Transcript 2011-WAC-Upper airway diseases

OSA SYNDROME AND ALLERGIC RESPIRATORY DISEASES
Upper Airway Diseases
A. Kaditis, MD
Pediatric Pulmonology Unit, Sleep Disorders Laboratory
First Department of Pediatrics
University of Athens School of Medicine
and Aghia Sophia Children’s Hospital
Athens, Greece
Obstructive Sleep-Disordered Breathing (SDB)
Spectrum of abnormal respiratory patterns
during sleep characterized by snoring
and increased respiratory effort
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Primary snoring
Upper airway resistance syndrome
Obstructive hypoventilation
Obstructive sleep apnea (OSA)
OSA: Syndrome of Upper Airway Dysfunction
Genes,
environment
Genes,
environment
Multiple
Disorders
affecting
components of
the Upper
Airway (e.g.
tonsils, facial
structures,
dilator muscles)
Upper Airway
Dysfunction
over time may
lead to overt
morbidity (e.g.
hypertension,
enuresis, EDS)
Upper
Airway
Resistance
Apnea
Hypopnea
Step 1: Recognize the
child at risk for
obstructive SDB
Step 2: Identify SDBrelated morbidity or
conditions co-existing
with SDB (probably
common pathogenesis)
Step 3:
Step 4: Assess Step 5:
Recognize
severity of
Determine
factors
SDB
indications
predicting
objectively (if
for treatment
persistence of
equipment
SDB
available)
Step 6: Stepwise
Step 7: Follow-up,
treatment approach for
diagnosis and
SDB
management of
persistent SDB
Step 1: Recognize
 Symptoms of nocturnal airway
obstruction
the child at risk for
1. Snoring
obstructive SDB
Assess by history +
exam
2. Reported apneas during sleep
3. Difficulty breathing during sleep
4. Restless sleep
5. Frequent arousals
 Abnormalities predisposing to
upper airway obstruction
1. Adenotonsillar
hypertrophy/allergic rhinitis
2. Obesity
3. Craniofacial abnormalities
4. Neuromuscular disorders
 History increasing the risk for
SDB
1. Premature birth
2. Family history of SDB
Upper Airway Dysfunction and Adenotonsillar Hypertrophy
Villa et al. Randomized
controlled study of an
oral jaw-positioning
device for treatment of
OSA in children with
malocclusion. AJRCCM
2002;165:123-7
Step 2: Identify SDBrelated morbidity or
conditions coexisting with SDB
(probably common
pathogenesis)
Morbidity
 Cardiovascular system
 Central nervous system
 Enuresis, inadequate
somatic growth
Conditions co-existing with
SDB
 Metabolic syndrome
 Recurrent otitis media,
serous otitis
 Recurrent wheezing
Amin et al. Activity-adjusted 24-hour ambulatory BP and
cardiac remodeling in children with SDB.
Hypertension 2008;51:84-91
Obstructive SDB in Childhood and CNS Morbidity
Evidence from
population-based studies
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Hyperactivity
Inattention
Excessive daytime sleepiness
Learning problems
Kaditis et al. Enuresis and Snoring in Healthy Children.
Urology 2006; 68:406-9
Variables
Children
with
enuresis
Children
without
enuresis
Adjusted odds
ratio
n = 43
n = 1778
(95% CI)
Age
≤ 9 y.o.
> 9 y.o.
32 (74.4 %)
11 (25.6 %)
904 (50.8 %)
874 (49.2 %)
2.87 (1.43-5.76)
baseline
Gender
Male
Female
34 (79.1 %)
9 (20.9 %)
891 (50.1 %)
887 (49.9 %)
3.73 (1.77-7.86)
baseline
Habitual
snoring†
Yes
No
10 (23.3 %)
33 (76.7 %)
125 (7 %)
1653 (93 %)
3.54 (1.68-7.44)
baseline
Redline et al. Risk Factors for SDB in Children.
AJRCCM 199;159:1527
Risk factors adjusted
for race, obesity
AHI>10
OR (95% CI)
p
Occasional wheeze
3.29
(1.24-8.94)
<0.05
Persistent wheeze
7.45
(2.03-27.39)
<0.05
Cough
8.83
(2.29-34.05)
<0.05
History of asthma
3.83
(1.39-10.55)
<0.05
Step 3: Recognize
factors predicting
 Male gender
persistence of SDB in  Obesity
the long term
 Increasing body mass index
percentile
Goodwin et al. Incidence and Remission of SDB and
Related Symptoms in 6- to 17-y.o children.
J Pediatr 2010;157:57-61
6-11 y.o.
Over 5 years
10-18 y.o.
-70.8% remission
Snore
15%
9.7%
+10% new cases
-60% remission
AHI ≥ 1
23.9%
15.3%
+4.1% new cases
Goodwin et al. Incidence and Remission of SDB and
Related Symptoms in 6- to 17-y.o children.
J Pediatr 2010;157:57-61
Step 4: Assess severity
of SDB objectively (if
equipment available)
 Nocturnal polysomnography
 Nocturnal polygraphy
 Nocturnal oximetry
Step 5: Determine
indications for
treatment
 Clinically important upper airway
obstruction even during
wakefulness
 AHI>5 episodes/h (or positive
screening method) irrespective of
morbidity
 AHI 1-5 and morbidity or treatable
co-existing condition
 AHI 1-5 and craniofacial
abnormalities or neuromuscular
disorders
 AHI 1-5 and risk for long-term
SDB persistence
Step 6: Stepwise  Wt control for obesity
 Antiinflammatory medications for mild
treatment
SDB prior to AT
approach for
 AT for adenotonsillar hypertrophy
SDB
 Orthodontic devices for mandibular
malpositioning, narrow maxilla
 nCPAP for i) residual SDB after AT or
orthodontic devices; ii) SDB related to
obesity, craniofacial abnormalities; iii)
neuromuscular disorders unresponsive
to other measures
 Craniofacial surgery if SDB not
responsive to orthodontic devices,
nCPAP
 Tracheostomy if all other measures fail
or while waiting for craniofacial surgery
Berlucchi et al. The Role of Mometasone Nasal Spray in
the Treatment of Adenoidal Hypertrophy.
Pediatrics 2007;119:e1392-1397
Mometasone 100 mcg/d (40 days)
vs. Placebo (40 days)
Villa et al. Randomized controlled study of an oral jawpositioning device for treatment of OSA in children with
malocclusion. AJRCCM 2002;165:123-7
Villa et al. Randomized controlled study of an oral jawpositioning device for treatment of OSA in children with
malocclusion. AJRCCM 2002;165:123-7
Before
After
Step 7:
 Follow up after each therapeutic
Follow-up,
intervention and if no response move
diagnosis
to the next intervention
and
management  Consider objective testing for
of persistent
selected children for selected
SDB
children:
-High AHI pre-treatment
-post AT in children with obesity,
craniofacial abnormalities,
neuromuscular disorders
-post orthodontic treatment
-post nCPAP
-prior to craniofacial surgery or
tracheostomy
Bhattarjee et al. AT outcomes in Treatment of OSA in
Children. AJRCCM 2010; 182:676-683
Conclusions
Intermittent upper airway obstruction
during sleep in childhood:
 Is associated with disorders affecting upper airway
resistance and pharyngeal neuromotor tone
 Is related to morbidity from the CNS and the
cardiovascular system
 Severe upper airway obstruction during sleep and
mild obstruction with morbidity or risk factors for
persistence should be treated
 All disorders leading to upper airway obstruction
should be addressed in a stepwise fashion