Treatment of Pediatric OSA

Dr Meir Kryger

Introduction: Why this is important

• State of alertness affects a child's ability to• Concentrate• Focus• Learn• Succeed

• Sleepiness can ruin a child’s life• Disorders causing sleepiness such as OSA

can be treated

Objectives

• Recognize the faces of sleepiness• Understand the causes of sleepiness• What to do with a sleepy child suspected of

OSA

Overview

• Sleep breathing disorders in children are common

• They can cause children to fail• The symptoms can be easily recognized• The disorders can be treated• Once treated performance can be normal

Important principles in dealing with pediatric sleep problems

• Children almost never bring a sleep problem to anyone’s attention

• The medical encounter is started by a parent or a teacher

• What is the problem?• Whose problem is it?

How do children with apnea present?

• Behavioral symptoms• Manifestations of sleepiness

• Observations of their sleep• What does the parent see?

The faces of the sleepy child

• Falling asleep• Difficulty concentrating• Memory lapses• Loss of energy• Lack of initiative• Emotional lability• Hyperactivity

The differential diagnosis of sleepiness

• Reduced quantity of sleep• Deprivation, abnormal body clock

• Reduced quality of sleep• Sleep disruption

• Primary Sleep Disorder• Sleep apnea• Narcolepsy

Almost all students are sleep deprived!

Diary of a night owl

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

0 2 4 6 8 10 12 14 16 18 20 22 24

Time

What the parent observes

• Noisy breather• Snoring, snorting • Gasping• Stopping breathing• Restless• Moves a lot• Sweats

The HPI will cover

• Behavioral symptoms• Manifestations of sleepiness

• Observations of their sleep• What does the parent see?

• Medications• Other illnesses

What illnesses?

• Congenital• Skeletal structures• Control of breathing

• Acquired

14

Patient

Central canal

Spinal cordSpinal

Cord

Normal

Congenital: Syringomyelia

Congenital: Klippel Feil

16

Congenital: Down syndrome

Congenital: Mucopolysaccharidosis

18

19

Infiltration of airway

20

Congenital: mysteries

21

Acquired: enlarged tonsils

22

Acquired: enlarged tonsils

Acquired: enlarged tonsils

24

Acquired: (from parent) Small lower jaw

25

Acquired: obesity in toddler

Acquired: obesity in teen

Confirming the diagnosis

Confirming the diagnosis

• What you end up doing depends on • Beliefs of parents• Beliefs of referring clinician• Beliefs of insurance companies• Whether long term treatment will be needed

• Most of the times you’ll end up doing PSG

Nitty gritty of PSG in children

• Show child bedroom before they come in• Have them bring in whatever they use to

fall asleep (blankets, teddy bears)• Parent/guardian in room• One tech per patient– need experienced

tech• Don’t do split in child

End tidal PCO2

Synchronized video

Pediatric PSG

Pediatric PSG

Pediatric PSG: may be classic

Pediatric PSG: may be classic with surprises

Pediatric PSG: with more surprises

Pediatric PSG: yet more surprises

What is observed: may be subtle

What is observed sped up

Restless sleep and apnea

Mask fitting in child may be difficult

3 case studies• Presentation

• What is the problem? Whose problem is it?• Assessment

• What data is needed to find cause of problem?• Analysis

• How is data used to find cause of problem?• Solution

• What was done

Case 1: Falling asleep in class

• Presentation• 12 year old female student who dropped out of

school 3 months before because of “depression”; on antidepressants

• Fell asleep repeatedly in class for about a year• Referred for diagnosis of sleep disorder

• Assessment• Analysis• Solution

Case 1: Falling asleep in class

• Presentation• Assessment

• Explore typical sleep wake pattern• Explore daytime performance• Explore symptoms of sleep disorders• Explore development of problem

• Analysis• Solution

Case 1: Falling asleep in class

• Presentation• Assessment

• Explore typical sleep wake pattern• Falls asleep whenever in low stimulus situation• Never feels refreshed

• Analysis• Solution

Case 1: Falling asleep in class

• Presentation• Assessment

• Explore daytime performance• School performance has been poor for 2 years • Frequently absent• Daydreams or falls asleep in class

• Analysis• Solution

Case 1: Falling asleep in class

• Presentation• Assessment

• Explore symptoms of common sleep disorders• Loud snoring and stops breathing• Overweight• Large tonsils; large overbite (small jaw)• No dream related symptoms

• Analysis• Solution

Case 1: Falling asleep in class

• Presentation• Assessment• Analysis

• Classic sleep apnea • Confirmed by sleep test

• Solution

Case 1: Falling asleep in class• Presentation• Assessment• Analysis• Solution

• Referral to surgeon for possible tonsillectomy• May require orthodontic evaluation• Weight loss program

Case 1: Falling asleep in class

• Sleep apnea occurs in children• History of snoring• Often have big tonsils, obesity or overbite• Check bite during health exam• Usually cured with treatment• Remember the orthodontic window

Take home messages

Case 2: Hyperactive child

• Presentation• 5 year old boy who was expelled from

kindergarten because of “hyperactivity”; small for age

• “Crashes” during the midafternoons• Referred for diagnosis of sleep disorder

• Assessment• Analysis• Solution

Case 2: Hyperactive child

• Presentation• Assessment

• Explore typical sleep wake pattern• Explore daytime performance• Explore symptoms of sleep disorders

• Snoring and restless sleep• Explore development of problem

• Analysis• Solution

Case 2: Hyperactive child

• Presentation• Assessment• Analysis:

• Classic sleep apnea • Confirmed by sleep test

• Solution

Case 2: Hyperactive child• Presentation• Assessment• Analysis• Solution

• Referred to surgeon for tonsillectomy• Had complete cure of all symptoms• Had growth spurt after surgery

Case 2: Hyperactive child

• Sleepiness in a child may paradoxically present as hyperactivity

• Do sleep evaluation in ADHD children

Take home messages

Case 3: Falling asleep in class• Presentation

• A nine year old girl with insomnia characterized by frequent awakenings with shortness of breath.

• Strep B tonsilitis 9 months previously and followed within a week of a movement disorder lasting a few days characterized by twitches involving muscles of her face and uncoordinated, rapid, jerking movements affecting extremities

• Assessment• Analysis• Solution

How do you put this case together?

1. Since the apnea episodes are less than 20 seconds, no diagnosis of central apnea can be made using pediatric rules

2. The patient has a neurological disease3. The patient likely has cardiac valve

disease.4. The patient has idiopathic central apnea

You have 10 seconds!!!!

Answer

3. The patient had a streptococcus B. infection of her tonsils, followed by bizarre neurological symptoms. These symptoms are those of Sydenham's Chorea, which is very frequently associated with rheumatic fever, which in turn often causes valvular heart disease. The Chorea (also called St. Vitus's dance) can come on up to several months after the rheumatic fever.

What to expect with treatment

Summary

• You have learned• sleep disorders common in children• can cause difficulty in school• patterns can be recognized

• How you can help the child• suspect sleep problems when

• student falls asleep in class or• is hyperactive• snores or jaw is small

Thank you

• I’ll be happy to take questions