Pediatric Obstructive Sleep Apnea Stuart Morgenstein, D.O.

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Pediatric Obstructive Sleep ApneaStuart
Morgenstein, D.O.
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Goals

• Upper airway anatomy
• Causes of Obstructive Sleep Apnea
• Diagnosis
• Treatment
• New 2011 Tonsillectomy Guidelines
• Tonsillectomy Techniques

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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

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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

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Risk Factors

• African-American 4 X risk
• Obesity prepubertal 5 x teens
• Hx Prematurity - 3 X risk
• ?? Prior TA
• Positive Family Hx
• Cerebral Palsy / Syndromes

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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.

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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

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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

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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

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Sleep Requirements

• School age 10 hrs.
• High School/College 9
• Average 7 hrs/ sleep deprivation
• (cell phones, MP3s, computers )
• Impact MVA, risk taking behavior, school
  dysfunction, poor dietary choices, disciplinary
  problems

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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

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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.

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Metabolic Consequences

• Incidence type 2 Diabetes 30 OSA patient vs.
  18 no OSA
• Increase glucose intolerance and insulin
  resistance

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Causes

• Craniofacial Abnormalities ieChoanal
  Atresia/Cleft Palate
• Hypertrophic Tonsils and/or Adenoids (Most
  common)
• Obesity
• GERD (Laryngeal/pharyngeal edema)
• Neuromuscular Disorders MD
• Achondroplasia
• Mucopolysaccharidosis
• Nasal Polyps (CF)

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Craniofacial Disorders

• Down syndrome
• Crouzon
• Aperts
• Treacher-Collins
• Pierre-Robin sequence
• Nagers Syndrome
• Goldenhars Syndrome
• Choanal Atresia

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Pierre Robin Sequence

• Micrognathia/Mandibular Hypoplasia
• Glossoptosis
• Cleft Palate

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OSA and OBESITY

• Narrowing Upper airway
• Increase pharyngeal floppiness
• Limitation diaphragm movement restrictive
  effect
• Increased abdominal and chest wall mass
  decrease lung volume

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OBESITY and INFLAMMATION

• Tumor necrosis factor
• Interleukin (IL) 6
• Leptin

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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

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Caregiver Observations

• Snoring/ Arousals/ Agitated sleep
• Labored breathing
• Neck Hyperextension
• Excessive daytime sleepiness/ naps
• Hyperactivity or aggressive behavior
• Enuresis

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DiagnosisSleep 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

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Sleep Study (Polysomnogram)

• Apnea Cessation of breathing 10sec
• Hypopnea (hypoventilation) O2 desaturation 3-
  4 10sec or more
• AHI apnea/hypopnea index
• apnea hypopnea AHI
• RDI apnea hypopnea / total sleep time

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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 gt 1 ? gt 5 etc
• CAUTION Be careful comparing sleep studies
  from different labs. Controversy exists which
  respiratory events in children are significant
  enough to be recorded ?

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American Academy of Oto/Hd Neck surgery

• Clinical Practice Guideline Polysomnography for
  Sleep- DisorderedBreathing Prior to
  Tonsillectomy in Children
• July, 2011

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1 Complex Medical Conditions Obesity,
Down Syndrome, Mucopolysaccharidoses,
Craniofacial Abnormalitites, Neuromuscular
disorders, Sickle cell dz,
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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
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3 In children for whom Sleep Study (PSG) is
indicated, clinicians should obtain laboratory
based (attended) study when available vs.
Portable (Home) Monitoring (PM)
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Sleep Studies

• Inconvenient
• Expensive
• ?? Unavailable

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When To Do Sleep Study???

• Family concerns ie reassurance
• Physician concerns ie confirmation

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Treatment

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

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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.

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Difficulties with CPAP Tx

• Difficulty wearing
• Skin breakdown
• Nasal congestion
• Midface hypoplasia
• Reserve for complex cases

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Repair Choanal Atresia

• Transnasal/Endoscopic
• Transpalatal

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Treatment Pierre Robin Sequence

• Prone position (70 Successful)
• vs. SIDS
• Nasopharyngeal airway (trumpet)
• Tonque/lip adhesion procedure
• Mandibular distraction
• Tracheostomy
• ?TA (Abnormal nasal speech post-op)

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Mandibular Distraction(Goal Lengthen Mandible)
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Mandibular Distraction

• 25mm over several weeks
• Daily advancement at home

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Pierre Robin Syndrome (Newborn)
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Hyoid Advancement
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Thryoid/Hyoid Advancement Suspension
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American Academy of Otolaryngology/Head and Neck
Surgery 2011 Clinical Practice Guideline
Tonsillecomy in Children
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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.

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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

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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

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Harmonic Scalpel
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Microdebrider
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Coblation
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Complications of TA

• Hemorrhage 0.1-3
• Trauma dental, larynx, palate (stenosis),
• Difficult intubation
• Laryngospasm, laryngeal edema, aspiration
• Airway fires
• Cardiac arrest
• Mandibular condyle fracture

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Complications of TA

• Lip burn
• Eye injury
• Dehydration
• Postobstructive pulmonary edema
• VPI (velopharyngeal insufficiency)
• Nasopharyngeal stenosis
• Mortality 1 in 16,000-35,000 surgeries

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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

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???? 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.

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Surgical Option

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

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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

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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

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When to Refer??

• Family requests ENT opinion
• Pediatrician concerns ie OSA
• Tonsillectomy guidelines

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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
• TA 60 successful. Must Respect!!!!

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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 TA with no significant benefit
• to QOL (qualtiy of life)

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CHAT Childhood AdenoTonsillectomy Study

• NIH- sponsored multi-site study ages 5-9yr
• TA early vs watchful waiting
• Measure efficacy of tx
• Neuro-cognitive outcomes
• Respiratory outcomes (AHI)
• Behavior, growth, QOL, BP

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Conclusion

• Pathophysiology Pediatric OSAS likely
  combination of anatomical and neuromuscular
  factors
• ?? Threshold for treatment
• Does TA cure OSA and do neurobehavioral
  problems resolve
• ?? Natural Hx of benign snoring/mild OSA
• Its OK to Snore!!!

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Thank You

• Questions?
• 630-464-7540 (cell)
• 317-312-1040 (Pager)
• 317-944-4235 (office)

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OSAS Caregiver Hx

• Snoring / labored breathing
• Arousals
• Neck Hyperextension
• Excessive daytime sleepiness/ naps
• Hyperactivity or aggressive behavior

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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

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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

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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

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Microdebrider
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