Pediatric Obstructive Sleep Apnea

Stuart Morgenstein, D.O.

Goals

• Upper airway anatomy

• Causes of Obstructive Sleep Apnea

• Diagnosis

• Treatment

• New 2011 Tonsillectomy Guidelines

• Tonsillectomy Techniques

American Academy of PediatricsPractice Guidelines April, 2002

• All children should be screened for snoring

• Sleep hx for snoring should be a part of routine health care hx

Introduction

• Prevalence OSAS 2% Children

• 3-12% “ Primary Snoring”

• Peak incidence Preschoolers (4-6yo) (tonsils/adenoids largest in relation to airway size overall)

• 25-30% snoring children have OSAS

Risk Factors

• African-American 4 X risk

• Obesity – prepubertal 5 x teens

• Hx Prematurity - 3 X risk

• ?? Prior T&A

• Positive Family Hx

• Cerebral Palsy / Syndromes

Definition Primary Snoring

• Snoring without obstructive sleep apnea , frequent arousals from sleep, or gas exchange abnormalities

• Healthy, thriving kids. Rested in AM. Active. Growing. Reasonable behavior.

Definition OSA

• “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” . Pediatrics Vol 109 No.4 April 2002

OSA Definition in Children

• Challenging to define with the same precision as adults

• Normal variability of sleep patterns• Lack of widely available and Reproducible sleep

lab measurements • Brief apneas may be physiologic :

infants/prematurity• Brief cessation of oronasal air flow is normal with

end of a breath cycle

Definition

• Apneas common but disconcerting to parents: gasping for air, waking up “mini-arousals”

• What constitutes apnea/hyponea unclear , not well defined, varies with age

Sleep Requirements

• School age: 10+ hrs.

• High School/College: 9+

• Average: 7 hrs/ sleep deprivation

• (cell phones, MP3”s, computers )

• Impact: MVA, risk taking behavior, school dysfunction, poor dietary choices, disciplinary problems

Morbidity OSA

• Behavioral/ Mood Disturbances/ ? ADHD

• Inattention/ Poor Memory/Hyperactivity

• School Problems : Low IQ

• Family Disruption

• Reduced quality of life

• Pulmonary Hypertension/Elevated Diastolic /Increase left Ventricular wall thickness

• Increased healthy expenses

Neurobehavioral Consequences

• Deficits in learning, memory , vocabulary

• IQ loss of 5 points or more

• Apneic events inversely related to memory and learning performance

• Treatment of OSA liley improves behavior, attention, quality of life, neurocognitive functioning.

Metabolic Consequences

• Incidence: type 2 Diabetes 30% OSA patient vs. 18 % no OSA

• Increase glucose intolerance and insulin resistance

Causes

• Craniofacial Abnormalities ie:Choanal Atresia/Cleft Palate

• Hypertrophic Tonsils and/or Adenoids (Most common)

• Obesity• GERD (Laryngeal/pharyngeal edema) • Neuromuscular Disorders : MD• Achondroplasia• Mucopolysaccharidosis• Nasal Polyps (CF)

Craniofacial Disorders

• Down syndrome• Crouzon• Aperts• Treacher-Collins• Pierre-Robin sequence• Nager’s Syndrome• Goldenhar’s Syndrome• Choanal Atresia

Pierre Robin Sequence

• Micrognathia/Mandibular Hypoplasia

• Glossoptosis

• Cleft Palate

OSA and OBESITY

• Narrowing Upper airway

• Increase pharyngeal floppiness

• Limitation diaphragm movement – restrictive effect

• Increased abdominal and chest wall mass – decrease lung volume

OBESITY and INFLAMMATION

• Tumor necrosis factor

• Interleukin (IL) 6

• Leptin

Diagnosis OSA

• Caregiver Obervations• Sleep Study Required to confirm Dx (Exam

findings limited correlation )• Limited consensus what is “abnormal:• Sleep centers use different scoring criteria• Adult OSA criteria not applicable to children • Must use age related criteria for OSA:

Caregiver Observations

• Snoring/ Arousals/ Agitated sleep

• Labored breathing

• Neck Hyperextension

• Excessive daytime sleepiness/ naps

• Hyperactivity or aggressive behavior

• Enuresis

Diagnosis:Sleep Study (Polysomnogram)”Gold –

Standard”• Oxygen saturation

• Volume/frequency of oronasal air flow

• Spirometry volumes/flow rates

• Respiratory muscle (ie: chest) excursion

• End-Tidal pCO2

• ECG

• Cortical activity EEG

Sleep Study (Polysomnogram)

• Apnea: Cessation of breathing 10+sec

• Hypopnea: (hypoventilation) O2 desaturation 3- 4% 10sec or more

• AHI: apnea/hypopnea index:

• #apnea + # hypopnea = AHI

• RDI: #apnea + #hypopnea / total sleep time

Diagnosis OSA: Sleep Study

• End-tidal pCO2 50-55m Hg 10% TST) ??

• End-tidal pCO2 45mm Hg or greater 60% of total sleep time ??

• AHI/ RDI ??? Abnormal : No validated severity scales available: > 1 ? > 5 etc

• CAUTION: Be careful comparing sleep studies from different labs. Controversy exists: which respiratory events in children are significant enough to be recorded ?

American Academy of Oto/Hd & Neck surgery

• Clinical Practice Guideline: Polysomnography for Sleep- DisorderedBreathing Prior to Tonsillectomy in Children

• July, 2011

# 1 Complex Medical Conditions:

Obesity, Down Syndrome, Mucopolysaccharidoses,

Craniofacial Abnormalitites, Neuromuscular disorders, Sickle

cell dz,

# 2 No comorbidities listed in #1 and need for OR is uncertain or

there is discordance between tonsil size on exam and reported

severity of OSA

#3 : In children for whom Sleep Study (PSG) is indicated, clinicians should obtain

laboratory –based (attended) study when available vs. Portable

(Home) Monitoring (PM)

Sleep Studies

• Inconvenient

• Expensive

• ?? Unavailable

When To Do Sleep Study???

• Family concerns ie: reassurance

• Physician concerns ie: confirmation

Treatment• Weight loss/ ? Bariatric Surgery: Major Risks• CPAP – use will increase in future: obese teens • T&A (? 10-20% residual OSAS) • Mandibular Advancement• Distraction Osteogenesis• Tracheostomy• Repair Choanal Atresia• Tongue Reduction• Hyoid Advancement• Uvulopalatopharyngoplasty (UPPP)

Weight Loss

• ie: weight loss 18 kg over 20 weeks, AHI decrease 14 to 2 / Hr.

• Bariatric surgery : 58 kg loss over 5 months AHI decrease 9 to 0.7 / hr.

Difficulties with CPAP Tx

• Difficulty wearing

• Skin breakdown

• Nasal congestion

• Midface hypoplasia

• Reserve for complex cases

Repair Choanal Atresia

• Transnasal/Endoscopic

• Transpalatal

Treatment Pierre Robin Sequence

• Prone position (70% Successful)

• vs. SIDS

• Nasopharyngeal airway (“trumpet”)

• Tonque/lip adhesion procedure

• Mandibular distraction

• Tracheostomy

• ?T&A (Abnormal nasal speech post-op)

Mandibular Distraction(Goal: Lengthen Mandible)

Mandibular Distraction

• 25mm over several weeks

• Daily advancement at home

Pierre Robin Syndrome (Newborn)

                                                                                                          

Hyoid Advancement

Thryoid/Hyoid Advancement Suspension

American Academy of Otolaryngology/Head and Neck

Surgery: 2011 Clinical Practice

Guideline: Tonsillecomy in Children

Indications for Tonsillectomy 2011

• 7 Documented episodes tonsillitis past entire year

• 5 Documented episodes per year past 2 yrs

• 3 Documented episodes per year past 3 yrs

• Documented recurrent episodes with modifying factors

• SDB (Sleep Disorder Breathing) : Based on Sleep Study, clinical history, exam.

Tonsillectomy

• Cold Knife• Coblation- Ionized Na+ molecules broken down –

40-70 celcius• Harmonic Scalpel-ultrasonic- vibrates 55,000

beats/sec• Microdebrider – “biological dressing” limits

inflammation/pain• “Bovie”/Electrosurgical devices 400 celcius• Guillotine

• Harmonic Scalpel

• Simultaneous cutting and coagulation of blood vessels

• Mechanical vibration at 55.5 kHz

• Ruptures hydrogen bonds of the proteins, proteins denatured , forms a coagulum and seals vessel

• Low temperature

Harmonic Scalpel

Microdebrider

Coblation

Complications of T&A

• Hemorrhage: 0.1-3 %

• Trauma: dental, larynx, palate (stenosis),

• Difficult intubation

• Laryngospasm, laryngeal edema, aspiration

• Airway fires

• Cardiac arrest

• Mandibular condyle fracture

Complications of T&A

• Lip burn

• Eye injury

• Dehydration

• Postobstructive pulmonary edema

• VPI (velopharyngeal insufficiency)

• Nasopharyngeal stenosis

• Mortality: 1 in 16,000-35,000 surgeries

Hospital Admission Post-op

• Age less than 3 yo• AHI elevated (?? 10) Elevated End-tidal pCO2 • O2 Nadir 80% ??• Abnormal EKG• Weight less than 5th Percentile for age• Craniofacial Anomalies• Neurologic : seizures, Cerebral Palsy, Downs

Syndrome• PACU Staff + Anesthesia + Surgeon = Decision

???? Success

• Greater than 50% reduction in AHI to absolute level less than 15 events /hr and no oxygen desaturation below 85%

• ET CO2 greater than 50 mm Hg 10% or less total sleep time.

Surgical Option

• Other than T&A, other procedures offer disappointing, unpredictable results,,technically challenging , and associated with significiant morbidity

Tonsillectomy and OSA

• Tonsillectomy effective 60-70% of children with significant tonsillar hypertrophy

• Tonsillectomy produces resolution of OSA in only 10-25% of obese children

• Tonsillectomy is not curative in all cases of OSA

Tonsillectomy and OSA: Caregiver Counseling Summary

• Hypertrophic tonsils/adenoids contribute to OSA in children

• OSA often is multifactorial: Tonsils/adenoids size, craniofacial anatomy, neuromuscular tone

• Obesity plays a key role in OSA in some children

• Sleep study: Gold-standard but not necessary in all cases : access/payment issues

When to Refer??

• Family requests ENT opinion

• Pediatrician concerns ie: OSA

• Tonsillectomy guidelines

What is known• No clinical relation between size of tonsils and adenoids

and presence of OSAS• Loudness of snoring does not correlate with degree of

OSA• Sleep questionaires minimal usefulness. • Utility of unattended home studies in peds has not been

well studied and is currently not recommended or approved by the American Academy of Sleep Medicine

• 15-20% of Severe OSA post-op patients may still manifest significant OSA on post-op study

• T&A 60+% successful. Must Respect!!!!

Some ???

• What is natural hx of mild to moderatre OSA

• ?? Longterm consequences if untreated

• Are we , simply, with treatment,

• correcting an abnormal sleep study

• with T&A with no significant benefit

• to QOL (qualtiy of life)

“CHAT” : Childhood AdenoTonsillectomy Study

• NIH- sponsored multi-site study ages 5-9yr

• T&A early vs watchful waiting

• Measure efficacy of tx:

• Neuro-cognitive outcomes

• Respiratory outcomes (AHI)

• Behavior, growth, QOL, BP

Conclusion

• Pathophysiology Pediatric OSAS likely combination of anatomical and neuromuscular factors

• ?? Threshold for treatment

• Does T&A “cure” OSA and do neurobehavioral problems resolve

• ?? Natural Hx of benign snoring/mild OSA

• It’s OK to Snore!!!

Thank You

Questions?

630-464-7540 (cell)

317-312-1040 (Pager)

317-944-4235 (office)

OSAS Caregiver Hx

• Snoring / labored breathing

• Arousals

• Neck Hyperextension

• Excessive daytime sleepiness/ naps

• Hyperactivity or aggressive behavior

Signs and Symptoms• Heroic Snoring• Irritable/ ? ADHD/Temper Tantrums• Poor Concentration/ Poor school

performance/low IQ• Failure to Thrive /Low on Growth

Curves/Reduced growth hormone ( normally secreted at night)

• Enuresis/Nightmares/Diaphoresis• Hyperactivity (vs. Adults Daytime somnolence)• Elevations in insulin and CRP levels

Ten Most Common Indications for Tonsillectomy: 2010

• Infections• Swallowing problems• Look ugly• Halitosis• Snoring• Grandma wants them out• Dr. Phil says to do it• Lady Gaga had them out• Jonas brothers had them out• Oprah says you should

Differential Diagnosis

• Infants: Apnea Prematurity: caffeine/theo• Apnea Infancy: sporadic pauses 20sec or more

(central, obstructive, mixed)• Periodic breathing :3-6sec pauses, gradual desat

(Immature pattern) • Syndromic children• Neuro-developmental delay• Central / cortical component • Seizures• Parasomnias : night terrors/ sleep walking

                                                                                                  

Microdebrider