Transcript Childhood Obstructive Sleep Apnea Syndrome

Childhood Obstructive Sleep Apnea
Syndrome
New Recommendations For Diagnosis and
Management
By
Dr. MAHMOUD HUSSEIN
INTRODUCTION
Obstructive sleep apnea syndrome ( OSAS) is a
common condition in childhood and can result in
severe complications if left untreated. OSAS occurs
in children of all ages, from neonates to adolescents.
However, it is most common in preschool-aged
children, which is the age when the tonsils and the
adenoids are the largest in relation to the underlying
airway size In August 27, 2012, the American
Academy of Pediatrics ( AAP) published a practice
guideline for the diagnosis and management of
uncomplicated childhood OSAS .
DEFINITION
OSAS in children is defined as a “disorder of breathing during
sleep characterized by prolonged partial upper airway
obstruction and/or intermittent complete obstruction
(obstructive apnea) that disrupts normal ventilation during sleep
and normal sleep patterns.
Prevalence rates of OSAS range from 1.2% to 5.7% worldwide.
in children , the symptoms of OSAS are often subtle and do not
exhibit uniquely specific features that would make such
symptoms immediately recognizable.
Conditions Associated With OSAS in
Children
 Adenotonsillar hypertrophy
 Obesity
 Allergic Rhinitis, Asthma
 Sickle cell disease,
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 Micrognathia,Down syndrome
 Craniofacial syndromes (Treacher-
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Collins, midfacial hypoplasia,
Crouzon syndrome, Apert syndrome,
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Pierre Robin sequence, etc
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 Achondroplasia,
Mucopolysaccharidoses, Macroglossia
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Myelomeningocele
Neuromuscular disorders
(Duchenne muscular dystrophy,
spinal muscular atrophy, etc)
Cleft palate repair and
velopharyngeal flap
Foreign body, Cerebral palsy
Vascular hemangioma and other
tumors
Nasoseptal obstruction, Prematurity
Pathophysiology
 Disordered breathing during sleep is a hallmark of OSAS. Breathing
abnormalities include apnea and hypopnea
 The ability to maintain upper airway patency during the normal
respiratory cycle is the result of a delicate equilibrium between the
forces that promote airway closure and dilation. The 4 major
predisposing factors for upper airway obstruction are the following:
-Anatomic narrowing
-Abnormal mechanical linkage between airway dilating
muscles and airway walls
-Muscle weakness
-Abnormal neural regulation
 Recurrent episodes of upper airway obstruction typical of
OSAS will result in intermittent hypoxia, hypercapnia,
and significant swings of intrathoracic pressures, all of
which may lead to disturbances in autonomic function.
 autonomic dysfunction are one of major underlying
processes ultimately leading to sustained increases in
vasomotor tone in patient s with OSAS, leading to
systemic hypertension.
Symptoms and Signs of OSAS
History
Frequent snoring ( ≥3 nights/wk)
Labored breathing during sleep
Gasps/snorting noises/observed
episodes of apnea
Sleep enuresis (especially secondary enuresis)
Sleeping in a seated position or with the neck
hyperextended
Cyanosis
Headaches on awakening
Daytime sleepiness
Attention-deficit/hyperactivity disorder
Learning problems
Physical examination:
Underweight or overweight
Tonsillar hypertrophy
Adenoidal facies
Micrognathia/retrognathia
High-arched palate
Failure to thrive
Hypertension
complications
Morbidities can generally be divided into the 4 following
immediate consequences of upper airway obstruction
during sleep:
 •Sleep fragmentation
 •Increased work of breathing
 •Alveolar hypoventilation
 •Intermittent hypoxemia
A. Cardiovascular Complications
 • Right heart strain
 • Reduced right ventricular ejection fraction
 • Right ventricular hypertrophy
 • Leftward shift of the interventricular septum
 • Cor Pulmonale
 • Systemic hypertension
B. Growth
 poor growth and failure to thrive. Post treatment, sleeping energy
expenditure decreased and weight increased. Treatment of OSAS
results in increases in weight and height, even in children who were
initially obese.
C. Cognitive and Behavioural
 The AAP Subcommitee on OSAS pooled 6 cross-sectional studies that
examined the cognitive and behavioural abnormalities in childhood
OSAS. Abnormalities include
- decreased school performance, inattention, excessive daytime sleepiness,
aggression, hyperactivity and ADHD.
- Young children who snore loudly and frequently are at higher risk for
having lower grades in school several years after the snoring has
resolved. These findings suggest that the adverse neurocognitive outcome
and diminished academic performance in sleep disordered breathing may
be only partially reversible,
- particularly when the sleep disordered breathing occurs during critical
phases of brain growth and development.
Differential Diagnoses
1.simple snoring, usually not accompanied by oxygen desaturation,
hypercapnia, or sleep disruption. Overnight polysomnography can be
performed to differentiate
2.Daytime somnolence: Chaotic sleep schedules with inconsistent
bedtimes and rise times , Narcolepsy.
3.Chronic Fatigue Syndrome
4.Congenital Stridor
5.Nocturnal Gastroesophageal Reflux
6.Sleep Disorder: Night Terrors, Nightmares
Effeective strategies for evaluation of OSAS
 1. history
 2.physical examination
 3.testing:
- polysomnography
- Apnea Hypopnea Index
- Daytime Nap Studies
- Overnight Oximetry
- Anteroposterior and Lateral Neck Radiography
- Thyroid-Stimulating Hormone and Thyroxine
- Multiple Sleep Latency Test (MSLT)
Polysomnography
 Polysomnography remains the criterion standard for
establishing the diagnosis of (OSA) in infants, children, and
adults. Ideally, polysomnography should be performed
overnight and during the patient's usual bedtime.
 Polysomnography is necessary to document obstructive sleep
apnea and gauge its severity. A history of snoring alone is not
adequate for making a diagnosis of obstructive sleep apnea or
for determining its seriousness.
Polysomnography provides the following measures:
 •Sleep state (≥2 EEG leads)
 •Electrooculogram (right and left)
 •Submental electromyelogram (EMG)
 •Airflow at nose and mouth (thermistor, capnography, or mask and
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pneumotachygraph)
•Chest and abdominal wall motion (impedance or inductance
plethysmography)
•Electrocardiogram (preferably with R-R interval derivation technology)
•Pulse oximetry (including a pulse waveform channel)
•End-tidal carbon dioxide (sidestream or mainstream infrared sensor)
•Video camera monitor with sound montage (analog or digital)
•Transcutaneous oxygen and carbon dioxide tensions (in infants and
children < 8 y)
Apnea Hypopnea Index
 polysomnographic-derived index known as the apnea
hypopnea index (AHI). The AHI is the total number of apneas
and hypopneas that occur divided by the total duration of
sleep in hours. An AHI of 1 or less is considered to be normal
by pediatric standards. An AHI of 1-5 is very mildly
increased, 5-10 is mildly increased, 10-20 is moderately
increased, and greater than 20 is severely abnormal.
Daytime Nap Studies
 Daytime nap studies are specific, but not sensitive, in
detecting sleep apnea. This is because obstructive events
are more likely to occur during rapid eye movement
(REM) sleep than during other sleep stages, and very little
(if any) REM sleep occurs during daytime naps in
noninfants. Therefore, children with symptoms of
obstructive sleep apnea who have normal nap study
findings must undergo nocturnal polysomnography to
exclude the diagnosis. Sleep studies should be performed
without sedation
Overnight Oximetry
 Unattended home overnight oximetry has been proposed as a
screening study. However, it may miss the child with significant
obstructive sleep apnea who does not have marked episodes of
oxygen desaturation.
 Overnight pulse oximetry by itself is not adequate for establishing
the diagnosis or excluding obstructive sleep apnea in children
because it provides no information concerning sleep staging/sleep
fragmentation or carbon dioxide.
Anteroposterior and Lateral Neck Radiography:
 Neck radiography for soft tissue detail help define upper
airway anatomy and adenoid size and exclude the possibility
of rare nasal pharyngeal neoplasms.
Thyroid-Stimulating Hormone and Thyroxine:
 Thyroid function studies are useful to exclude
hypothyroidism, which is associated with tongue
enlargement, weight gain, and obstructive sleep apnea.
Multiple Sleep Latency Test (MSLT)
 If the clinical history suggests the possibility of narcolepsy,
the MSLT should be ordered in conjunction with overnight
polysomnography.
MRI of the Brain and Brainstem
A history of severe snoring, headaches, neck pain, urinary
frequency, or swallowing problems raises the suspicion of
Chiari malformation. Chiari malformations may occur in
otherwise normal children and in association with
congenital myelomeningocele. If brainstem dysfunction is
suspected, MRI is necessary. Cranial CT imaging is not
adequate to assess for brainstem and upper cervical cord
lesions.
Workup
The AAP clinical practice guideline focuses on
uncomplicated childhood OSAS associated with
adenotonsillar hypertrophy or obesity in otherwise
healthy children in the primary care setting. The AAP
subcommittee was composed of pediatricians and
experts in sleep medicine, pulmonology, otolaryngology,
and epidemiology; and liaison members from the AAP
Section on Otolaryngology-Head and Neck Surgery, the
American Thoracic Society, the American Academy of
Sleep Medicine, the American College of Chest
Physicians, and the National Sleep Foundation.
Study Synopsis and Perspective
 As part of a routine health maintenance visit, clinicians should
determine whether a pediatric patient snores, new guidelines advise.
If he or she does snore or presents with symptoms of OSAS, a more
focused evaluation is in order.
 These are among the recommendations included in updated evidencebased guidelines for the diagnosis and management of childhood
OSAS.
 "Asking about snoring at each health maintenance visit [as well as at
other appropriate times, such as when evaluating for tonsillitis] is a
sensitive, albeit nonspecific, screening measure that is quick and easy
to perform
Study Highlights
 The investigators identified 350 articles from a literature
search of relevant studies from 1999 to 2010.
 Exclusion criteria were reviews, case reports, letters to the
editor, abstracts, non–English-language studies; animal
studies; and studies of participants younger than 1 year, with
central apnea or hypoventilation syndromes, or with OSAS
related to other medical disorders.
 The investigators devised 8 key recommendations.
Recommendation #1
 At routine healthcare maintenance visits, clinicians
should ask whether children snore. If children do snore
or have signs or symptoms of OSAS, then a more focused
evaluation is warranted.
 Screening for snoring is sensitive but nonspecific.
Recommendation #2A
 Children who snore regularly and have any OSAS signs and
symptoms should undergo polysomnography or, alternatively, be
referred to a sleep specialist or to an otolaryngologist.
 The gold standard is overnight, attended, in-laboratory polysomnography.
 Specific pediatric criteria should be used.
 Polysomnography identifies the presence and severity of OSAS.
 Specialists might be able to diagnose and determine the severity of OSAS.
Recommendation #2B
 If polysomnography is not available, alternative diagnostic tests
include nocturnal video recording, nocturnal oximetry, daytime
nap polysomnography, or ambulatory polysomnography.
 Alternative tests vs polysomnography have weaker positive and
negative predictive values
 Recommendation #3
 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.
 Research is needed to identify which obese children are most likely to
benefit from adenotonsillectomy.
 The benefits and risks associated with adenotonsillectomy are preferable
compared vs those of other treatment options.
Recommendation #4
 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.
Recommendation #5
 Patients should be reassessed for OSAS signs and
symptoms after therapy to determine if further
treatment is needed.
 The usual recommended time for re-evaluation is 6 to 8 weeks
after treatment.
 Persistent symptoms should be assessed by objective testing or
by a sleep specialist.
Recommendation #5B
 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.
Recommendation #6
 Patients should be referred for CPAP management if
OSAS signs or symptoms or objective evidence persists
after adenotonsillectomy or if adenotonsillectomy is not
performed.
 CPAP is the most effective treatment of persistent postoperative
OSAS.
 Alternative treatment is needed if adherence is suboptimal, even
after behavioral modification methods are used.
Recommendation #7
 In addition to other treatment, weight loss is recommended in
children with OSAS who are overweight or obese.
 Weight loss relieves OSAS, but it is a slow and unreliable method.
Recommendation #8
 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.
Treatment
 Adenotonsillectomy: Adenotonsillectomy, along with weight normalization, is
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considered the first line of therapy in children and adolescents with
obstructive sleep apnea.
Dietary restrictions: if obesity complicates obstructive apnea
Positive-Pressure Ventilation
Oral Appliances :assist in bringing the lower jaw and tongue forward during
sleep, thus improving obstructive sleep apnea. These devices are expensive,
require special dental expertise, and are associated with frequent adverse
effects such as jaw pain and temporal mandibular joint dysfunction. Small
growing children are likely to outgrow appliances, necessitating refitting and
replacement.
Nasal Fluticasone: administered daily for 6 weeks is shown to ameliorate the
frequency of obstructive events in children with mild-to-moderate
obstructive sleep apnea due to tonsil or adenoid hypertrophy by about one
half.
Uvulopalatopharyngoplasty successful in relieving obstructive sleep apnea
only if the major site of obstruction is localized to the soft palate
Tongue Reduction
Clinical Implications
 Updated guidelines by the AAP recommend that all children
be screened for snoring. The recommended diagnostic test
for OSAS in children who snore and who have signs or
symptoms of OSAS is polysomnography.
 The first-line treatment of childhood OSAS is
adenotonsillectomy for children with adenotonsillar
hypertrophy.
 Other treatments include CPAP if adenotonsillectomy is not
performed or if persistent postoperative OSAS is present,
weight loss for overweight or obese children, and intranasal
corticosteroids for mild OSAS if adenotonsillectomy is
contraindicated or if mild postoperative OSAS is present.