Obstructive Sleep Apnea

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Obstructive Sleep Apnea

• David E Karas MD
• Chief, Pediatric Otolaryngology
• Yale-New Haven Childrens Hospital
• Connecticut Pediatric Otolaryngology

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Discussion Points

• How to diagnose and treat OSA
• Understanding the severity, prevalence and
  clinical relevance of mild disease
• Appreciate the inter-relatedness of clinical
  entities that disturb sleep

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Obstructive Sleep Apnea Syndrome (OSAS)

• Disorder of breathing during sleep characterized
  by prolonged partial (or complete) upper airway
  obstruction that disrupts normal ventilation
  during sleep and normal sleep patterns

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Historical Perspective

• Weve known about the effects of having big
  tonsils and adenoids for a long time

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The expression is dull, heavy and apathethicIn
longstanding cases the child is very
stupid-looking and responds slowly to questions
Dr. William Osler, 1892 (on daytime
symptoms in children with enlarged tonsils and
adenoids).
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2007 Headlines

• Expanded spectrum of OSA as well as expanded
  incidence
• Association with neurocognitive manifestations
• Asthma on the rise
• Obesity on rise

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Symptoms

• Snoring with intermittent gasps and snorts and
  pauses
• Disturbed sleep
• Daytime neurobehavioral problems
• Daytime tiredness

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How do you make the diagnosis?

• History
• Physical exam
• Video-taping
• Audio-taping
• Pulse oximetry
• Polysomnography

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History

• Snoring
• Labored breathing
• Apnea
• Restless sleep
• Enuresis
• Cyanosis
• Excessive Daytime Tiredness
• Behavior or Learning Problems (ADHD)

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History

• Five Key Questions
• Snoring
• Restless Sleep
• Tired on Awakening
• Short Sleep Latency
• Hyperactivity

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Physical Exam

• Adenotonsillar Hypertrophy
• Mouth Breathing
• Nasal Obstruction during wakefulness
• Adenoidal facies
• Hyponasal Speech (M test)

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Physical Exam

• Nasal Cavity
• Turbinates
• Adenoids
• Oral Cavity
• Tongue
• Tonsils
• Size of Pharynx
• Obesity

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Does Tonsil Adenoid Size Correlate With OSAS?

• Not necessarily
• Tonsil size
• 0 in fossa
• 1 (lt25)
• 2 (25-50)
• 3 (50-75)
• 4 (gt75)

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Diagnostic Tests for OSAS

• Nocturnal Polysomnography (sleep study)
• Audiotaping or Videotaping (sounds of struggling
  were more predictive than pauses)
• Abbreviated Polysomnography (overnight oximetry,
  nap studies)

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Snoring and OSA

• Not all snoring children have OSA
• Primary snoring
• no apnea, hypopnea, hypoxemia or significant
  arousal
• Upper airway resistance syndrome
• Snoring, increased effort, but no decreased
  airflow or ventilatory abnormalities

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Treatment Options

• Tonsillectomy and Adenoidectomy
• Turbinectomy
• Surgical Correction of other obstructing lesions
• Continuous Positive Airway Pressure
• Weight Loss
• Mandibular Advancement
• Craniofacial surgery
• Tracheostomy

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Risk Factors for Post Operative Complications

• Younger than 2 years of age
• Severe OSAS on polysomnography
• Failure to thrive
• Obesity
• Prematurity
• Recent respiratory infection
• Craniofacial anomalies
• Neuromuscular disorders

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Helping Your Child Sleep

• Make Sleep a Positive Priority
• Address Sleep hygiene
• Conducive sleep environment
• Regular sleep/wake schedule
• No caffeine! (consider effects of chocolate too)
• Wind-down time before sleep (unplug!)
• ADEQUATE TIME FOR SLEEP

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Developmental Sleep Needs

• Newborns 16 - 20 hrs
• At 6 months 13 - 14 hrs
• Toddlers 12 - 14 hrs
• Preschoolers 11 - 12 hrs
• 5 - 7 year olds 10 - 11hrs
• 7 - 11 year olds 9 - 10 hrs
• 12 - 21year olds 9 - 9.5 hrs

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National Sleep Foundation Sleep in America
PollMarch 2004

• Telephone interviews
• 1,473 adults surveyed
• Caregiver for child 10 years of age or younger

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National Sleep Foundation Sleep in America
PollMarch 2004

• 18 of children snore
• 9 have symptoms of sleep apnea
• 14 have difficulty falling asleep
• 30 of school age children are difficult to
  awaken in the morning

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National Sleep Foundation Sleep in America
PollMarch 2004

• Children are not getting the recommended amount
  of sleep for their age group
• Parents are not aware that their children might
  not be getting enough sleep
• Parents are not aware of best sleep practices
• 69 of parents report sleep related problems
• 76 of parents would change something about
  childs sleep habits
• 52 say their doctors dont ask about childs
  sleep habits

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Some Connecticut Numbers

• 2000 census
• 925,000 children in Connecticut birth to 19 years
• If 18 snore166,000 snoring kids

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Neurocognitive Deficits and OSA

• ADHD with OSA a treatment study outcome. Huang,
  Guilleminault, et.al. Sleep Med. 2007 Jan8 (1)
  18-30
• 66 school age children with ADHD
• All had AHI between 1 and 5
• Treated with either Ritalin, TA, or nothing
• Rit and TA did better than no treatment (end
  results were ADHD rating scale, child behavior
  checklist (CBCL), test of variables of attention
  (TOVA), quality of life in OSA (OSA-18)
• TA did better than ritalin with some scales
  approaching normal.
• Note All kids had mild OSA and surgery
  practically normalized things

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Speaking of Mild OSA

• Sleep architecture and AHI in children with OSA.
  Matsumoto E, et.al. J Oral Rehabil. 2007 Feb 34
  (2) 112-20
• Looked at altered sleep architecture at different
  AHIs
• AHIgt3 is cutoff for altered sleep architecture
• Note it was an oral surgery dept. that did this
  study

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Neurocognitive Deficits and OSA

• C reactive Protein (CRP), OSA and Cognitive
  dysfunction in School aged Children. Gozal,
  et.al. Am J Respir Crit Care Med. 2007, Mar 30
• 278 habitual snorers, 5-7 years old, PSG, CRP and
  neurocog testing
• Divided into snorers with OSA, without OSA
• OSA divided into OSA with gt2 abnormal subtests
• CRP is higher in OSA and highest in kids with OSA
  and neurocognitive deficits
• Suggests that inflammatory response elicited by
  OSA is related to neurocog dysfunction

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Neurocognitive Deficits and OSA

• Increased cerebral blood flow velocity in
  children with mild sleep disordered breathing a
  possible association with abnormal
  neuropsychological function. Hill, et.al.
  Pediatrics. 2006 Oct 118 (4) e1100-8.
• 31 snoring children 3-7 years old
• PSG, neuropsych testing, transcranial doppler
• 21 of 31 had AHIlt5
• All had elevated CBF velocity compared to
  controls
• Measures of processing speed and visual attention
  significantly lower in the 21 kids
• Conclusion Mild OSA associated with
  neurocognitive deficits. Changes in CBF may play
  a role.

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ADHD and Sleep Disorders in Children

• Children with a diagnosis of ADHD have a high
  rate of untreated sleep disorders.
• Children must be evaluated and treated for any
  underlying sleep disorders before a diagnosis of
  ADHD can be made.

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Asthma and OSA

• Sleep disturbance and daytime symptoms in
  wheezing school aged children. Desager, et.al. J
  Sleep Res. 2005 Mar 14 (1)77-82
• Children (6-14 yo) who had wheezed in previous 12
  months had more night awakenings, restless sleep
  and daytime sleepiness. Significant correlation
  with cough, rhinitis, snoring
• Nocturnal symptoms and sleep disturbances in
  clinically stable asthmatic children. Chugh,
  et.al. Asian Pac J Allergy Immunol. 2006 Jun-Sep
  24 (2-3) 135-42
• Stable asthmatics (questionnaire based) had more
  disturbed sleep and greater likelihood to have
  flares and exercise intolerance
• Sleep and Pulmonary function in children with
  well-controlled, stable asthma. Sadeh A, et.al.
  Sleep. 1998 Jun 15 21 (4) 379-84
• Asthmatics had lower percentages of quiet sleep
  and more activity during sleep. Lower PFs
  correlated with restlessness and subjective
  complaints of sleepiness.

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Obstructive Sleep Apnea
Asthma
Obesity
Learning and Behavior
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Summary of the AAP Recommendations for OSAS

• All children should be screened for snoring
• Complex high risk patients should be referred to
  a specialist
• Patients with cardiopulmonary failure cannot
  await an elective evaluation
• Thorough diagnostic evaluation should be performed

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Summary of the AAP Recommendations for OSAS

• Adenotonsillectomy is the first line treatment
  for most children (CPAP an option for
  non-surgical candidates)
• High-risk patients should be monitored as
  inpatients postoperatively
• Patients should be re-evaluated postoperatively
  to determine whether additional treatment is
  required.

Pediatrics 109704-712, 2002
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Take Home Messages

• Healthy sleep is vital for a childs
• normal growth
• maintenance of body and mental health
• learning and memory
• Sleep loss due to lack of sleep or a sleep
  disorder has big costs for children
• Impact on body health and growth
• Problems with behavior, impulsivity, mood and
  learning difficulties.

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• THANK YOU

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Sleep stages cycle through a nights sleep