Pediatric Obstructive Sleep Apnea

Lisa Musso, ARNPSeattle Children’s Hospital

Pulmonary/Sleep DivisionRonna Smith, ARNP

Seattle Children’s HospitalOtolaryngology Division

Sleep Disordered Breathing (SDB)Dynamic imbalance between

airway patency and collapse during sleep leading to recurrent airways obstruction (partial or complete) resulting in:Gas exchange abnormalitiesCortical arousals leading to sleep

fragmentationAutonomic arousals leading to

systemic fragmentationDiagnosed by presenting

symptoms (night and day) and sleep study

Naturally occurring model of sleep fragmentation

Primary Snoring

OSAS

UARS

Notes about SDB in children

• Breathing worse in sleep, especially REMLess cortical input overallSmaller lung volumesLow muscle tone upper airway collapse, decreased amount of air

exchangeRelative immaturity of the respiratory system particularly in infantsBlunted hypoxic and hypercapnic responses

• Smallest airway to pharyngeal structure ratio is during childhood (3-6 years of age)

• Craniofacial abnormalities most impactful in infancy

Case StudyPete is a 9 month old baby

with a nearly lifetime history of nasal congestion. He is described as a ‘poor sleeper’ by mom. He wakes up at least twice per night. He snores every night, sometimes it is loud. Mom is not sure if he has apneic spells. He has trouble drinking from a bottle, was a difficult breast feeder. Mom says he pulls off the nipple often to breathe.

BEARSB: bedtime problems

Has to be rocked to sleep or have a bottle?No consistent routine?

E: excessive sleepiness/dysfunctionFussy, no nap/sleep routine?Essentially difficult to assess in an infant

A: awake after sleep onset?Night time awakenings

R: sleep routineReally non-existent

S: snoringQuality/quantity/frequency/positional/witnessed apnea

Physical ExamPete has clear rhinitis

which mom says is ‘constant.’ He has loud nasal breathing or mouth breathing throughout the visit. His nares are normal to exam. His tonsils are 1-2+. The rest of the physical exam is normal.

What next?Would you refer?Would you get any imaging?Sleep clinic or OTO?

How OSAS can present in infantsSlam dunk

Otherwise healthyLoud, obstructive snoringBIG tonsils and/or adenoidsAbnormal sleep study

History/exam don’t really match: snoring, but no tonsil hyperplasia

Neuromuscular abnormalities/syndromes

Adenoid film

Case StudyLily is a 3 year old with mild

global developmental delay. She walked at 18 months and has a moderate speech delay. She was born at 32 weeks gestation. Other medical problems include GERD and asthma. She snores most nights and is a restless sleeper. She will sleep for 11 or 12 hours and still appears tired in the morning. She takes long naps during the day.

BEARSB: falls asleep easily on her own. Sleeps in

her own bed, does not awaken at night. E: hard to get her up for preschool, very

moody if nap is missed. Multiple behavior concerns, parents have attributed this to her global DD.

A: does not awaken at night. R: sleep times predictableS: snores every night, described as ‘scary’

when she is sick.

Physical ExamLily is height/weight

appropriate, her tonsils are 2+. She has a high arched palate and a narrow oropharynx. The remainder of the exam is normal.

What next?Would you refer?Would you get any imaging?Sleep clinic or OTO?

How OSAS presents in toddlers/preschoolersSlam dunk

Otherwise healthyLoud, obstructive snoringBIG tonsils and/or adenoidsAbnormal sleep study

Behavior concerns: moody, emotionally labileFatigue, daytime lethargy OR hyperactivityCognitive impairment-concentration focus,

attention

Case StudyJose is a 10 year old

who was recently evaluated for ADHD. He has had a long history of behavior problems. He also has a speech articulation difficulty and has been getting speech therapy at school.

BEARSB: has a TV in his room. Typically sleeps 7-8 hours per

night. Somewhat difficult to awaken in the morning. E: parents deny sleepiness, but Jose says he is tired.

Parents describe him as ‘very busy.’ Teachers say he lacks focus and attention. He is impulsive and gets in trouble at school.

A: doesn’t awaken at night, often wets the bed.R: occasionally irregular bedtime, but typically

predictableS: parents say he snores ‘sometimes’ but are not

concerned about it. They deny any history of pausing, gasping or dyspnea in sleep.

Physical ExamJose is in your office for a well

child exam. He has no history of recent illness. On exam, you see 3+ tonsils that nearly meet in the midline. You notice that he keeps his mouth open throughout the entire visit. When you ask him to breathe through his nose, he is unable to. He seems to be cooperative, able to follow instructions and is engaging in an age appropriate manner.

What next?Would you refer?Would you get any imaging?Sleep clinic or OTO?

How OSAS presents in school aged kidsSlam dunk

Otherwise healthyLoud, obstructive snoringBIG tonsils and/or adenoidsAbnormal sleep study

Behavior concerns: moody, emotionally labile, impulsivity, non-compliance

Fatigue, daytime lethargy OR hyperactivityCognitive impairment-concentration focus, attention,

memory concerns, symptoms of ADHD, problem solving skills

School problems: tardiness, behavior, academic problems, falling asleep in school or on the bus

SDB: Clinical Presentations “Classic” or Type 1

3-6 year old Adenotonsillar hypertrophy or other

obvious craniofacial malformation Open mouth breathing, adenoidal

facies Normal BMI Thin or even FTT Tend to be inattentive and hyperactive;

if they are overtly sleepy it’s pretty severe

80-90% “cured” with T & A Clinically resolved SDB Oftentimes sleep studies still with

residual abnormalities

Case StudyShayla is a 17 year old obese

girl who comes to clinic with a complaint of ‘sleepiness.’ She says she is having trouble getting up in the morning for school and has fallen asleep in class. She wonders if she has ‘mono.’ Parents say she is getting very good grades but recently is having trouble with tardiness and they think she is not getting enough sleep.

BEARSB: Shayla often stays up late studying. She is often

on her phone texting with friends until late at night. She stays up very late on weekends.

E: Often naps after school.A: wakes up in the middle of the night and is

sometimes unable to go back to sleep.R: No predictable schedule. S: Snores loudly every night and has since early

childhood. Parents have not perceived this as a problem because she doesn’t snore as ‘bad as dad’ and she has always been very highly functional.

Physical ExamShayla’s BMI is 25. Her tonsils are 3+ with no

signs of infection. She has no signs of acute illness. Her turbinates are very enlarged and obstructive, she tends to mouth breathe. She has acanthosis nigricans around her neck. She is her own historian and disagrees with some of her parents’ version of the history. She denies any ‘sleep problem’ and is convinced she has mono. She thinks that because her grades are fine and her schedule has not changed, her sleep can’t be the problem.

What Next?Would you refer?Would you get any imaging?Sleep clinic or OTO?

How OSAS presents in adolescentsSlam dunk

Otherwise healthy Loud, obstructive snoring BIG tonsils and/or adenoids Abnormal sleep study

Moodiness, irritability, emotionally labile, anger, depression, impulsivity, non-compliance

Fatigue, daytime lethargy, somatic complaints (HA, muscle aches)Cognitive impairments, memory, attention, concentration,

decision making, problem solvingRisk taking behaviorsUse of stimulants, e.g. caffeine, borrowed Ritalin, etcSchool failure

SDB: Clinical Presentations

“New” (but the old Pickwickian model), Type IIadolescentsObesity with variable, even

minimal adenotonsillar hypertrophy

Early metabolic syndrome (borderline HTN, acanthosis)

Tend to be sleepy and inattentive as opposed to hyper and distractable

<50% cured with T & A although usually improved in severity, many need PAP

Most studies heavily confounded by obesity

SDB: Referral – when to order a sleep study?What the AAP says

Every child should be screened for snoring by their pediatricians at well child checks

For those who do snore, and there is suspicion of OSA, a sleep study is recommended to qualify and quantify severity to determine if it is truly OSA vs. primary snoring

Treatment for OSA is adenotonsillectomy, and CPAP for those who are not surgical candidates or non-responders.

High risk/complex patients should be referred to a specialist monitored in-patient post-operatively

All patients should undergo clinical re-evaluation, and high-risk patients should have repeat sleep studies

Pediatrics, 2002

Polysomnogram (sleep study) What we actually monitor:

EEGEOG (eye movements) to determine

REM sleepEMG (chin, leg)ECGOral and nasal airflow via

thermistor and nasal cannulaSnore microphone to evaluate for

audible and non-audible snoringPulse oximetry, end-tidal CO2,

transcutaneous CO2

Thoracic and Abdominal Movements

Video recording: for everything!

Questions……