Dr. Norman Friedman - Down Syndrome and Sleep Apnea - English

7/30/2019 Dr. Norman Friedman - Down Syndrome and Sleep Apnea - English

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Down Syndrome and Sleep Apnea

Norman R. Friedman, MD

Director- Pediatric Sleep Lab


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Financial Disclosures

nNo relevant financial relationships with anycommercial interests.

Norman Friedman, MD, DABSM


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Should All Children be tested?

Prospective Study from Cincy 5 year longitudinal study 35 had Questionnaire prior to PSG

Of the 24 parents who reported no sleepconcerns, the psg was abnl > 50 %

Shott SRArch Oto-HNS 200


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Predisposing Factors

n Anatomic Maxillary Hypoplasia Relative Macroglossia Obesity Smaller Airways Pulmonary Hypoplasia: poorer gas exchange

n Neurologic Hypotonia

n Reflux More inflammation


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Lung Volumes affects Desaturation


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AAP: Down Syndrome Guidelines

n Evaluate for SDB at each well child visitn Refer to specialist if suspect SDBn Request PSG by 4 years of age regardless

of evaluation

Poor correlation b/w parent report and PSGresults

Parent may not observing closely enough as well as difficult todetect partial obstructive hypoventilation

Bull, M Pediatrics 2011Pediatrics 2011


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AASM: PSG Guidelines

Standardn When clinical assessment suggests OSAn Post-operatively

Mild OSA pre-op with residual symptoms Moderate or Severe OSA pre-op Obesity, Down, Craniofacial, Neurologic

n To initiate non-invasive ventilationn Guideline: If considering adenotonsillectomy

Aurora R SLEEP 2011


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What does a sleep study evaluate?

EOG (Eyes)

EMG (Muscles)

HR / RR

Snore Microphone

Airflow

&Effort

Gas Exchange(Oxygen & Carbon Dioxide)

Position

EEG (Brain)

*

* *

*


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Why request one

n Baselinen Peri-operative planning

Hypoxemia AnesthesiaNarcotics Monitoring


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Is a respiratory event present?


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Yes: If you use a nasal pressure sensor !


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ETCO2

ETCO2

End Tidal CO2 waveform


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Morbidity of SDB

nNeuropsychological Cognitive

Learning Executive Function

Behavioraln Cardiovascularn Growthn Systemic Inflammation :TBD


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Behavioral Abnormalities

n Attention deficit hyperactivity disorder (ADHD)n ADHD symptomsn

Hypersomnolencen Depressionn Externalizing

Aggression Irritable Oppositional

n Internalizing Somatic complaints Social withdrawal


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Cardiovascular

n OSA may compromise long term CV health Cardiac dysfunction Blood Pressure Autonomic regulation Brain oxygenation Cerebral blood flow


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FLOW

Paradoxical


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Is Adenotonsillectomy Curative???

Outcome Measures

N=157 N=453

Cure

27%

78%

Bhattacharjee RAm J Resp C2010


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Does Obesity Affect Success ???

0%

20%

40%

60%

80%

100%

AHI


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Residual OSA

n Awake Flexible Scopen Sleep Endoscopyn Cine MRI


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Video


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Advantages

n Dynamicn 3-dimensional viewn Total upper Airway Evaluation

Cine MRI does not image the larynxn The surgeon interprets the findingsn

Airway manipulation Jaw Thrust

n Potential for one anesthetic


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Pitfalls of Sleep Studies

n Different Laboratoryn Rebound REM sleepnNasal Pressure sensorn Increase supine sleepn RDI rather than OAHIn Develop a close relationship

with your sleep lab


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Oximetry

Dr. Norman Friedman - Down Syndrome and Sleep Apnea - English

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