obstructive sleep apnea in childhood and its cardiovascular effects a. kaditis, md
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Obstructive Sleep Apnea in Childhood and its Cardiovascular Effects A. Kaditis, MD. University of Thessaly School of Medicine and Larissa University Hospital Department of Pediatrics and Sleep Disorders Laboratory. Obstructive Sleep Apnea in Childhood. Clinical Presentation and Etiology. - PowerPoint PPT PresentationTRANSCRIPT
Obstructive Sleep Apnea in Childhood and its Cardiovascular Effects
A. Kaditis, MD
University of Thessaly School of Medicine and Larissa University Hospital
Department of Pediatrics and
Sleep Disorders Laboratory
Clinical Presentation and Etiology
Obstructive Sleep Apnea in Childhood
Obstructive Sleep Apnea in Childhood Clinical Presentation
Snoring Apnea Mouth breathing Restless sleep Frequent arousals
Obstructive Sleep Apnea in Childhood Adenoidal-Tonsillar Hypertrophy
Pathogenesis
Obstructive Sleep Apnea in Childhood
Inspiration: The Thoracic Pump
0 cmH2O
-5
-10
Airway Diameter and Respiratory Phase
EXPIRATION INSPIRATION
OSA: Airway-Adenoids-Tonsils (Arens R, et al. AJRCCM 2001;164:698)
Obstructive Sleep Apnea in Childhood-Pathogenesis Model
Pathophysiology
Obstructive Sleep Apnea in Childhood
Intermittent Upper Airway Obstruction and Gas Exchange Abnormalities
Hypercapnia Hypoxia
Cardio-Respiratory Interactions
Respiratory Dysfunction
↕
Cardıac Dysfunction
Upper Airway Obstruction and Cardiac Function
OSA
Defense of the Central Nervous System to Upper Airway Obstruction
Arousal from Sleep
And
Increase in Tone of Pharyngeal Muscles
OSA and Cardiovascular System
Obstructive Sleep Apnea in Childhood
AHI Odds ratio
0-1.3 1.0
1.4-4.4 0.98
4.4-11 1.28
> 11 1.42
Shahar et al. Sleep-Disordered Breathing and Cardiovascular Disease.
AJRCCM 2001;163:19-25
OSA-CV disease-Pathogenesis Quan and Gersh. Circulation 2004;109:951
Obstructive Apnea-Hypopnea
Hypoxia Arousals ↓ Intrathoracic Pressure
Oxidative stress↑ Sympathetic
tone
Endothelial dysfunction-
↓arterial distensibility
Inflammation- metabolic
disturbances
BP abnormalities
Δ in cardiac structure-function
OSA and Inflammation
Obstructive Sleep Apnea in Childhood
Obstructive SDB and CRP Levels in Children
CRP
AHIAHI
Tauman et al. Pediatrics 2004;113:e564
Kaditis et al. AJRCCM 2005;171:282
Log
CRP
AHIAHI
Larkin et al. CRP and AHI: Threshold EffectsCirculation 2005;111:1978
Kaditis et al. Fibrinogen in Children with Sleep-Disordered Breathing. Eur Respir J 2004; 24:790
AHI>5AHI<5Controls
Fib
rin
og
en
(m
g/d
L)
600
400
200
0Kruskal-Wallis
P = 0.002
114 children
3-10 yo
OSA and Insulin Resistance
Obstructive Sleep Apnea in Childhood
de la Eva R, et al. Metabolic Correlates with OSA in Obese Subjects. J Pediatr 2002; 140: 654-9
AHI ≥ 5 AHI < 5
-0.5
0
0.5
1
1.5
2
50 100 150
Relative BMI (%)
Log
insu
lin
Kaditis A, et al. Obstructive SDB and Fasting Insulin Levels in non-Obese Children. Pediatr Pulmonol 2005;40:515
110 children
2-13 yo
Tauman R, et al. Obesity determines Insulin Resistance in Snoring Children. Pediatrics 2005; 116: e66
135 children
8.9 ± 3.5 yo
OSA and Blood Pressure
Obstructive Sleep Apnea in Childhood
BP in Children with OSA
Marcus et al. AJRCCM 1998;157:1098
Kaditis et al. Morning BP in Children referred for Polysomnography.American Thoracic Society Meeting 2006
164 children
2.9-15 yo p < 0.01
Diastolic BP Index
(%)
p < 0.01
AHI≥5 1≤AHI<5 AHI<1
p < 0.01
Elevated Diast BP
For AHI>5 OR 6.9
For 1<AHI<5 OR 3.3
Kaditis et al. BP and Habitual SnoringPediatr Pulmonol 2005;39:408
760 children
4-14 yo
OSA and Cardiac Function
Obstructive Sleep Apnea in Childhood
A. Tal, et al. Ventricular Dysfunction in Children with OSA. Pediatr Pulmonol 1988; 4: 139
Amin et al. Left Ventricular Hypertrophy in Children with OSAAJRCCM 2002; 165:1395
28 subjects with OSA 19 subjects with Primary Snoring Left Ventricular Mass Index higher in OSA AHI significant predictor of
Left Ventricular Mass Index
Amin et al. Left Ventricular Function in Children with SDBAm J Cardiol 2005; 95:801
25 children with AHI>5 23 children with AHI=1-5 15 children with AHI<1 Left Ventricular Mass Index higher in OSA AHI significant (negative) predictor of
Left Ventricular Diastolic Function
Kaditis et al. Nocturnal Cardiac Strain in Children with Obstructive SDB. American Thoracic Society Meeting 2006
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
0 10 20 30
AHI (episodes/hour)
log
BN
P r
atio
AHI ≥ 5 AHI < 5 Controls
R =0.29; p < 0.05
Conclusions-Research Questions
Pediatric SDB is related with mechanisms predisposing to CV morbidity in adulthood
Unknown threshold of SDB severity above which associated morbidity