Management of Pediatric Management of Pediatric OSAOSA

Gerald D. Suh, MDGerald D. Suh, MDENT and Allergy AssociatesENT and Allergy Associates

Board Certified in Otolaryngology and Sleep MedicineBoard Certified in Otolaryngology and Sleep MedicineMedical Director-Night and Day Sleep CentersMedical Director-Night and Day Sleep Centers

Queens Pediatric SymposiumQueens Pediatric Symposium January 16, 2013January 16, 2013

Sleep Disordered Breathing

Spectrum of abnormal breathing, affects 12% of childrenSpectrum of abnormal breathing, affects 12% of children

Primary Snoring-Primary Snoring- Snoring without obstructive apnea, frequent arousals from Snoring without obstructive apnea, frequent arousals from sleep, or gas exchange abnormalitiessleep, or gas exchange abnormalities

Upper Airway Resistance Syndrome (UARS)Upper Airway Resistance Syndrome (UARS) −− Snoring, labored breathing Snoring, labored breathing (increased negative intrathoracic pressure during inspiration), and disrupted (increased negative intrathoracic pressure during inspiration), and disrupted sleep (arousals and sleep fragmentation) without discrete obstructive apneas sleep (arousals and sleep fragmentation) without discrete obstructive apneas or hypopneas.or hypopneas.

Obstructive Hypoventilation Syndrome-Obstructive Hypoventilation Syndrome- Persistent partial upper airway Persistent partial upper airway obstruction associated with gas exchange abnormalities, rather than discrete, obstruction associated with gas exchange abnormalities, rather than discrete, cyclic apneas.cyclic apneas.

Obstructive sleep apnea (OSAObstructive sleep apnea (OSA) ) −− Recurrent partial or complete upper airway Recurrent partial or complete upper airway obstruction/ absence of airflow despite respiratory effortobstruction/ absence of airflow despite respiratory effort

Central sleep apneaCentral sleep apnea −− No respiratory effort No respiratory effort

Sleep Disordered Breathing Sleep Disordered Breathing (SDB)(SDB)

Pediatric OSA-EpidemiologyPediatric OSA-Epidemiology

Prevalence OSAS 1-4% ChildrenPrevalence OSAS 1-4% Children Prevalence is higher among African AmericanPrevalence is higher among African Americans and s and

Asian childrenAsian children Most studies have shown 4% to 11% prevalence of Most studies have shown 4% to 11% prevalence of

parent-reported apnea.parent-reported apnea. Males=Females pre-puberty, M>F after pubertyMales=Females pre-puberty, M>F after puberty Peak incidence Preschoolers (2-8yo) (tonsils/adenoids Peak incidence Preschoolers (2-8yo) (tonsils/adenoids

largest in relation to airway size overall)largest in relation to airway size overall) As obesity is increasing in pediatrics the age distribution As obesity is increasing in pediatrics the age distribution

shifting shifting 25-30% snoring children have OSAS25-30% snoring children have OSAS

EVALUATIONEVALUATION

Medical HistoryMedical History Developmental and School historyDevelopmental and School history Family HistoryFamily History Behavioral assessmentBehavioral assessment Physical ExaminationPhysical Examination GrowthGrowth HEENTHEENT Cardiac examinationCardiac examination Radiologic StudiesRadiologic Studies

Lateral NeckLateral Neck

LaryngoscopyLaryngoscopy

CLINICAL FEATURESCLINICAL FEATURES Nocturnal Symptoms Nocturnal Symptoms

Symptoms vary by age-especially in infants!Symptoms vary by age-especially in infants! Snoring-Volume does not correlate with the degree Snoring-Volume does not correlate with the degree

of obstructionof obstruction Observed apneic pausesObserved apneic pauses Snorting / gasping / chokingSnorting / gasping / choking Restless sleepRestless sleep DiaphoresisDiaphoresis Paradoxical chest wall movementParadoxical chest wall movement Abnormal sleeping position Abnormal sleeping position SweatingSweating Mouth BreathingMouth Breathing Secondary enuresisSecondary enuresis Night terrorsNight terrors

CLINICAL FEATURESCLINICAL FEATURESDaytime Symptoms-Physical and BehavioralDaytime Symptoms-Physical and Behavioral

Morning headachesMorning headaches Difficulty awakening in AMDifficulty awakening in AM Hyponasal SpeechHyponasal Speech Nasal congestion, Chronic RhinorheaNasal congestion, Chronic Rhinorhea Mouth breathing, Dry MouthMouth breathing, Dry Mouth Frequent infectionsFrequent infections Difficulty swallowingDifficulty swallowing Poor appetitePoor appetite Daytime somnolence-7-10%Daytime somnolence-7-10% Mood changes Mood changes Internalizing behaviorsInternalizing behaviors Externalizing behaviorsExternalizing behaviors ADHD like symptoms, School problemsADHD like symptoms, School problems

Neurobehavioral ConsequencesNeurobehavioral Consequences

Deficits in learning, memory , vocabularyDeficits in learning, memory , vocabulary IQ loss of 5 points or moreIQ loss of 5 points or more Apneic events inversely related to memory and Apneic events inversely related to memory and

learning performancelearning performance Treatment of OSA likely improves behavior, Treatment of OSA likely improves behavior,

attention, quality of life, neurocognitive attention, quality of life, neurocognitive functioning. functioning.

AAggressionggression

PPoor school performanceoor school performance

RRestlessestless

IIrritable/ hyperactivityrritable/ hyperactivity

LLacks attentionacks attention

Neurobehavioral ComplicationsNeurobehavioral Complications(APRIL)(APRIL)

ASSOCIATED FEATURESASSOCIATED FEATURES

Increase in partial arousal parasomniasIncrease in partial arousal parasomnias Worsening GERDWorsening GERD Increase in seizure frequency in Increase in seizure frequency in

predisposed childrenpredisposed children Other CO-Morbid Sleep problemsOther CO-Morbid Sleep problems

-RLS,PLMS-RLS,PLMS

-Circadian Rhythm Disorders-Circadian Rhythm Disorders

-Bedtime resistance , nightwakings-Bedtime resistance , nightwakings

Metabolic ConsequencesMetabolic Consequences

Incidence: type 2 Diabetes 30% OSA Incidence: type 2 Diabetes 30% OSA patient vs. 18 % no OSApatient vs. 18 % no OSA

Increase glucose intolerance and insulin Increase glucose intolerance and insulin resistance resistance

CAUSES/ RISK FACTORSCAUSES/ RISK FACTORS

-Adenotonsillar Hypertrophy-Upper airway congestion; allergies -Upper airway obstruction , choanal stenosis, larnygomalacia, subglottic stenosis-GERD/LPR-Cleft palate-Craniofacial dsymorphism : Mid -facial hypoplasia –Down’s syndrome Micrognothia – Pierre-Robin syndrome-Cranial base malformation- Achondroplasia-Neuromuscular disorder: Hypotonia-Down’s syndrome, Muscular dystrophy Spasticity –Cerebral Palsy-Overweight-Mucopolysaccharidosis-Sickle cell disease-Cystic fibrosis (Nasal Polyps)-Chronic lung disease/ BPD-Scoliosis-Brain and spinal disorders – Spin Bifida, ACM type II

High-Risk GroupsHigh-Risk Groups

Down syndrome (54-Down syndrome (54-100% with OSA)100% with OSA)

AchondroplasiaAchondroplasia Metabolic storage Metabolic storage

diseases diseases Craniofacial syndromesCraniofacial syndromes

Anatomy

Hard to miss!

Waldeyer’s RingWaldeyer’s Ring

Adenoid Lingual Tonsils

Adenoid

Septum

Adenoid FaciesAdenoid Facies Elongated faceElongated face Gummy smileGummy smile Open mouth postureOpen mouth posture

Dental ChangesDental Changes

Open biteOpen bite

Cross biteCross bite

Narrow maxillary archNarrow maxillary arch

MALLAMPATI CLASSIFICATION

Adenoid EvaluationAdenoid Evaluation

Fiberoptic Laryngoscopy

MULLER MANEVEURMULLER MANEVEUR

LARNYGOMALACIA

SUBGLOTTIC STENOSIS

OSA DiagnosisOSA Diagnosis Home Sleep TestingHome Sleep Testing

Not validated below the age of Not validated below the age of 1616

Abbreviated (Nap) PSGAbbreviated (Nap) PSG High PPV but Low NPV.High PPV but Low NPV. Useful if results are positive.Useful if results are positive.

False positive results in False positive results in patients with coexistent patients with coexistent medical problems (obesity, medical problems (obesity, asthma).asthma).

Polysomnogram (PSG)Polysomnogram (PSG) ““Gold Standard.”Gold Standard.” Can assess severity of SDB.Can assess severity of SDB. Includes EEG, EKG, EOG, Includes EEG, EKG, EOG,

EMG, saturation monitor, EMG, saturation monitor, respiratory effort and airflow respiratory effort and airflow monitor.monitor.

American Academy of PediatricsAmerican Academy of PediatricsOSA Guidelines 2012OSA Guidelines 2012

Evaluate for snoring at all routine healthcare maintenance visits.Evaluate for snoring at all routine healthcare maintenance visits. If children do snore or have signs or symptoms of OSAS, then a If children do snore or have signs or symptoms of OSAS, then a more focused evaluation is warranted. more focused evaluation is warranted.

Children who snore regularly and have any OSAS signs and Children who snore regularly and have any OSAS signs and symptoms should undergo polysomnography or, alternatively, be symptoms should undergo polysomnography or, alternatively, be referred to a sleep specialist or to an otolaryngologist. referred to a sleep specialist or to an otolaryngologist.

The gold standard is overnight, attended, in-laboratory The gold standard is overnight, attended, in-laboratory polysomnography. polysomnography.

Specific pediatric criteria should be used. Specific pediatric criteria should be used. Polysomnography identifies the presence and severity of OSAS. Polysomnography identifies the presence and severity of OSAS. Specialists might be able to diagnose and determine the severity Specialists might be able to diagnose and determine the severity

of OSAS.of OSAS.Only 55% of children with suspected OSA, based on clinical evaluation, actually have OSA confirmed on sleep study

AAP OSA GuidelinesAAP OSA Guidelines The first-line treatment of children with OSAS, adenotonsillar

hypertrophy, and no contraindication to surgery is adenotonsillectomy.

Adenoidectomy or tonsillectomy alone may be insufficient. The rate of serious complications is low.

High-risk patients undergoing adenotonsillectomy should be monitored in the hospital postoperatively.

Risk factors for postoperative respiratory complications are age younger than 3 years, severe OSAS by polysomnography, cardiac complications of OSAS, failure to thrive, obesity, craniofacial anomalies, neuromuscular disorders, and current respiratory tract infection.

AAP OSA Guidelines 2012

High-risk patients, including those with significantly abnormal baseline polysomnogram results, sequelae of OSAS, obesity, or symptoms of OSAS, should be reassessed for persistent OSAS after adenotonsillectomy by objective testing or by a sleep specialist.

A large proportion of high-risk children have persistent OSAS postoperatively.

Intranasal corticosteroids may relieve mild OSAS if adenotonsillectomy is contraindicated or if mild postoperative OSAS is present.

Mild OSAS is defined as an apnea-hypopnea index of less than 5 per hour.

Response should be measured objectively after approximately 6 weeks. Patients should be observed for recurrence of OSAS and adverse

effects of corticosteroids.

AAO-HNS PSG IndicationsAAO-HNS PSG Indications

Complex medical condition-should undergo PSGComplex medical condition-should undergo PSG ObesityObesity Down SyndromeDown Syndrome Craniofacial AbnormaltyCraniofacial Abnormalty Neuromuscular DisorderNeuromuscular Disorder Sickle Cell DiseaseSickle Cell Disease MucopolysaccaridosesMucopolysaccaridoses

AAO-HNS PSG IndicationsAAO-HNS PSG Indications

Advocate for PSGAdvocate for PSG Differing opinions on need for surgeryDiffering opinions on need for surgery Discordance between physical exam and reported Discordance between physical exam and reported

severity of symptomsseverity of symptoms

Other RecommendationsOther Recommendations Recommend overnight admission for age <3 or Recommend overnight admission for age <3 or

severe OSA (AHI>10, oxygen desaturations below severe OSA (AHI>10, oxygen desaturations below 80%, or both80%, or both

Laboratory-based PSG should be obtainedLaboratory-based PSG should be obtained

POLYSOMNOGRAPHYPOLYSOMNOGRAPHY

It should be performed without sedation It should be performed without sedation and sleep deprivationand sleep deprivation

In a child- friendly environmentIn a child- friendly environment By personnel with training in recording By personnel with training in recording

and scoring pediatric PSG’sand scoring pediatric PSG’s Should be interpreted by physicians with Should be interpreted by physicians with

expertise in pediatric sleep medicineexpertise in pediatric sleep medicine

Pediatric PSG ParametersPediatric PSG Parameters Apnea:Apnea:

Any pause in respiration (>90% decreased airflow) lasting longer Any pause in respiration (>90% decreased airflow) lasting longer than two breaths.than two breaths.

Versus at least 10 s in adults.Versus at least 10 s in adults. Hypopnea:Hypopnea:

Reduction of airflow by >30% for two respiratory cycles accompanied Reduction of airflow by >30% for two respiratory cycles accompanied by reduction of saturation by 3% or arousal from sleep. by reduction of saturation by 3% or arousal from sleep.

AHI:AHI:

Sum of Apneas and Hypopneas per hour of sleep.Sum of Apneas and Hypopneas per hour of sleep. RDI:RDI:

Sum of Apneas, Hypopneas, and respiratory event-related arousals Sum of Apneas, Hypopneas, and respiratory event-related arousals per hour of sleep.per hour of sleep.

RERAs: RERAs:

Arousals associated with increased respiratory effort, decreased Arousals associated with increased respiratory effort, decreased airflow, snoring, or increased end-tidal PCO2airflow, snoring, or increased end-tidal PCO2

PEDIATRIC OSA -SEVERITYPEDIATRIC OSA -SEVERITY

OSA SEVERITY LEVEL

AHI SpO2 NADIR %

PEAK ETCO2TORR

PEAK ETCO2 > 5O T0rr%TST

MILD 1-4 86-91 >53 10-24

MODERATE 5-10 76-85 >60 25-49

SEVERE >10 <75 >65 >50

MANAGEMENTMANAGEMENT Any child with AHI> 5 intervention is necessary.Any child with AHI> 5 intervention is necessary. Less of a consensus regarding AHI 1-5.Less of a consensus regarding AHI 1-5. SurgicalSurgical

Adenotonsillectomy – Adenotonsillectomy – First Line of therapyFirst Line of therapy Turbinate reductionTurbinate reduction Craniofacial surgery- Craniofacial surgery- Mandibular advancement/ Maxillary distraction.Mandibular advancement/ Maxillary distraction. Lingual Tonsillectomy/ EpiglottopexyLingual Tonsillectomy/ Epiglottopexy Hyoid SuspensionHyoid Suspension TracheostomyTracheostomy

MedicalMedical Weight lossWeight loss Continuous positive airway pressure Continuous positive airway pressure Intranasal steroids Intranasal steroids (modest effect)-Mild patients(modest effect)-Mild patients Leukotriene antagonist- Mild patientsLeukotriene antagonist- Mild patients Oral appliancesOral appliances Positional therapyPositional therapy

Tonsillectomy and OSATonsillectomy and OSA

Tonsillectomy “effective” 60-70% of Tonsillectomy “effective” 60-70% of children with significant tonsillar children with significant tonsillar hypertrophy (if use AI<1 as measure of hypertrophy (if use AI<1 as measure of success)success)

82% of children had resolution of OSA (if 82% of children had resolution of OSA (if use AHI <5 as measure).use AHI <5 as measure).

Tonsillectomy produces resolution of OSA Tonsillectomy produces resolution of OSA in only 10-25% of obese childrenin only 10-25% of obese children

AdenotonsillectomyAdenotonsillectomy EfficacyEfficacy

AHIAHI Quality of lifeQuality of life CognitionCognition

Pediatric Sleep QuestionnairePediatric Sleep Questionnaire IQ TestIQ Test

Cardiovascular ParametersCardiovascular Parameters Cerebral blood flowCerebral blood flow Hemoglobin SaturationHemoglobin Saturation Pulse RatePulse Rate Pulse variabilityPulse variability

School performanceSchool performance Significant improvement in grades from 1Significant improvement in grades from 1stst to 2 to 2ndnd grade in grade in

cohort that underwent adenotonsillectomy.cohort that underwent adenotonsillectomy. No significant change in control group and group that No significant change in control group and group that

chose not to have adenotonsillectomy..chose not to have adenotonsillectomy.. Enuresis/IncontinenceEnuresis/Incontinence

Children with OSA have increased risk for enuresis.Children with OSA have increased risk for enuresis. Possibly related to increased levels of BNP?Possibly related to increased levels of BNP?

Significant decrease in nocturnal enuresis and voids/day Significant decrease in nocturnal enuresis and voids/day after adenotonsillectomy.after adenotonsillectomy.

HIGH RISK PATIENTSHIGH RISK PATIENTS

Risk Factors for Postoperative Respiratory Complications in Children with OSAS undergoing Adenotonsillectomy

–Age Younger than 3 years

–Severe OSAS on PSG, AHI>10

–Pulmonary hypertension

–Congenital heart disease

–Failure to Thrive

–Prematurity, CLD.

–Recent URI

– Morbid Obesity

–Trisomy 21

–Craniofacial abnormalities

–Neuromuscular disorders, Cerebral Palsy

–Asthma

–Seizures

CPAPCPAP

Almost always an Almost always an alternative to surgeryalternative to surgery

Surgical failureSurgical failure Morbid Obesity Morbid Obesity Complex OSAComplex OSA Non-Surgical candidatesNon-Surgical candidates FDA approved for FDA approved for

children > 30 kgchildren > 30 kg

Role of Sleep EndoscopyRole of Sleep Endoscopy

Performed with IV Propofol infusionPerformed with IV Propofol infusion Highest reliability for evaluation of Highest reliability for evaluation of

hypopharyngeal structureshypopharyngeal structures Consider for patients who have failed Consider for patients who have failed

previous sleep apnea surgery or initially as previous sleep apnea surgery or initially as part of staged surgerypart of staged surgery

Sleep Endoscopy

BOT Collapse

ConclusionConclusion Loudness of snoring does not correlate with degree Loudness of snoring does not correlate with degree

of OSAof OSA In-lab PSG is gold-standard to confirm OSAIn-lab PSG is gold-standard to confirm OSA Only 55% of children with suspected OSA, based on Only 55% of children with suspected OSA, based on

clinical evaluation, actually have OSA confirmed on clinical evaluation, actually have OSA confirmed on sleep studysleep study

Adenotonsillectomy is first line treatmentAdenotonsillectomy is first line treatment T&A 60+% effective if use AI<1 as measure of T&A 60+% effective if use AI<1 as measure of

success and over 80% effective if use AHI<5 as success and over 80% effective if use AHI<5 as measuremeasure

Need to think of multi-disciplinary approachNeed to think of multi-disciplinary approach ENT, sleep medicine physician, nutritionist, oral ENT, sleep medicine physician, nutritionist, oral

surgeon, bariatric surgeonsurgeon, bariatric surgeon