Pediatric Obstructive Sleep
Apnea
Stuart Morgenstein, D.O.
Goals
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Upper airway anatomy
Causes of Obstructive Sleep Apnea
Diagnosis
Treatment
New 2011 Tonsillectomy Guidelines
Tonsillectomy Techniques
American Academy of Pediatrics
Practice 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
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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
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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 “miniarousals”
• What constitutes apnea/hyponea unclear ,
not well defined, varies with age
Sleep Requirements
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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
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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
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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
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Snoring/ Arousals/ Agitated sleep
Labored breathing
Neck Hyperextension
Excessive daytime sleepiness/ naps
Hyperactivity or aggressive behavior
Enuresis
Diagnosis:Sleep Study
(Polysomnogram)”Gold –
Standard”
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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 SleepDisorderedBreathing 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
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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
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Difficulty wearing
Skin breakdown
Nasal congestion
Midface hypoplasia
Reserve for complex cases
Repair Choanal Atresia
• Transnasal/Endoscopic
• Transpalatal
Treatment Pierre Robin Sequence
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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
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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
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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
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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
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,
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correcting an abnormal sleep study
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with T&A with no significant benefit
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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
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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
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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