pediatric obstructive sleep apnea

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Pediatric Obstructive Sleep Apnea. Lisa Musso, ARNP Seattle Children’s Hospital Pulmonary/Sleep Division Ronna Smith, ARNP Seattle Children’s Hospital Otolaryngology Division. Primary Snoring. OSAS. Sleep Disordered Breathing (SDB). - PowerPoint PPT Presentation


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Pediatric Obstructive Sleep ApneaLisa Musso, ARNPSeattle Childrens HospitalPulmonary/Sleep DivisionRonna Smith, ARNPSeattle Childrens HospitalOtolaryngology Division1Sleep Disordered Breathing (SDB)Dynamic imbalance between airway patency and collapse during sleep leading to recurrent airways obstruction (partial or complete) resulting in:Gas exchange abnormalitiesCortical arousals leading to sleep fragmentationAutonomic arousals leading to systemic fragmentationDiagnosed by presenting symptoms (night and day) and sleep studyNaturally occurring model of sleep fragmentation

Primary SnoringOSASUARSNotes about SDB in childrenBreathing worse in sleep, especially REMLess cortical input overallSmaller lung volumesLow muscle tone upper airway collapse, decreased amount of air exchangeRelative immaturity of the respiratory system particularly in infantsBlunted hypoxic and hypercapnic responsesSmallest airway to pharyngeal structure ratio is during childhood (3-6 years of age)Craniofacial abnormalities most impactful in infancy3Case StudyPete 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.

BEARSB: bedtime problemsHas to be rocked to sleep or have a bottle?No consistent routine?E: excessive sleepiness/dysfunctionFussy, no nap/sleep routine?Essentially difficult to assess in an infantA: awake after sleep onset?Night time awakeningsR: sleep routineReally non-existentS: snoringQuality/quantity/frequency/positional/witnessed apneaPhysical ExamPete 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.

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

Open for discussion. 7How OSAS can present in infantsSlam dunkOtherwise healthyLoud, obstructive snoringBIG tonsils and/or adenoidsAbnormal sleep studyHistory/exam dont really match: snoring, but no tonsil hyperplasiaNeuromuscular abnormalities/syndromes

Adenoid film

Case StudyLily 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.

BEARSB: 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 predictableS: snores every night, described as scary when she is sick. Physical ExamLily 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.

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

How OSAS presents in toddlers/preschoolersSlam dunkOtherwise healthyLoud, obstructive snoringBIG tonsils and/or adenoidsAbnormal sleep studyBehavior concerns: moody, emotionally labileFatigue, daytime lethargy OR hyperactivityCognitive impairment-concentration focus, attention

Case StudyJose 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.

BEARSB: 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: doesnt awaken at night, often wets the bed.R: occasionally irregular bedtime, but typically predictableS: parents say he snores sometimes but are not concerned about it. They deny any history of pausing, gasping or dyspnea in sleep. Physical ExamJose 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.

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

During discussion, be sure to mention hearing eval, look for ETD with effusions, think ADENOID along with tonsils. Lit now supports assoc between adhd/ osas. Discuss how SLEEP would proceed vs. how OTO would proceed. 18How OSAS presents in school aged kidsSlam dunkOtherwise healthyLoud, obstructive snoringBIG tonsils and/or adenoidsAbnormal sleep studyBehavior concerns: moody, emotionally labile, impulsivity, non-complianceFatigue, daytime lethargy OR hyperactivityCognitive impairment-concentration focus, attention, memory concerns, symptoms of ADHD, problem solving skillsSchool problems: tardiness, behavior, academic problems, falling asleep in school or on the bus

SDB: Clinical PresentationsClassic or Type 13-6 year oldAdenotonsillar hypertrophy or other obvious craniofacial malformationOpen mouth breathing, adenoidal faciesNormal BMI Thin or even FTTTend to be inattentive and hyperactive; if they are overtly sleepy its pretty severe80-90% cured with T & AClinically resolved SDBOftentimes sleep studies still with residual abnormalities

Case StudyShayla 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.

BEARSB: 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 doesnt snore as bad as dad and she has always been very highly functional. Physical ExamShaylas 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 cant be the problem. What Next?Would you refer?Would you get any imaging?Sleep clinic or OTO?

1. Sleep schedule 2. risk of residual osas even after t&A 3. surgical risk with obesity, needs icu bed? Echo, ekg? o/n stay? Baseline sleep study to help quantify risk? 24How OSAS presents in adolescentsSlam dunkOtherwise healthyLoud, obstructive snoringBIG tonsils and/or adenoidsAbnormal sleep studyMoodiness, irritability, emotionally labile, anger, depression, impulsivity, non-complianceFatigue, daytime lethargy, somatic complaints (HA, muscle aches)Cognitive impairments, memory, attention, concentration, decision making, problem solvingRisk taking behaviorsUse of stimulants, e.g. caffeine, borrowed Ritalin, etcSchool failure

SDB: Clinical PresentationsNew (but the old Pickwickian model), Type IIadolescentsObesity with variable, even minimal adenotonsillar hypertrophyEarly metabolic syndrome (borderline HTN, acanthosis)Tend to be sleepy and inattentive as opposed to hyper and distractable


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