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Obstructive Sleep Apnea in Children

Clinical Findings, Diagnosis & Management
by

Khalid Abu-Rumman

on 9 March 2013

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Transcript of Obstructive Sleep Apnea in Children

Khalid Abu-Rumman Obstructive Sleep Apnea Divided into sleep-related and daytime symptoms In children and adolescents are:
Loud, frequent, and disruptive snoring
Breathing pauses
Choking or gasping arousals
Restless sleep
Nocturnal diaphoresis Clinical Manifestations Many children who snore do not have OSA,
And very few children with OSA do not snore Nocturnal Manifestations But! Most children, like adults, tend to have more frequent and more severe obstructive events in REM sleep and when sleeping in the supine position.
Children with OSA may adopt unusual sleeping positions, keeping their necks hyperextended in order to maintain airway patency. Frequent arousals associated with obstruction may result in nocturnal awakenings, but are more likely to cause fragmented sleep. Cont. Day time Symptoms Mouth breathing and dry mouth
Chronic nasal congestion/rhinorrhea
Hyponasal speech
Morning headaches
Difficulty swallowing
Poor appetite. Most likely as a result of the disruption of the
normal nocturnal pattern of antidiuretic hormone secretion Secondary Enuresis Partial Arousal Parasomnias Sleepwalking and Sleep terrors
May occur more frequently in children with OSA,
related to the frequent associated arousals and an increased percentage of delta sleep, or SWS Neurobehavioral Consequences Include daytime sleepiness with drowsiness,
difficulty in morning waking, and unplanned
napping or dozing off during activities,
although evidence of frank hypersomnolence
tends to be less common in children
compared to adults with OSA. There is a substantial overlap between the
clinical impairments associated with OSA and
the diagnostic criteria for ADHD, including
inattention, poor concentration,
and distractibility ADHD Diagnosis There are no physical examination findings that are truly pathognomonic for OSA, and most healthy children with OSA appear normal Growth parameters may be abnormal (obesity or, less commonly, failure to thrive)
There may be evidence of chronic nasal obstruction (hyponasal speech, mouth breathing, septal deviation, “adenoidal facies”),
As well as signs of atopic disease
(i.e., “allergic shiners”). Oropharyngeal examination may reveal enlarged tonsils, excess soft tissue in the posterior pharynx, and a narrowed posterior pharyngeal space.
Any abnormalities of the facial structure, such as retrognathia and/or micrognathia, midfacial hypoplasia, best appreciated by inspection of the lateral facial profile In very severe cases, there
may be evidence of:
Pulmonary hypertension
Right-sided heart failure
Cor pulmonale
Systemic hypertension
(no so common) History and Physical examination
Audiotaping or Videotaping,
Pulse oximetry
Full Polysomnography GOLD STANDARD Abbreviated Polysomnography Overnight oximetry can be useful if it shows
a pattern of cyclic desaturation.

Nap polysomnography is appealing, because it
can be performed in the daytime and is,
therefore, more convenient for patients
and laboratory staff. Overnight Polysomnogram (PSG) Is a technician-supervised, monitored study that documents physiologic variables during sleep which include:
Sleep staging
Arousal measurement
Cardiovascular parameters
Body movements
A combination of breathing monitors chest/abdominal monitors Most commonly used parameter in evaluating for sleep disordered breathing is the apnea/hypopnea index (AHI)
Normal preschool and early school-aged children may have a total AHI of less than 1.5
in adolescents, the adult cutoff of an AHI ≥5 is generally used.
In cases in which the AHI is between 1 and 5 obstructive events per hour, clinical judgment regarding risk factors for OSA, evidence of daytime sequelae, and the technical quality of the overnight sleep study should determine further management. The decision of whether and how to treat OSA specifically in children is contingent on a number of parameters, including severity (nocturnal symptoms, daytime sequelae, sleep study results), duration of disease, and individual patient variables such as age, co-morbid conditions, and underlying etiologic factors. Treatment Is the first-line treatment in any child with significant adenotonsillar hypertrophy, even in the presence of additional risk factors such as obesity
In uncomplicated cases generally (70-90% of children) results in complete resolution of symptoms Adenotonsillectomy Continuous Positive Airway Pressure (CPAP) For patients with specific surgical contraindications, minimal adenotonsillar tissue, or persistent OSA after adenotonsillectomy or for those who prefer nonsurgical alternatives Weight loss
Positional therapy
Aggressive treatment of additional risk factors when present, such as asthma, seasonal allergies, and gastroesophageal reflux
There is some evidence that intranasal corticosteroids and leukotriene inhibitors may be helpful in mild OSA.
Other surgical procedures, such as uvulopharyngopalatoplasty, and maxillofacial surgery are seldom performed in children but may be indicated in selected cases.
Oral appliances, such as mandibular advancing devices and tongue retainers, are typically considered for adolescents in whom facial bone growth is largely complete. Additional Treatment Measures Thank You Channels commonly recorded during a PSG
– Brain wave activity (EEG),
– Eye movement (EOG),
– Muscle tone (chin EMG),
– Airflow via thin catheters placed in front of nostrils and mouth
– Breathing effort via belts placed over chest and abdomen
– Snoring (microphone placed over the neck)
– heart rhythm (EKG)
– Oxygen level (SpO2)
– Leg muscle activity (PLM)
– Body position
– Video recording
Intercom to communicate with technician
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