leyla akanli, m.d. f.a.a.p f.c.c.p pediatric pulmonology and sleep medicine pediatric obstructive...

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Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

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Page 1: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

Leyla Akanli, M.D. F.A.A.P F.C.C.P

Pediatric Pulmonology and Sleep Medicine

PEDIATRIC OBSTRUCTIVE SLEEP APNEA

Page 2: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

DEFINITIONSSleep-disordered breathing (SDB) refers to the clinical

spectrum of repetitive episodes of complete or partial obstruction of the airway during sleep.Primary Snoring (PS)

Snoring without obstructive apnea, frequent arousals from sleep,

or gas exchange abnormalities.

Obstructive Hypoventilation Syndrome (OHS)

Persistent partial upper airway obstruction associated with gas

exchange abnormalities, rather than discrete, cyclic apneas.

Upper Airway Resistance Syndrome (UARS)

Increasingly negative intrathoracic pressures during inspiration

that lead to arousals and sleep fragmentation.

Obstructive sleep apnea (OSA)

Disorder of breathing during sleep characterized by prolonged

partial upper airway obstruction and/or intermittent complete obstruction.

Page 3: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

PRIMARY SNORING

Snoring is related to upper airway narrowing Can not be diagnosed on clinical basis alone PSG shows No sleep fragmentation No discrete events No desaturation No hypercapnia PSG is essential to differentiate from PS from OSA Clinical consequences of PSD is unknown

Page 4: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

UPPER AIRWAY RESISTANCE SYNDROME-UARS

Snoring is due to upper airway narrowing or floppiness Clinical history suggestive sleep fragmentation PSG shows Increased intra-thoracic pressure swings Flow limitation of nasal pressure monitoring Non –REM asynchronous breathing Increased arousals No gas exchange abnormalities PSG is essential to differentiate UARS from OSA

Page 5: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

OBSTRUCTIVE HYPOVENTILATION

Prolonged periods of partial airway obstruction More common in children than adults Clinical history similar to OSA PSG demonstrates Asynchronous breathing Absence of discrete events Sleep fragmentation Abnormal gas exchange – maybe present only during

REM sleep –Hypoxia , Hypercarbia PetCO2 > 53 torr

Page 6: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

MILESTONES

1837 – Dickens – describes overweight/hypersomnolent boy in the Posthumous papers of the Pickwick Club (term “pickwickian” used by Osler)

1907- Osler 1973-Guilleminault

W. Hill described the obstructive sleep apnea sufferer child as in 1889;

“ The stupid -lazy child who frequently suffers from headaches at school, breathes through his mouth instead of his nose, snores and restless at night and wakes up with a dry mouth in the morning is well worthy of the solicitous attention of the Scholl medical officer.”

Page 7: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

ADULT VS PEDIATRIC OSAPediatric OSA

Adult OSA

Age Preschool Elderly

Gender M=F M>F

Etiology Adenoid/Tonsilhypertrophy

Obesity

Weight FTT, normal, or obese

Obese

Behavioral Hyperactive Somnolent

Sleep architecture

Normal Decreased delta and REM sleep

Surgical Rx T&A UPPP

Medical Rx CPAP (rarely) CPAP

Page 8: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

EPIDEMIOLOGY Most studies showed 4% to 11% prevalence of parent-

reported apnea. Depending on threshold of AHI to diagnose, the

prevalence of pediatric OSA ranges from 1% to 4% in most studies.

Children with abnormal PSG that go untreated will continue to have abnormal findings.

Snoring and adverse neurocognitive, neurobehavioral outcomes

Overall prevalence of snoring in pediatric patient population 8% and 5% in infants

Always snoring in 1.5%-6%

Page 9: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

EPIDEMIOLOGY

Peaks ages two to 8 years As obesity is increasing in pediatrics the age distributed shifted Gender distribution: M>F after puberty, equal pre-puberty Prevalence is higher among African Americans and Asian children Family history Prematurity Other Co-Morbid conditions

Page 10: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

PATHOPHYSIOLOGY

Neuromotor tone• Cerebral palsy• Genetic diseases

Structural factors• Adenotonsillar hypertrophy• Craniofacial abnormality• Obesity

Other factors• Genetic• Hormonal• ? Diet, Inflammation, Passive smoking

OSA

Anatomic narrowingRequires increased inspiratory pressures

Abnormal neuromuscular controlReflex activation of dilators in response to airway obstruction often fails

Page 11: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

RISK FACTORSAdenotonsillar HypertrophyUpper airway congestion; allergies Upper airway obstruction , choanal stenosis, larnygomalacia, subglottic stenosis GER/LPR Cleft palate Craniofacial dsymorphism : Mid -facial hypoplasia –Down’s syndrome Micrognothia – Pierre-Robin syndrome Cranial base malformation- AchondroplasiaNeuromuscular disorder: Hypotonia-Down’s syndrome, Muscular dystrophy Spasticity –Cerebral Palsy OverweightSickle cell diseaseCystic fibrosisChronic lung disease/ BPDScoliosisBrain and spinal disorders – Spin Bifida, ACM type II

Page 12: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

Trisomy 21

Small midface and cranium

Relatively narrow nasopharynx

Macroglossia

Hypotonia

Tendency for obesity

Relatively small larynxIn addition, given their congenital

heart defects, they are already predisposed to cor pulmonale.

Because of these factors, the incidence of OSA in patients with DS has been estimated to be from 54% to 100%.

REDUCED MUSCLE TONE

Page 13: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

REDUCED MUSCLE TONE

Neuromuscular disease Hypothyroidism Cerebral Palsy Moebius, MG Reduced Central Ventilatory Drive

ACM type I/II

Myelomeningocele

Brainstem injury or masses

Page 14: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

MEDICAL CONDITIONS

Craniofacial syndromes

Apert

Crouzon

Pierre-robin

Treacher-Collins

Pfeiffer

Miscellaneous

Achondroplasia

Beckwith-Wiedeman

Goldenhar

Marfan

Mucopolysaccoridoses

Prader Willi

Sickle Cell Disease

Prematurity /CLD

Page 15: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA
Page 16: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

CLINICAL FEATURESNocturnal Symptoms

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

obstruction Observed apneic pauses Snorting / gasping / choking Restless sleep Diaphoresis Paradoxical chest wall movement Abnormal sleeping position SweatingMouth BreathingSecondary enuresis

Page 17: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

CLINICAL FEATURESDaytime Symptoms-Physical and Behavioral

Morning headachesDifficulty awakening in AMHyponasal SpeechNasal congestion, Chronic RhinorheaMouth breathing, Dry MouthFrequent infectionsDifficulty swallowingPoor appetiteDaytime somnolence-7-10%Mood changes Internalizing behaviorsExternalizing behaviorsADHD Like symptoms, School problems

Page 18: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

ASSOCIATED FEATURES

Increase in partial arousal parasomnias Worsening GERD Increase in seizure frequency in predisposed children Other CO-Morbid Sleep problems

RLS,PLMS

Circadian Rhythm Disorders

Bedtime resistance , nightwakings

Page 19: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

EVALUATION Medical HistoryDevelopmental and School history

Family History

Behavioral assessment

Physical ExaminationGrowth

HEENT

Cardiac examination

Diagnostic TestsFor the most part are unnecessary

Radiologic StudiesLateral Neck

Laryngoscopy

EKG/ECHO

Cine-MRI

Page 20: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA
Page 21: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

MALLAMPATI CLASSIFICATION

Page 22: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

MULLER MANEVEUR

Page 23: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

LARNYGOMALACIA

Page 24: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

SUBGLOTTIC STENOSIS

Page 25: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

GERD

Page 26: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

MRI Excellent soft tissue anatomyMultiple planesNo ionizing radiationDisadvantages

CostWeight limitationsNoisyclaustrophobia

Page 27: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

HOME OXIMETRY TESTING Readily available and relatively inexpensive Subject to presence of significant artifact Artifact reduction maybe accomplished with

simultaneous –heart rate measurement and Pletsymography waveform

Excellent positive predictive value-97%* Poor negative predictive value-47%* Disorders with predominant sleep disruption and

hypercapnia will be missed.

*Brouillette RT et al. Pediatrics 2000

Page 28: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

NAP STUDY

Child may not achieve natural sleep – REM sleep may not be captured

Severity may be underestimated- Events usually worsens as the sleep progress

Excellent positive predictive value-77-100%* Poor negative predictive value-17-49%*

Keens TG, et al.Pediatric Pulmonol 1992, &Chest 2000

Page 29: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

POLYSOMNOGRAPHY

PSG IS THE GOLD STANDARD

Meet diagnostic criteria of pediatric OSAS according to ICSD 2 Differentiate OSA from other SDB Define severity of OSAS Screen high risk children Evaluate success of treatment Titrate PAP therapy

Page 30: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

POLYSOMNOGRAPHY

It should be performed without sedation and sleep deprivation

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

pediatric PSG’s Should be interpreted by physicians with expertise in

pediatric sleep medicine

Page 31: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

Courtesy of Dr. Carol Rosen

PEDIATRIC POLYSOMNOGRPAHY

Tech Observer Video Camera

Sao2

Leg EMG (2)

Microphone

EKG

Chin EMG (2)

EEG EOG

Nasal EtCO2

Record behaviorDocuments arousals, parasomnias, abnormal sleeping position, and attends to any technical problem

Respiratory Effort

Nasal Oral Airflow

Page 32: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

PSG PARAMETERS Apnea

Any pause in respiration lasting longer than two breaths.

Versus at least 10 s in adults. Hypopnea

Reduction of airflow by 50% for two respiratory cycles accompanied by reduction of saturation by 3% or arousal from sleep.

AHI

Sum of Apneas and Hypopneas per hour of sleep. RDI

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

No universally accepted PSG normal reference values AHI >1.5 or AI >1 per hour is most often used to identify

children- up to 12 years with OSA. Oxygen saturation<91% Change in nadir 02 from baseline>9% Maximal ETCO2>54

Page 33: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

PEDIATRIC POLYSOMNOGRAPHY

In contrast to adults, children have:

Obstructive hypoventilation

Fewer obstructive apneas

Desaturation with shorter events–Higher respiratory rate–Lower functional residual capacity–Smaller oxygen store

Page 34: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

PEDIATRIC 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

Page 35: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

PARADOXICAL RIB-CAGE MOTION

HYPERCAPNIA

Page 36: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

OBSTRUCTIVE APNEA

This tracing depicts cyclic obstructive apneas

Page 37: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

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

Surgical–Adenotonsillectomy – First Line of therapy–Turbinate reduction–Craniofacial surgery- Mandibular advancement Lefort osteotomies and maxillary distraction.–Uvulopalatopharyngoplasty- Not a good idea !–Tracheostomy

Medical–Weight loss–Continuous positive airway pressure –Intranasal steroids (modest effect)-Mild patients–Leukotriene antagonist- Mild patients–Oral appliances–Positional therapy–Snore aids

Page 38: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

ADENOTONSILLECTOMY

First-line of treatment

Presence of additional risk factors not a contraindication to adenotonsillectomy

25 % residual OSA Re-assessment of high risk groups with post-operative polysomnography is recommended CHAT study –RCT 5-9 years old

Page 39: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

HIGH RISK PATIENTSRisk 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–FTT–Prematurity, CLD.–Recent URI– Morbid Obesity–Trisomy 21–Craniofacial abnormalities–Neuromuscular disorders, CP–Asthma

Page 40: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

SEVERE OSA

Children with severe OSA show a significant improvement in RDI and quality of life.

OSA does not resolve in the majority of these patients.

Postoperative PSG is recommended for all children with severe OSA.

To identify those who may

require further therapy.

Page 41: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

SEVERE OSA

Page 42: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

CPAP Almost always an alternative to surgery Surgical failure; Morbid Obesity Complex OSA Non-Surgical candidates Local and systemic anti-inflammatory effect Act as a pneumatic splint Stimulates ventilation Reduces activity of inspiratory, upper airway muscles

and diaphragm Restores sleep, promotes weight loss Improves cardiac function, Suppresses GERD Decrease AHR FDA approved for children > 30 kg

Page 43: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

CPAP

Page 44: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

CPAP-AIRWAY

Page 45: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

Management Algorithm

Page 46: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

COMPLICATIONS OF OSA

Effects on growth

Neurocognitive morbidity

Cardiovascular consequences

Metabolic

Page 47: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

IMPROVEMENT IN WEIGHT

Marcus et al. J Pediatr 1994

Girls Boys

Page 48: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

NEUROCOGNITIVE MORBIDITY

Hyperactivity, inattention, aggression

Impaired school performance

Daytime sleepiness

Depression

Page 49: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

CARDIOOVASCULAR MORBIDITY

Pulmonary Hypertension

Cor Pulmonale

Systemic Hypertension

Page 50: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

HYPERTENSION

Page 51: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

HYPERTENSION

Marcus et al. Am J Respir Crit Care Med 1998

Page 52: Leyla Akanli, M.D. F.A.A.P F.C.C.P Pediatric Pulmonology and Sleep Medicine PEDIATRIC OBSTRUCTIVE SLEEP APNEA

AAP GUIDELINES Screening of all children for snoring Specialty referral of complex high-risk patients Urgent evaluation of cardio-respiratory failure PSG as Gold Standard for diagnosis Adenotonsillectomy as first-line treatment Inpatient monitoring of high-risk patients Post-operative reevaluation to determine if additional

treatment is required