 114 No. 2 August 2004
Complications: CVS
Complications: Neurocognitive & Behavioral Guilleminault, Lung, 1981: 50 children with OSAS (PSG)
– 84% - excessive daytime sleepiness– 76% - behavior disturbance– 42% - hyperactive– 16% - school performance
Complications: Neurocognitive & BehavioralGozal, Pediatrics, 1998:297 first graders who were in the lowest
10th academically were evaluated for OSAS by questionnaire combined with home oximetry– 54/297 (18.1%) had positive results
• (recommended T&A)
– 24/54 underwent T&A and improved their grading significantly, with no change in the untreated OSAS group or the non-OSAS group
Complications: Neurocognitive & BehavioralGozal D, Sleep, 2004
Health-related Quality of Life and Depressive Symptoms in Children with Suspected Sleep-Disordered Breathing
Conclusions: Children with suspected OSAS, regardless of the severity of RDI or the presence of obesity, had more impairments in quality of life and depressive symptoms than did children who did not snore
Complications: Neurocognitive & BehavioralPillar, Sleep, 2004 Sleep Disorders and Daytime Sleepiness in Children with
ADHD Of the children with ADHD, 17 (50%) had signs of OSAS,
compared with 7 of the control group (22%, P < .05) Children with ADHD demonstrate objective daytime
somnolence (by MSLT), which may explain the beneficial effects of Tx with stimulants
Primary sleep disorders, especially sleep-disordered breathing and PLMS, should be looked for
Complications:FTT
FTT in OSAS children and reports of growth spurt following T&A
Proposed mechanisms:1. Low caloric intake
• Dysphagia
2. High caloric expenditure • Work of breathing
3. Abnormal GH secretion• Interrupted SWS, post T&A - IGF
Complications: Enuresis
Brooks, J Pediatr, 2003:Children 4 y and older who had suspected
OSAS were asked about enuresis– 160 pt (90/70; M:F)– 41% had enuresis (primary/secondary - 3:1)– RDI <1: significantly lower prevalence of
enuresis (17 vs. 47%)– The prevalence of enuresis is associated to
the OSAS severity (1-5, 5-15, or >15 events per hour)
Complications: Enuresis
Weider, Otolaryngol Head Neck Surg, 1991:
115 enuretic children undergoing T&A– 66% and 77% reduction in enuretic
nights 1m and 6 m Post-T&A– In the group with secondary enuresis,
100% were dry 6 m Post-T&A
Evaluation: Polysomnography (PSG)PSG is the gold STD for diagnosisEstablishment of diagnosis and
severity– Prediction of complications, particularly
in the immediate Post-Op period– Pre-Op baseline for Post-Op further
evaluationHigh costs and shortage of sleep
labs >> screening techniques
Evaluation: Screening
QuestionnairesSnoring audiotapesENT exam
– low sensitivity and specificityNocturnal VideotapesOximetryNap-PSG
– High false-negative rate, indicative if positive
Evaluation: Pulse Oximetry
Brouillette, Pediatrics, 2000:349 children, pulse oximetry
during PSG – OSAS prevalence – 60.2%– PPV - 97% – NPV - 53%
Treatment: T&A Tonsillectomy with or w/o adenoidectomy is
efficient Tx for OSAS Clinical improvement of symptoms and post-Op
complications: CVS, neurocognitive, enuresis, growth
Suen, Arch Otolaryngol Head Neck Surg, 1995: 69 with susp OSAS had PSG, 35/69 had RDI > 5
and referred for T&A, 30/35 had T&A, 26/30 had follow-up PSG– Cure rate 85%– Post-Op snoring: NPV - 100%, and PPV - 57%– A high Pre-Op RDI (>19) was a strong predictor of
abnormal Post-Op residual abnormality
Treatment: T&A
Nieminen, Arch Otolaryngol Head Neck Surg. 2000:– 95% cure rate for a group of 21
children after T&A or tonsillectomy– Postoperative snoring NPV 100%, PPV
20% – 73% of this group had a previous
adenoidectomy, indicating the lack of efficacy of adenoidectomy alone
Treatment: T&A
Post-Op respiratory compromise (16-27%)Causes:
– Upper airway edema– Increased secretions– Respiratory depression – 2nd to
analgesic/anesthetic agentsRisk factors
– Age <3 yr– severe OSAS– Children with additional medical conditions
Treatment: T&A
Follow-up PSG (6–8 wk Post-Op) , to ensure that additional Tx is not required– Children with additional risk factors– Children with a Pre-Op high RDI
Other Tx alternatives
Uvulopharyngopalatoplasty (UPPP): in CP pt and hypotonic upper airway muscles; it has not been studied in the uncomplicated pediatric pt
Oral appliances has not been reported in children (it may adversely affect the facial configuration of the growing child)
In children, CPAP is usually used when T&A is unsuccessful or contraindicated rather than as a primary treatment– Young infants– Medical conditions
Treatment: Oxygen
Improved oxygenation during sleep, w/o obstruction worsening
PCO2 :– Few individuals show marked increase in PCO2
– With no apparent predictive factors for which pt would develop hypercapnia
Oxygen should never be administered w/o 1st measuring PCO2 response
Oxygen does not address many of the associated pathophysiological features
The end!