OBSTRUCTIVE SLEEP APNEA

IN CHILDRENMOHAMED ALFAKI

Sleep-disordered breathing (SDB) refers to the clinical spectrum of repetitive episodes of complete or partial obstruction of the airway during sleep that disrupt nocturnal respiration and sleep architecture.

•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

OSA common in young children, with a peak prevalence around 2 to 8 years, and subsequent declines in frequency.

is currently estimated to affect approximately 2% to 3% of young children..

Is scored where there is >90% drop in airflow compared to pre-event baseline for >90% of the duration of the event, lasting at least two missed breaths, with continued effort in chest and abdomen.

PHYSIOPATHOLOGY

Pathophysiology:Thus, it appears that childhood OSA is a dynamic process resulting from a combination of structural and neuromotor abnormalities rather than from structural abnormalities alone. These predisposing factors occur as part of a spectrum: In some children (e.g., those with craniofacial anomalies), structural abnormalities predominate, whereas in others (e.g., those with cerebral palsy), neuromuscular factors predominate. In otherwise healthy children with adenotonsillar hypertrophy, neuromuscular abnormalities are probably subtle.

Gozal D., Simakajornboon N., Holbrook C.R.: Secular trends in obesity and parentally reported daytime sleepiness among children referred to a pediatric sleep center for snoring and suspected sleep-disordered breathing (SDB). Sleep. 29:A74 2006

Diagnosis

DAYTIME SYMPTOMS

1. MOUTH BREATHING

2. DIFFICULTY TO WAKE UP

3. MOODINESS

4. NASAL OBSTRUCTION

5. DAYTIME SLEEPINESS

6. HYPERACTIVITY

7. COGNITIVE PROBLEMS

8. MORNING HEADACHES

NIGHTTIME SYMPTOMS AND SIGNS INCLUDE

1. SNORING

2. NOISY BREATHING & SECONDARY ENURESIS

3. PARADOXICAL CHEST AND ABDOMINAL MOTION

4. RETRACTIONS & LABORED BREATHING.

5. WITNESSED APNEA

6. SWEATING

7. RECURRING NIGHTMARES

8. OPEN THEIR MOUTHS AND HYPEREXTEND THEIR NECKS TO BREATHE.

EXAMINATION

• VITAL SIGN : HYPERTENSION• GROWTH PARAMETERS : FTT OR OBESITY• NOSE :ALLERGIC RHINITIS, NASAL POLYPS,

NASAL SEPTUM DEVIATION & ADENOIDAL FACIES.• TONSILS & HIGH-ARCHED PALATE.• MICRO OR RETROGNETHIA.• SYNDROMIC FEATURES• CVS : LOUD S2

WORKUP

PSG IS THE MAIN TOOL FOR DIAGNOSIS.PULSE OXIMETRY.OTHER SUPPORTING INVESTIGATIONABGAP AND LATERAL XR.ECHO AND ECG.BRAIN MRI .

ROLE OF PSG

• PSG IS AN IMPORTANT TOOL THAT HELPS:

1. TO CONFIRM OR EXCLUDE OSAS.2. TO DETERMINE THE SEVERITY OF

OSAS AND TREATMENT STRATEGY.3. TO EXCLUDE OTHER.

OTHER OPTION?

• OXIMETRY MAY BE USED AS A SCREENING TOOL IN SELECTED POPULATIONS BUT THERE IS NO EVIDENCES SUPPORTING THE IDEA THAT OXIMETRY ALONE CAN REPLACE PSG FOR OSAS.

• POSITIVE NOCTURNAL OXIMETRY MAY BE RELATIVELY SPECIFIC FOR OSAS, BUT NEGATIVE OXIMETRY DOES NOT EXCLUDE THE DISORDER.

Treatment

Genral measures Wt reductionAvoidance of sedativesWay of sleep

• TONSILLECTOMY AND ADENOIDECTOMY IS USUALLY THE FIRST LINE OF TREATMENT FOR PEDIATRIC OSA• (EVIDENCE QUALITY: GRADE B )

•CPAP- PATIENTS SHOULD BE REFERRED FOR CPAP

MANAGEMENT IF SYMPTOMS/ SIGNS OR OBJECTIVE EVIDENCE OF OSAS PERSISTS AFTER ADENOTONSILLECTOMY OR IF ADENOTONSILLECTOMY IS NOT PERFORMED. (EVIDENCE QUALITY: GRADE B )

• TOPICAL INTRANASAL CORTICOSTEROIDS FOR CHILDREN WITH MILD OSAS IN WHOM ADENOTONSILLECTOMY IS CONTRAINDICATED OR FOR CHILDREN WITH MILD POSTOPERATIVE OSAS. • (EVIDENCE QUALITY: GRADE B)

Pediatrics. 2012 Sep;130(3):e575-80. Goldbart AD, Greenberg-Dotan S, Tal A.

•Introduction •DS occurs in approximately 1.5 of 1000 births. •10% of mentally retarded persons.   •DS children commonly have otolaryngologic problems. 

•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%

•Summary •T&A is successful in the majority of patients with Down Syndrome (69%).  •More aggressive intervention such as 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

REFERENCES

• CLINICAL PRACTICE GUIDELINE DIAGNOSIS AND MANAGEMENT OF CHILDHOOD OBSTRUCTIVE SLEEP APNEA SYNDROME PEDIATRICS VOLUME 130, NUMBER 3, SEPTEMBER 2012 .

• KENDIK PEDIATRIC PULMONOLOGY• A. KADITIS ET AL. / SLEEP MEDICINE REVIEWS 27 (2016).• PEDIATRICS. 2012 SEP;130(3): MONTELUKAST FOR CHILDREN WITH

OBSTRUCTIVE SLEEP APNEA: A DOUBLE-BLIND, PLACEBO-CONTROLLED STUDY.

• N ENGL J MED. 2013 MAY 21. A RANDOMIZED TRIAL OF ADENOTONSILLECTOMY FOR CHILDHOOD SLEEP APNEA.

THANKS A LOT AND HAVE ANICE DAY