Transcript PEDIATRIC SLEEP APNEA Allen J Moses, DDS

PEDIATRIC SLEEP APNEA
AND ITS CLOSE RELATIVE
UPPER AIRWAY RESISTANCE SYNDROME
Allen J Moses, DDS
Assistant Professor Rush University
[email protected]
http://www.kidsapnea.com
OBSTRUCTIVE SLEEP APNEA IN
CHILDREN IS A SERIOUS PROBLEM
•ADHD
•ENEURESIS
•FAILURE TO THRIVE
•LEARNING DISORDERS
•COGNITIVE
DISORDERS
•BEHAVIORAL
DISORDERS
•DISRUPTED SLEEP
•CARDIOVASCULAR
PROBLEMS
•HYPERTENSION
•HYPOTROPHIC FACES
AND JAWS
•DELAYED
DEVELOPMENT OF
MOTOR SKILLS
•EXECUTIVE
DYSFUNCTION
ARE SOME OF THE
COMORBID SYMPTOMS
OF KIDS’ OSA
CHILDREN WITH OSA GENERATE
2.6 TIMES THE AMOUNT OF
HEALTHCARE EXPENSES AS NONOSA CHILDREN
THESE KIDS ARE NOSE BREATHERS, SLEEPING WITH THEIR MOUTHS
CLOSED. THEIR TONGUE IS IN THE ROOF OF THE MOUTH FACILITATING
NORMAL GROWTH OF THE PALATE, BROAD DENTAL ARCHES STRAIGHT
TEETH AND BEAUTIFUL SMILES
THESE KIDS ARE SLEEPING WITH THEIR MOUTHS OPEN. NASAL BREATHING IS OBSTRUCTED.
THEY ARE MOUTH BREATHERS. THE TONGUE IS IN THE FLOOR OF THE MOUTH . THIS WILL
AFFECT THE POSITION OF THEIR DEVELOPING TEETH
THE AIRWAY COLLAPSES DURING AN
APNEA EPISODE IN SLEEP
CHILDREN WHO HAVE OSA HAVE
SMALLER AND MORE OBSTRUCTED
AIRWAYS THAN NON-OSA CHILDREN
THE SAME STRUCTURAL AND
FUNCTIONAL PROBLEMS CREATED
BY AIRWAY OBSTRUCTIONS
DURING SLEEP RESULT IN
INTERMITTENT HYPOXIAS AND
HYPERCARBOXIAS IN CHILDREN
THESE SAME CONDITIONS EXIST
DURING THE DAY AND AFFECT
GROWTH, POSTURE, OROFACIAL
STRUCTURE AND FUNCTION,
NEUROLOGICAL AND
CARDIOVASCULAR FUNCTION,
LEARNING ABILITY AND BEHAVIOR
THE GOLD STANDARD FOR
DIAGNOSIS OF SLEEP DISORDERED
BREATHING IS A
POLYSOMNOGRAPHIC STUDY
PERFORMED AT A SLEEP LAB
1. UARS IS MORE COMMON IN KIDS THAN OSA
2. FLOW LIMITATION (UARS) CAN BE MEASURED WITH NASAL PRONGS
3. MILD CRANIOFACIAL
DEVELOPMENTAL ANOMALY IS
OFTEN SEEN IN KIDS WITH UARS
4. EXAMINATION TO ASSESS THE NEED FOR ORTHODONTICS
IS THE SUBJECT OF TODAY’S LECTURE
TODAY WE ARE
DISCUSSING
DIAGNOSTIC
FACTORS FOUND ON
EXAMINATION THAT
SUGGEST
CONSERVATIVE
TREATMENT AND/OR
PREVENTION
EARLY RECOGNITION AND PREVENTION ARE THE KEY WORDS
FAILURE TO TREAT SLEEP
DISORDERED BREATHING IN
CHILDREN PUTS THEM AT RISK
FOR VERY SERIOUS HEALTH
PROBLEMS LATER IN LIFE
THE EVIDENCE IS INDISPUTABLE
THAT EARLY DIAGNOSIS AND
TREATMENT OF SLEEP BREATHING
DISORDERS IN KIDS IS MANDATED
THERE IS STRONG EVIDENCE THAT NO
ONE TREATMENT MODALITY GETS
1OO% SUCCESSFUL RESULTS
THIS LECTURE EMPHASIZES
MULTIDISCIPLINARY INVOLVEMENT
•PEDIATRICIAN
•SLEEP SPECIALIST
•ALLERGIST
•SURGEON
•NEUROLOGIST
•DENTIST
•MYOFUNCTIONAL
THERAPIST
•PULMONOLOGIST
ADENOTONSILLECTOMY IS THE FIRST
LINE TREATMENT FOR KIDS’ OSA
•CURE RATE 80% DEFINED AS DISAPPEARANCE OF
SIGNS AND SYMPTOMS, NORMALIZATION OF
RESPIRATORY MEASURES
•20% PERSISTANCE OF OSA
•T&A DOES NOT ADDRESS ACCOMPANYING
SYMPTOMS SUCH AS ALLERGIES, DYSFUNCTIONAL
REFLEX PATTERNS OF SWALLOWING, MOUTH
BREATHING AND OROFACIAL HYPOPLASIA,
INFLAMED, ENLARGED, INFECTED
TONSILS AND ADENOIDS ARE NOT THE
CAUSE OF OSA
•KIDS WITH OSA AT NIGHT DO NOT OBSTRUCT
DURING THE DAY
•REPEATED STUDIES HAVE NOT BEEN ABLE TO
RELATE THE SIZE OF T & A TO INCIDENCE OF OSA
•ALL KIDS WITH ENLARGED T & A DO NOT HAVE
OSA
•THERE ARE KIDS WITH VERY SMALL T & A WHO
HAVE OSA
•THERE ARE KIDS WITH OSA WHOSE OSA PERSISTS
AFTER T & A
FAILURE TO THRIVE
• DYSPHAGIA DUE TO HYPERTROPHIC
TONSILS AND ADENOIDS MAY CAUSE
OLFACTORY CHANGES
•INCREASED RESPIRATORY EFFORT LEADS
TO INCREASED METABOLIC EXPENDITURE
•HORMONAL BINDING FACTORS SUCH AS
INSULIN GROWTH FACTOR-1 DECREASE
APPETITE
EARLY DIAGNOSIS AND TREATMENT AVERT
SERIOUS MORBID AND IRREVERSIBLE
CONSEQUENCES
CARDIOVASCULAR CONSEQUENCES OF OSA
• KIDS WITH OSA ARE 3X MORE LIKELY TO HAVE
HYPERTENSION
• THE ELEVATION OF B.P. IN KIDS IS PROPORTIONATE
TO THE SEVERITY OF OSA
• OSA IN KIDS PREDICTS CARDIOVASCULAR RISKS
LATER IN LIFE
• C-REACTIVE PROTEIN INCREASES IN KIDS WITH OSA,
IS SENSITIVE MARKER FOR SYSTEMIC
INFLAMMATION
• INFLAMMATION CONTRIBUTES TO ENDOTHELIAL
DYSFUNCTION, VASO CONSTRICTION, AND
ATHEROSCLEROSIS
BY AGE 4, 60% OF FACIAL GROWTH IS COMPLETE
BY AGE 6, 80% OF FACIAL GROWTH IS COMPLETE
BY AGE 11, 90% OF FACIAL GROWTH IS COMPLETE
(WHEN THE SECOND MOLARS HAVE ERUPTED)
•ORTHODONTIC TX AFTER AGE 12
VIRTUALLY ASSURES RELAPSE
•EARLY ORTHODONTICS ADDRESSES
BREATHING, SWALLOWING AND POSTURE
PROBLEMS AS WELL AS MAKING MORE
BEAUTIFUL FACES
APNEIC KIDS CANNOT WAIT UNTIL AGE 12
OR OLDER TO BREATHE PROPERLY
KIDS ARE HAPPIER, SMARTER AND BETTER
BEHAVED WHEN THEY SLEEP WELL
ORTHODONTICS AT AS EARLY AN AGE AS
POSSIBLE TAKES ADVANTAGE OF GROWTH
AND REAPS HUGE PSYCHOLOGICAL AND
PHYSIOLOGICAL GAINS FOR THE CHILD
PALATAL EXPANSION
•CREATES MORE SPACE IN THE MOUTH FOR THE
TONGUE
•FACILITATES POSITIONING THE TONGUE
ANTERIORLY AND IN THE ROOF OF THE MOUTH
•WIDENS THE NASAL PASSAGE & FACILITATES
NASAL BREATHING (ROOF OF THE MOUTH IS THE
FLOOR OF THE NOSE)
•DECREASES NASAL RESISTANCE AND
COLLAPSIBILITY OF THE NASAL PASSAGES
KIDS WHOSE AIRWAYS DO NOT COLLAPSE AT
NIGHT AS A RESULT OF PALATAL EXPANSION ALSO
ENJOY IMPROVED BREATHING DURING THE DAY
TEETH AND DENTAL ALVEOLI LIE IN A
POSITION OF BALANCE BETWEEN CHEEKS
LIPS AND TONGUE
• IDEALLY THE TONGUE IS IN CONTACT WITH THE
ROOF OF THE MOUTH AT REST, DURING
SWALLOWING AND NASAL BREATHING
• INTERVENTIONS THAT DISRUPT NASAL
BREATHING CAUSE OPENING OF LIPS, LOW
TONGUE POSITION, HEAD FORWARD POSTURE
AND MALOCCLUSIONS
BREATHING IS A PRIMAL FUNCTION
NECESSARY FOR SURVIVAL
THE RESPIRATORY CENTRAL PATHWAY
MAINTAINS THE PATENT AIRWAY AND
DOMINATES REFLEX CONTROL OF THE
OROPHARYNX
IT SUPERCEDES ALL OTHER REFLEXES
HUMAN BEINGS ARE OBLIGATE
NASAL BREATHERS
•THE MOUTH IS MERELY A BACK-UP BREATHING ORGAN
•THE NOSE IS IDEAL FOR WARMING, FILTRATION AND
HUMIDIFICATION OF INHALED AIR
•WITH NASAL OBSTRUCTION THE LIPS MUST PART TO
ALLOW AIR TO ENTER THE MOUTH
•THE TONGUE MUST LOWER ITSELF TO ALLOW AIR INTO
THE PHARYNX
•HYOID BONE LOWERS
•MANDIBLE BECOMES RETROGNATHIC
•AIRWAY NARROWS
•HEAD ASSUMES A MORE FORWARD POSITION ON
SPINAL COLUMN
NOSE BREATHER VS MOUTH BREATHER
SNIFF TEST: CLOSE YOUR LIPS TAKE A BREATH THROUGH
YOUR NOSE AS DEP AND AS FAST AS YOU CAN
MOUTH BREATHER:
NARES CONSTRICT
NOSE BREATHER: NARES FLARE
THE LOW TONGUE POSITION AND
MOUTH BREATHING, ONCE LEARNED
BECOME THE DOMINANT REFLEX
CHILD’S HABITUAL OPEN MOUTH AND
DYSPHAGIA ARE DYSFUNCTIONAL
STRUCTURAL AND POSTURAL
CHANGES OCCUR AS A RESULT
THE LOWERED TONGUE POSITION
THE NARROWING OF THE AIRWAY
AND SUBSEQUENT INCREASED
COLLAPSIBILITY DURING SLEEP
PREDISPOSE TO
PEDIATRIC OSA, SNORING AND
UARS
REFLEXES FROM THE
OROPHARYNGEAL AREA PROTECT
THE ANTERIOR PORTAL OF THE
GASTROINTESTINAL TRACT
•TRANSPORT OF FOOD AND LIQUIDS
•AIRWAY FOR GASEOUS EXCHANGE BY
THE LUNGS
•PROTECTION OF LUNGS FROM
ASPIRATION OF FOOD AND LIQUIDS
THE SWALLOW IS THE MOST COMPLEX
REFLEX ACTIVITY THE HUMAN
NERVOUS SYSTEM PERFORMS
THE TEETH TOUCH IN A POSITION OF
MAXIMUM OCCLUSION
THE LIPS ARE SEALED AND THE
TONGUE PROPULSES THE BOLUS
DISTALLY AGAINST THE PALATE
THE HEAD IS BRACED ON THE SPINAL
COLUMN AND DOES NOT MOVE
KIDS HAVE COMPENSATORY REFLEXES
IN ADDITION TO MOUTH BREATHING
THAT RESPOND TO OBSTRUCTED
NASAL BREATHING
THEY INVOLVE ABNORMAL ADAPTIVE
LIP, TONGUE AND HEAD POSTURES
THAT ALTER NORMAL FACIAL GROWTH
MOUTH BREATHER, LIPS APART AT REST, CHRONIC DRY CHAPPED LIPS
STRAINED FACIAL MUSCLES TO ATTAIN LIP CLOSURE. NOTE LOWER LIP PUSHING IN
MALOCCLUSION EVIDENT ON SMILE
LIPS PUSHED LOWER TEETH IN. TONGUE PUSHED UPPER TEETH OUT
NATURAL REST POSITION
SWALLOWING – NOTE LIPS
ANTERIOR
TONGUE THRUST
REST POSITION
WALLOWING
E STRAINED LIPS
THERE IS MORE TO LOOK AT IN
KIDS’ BREATHING THAN PSG
•LIP POSTURE – RELATES TO SPEECH, SWALLOW
AND BREATHING
•SWALLOW – RELATES TO HEAD MOVEMENT AND
TOOTH POSITION
•HEAD POSTURE – RELATES TO SWALLOW AND
BREATHING
•TEETH – REFLECT LIP POSTURE, ORAL/MOUTH
BREATHING, SWALLOW TONGUE POSTURE, HEAD
MOVEMENT
•TONGUE POSTURE - RELATES TO BREATHING,
FACIAL GROWTH , AND SWALLOWING
NORMAL ORTHODONTIC FORCE
The need to retrain deleterious muscle forces is
imperative to successful orthodontic treatment
SHORT FACE
•
•
•
•
•
•
RETROGNATHIA
DEEP OVERBITE
MANDIBULAR STEP PLANE OF OCCLUSION
LATERAL TONGUE THRUST DYSPHAGIA
REDUCED VERTICAL DIMENSION IN C.O.
REDUCED TONGUE SPACE DISTAL IN C.O.
STEP PLANE OF OCCLUSION
SHORT FACE
NOTE:
1. PROTRUDING
UPPER LIP
2. RETRUDED
LOWER JAW
3. DEEP LABIAL
GROOVE
4. LOW TONGUE
POSITION
5. THIS KID IS A MOUTH BREATHER
6. HEAD FORWARD POSTURE
LONG FACE
•
•
•
•
•
•
•
•
•
OPEN MOUTH RESTING POSTURE
LOW TONGUE POSITION
MOUTH BREATHER
OBSTRUCTION INHIBITS NASAL BREATHING
USUALLY CROSSBITE
MAYBE ANTERIOR OPEN BITE
MAYBE ANTERIOR TONGUE THUST SWALLOW
MAYBE PROGNATHIC
STRAIN NOTED TO CLOSE LIPS
LONG FACE
NOTE:
1. THE STRAINED CLOSED
LIP POSTURE
2. STRAINED MENTALIS
MUSCLE
3. NARROW NOSTRILS
INDICATIVE OF NASALLY
OBSTRUCTED
BREATHING
4. ALLERGIC SHINERS
HOW DO YOU THINK THE
TEETH LOOK ?
ALL KIDS WITH MALOCCLUSION DO NOT HAVE OSA
UNDERSTANDING THE RELATIONSHIPS BETWEEN
MALOCCLUSIONS AND BREATHING PROBLEMS MAY
INCREASE QUALITY OF LIFE AND PREVENT OSA
SURGICAL REMOVAL OF TONSILS
ADENOIDS AND OTHER
OBSTRUCTIONS TO NASAL
BREATHING DOES NOT ELIMINATE
THE LEARNED COMPENSATORY
REFLEXES FOR LIP, SWALLOW AND
TONGUE FUNCTION
THERE ARE TWO DISTINCT TYPES OF
ORAL FUNCTION – TONIC AND PHASIC
• TONIC: LIP AND TONGUE RESTING
POSTURE
• PHASIC: SWALLOWING, SPEECH AND
BREATHING
PSYCHOPHYSIOLOGIC RE-EDUCATION
OF TONIC FUNCTION
• GETTING THE TONGUE TO STAY IN
THE ROOF OF THE MOUTH AT REST
• GETTING THE LIPS TO STAY
TOGETHER AT REST WITH THE
PATIENT BREATHING THROUGH THE
NOSE
PSYCHOPHYSIOLOGICAL REEDUCATION OF PHASIC FUNCTION
• IN A CORRECT SWALLOW, TONGUE AGAINST THE
ROOF OF THE MOUTH PROPULSES THE BOLUS OF
FOOD BACKWARD
• TEETH TOUCH IN CENTRIC OCCLUSION DURING A
SWALLOW TO BRACE THE HEAD ON THE SPINAL
COLUMN
• LIPS TOUCH AND ARE UNSTRAINED
• HEAD IS HELD IN A STEADY POSITION ON SPINAL
COLUMN AND DOES NOT MOVE DURING A
SWALLOW
FLUTTER DVD