Transcript Sleep Apnea Syndrome

Obstructive Sleep Apnea
Syndrome
Dr. Amir Bar,
Bnei-Zion Medical Center,
Haifa
A “new syndrome”
 “PubMed” search (Sleep Apnea; 0-18y):
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 A common syndrome
 Has significant complications w/o Tx
 Can be efficiently treated in the majority of cases
>>Awareness
and early diagnosis and Tx
EEG
Non-REM Sleep Stages
EEG
REM sleep
EOG
M. Tone
Rapid
Normal
St 1
Sleep
physiology
Slow
+/-
St 2
None
Relaxation
St 3-4
“SWS”
None
None
Relaxation Metabolism , GH secretion
Relaxation Para-sympathetic predominance
REM
Rapid
Atonia
Wake
Dreams, Mental, Memory
Sympathetic predominance (MI)
Penile- erection
REM-Related OSA
REM
Classification
Apnea: a Greek word - “want of breath”
– Obstructive
– Central
– Mixed
m/p the Greeks describe obstructive type
Classification
 Respiratory Disturbance Index (RDI)
–
Normal value <1-2 per hour of sleep
1. Apnea: complete airflow cessation (2 respiratory
cycles)
2. Hypopnea: airflow reduction (2 respiratory cycles)
3. Respiratory Effort Related Arousal (RERA):
prolonged flow limitation with associated
arousal (Upper Airways Resistance Syndrome)
• Normal oxygen saturation
Epidemiology
 Prevalence:
– OSAS: 1-3%
– Primary snoring (PS): 3-12%
 Gender:
– M/F ratio 1:1 (Adults: male predominance)
 Age:
– From neonates to adolescents
– Commonest in preschool children (2-5y)
• (Peak incidence of adenotonsillar hypertrophy)
 Race:
– More common in African-American children ??
Nocturnal presentation
Apnea
Dyspnea
Snoring
Mouth breathing
Restless sleep
Pathophysiology
•Muscle relaxation (Sleep)
•Muscle atonia (REM)
•Neuromuscular dis
Pharyngeal dilators
Opened AW
Closed AW
•Anatomical factors
Insp. Neg. pressure
Upper Airways
Anatomical Factors
Anatomical Factors
Neuromuscular Factors
Pathophysiology
Vast majority of cases are associated
with adeno-tonsillar hypertrophy (ATHt)
Obesity in children is a risk factor for
OSAS, and the severity of OSAS is
proportional to the degree of obesity
– In contrast to adults, most OSAS children are
not obese (may have FTT)
Pathophysiology
 Although strongly associated with AT-Ht,
childhood OSAS is not caused by AT-Ht
alone:
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Deficit in arousal mechanisms
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No obstruction during wakefulness
Adenotonsillar size and OSAS are not correlated
Elevated arousal thresholds in response to
hypercapnia and increased UA resistance
Abnormal centrally mediated activation of UA
muscles
Complications
CVS – systemic and pulmonary HTN
Neurocognitive/behavioral problems
FTT
Enuresis
EEG
OSAS: PSG screen
ECG
Chin EMG
Airflow
Peripheral Pulse
Volume
BP
Leg Mt.
Oximetry
Complications:
CVS
 Cor-pulmonale - used to be a common
presentation, but is currently rare
– When it does develop-can be reversed by Tx
Tal, Pediatr Pulmonol, 1988:
 Ventriculography in children who had
abnormal questionnaire for OSAS:
– 37% had Rt. ventricular EF 
– 67% had abnormal wall motion
– All of the 11 pt who had a repeat evaluation after
T&A showed improvement
Complications:
CVS
Shiomi, Chest, 1993:
Pulsus-paradoxus and leftward shift of
the inter-ventricular septum in 3/6
children with OSAS
– Correlated with negative esophageal
pressures but not with oxygen
desaturation, reversed with CPAP
Complications:
CVS
Am J Respir Crit Care Med. 2004 Apr
24 h ambulatory BP in children with sleepdisordered breathing
 Background: OSAS causes intermittent
elevation of systemic BP during sleep
 Objective: to determine whether obstructive
apnea in children has a tonic effect on diurnal BP
 Conclusion: OSA in children is associated with
24 h BP dysregulation
Complications:
CVS
AAP
The Fourth Report on the Diagnosis, Evaluation,
and Treatment of High Blood Pressure in
Children and Adolescents
National High Blood Pressure Education Program
Working Group on High Blood Pressure in Children
and Adolescents
PEDIATRICS Vol. 114 No. 2 August 2004
Complications:
CVS
Complications:
Neurocognitive & Behavioral
Guilleminault, Lung, 1981:
50 children with OSAS (PSG)
– 84% - excessive daytime sleepiness
– 76% - behavior disturbance
– 42% - hyperactive
– 16% - school performance 
Complications:
Neurocognitive & Behavioral
Gozal, Pediatrics, 1998:
 297 first graders who were in the lowest 10th
academically were evaluated for OSAS by
questionnaire combined with home oximetry
– 54/297 (18.1%) had positive results
• (recommended T&A)
– 24/54 underwent T&A and improved their grading
significantly, with no change in the untreated
OSAS group or the non-OSAS group
Complications:
Neurocognitive & Behavioral
Gozal D, Sleep, 2004
Health-related Quality of Life and Depressive
Symptoms in Children with Suspected SleepDisordered Breathing
 Conclusions: Children with suspected OSAS,
regardless of the severity of RDI or the presence of
obesity, had more impairments in quality of life
and depressive symptoms than did children who
did not snore
Complications:
Neurocognitive & Behavioral
Pillar, Sleep, 2004
Sleep Disorders and Daytime Sleepiness in Children with
ADHD
 Of the children with ADHD, 17 (50%) had signs of
OSAS, compared with 7 of the control group (22%,
P < .05)
 Children with ADHD demonstrate objective daytime
somnolence (by MSLT), which may explain the
beneficial effects of Tx with stimulants
 Primary sleep disorders, especially sleep-disordered
breathing and PLMS, should be looked for
Complications:
FTT
 FTT in OSAS children and reports of growth
spurt following T&A
 Proposed mechanisms:
1. Low caloric intake
• Dysphagia
2. High caloric expenditure
• Work of breathing 
3. Abnormal GH secretion
• Interrupted SWS, post T&A - IGF 
Complications:
Enuresis
Brooks, J Pediatr, 2003:
 Children 4 y and older who had suspected
OSAS were asked about enuresis
– 160 pt (90/70; M:F)
– 41% had enuresis (primary/secondary - 3:1)
– RDI <1: significantly lower prevalence of enuresis
(17 vs. 47%)
– The prevalence of enuresis is associated to the
OSAS severity (1-5, 5-15, or >15 events per
hour)
Complications:
Enuresis
Weider, Otolaryngol Head Neck Surg,
1991:
115 enuretic children undergoing T&A
– 66% and 77% reduction in enuretic nights
1m and 6 m Post-T&A
– In the group with secondary enuresis,
100% were dry 6 m Post-T&A
Evaluation:
Polysomnography (PSG)
PSG is the gold STD for diagnosis
Establishment of diagnosis and
severity
– Prediction of complications, particularly in
the immediate Post-Op period
– Pre-Op baseline for Post-Op further
evaluation
High costs and shortage of sleep
labs >> screening techniques
Evaluation:
Screening
 Questionnaires
 Snoring audiotapes
 ENT exam
– low sensitivity and specificity
 Nocturnal Videotapes
 Oximetry
 Nap-PSG
– High false-negative rate, indicative if
positive
Evaluation:
Pulse Oximetry
Brouillette, Pediatrics, 2000:
349 children, pulse oximetry during
PSG
– OSAS prevalence – 60.2%
– PPV - 97%
– NPV - 53%
Treatment:
T&A
 Tonsillectomy with or w/o adenoidectomy is efficient
Tx for OSAS
 Clinical improvement of symptoms and post-Op
complications: CVS, neurocognitive, enuresis,
growth
Suen, Arch Otolaryngol Head Neck Surg, 1995:
 69 with susp OSAS had PSG, 35/69 had RDI > 5
and referred for T&A, 30/35 had T&A, 26/30 had
follow-up PSG
– Cure rate 85%
– Post-Op snoring: NPV - 100%, and PPV - 57%
– A high Pre-Op RDI (>19) was a strong predictor of
abnormal Post-Op residual abnormality
Treatment:
T&A
Nieminen, Arch Otolaryngol Head Neck
Surg. 2000:
– 95% cure rate for a group of 21 children
after T&A or tonsillectomy
– Postoperative snoring NPV 100%, PPV
20%
– 73% of this group had a previous
adenoidectomy, indicating the lack of
efficacy of adenoidectomy alone
Treatment:
T&A
 Post-Op respiratory compromise (16-27%)
 Causes:
– Upper airway edema
– Increased secretions
– Respiratory depression – 2nd to
analgesic/anesthetic agents
 Risk factors
– Age <3 yr
– severe OSAS
– Children with additional medical conditions
Treatment:
T&A
Follow-up PSG (6–8 wk Post-Op) , to
ensure that additional Tx is not
required
– Children with additional risk factors
– Children with a Pre-Op high RDI
Other Tx alternatives
 Uvulopharyngopalatoplasty (UPPP): in CP
pt and hypotonic upper airway muscles; it
has not been studied in the uncomplicated
pediatric pt
 Oral appliances has not been reported in
children (it may adversely affect the facial
configuration of the growing child)
 In children, CPAP is usually used when T&A
is unsuccessful or contraindicated rather
than as a primary treatment
– Young infants
– Medical conditions
Treatment: Oxygen
 Improved oxygenation during sleep, w/o
obstruction worsening
 PCO2 :
– Few individuals show marked increase in PCO2
– With no apparent predictive factors for which pt
would develop hypercapnia
 Oxygen should never be administered w/o
1st measuring PCO2 response
 Oxygen does not address many of the
associated pathophysiological features
The end !