Pediatric Obstructive Sleep Apnea Syndrome:Pediatric Obstructive Sleep Apnea Syndrome:Kids are not simply little adultsKids are not simply little adults

Ronald J. Green, MD, FCCPRonald J. Green, MD, FCCP

Diplomate, American Board of Sleep MedicineDiplomate, American Board of Sleep Medicine

Sleep Disorders & Pulmonary Disease, The Everett Clinic Sleep Disorders & Pulmonary Disease, The Everett Clinic

Medical DirectorMedical Director

North Puget Sound Center for Sleep DisordersNorth Puget Sound Center for Sleep Disorders

Everett, WAEverett, WA

425-339-5410; www.ilikesleep.com425-339-5410; www.ilikesleep.com

Obstructive Sleep Apnea Syndrome Obstructive Sleep Apnea Syndrome

CommonCommon

DangerousDangerous

Easily recognizedEasily recognized

TreatableTreatable

Apnea PatternsApnea Patterns

ObstructiveObstructive MixedMixed CentralCentral

AirflowAirflow

RespiratoryRespiratoryefforteffort

Measures of Sleep Apnea FrequencyMeasures of Sleep Apnea Frequency

Apnea IndexApnea Index

– # apneas per hour of sleep# apneas per hour of sleep

Apnea / Hypopnea Index (AHI)Apnea / Hypopnea Index (AHI)

– # apneas + hypopneas per hour # apneas + hypopneas per hour of sleepof sleep

Pediatric OSAS EpidemiologyPediatric OSAS Epidemiology

7% to 20% of children snore frequently7% to 20% of children snore frequently

1% to 3% of preschool age children have 1% to 3% of preschool age children have OSASOSAS

Peak age is two to five yearsPeak age is two to five years

Pathophysiology of Obstructive Pathophysiology of Obstructive ApneaApnea

Pathophysiology of OSASPathophysiology of OSAS

Awake: Small airway + neuromuscular compensationAwake: Small airway + neuromuscular compensation

Loss of neuromuscular Loss of neuromuscular compensationcompensation

Sleep OnsetSleep Onset Hyperventilate: Hyperventilate: correct hypoxia & correct hypoxia &

hypercapniahypercapniaDecreased pharyngeal Decreased pharyngeal

muscle activitymuscle activity Airway opensAirway opens

Airway collapsesAirway collapsesPharyngeal muscle Pharyngeal muscle

activity restoredactivity restored

ApneaApnea

Arousal from sleepArousal from sleepHypoxia & Hypoxia &

HypercapniaHypercapniaIncreased Increased

ventilatory effortventilatory effort

++

Adult OSAS Risk FactorsAdult OSAS Risk Factors

ObesityObesity Increasing ageIncreasing age Male genderMale gender Anatomic abnormalities of upper airwayAnatomic abnormalities of upper airway Family historyFamily history Alcohol or sedative useAlcohol or sedative use SmokingSmoking

Adult OSAS Risk Factors, cont’dAdult OSAS Risk Factors, cont’d

HypothyriodismHypothyriodism

AcromegalyAcromegaly

AmyloidosisAmyloidosis

Vocal cord paralysisVocal cord paralysis

Marfan syndromeMarfan syndrome

Down syndromeDown syndrome

Neuromuscular disordersNeuromuscular disorders

Pediatric OSAS Risk FactorsPediatric OSAS Risk Factors

Adenotonsillar hypertrophyAdenotonsillar hypertrophy

Craniofacial anomaliesCraniofacial anomalies

Down SyndromeDown Syndrome

ObesityObesity

Neurological disordersNeurological disorders

Family HistoryFamily History

Adapted from Redline S et al. Am J Resp Crit Care Med 1995;151.Adapted from Redline S et al. Am J Resp Crit Care Med 1995;151.

Likelihood of Sleep Apnea Likelihood of Sleep Apnea as Function of Family Prevalenceas Function of Family Prevalence

Risk Factor: Family HistoryRisk Factor: Family History

(Adjusted for(Adjusted forage, race, sex,age, race, sex,BMI)BMI)

Odds RatioOdds Ratio

0

0.5

1

1.5

2

2.5

3

3.5

4

11 2 2 3 3 Relative RelativesRelative Relatives Relatives Relatives

Adults: Clinical ConsequencesAdults: Clinical Consequences

Obstructive Sleep Apnea SyndromeObstructive Sleep Apnea Syndrome

Excessive daytime Excessive daytime sleepinesssleepiness

Sleep fragmentation, Sleep fragmentation, Hypoxia / HypercapniaHypoxia / Hypercapnia

Cardiovascular Cardiovascular ComplicationsComplications

MorbidityMorbidityMortalityMortality

Adult OSAS consequences Adult OSAS consequences

Excessive daytime sleepinessExcessive daytime sleepiness

Increased motor vehicle crashes & work-related accidentsIncreased motor vehicle crashes & work-related accidents

Poor job performancePoor job performance

Poor memory and concentrating abilityPoor memory and concentrating ability

Family discord from loud snoring and above symptomsFamily discord from loud snoring and above symptoms

Chronic headachesChronic headaches

HypertensionHypertension

Increased incidence of depressionIncreased incidence of depression

Decreased quality of lifeDecreased quality of life

Pediatrics: Clinical ConsequencesPediatrics: Clinical Consequences

Obstructive Sleep Apnea SyndromeObstructive Sleep Apnea Syndrome

Attention and Attention and hyperactivity hyperactivity

problemsproblems

Sleep fragmentation, Sleep fragmentation, Hypoxia / HypercapniaHypoxia / Hypercapnia

In very severe In very severe cases, cor cases, cor pulmonale and pulmonale and hypertensionhypertension

MorbidityMorbidityMortalityMortality

Pediatric OSAS consequencesPediatric OSAS consequences

Behavioral problems at home and at schoolBehavioral problems at home and at school Hyperactivity and inattention (ADHD symptoms)Hyperactivity and inattention (ADHD symptoms) Discipline problems at schoolDiscipline problems at school Poor school performancePoor school performance IrritabilityIrritability Difficulties with memory and concentrating abilityDifficulties with memory and concentrating ability

Morning headachesMorning headaches Failure to thriveFailure to thrive Decreased quality of lifeDecreased quality of life Uncommon symptom in pediatrics: Excessive Uncommon symptom in pediatrics: Excessive

daytime sleepinessdaytime sleepiness

Adult OSAS Diagnosis: HistoryAdult OSAS Diagnosis: History

Loud snoring (not all snore)Loud snoring (not all snore)

Nocturnal gasping and chokingNocturnal gasping and choking

– Ask bed partner (witnessed apneas)Ask bed partner (witnessed apneas)

Automobile or work related accidentsAutomobile or work related accidents

Personality changes or cognitive problemsPersonality changes or cognitive problems

Risk factorsRisk factors

Excessive daytime sleepiness (often not Excessive daytime sleepiness (often not recognized by patient)recognized by patient)

Frequent nocturia Frequent nocturia

Sleep Apnea: Is Your Patient at Risk? NIH Publication, No 95-3803.Sleep Apnea: Is Your Patient at Risk? NIH Publication, No 95-3803.

Pediatric OSAS Diagnosis: HistoryPediatric OSAS Diagnosis: History

Loud snoring (almost all snore loudly)Loud snoring (almost all snore loudly)

Snorting/gasping/chokingSnorting/gasping/choking

Observed apneic pauses (often not seen)Observed apneic pauses (often not seen)

Restless sleepRestless sleep

DiaphoresisDiaphoresis

Abnormal sleeping positionAbnormal sleeping position

Paradoxical chest wall movementParadoxical chest wall movement

Secondary enuresisSecondary enuresis

Pediatric OSAS Diagnosis: Pediatric OSAS Diagnosis: History, cont’dHistory, cont’d

Attention deficit and hyperactivity symptomsAttention deficit and hyperactivity symptoms

Behavioral problemsBehavioral problems

Poor school performancePoor school performance

Difficulty awakening in AMDifficulty awakening in AM

Morning headachesMorning headaches

Uncommon symptom in pediatrics: daytime Uncommon symptom in pediatrics: daytime somnolencesomnolence

Symptoms from adenotonsillar hypertrophySymptoms from adenotonsillar hypertrophy

Adult diagnosis: Adult diagnosis: Physical ExaminationPhysical Examination

Obvious airway abnormalityObvious airway abnormality

Upper body obesity / thick neckUpper body obesity / thick neck

>> 17” males 17” males

>> 16” females 16” females

HypertensionHypertension

Adult Physical Exam: OropharynxAdult Physical Exam: Oropharynx

Adult Physical ExaminationAdult Physical Examination

Guilleminault C et al. Sleep Apnea Syndromes. New York: Alan R. Liss, 1978.Guilleminault C et al. Sleep Apnea Syndromes. New York: Alan R. Liss, 1978.

Pediatric diagnosis: Pediatric diagnosis: Physical ExaminationPhysical Examination

Tonsillar hypertrophyTonsillar hypertrophy

Nasal obstructionNasal obstruction

OverbiteOverbite

Morbid obesityMorbid obesity

Behavior in exam roomBehavior in exam room

Note: PE often is normalNote: PE often is normal

Exam: Tonsillar HypertrophyExam: Tonsillar Hypertrophy

Shepard JW Jr et al. Mayo Clin Proc 1990;65.Shepard JW Jr et al. Mayo Clin Proc 1990;65.

Why Get a Sleep Study?Why Get a Sleep Study?

Signs and symptoms poorly predict Signs and symptoms poorly predict disease severitydisease severity

Appropriate therapy dependent on severityAppropriate therapy dependent on severity

Failure to treat leads to:Failure to treat leads to:

– Increased morbidity and mortalityIncreased morbidity and mortality

– Motor vehicle crashes and job-related Motor vehicle crashes and job-related accidents in adultsaccidents in adults

Other sleep disorders can cause same Other sleep disorders can cause same symptoms (especially restless legs syndrome in symptoms (especially restless legs syndrome in both pediatrics and adults)both pediatrics and adults)

Diagnosis of Sleep ApneaDiagnosis of Sleep Apnea

In-laboratory polysomnographyIn-laboratory polysomnography

– Gold standardGold standard

– Assess severityAssess severity

– Initiate treatmentInitiate treatment

– Look for other sleep disordersLook for other sleep disorders

PolysomnographyPolysomnography

Nocturnal PolysomnogramNocturnal Polysomnogram

Nocturnal PolysomnographyNocturnal Polysomnography

In contrast to adults, children have:In contrast to adults, children have:

Fewer obstructive apneasFewer obstructive apneas

Desaturation with shorter eventsDesaturation with shorter events

Higher respiratory rateHigher respiratory rate

Lower functional residual capacityLower functional residual capacity

Smaller oxygen storesSmaller oxygen stores

Pediatric OSAS treatmentPediatric OSAS treatment

SurgerySurgery

– Adenotonsillectomy (Adenotonsillectomy (treatment of choicetreatment of choice))

– Turbinate reduction if indicatedTurbinate reduction if indicated

– Maxillofacial surgeryMaxillofacial surgery

– Tracheostomy (very rarely)Tracheostomy (very rarely)

Weight loss if obese Weight loss if obese

Nasal Continuous Positive Airway Pressure Nasal Continuous Positive Airway Pressure (CPAP)----Will discuss in more detail under adult (CPAP)----Will discuss in more detail under adult treatment optionstreatment options

Pediatric OSAS treatment:Pediatric OSAS treatment:AdenotonsillectomyAdenotonsillectomy

Usually highly effective in children Usually highly effective in children with adenotonsillar hypertrophy, with adenotonsillar hypertrophy, even in the presence of other even in the presence of other underlying conditionsunderlying conditions

Children with severe pre-operative Children with severe pre-operative OSAS should have post-op PSG to OSAS should have post-op PSG to confirm complete remission of OSAconfirm complete remission of OSA

Pediatric groups at high risk for Pediatric groups at high risk for postoperative T&A complicationspostoperative T&A complications Age less than twoAge less than two

Severe OSAS by nocturnal polysomnographySevere OSAS by nocturnal polysomnography

Associated medical conditionsAssociated medical conditions

– Craniofacial anomaliesCraniofacial anomalies

– HypotoniaHypotonia

– Severe obesitySevere obesity

Complications of OSAS already presentComplications of OSAS already present

– Failure to thriveFailure to thrive

– Cor pulmonaleCor pulmonale

Postoperative monitoring of high Postoperative monitoring of high risk pediatric patientsrisk pediatric patients

Postoperatively, high risk Postoperatively, high risk patients should be patients should be observed overnight in a observed overnight in a facility where appropriate facility where appropriate monitoring and care are monitoring and care are available.available.

Adult OSAS treatment:Adult OSAS treatment:AdenotonsillectomyAdenotonsillectomy

Adenotonsillectomy by itself Adenotonsillectomy by itself does not work in adultsdoes not work in adults

Adult OSAS treatmentAdult OSAS treatment

Risk counselingRisk counseling– Motor vehicle crashesMotor vehicle crashes

– Job-related hazardsJob-related hazards

– Judgment impairmentJudgment impairment

Apnea and comorbidity treatmentApnea and comorbidity treatment– BehavioralBehavioral

– Medical (non-surgical)Medical (non-surgical)

– Surgical Surgical

The High-Risk DriverThe High-Risk Driver

Educate patientEducate patient

Document warningDocument warning

Resolve apnea quicklyResolve apnea quickly

Follow-upFollow-up

– EffectivenessEffectiveness

– ComplianceCompliance

Adults: Behavioral InterventionsAdults: Behavioral Interventions

Encourage patients to:Encourage patients to:

– Lose weightLose weight

– Avoid alcohol and sedativesAvoid alcohol and sedatives

– Avoid sleep deprivationAvoid sleep deprivation

– Avoid supine sleep positionAvoid supine sleep position

– Stop smokingStop smoking

Adults and kids: Weight lossAdults and kids: Weight loss

Should be prescribed for all Should be prescribed for all obese patientsobese patients

Can be curative but has low Can be curative but has low success ratesuccess rate

Other treatment is required until Other treatment is required until optimal weight loss is achievedoptimal weight loss is achieved

Medical InterventionsMedical Interventions

Positive airway pressurePositive airway pressure

– Continuous positive airway pressure (CPAP)Continuous positive airway pressure (CPAP)

– Bi-level positive airway pressureBi-level positive airway pressure

Oral appliancesOral appliances

Other (limited role)Other (limited role)

– Medications---don’t workMedications---don’t work

– OxygenOxygen

Positive Airway PressurePositive Airway Pressure

Positive Airway PressurePositive Airway Pressure

Special considerations for CPAP in Special considerations for CPAP in childrenchildren

Not FDA approvedNot FDA approved

Need wide variety of mask sizes and styles to fit Need wide variety of mask sizes and styles to fit childrenchildren

Compliance may be enhanced by behavioral Compliance may be enhanced by behavioral techniquestechniques

– EmpowermentEmpowerment

– Positive reinforcementPositive reinforcement

– DesensitizationDesensitization

– Role modelingRole modeling

Positive Airway Pressure: ProblemsPositive Airway Pressure: Problems

Positive Airway Pressure: ProblemsPositive Airway Pressure: Problems

CPAP ComplianceCPAP Compliance

Patient report: 75%Patient report: 75%

Objectively measured useObjectively measured use

>> 4 hrs for 4 hrs for >> 5 nights / week: 46% 5 nights / week: 46%

Asthma-medicine compliance: 30%Asthma-medicine compliance: 30%

Strategies to Improve ComplianceStrategies to Improve Compliance

Improve nasal patency--THIS IS THE KEYImprove nasal patency--THIS IS THE KEY Machine-patient interfacesMachine-patient interfaces

– MasksMasks– Nasal pillowsNasal pillows– Chin strapsChin straps

HumidifiersHumidifiers RampRamp DesensitizationDesensitization Bi-level pressureBi-level pressure

Oral AppliancesOral Appliances

Uvulopalatopharyngoplasty (UPPP)Uvulopalatopharyngoplasty (UPPP)

Surgical alternatives in adultsSurgical alternatives in adults

Reconstruct upper airwayReconstruct upper airway– Uvulopalatopharyngoplasty (UPPP)Uvulopalatopharyngoplasty (UPPP)– Laser-assisted uvulopalatopharyngoplasty Laser-assisted uvulopalatopharyngoplasty

(LAUP)(LAUP)– Radiofrequency tissue volume reductionRadiofrequency tissue volume reduction– Genioglossal advancementGenioglossal advancement– Nasal reconstructionNasal reconstruction– TonsillectomyTonsillectomy

Bypass upper airwayBypass upper airway– TracheostomyTracheostomy

Uvulopalatopharyngoplasty (UPPP)Uvulopalatopharyngoplasty (UPPP)

Usually eliminates snoringUsually eliminates snoring

41% chance of achieving AHI < 2041% chance of achieving AHI < 20

No accurate method to predict No accurate method to predict surgical successsurgical success

Follow-up sleep study requiredFollow-up sleep study required

Summary:Summary:Pediatric and Adult OSASPediatric and Adult OSAS

DangerousDangerous

Common Common

ADHD symptoms in kids vs. ADHD symptoms in kids vs. sleepiness in adultssleepiness in adults

Treatment: T&A in most kids vs. Treatment: T&A in most kids vs. CPAP in most adultsCPAP in most adults

Summary:Summary:Pediatric OSASPediatric OSAS

Not all kids with ADD or ADHD Not all kids with ADD or ADHD symptoms need OSAS symptoms need OSAS evaluationevaluation

Think about OSAS in kids with Think about OSAS in kids with ADHD symptoms then ask about ADHD symptoms then ask about loud snoring, poor/disrupted loud snoring, poor/disrupted sleep and look for sleep and look for adenotonsillar hypertrophyadenotonsillar hypertrophy