Pediatric Sleep Apnea

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23 Φεβ 2014 (πριν από 3 χρόνια και 3 μήνες)

60 εμφανίσεις

P
RESENTER
: S
RI

K
I RAN

C
HENNUPATI
, MD, PGY
-
5

F
ACULTY

D
I SCUSSANT
: R
ALPH

W
ETMORE
, MD

Pediatric Sleep Apnea


I
NTRODUCTI ON


D
EFINITIONS


S
IGNIFICANCE


D
IAGNOSIS


E
PIDEMIOLOGY


R
ISK

F
ACTORS


P
ATHOPHYSIOLOGY


M
ANAGEMENT


S
PECI AL

P
ATI ENTS

WI TH

S
LEEP

A
PNEA


S
EVERE

OSA


C
OMPLICATED

PATIENTS


C
LEFT

P
ATIENTS


D
OWN

S
YNDROME


C
ONCLUS I ONS


D
I S CUS S I ON

Objectives


THE

FAT

BOY

RETURNED
,
SLUMBERI NG

AS

PEACEABLY

I N

HI S

DI CKEY
,
OVER

THE

STONES
,
AS

I F

I T

HAD

BEEN

A

DOWN

BED

ON

WATCH

SPRI NGS
.

B
Y

SOME

EXTRAORDI NARY

MI RACLE

HE

AWOKE

OF

HI S

OWN

ACCORD
,
WHEN

THE

COACH

STOPPED
,
AND

GI VI NG

HI MSELF

A

GOOD

SHAKE

TO

STI R

UP

HI S

FACULTI ES
,
WENT

UPSTAI RS

TO

EXECUTE

HI S

COMMI SSI ON
.”

- -
C
HARLES

D
I CKENS

Introduction

Definitions


Sleep
-
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.


Disrupts normal ventilation.


Disrupts normal sleep patterns.

Significance


Significance


Daytime somnolence


Motor Vehicle Accidents


Cognitive dysfunction


Behavioral problems


ADHD


Impaired work performance


Impaired school performance


Metabolic effects


Insulin resistance


Type II diabetes


Metabolic Syndrome


Cardiovascular morbidity


Pulmonary Hypertension


Cor

Pulmonale


Systemic Hypertension


Stroke


Failure to Thrive


Rarely a presenting symptom now


Death


Hypothesized to be involved with SIDS

Diagnosis


History & Physical


Sleep history screening for snoring should be
part of routine health care visits.


OSA unlikely in absence of snoring.


If snoring history elicited should obtain more
detailed sleep history.


Including: labored breathing, apneas,
diaphoresis, enuresis, cyanosis,
behavior/learning problems.


Audio taping/Video taping


Discrepancies from different centers make this
method unreliable.


Abbreviated (Nap) Polysomnography


High PPV but Low NPV.


Useful if results are positive.


False positive results in patients with coexistent
medical problems (obesity, asthma).


Polysomnogram (PSG)


“Gold Standard.”


Can assess severity of SDB.


Includes EEG, EKG, EOG, EMG, saturation
monitor, respiratory effort and airflow monitor.


Diagnosis


Apnea


Any pause in respiration.


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.



AHI or RDI of 1 to 5 events per
hour is most often used to
identify children with OSA.


Versus
>

5 events in adults.

Epidemiology


Most studies showed 0.2% to
4.0% 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.


A significant proportion of
patients with primary snoring
will have resolution of this
symptom.


Only a small proportion of
patients that do not snore will
develop this habit.





Meta
-
analysis of almost 48 studies
evaluating

the
frequency of snoring, OSA and SDB in various
pediatric cohorts.

Epidemiology

Pediatric
OSA

Adult OSA

Age

Preschool

Elderly

Gender

Equal

M>F

Etiology

Adenoid/

Tonsil

hypertrophy

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

Review article that focuses on the difference
between pediatric and adult OSA from a
physiological development perspective.

Risk Factors

Cohort of 399 pediatric patients in the greater
Cleveland area aged 2
-
18 years investigated by
home
-
PSG.

Pathophysiology

Complications

Review article describing the consequences and
end
-
organ morbidity associated with pediatric OSA.

Pathophysiology

Review article from describing the mechanisms of
airway resistance during sleep in children with
OSA.

Pathophysiology

Large pediatric cohort of the Louisville, Kentucky
Jefferson County Public School system of children
aged 5
-
7 years. 378 randomly of those that snored
underwent PSG.

Pathophysiology

Cohort of 700 children from kindergarten to 5
th

grade of the Dauphin County public school system
in Hershey, Pennsylvania that underwent overnight
PSG.

Pathophysiology

Study from Cincinnati of 92 patients undergoing
adenotonsillectomy that underwent noninvasive
measurements of cerebral oxygenation during sleep
and wake periods.

“T
O

KNOW

EVEN

ONE

LI FE

HAS

BREATHED

EASI ER

BECAUSE

YOU

LI VED
. T
HI S

I S

TO

HAVE

S
UCCEEDED
.”

- -
R
ALPH

W
ALDO

EMERSON

Management

Positive Pressure Ventilation

Review of the literature of 5 prospective trials of
CPAP for OSA and explores mechanisms of its
beneficial effects.

Positive Pressure Ventilation


Effects


Local and Systemic Anti
-
inflammatory effects.


Restore sleep pattern.


Promote weight loss.


Suppress leptin secretion
in adipose tissue.


Improve cardiac function.


Suppress acid reflux.


Decrease airway hyper
-
responsiveness.

Positive Pressure Ventilation


Advantages


Avoids perioperative complications of adenotonsillectomy.


But does have localized/temporary effects from
equipment such as nasal irritation, skin breakdown.


May serve as a “bridge” preoperatively until surgery to
reduce morbidity.


Can be used postoperatively for residual OSA.


Useful in obese and complex patients.


High flow nasal cannula recently shown to also be
effective.



Disadvantages


Poor compliance


>
3
-
4h of use per night is considered good compliance.


Estimated at only 50
-
60%.


Children require more sleep than adults; therefore
such limited use may not be adequate.


Requires training for parents as well as patients.


Lifelong use required.


Risk for aspiration of stomach contents.


Very young.


Significant GERD.


Neuromuscular weakness.

Adenotonsillectomy


Exclusion Criteria


Children with BMI > 95
th

percentile.


Children with developmental
delay or neuromuscular
disease.


Children with craniofacial
syndromes or asthma.


All children showed
improvement in respiratory
parameters after surgery.


82% of children had
resolution of OSA (to AHI
<5).


Improvement in all fields of
OSA
-
18 .


Prospective Cohort Study of 79 patients that
underwent adenotonsillectomy w/ monopolar
cautery and suction ablation followed by PSG
3
-
6 months postoperatively.

Adenotonsillectomy


Prospective Cohort Study of 79 patients that
underwent adenotonsillectomy w/ monopolar
cautery and suction ablation followed by PSG
3
-
6 months postoperatively.

Adenotonsillectomy


Efficacy


AHI


Quality of life


Cognition


Pediatric Sleep Questionnaire


IQ Test


Cardiovascular Parameters


Cerebral blood flow


Hemoglobin Saturation


Pulse Rate


Pulse variability


School performance


Significant improvement in grades from 1
st

to 2
nd

grade in cohort that underwent
adenotonsillectomy.


No significant change in control group and group
that chose not to have adenotonsillectomy.


All patients started in lowest 10
th

percentile
of class.


Enuresis/Incontinence


Children with OSA have increased risk for
enuresis.


Possibly related to increased levels of BNP?


Significant decrease in nocturnal enuresis and
voids/day
after adenotonsillectomy.


Powered Intracapsular Tonsillectomy & Adenoidectomy
(PITA)


Advantages


Decreased pain compared to
extracapsular tonsillectomy.


Reduced dehydration.


Reduced need for analgesics
(narcotics).


Earlier return to normal diet.


Lower risk of hemorrhage.


Fewer exposed blood vessels.


Improves PSG and OSA
-
18 scores.



Disadvantages


Risk of tonsil re
-
growth.


Risk of recurrent tonsillitis.


Longer surgery.


Four minutes.


More blood loss.


Fifteen cc.

Powered Intracapsular Tonsillectomy & Adenoidectomy
(PITA)

Maxillary/Mandibular Distraction

Review of surgical management of pediatric OSA.

Maxillary/Mandibular Distraction


Patients with Pierre Robin
sequence or mandibular
hypoplasia have shown significant
improvement in flow limitation
with mandibular advancement.


Large meta
-
analysis of 1185 patients
included 88 tracheotomized patients
for poor airways.


78.4% decannulation rate after
distraction.


97% of children and 100% of adults
with OSA were cured of symptoms.


Patients with high
-
arched palates
or craniofacial abnormalities
resulting in maxillary narrowing
benefit from
Lefort

osteotomies
and maxillary distraction.


Can be curative.


Enlarges nasal cavity.


Enlarges lateral diameter of palate
and oropharynx.


Review of surgical management of pediatric OSA.

Tracheostomy


Tracheostomy is an effective for
upper airway obstruction.


Often avoids a difficult postoperative
course.


Provides an immediate improvement
in symptoms.


Can be used as a temporizing
measure in patients until skeletal
expansion and soft
-
tissue
reduction can be performed.


Syndromic patients


Craniosynostosis patients


Not perfect.


Complications


Stoma narrowing


Plugging


Accidental decannulation


Deleterious effect on psychosocial
function of patients and families.

Tracheostomy

This study is based on a quality of life survey sent to
patients that had either tracheostomy or sleep
apnea surgery (SAS) for OSA.

Management Algorithm

Study of 20 consecutive patients with refractory
OSA that underwent aggressive skeletal and soft
-
tissue surgery to avoid tracheostomy.

“[ P
EDI ATRI C

O
TOLARYNGOLOGI STS
]
TAKE

CARE

OF

SPECI AL

PROBLEMS

OR

SPECI AL

CHI LDREN
,
OR

BOTH
,
I N

A

SPECI AL

I NSTI TUTI ON
.”

- -
C
HARLES

D. B
LUESTONE

Special Patients with Sleep
Apnea

Complicated Patients


Risk Factors for Postoperative
Respiratory Complications in
Children with OSAS undergoing
Adenotonsillectomy


Age Younger than 3 years


Severe OSAS on PSG


FTT


Obesity


Prematurity


Recent URI


Craniofacial abnormalities


Neuromuscular disorders

Complicated Patients


Introduction


Patients at high risk for undergoing
general anesthesia and
oropharyngeal

surgery must be more thoroughly
scrutinized prior to surgery.


Asthma


CHD


Morbid obesity


Down Syndrome


CP


Craniofacial abnormalities


A double
-
edged sword because these are
the patients manifesting the worst
symptoms of OSA.


Failure to thrive


Pulmonary hypertension


Higher rate of complications because
they do not possess the reserve to easily
undergo the stress of surgery.


The multifactorial causes of upper airway
obstruction in these patients also implies
a lower probability of success.

A prospective and retrospective study examining
patients with complicated underlying medical
disorders with preoperative and postoperative
PSG.

Complicated Patients


Summary


Pre
-
op PSG when OSA suspected
with complicated medical
problems, craniofacial/
syndromic

children.


Post
-
op PSG with persistent
Sx
,
complicated medical problems,
craniofacial/
syndromic

children.


Pharyngeal surgery is effective at
treating OSA in patients with and
without complicated medical
problems.


UPPP is an alternative method to
tracheostomy in this population.


Post
-
op ICU monitoring with
overnight intubation should be
considered in this at
-
risk
population.

A prospective and retrospective study examining
patients with complicated underlying medical
disorders with preoperative and postoperative
PSG.

Severe OSA


Introduction


Children with severe OSA are
more likely to have respiratory
compromise after
adenotonsillectomy.


Overnight observation is
recommended after
adenotonsillectomy in patients
with severe OSA.


This study did not have a
control group of patients with
severe OSA that did not under
go adenotonsillectomy.


This study did not assess long
-
term efficacy of
adenotonsillectomy in severe
OSA.


Study on 29 children 1
-
18 years of age with
RDIs
>

30 that underwent
adenotonsillectomy followed by PSG 6
months postoperatively.

Severe OSA


Study on 29 children 1
-
18 years of age with
RDIs
>

30 that underwent
adenotonsillectomy followed by PSG 6
months postoperatively.

Severe OSA


Summary


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.


Study on 29 children 1
-
18 years of age with
RDIs
>

30 that underwent
adenotonsillectomy followed by PSG 6
months postoperatively.

Cleft Population


Introduction


Facial clefts (lip and palate) affect as
many as 1 in 680 live births in the
US/year.


Most attention is directed towards repairing
obvious facial deformities and correction of
speech and middle ear disease.


However, this population, with its
inherent craniofacial deformities, are
prone to multifactorial obstruction of
airways.


Nasal vestibule b/c of nasal floor closure.


Septal deviation towards non
-
cleft side.


Further in the nose, use of vomer flaps for
palatal reconstruction can thicken the palate.


Finally, VPI procedures (pharyngeal flaps
and sphincter
-
pharyngoplasties
) always
decrease the cross
-
sectional area of the
airway.



A three
-
year retrospective chart review by a tertiary
cleft and craniofacial team of 539 patients.

Cleft Population

A three
-
year retrospective chart review by a tertiary
cleft and craniofacial team of 539 patients.

Cleft Population


Roughly 1/3 improved,
1/3 remained
unchanged, and 1/3 had
worsening of PSG scores
after airway surgery.


TpA


Tonsillectomy


Flap takedown


Combination

A three
-
year retrospective chart review by a tertiary
cleft and craniofacial team of 539 patients.

Cleft Population


Summary


OSA is more common in the cleft
population (22% in this study).


Need for more detailed sleep history.


More common in syndromic cleft
population ( p < 0.001).


Source of obstruction is frequently
multifactorial.


More frequent use of pre
-
op and post
-
op PSG strongly suggested.


Complete adenoidectomy may
increased the risk of VPI in the cleft
population.


The adenoid pad may actually assist in
closure of the palate.


Many otolaryngologists perform only
a partial adenoidectomy leaving the
inferior rim of adenoid tissue to assist
with closure and speech.


A three
-
year retrospective chart review by a tertiary
cleft and craniofacial team of 539 patients.

Down Syndrome


Introduction


DS occurs in approximately 1.5 of 1000 births.


10% of mentally retarded persons.


DS children commonly have otolaryngologic
problems.


Frequent URIs, COM, HL and hypothyroidism.


They also fall into the group of children with
craniofacial and neurologic anomalies which
predispose them to OSA.


Small midface and cranium


Relatively narrow nasopharynx


Marcroglossia


Hypotonia


Tendency for obesity


Relatively small larynx


In addition, given their congenital heart defects,
they are already predisposed to
cor pulmonale
.


Known complication of prolonged OSA (part of
the Pickwickian syndrome).


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

A retrospective review of patients with a diagnosis
of Down syndrome who underwent tonsillectomy
and/or adenoidectomy.

Down Syndrome


Summary


T&A is successful in the majority of
patients with Down Syndrome (69%).


More aggressive intervention such as
UPPP, CPAP, tracheostomy are
necessary in some patients


Preoperative evaluation should include
assessment for cardiac, thyroid, and
cervical abnormalities.


Surgical planning should be based on
the severity of disease.


Follow up sleep studies are indicated to
evaluate for the need for more
aggressive treatment in patients with
persistent symptoms.


DS patients should be admitted post
-
operatively as persistent OSA and
other complications are common.


ICU monitoring is often necessary.

A retrospective review of patients with a diagnosis
of Down syndrome who underwent tonsillectomy
and/or adenoidectomy.


P
EDI ATRI C

OSA
I S

BECOMI NG

AN

I NCREASI NGLY

SI GNI FI CANT

DI SORDER
.


P
RE
-
OP

SCREENI NG

COST
-
EFFI CACY

NEEDS

TO

BE

ASSESSED
.


A
DENOTONSI LLECTOMY

I S

EFFECTI VE

I N

TREATI NG

PEDI ATRI C

OSA.


A
LGORI THMS

FOR

TREATI NG

PATI ENTS

WI TH

SEVERE

OSA
AND

SPECI AL

PATI ENT

POPULATI ONS

ARE

STI LL

BEI NG

OPTI MI ZED
.


P
OST
-
OP

PSG I
NDI CATI ONS

WI LL

CONTI NUE

TO

BE

A

TOPI C

OF

I NVESTI GATI ON

AND

CONTROVERSY
.

Conclusions

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-
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Discussion