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Obstructive sleep apnoea in children

Obstructive sleep apnoea in children. Joanne Edwards Senior Paediatric Registrar TCH. What is OSA. Repeat episodes of partial or complete upper airway obstruction during sleep Result in a disruption of normal ventilation and sleep patterns. Continuum of sleep disordered breathing.

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Obstructive sleep apnoea in children

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  1. Obstructive sleep apnoea in children Joanne Edwards Senior Paediatric Registrar TCH

  2. What is OSA • Repeat episodes of partial or complete upper airway obstruction during sleep • Result in a disruption of normal ventilation and sleep patterns

  3. Continuum of sleep disordered breathing

  4. Sleep in children • After 6 months • REM sleep and non-REM sleep

  5. REM sleep • Muscle atonia • Increased cerebral blood flow • Variable HR RR BP • Increased upper airway resistance • During REM get bursts of phasic events causing rapid eye movements and myoclonic twitches

  6. Non REM sleep • Reduced muscle tone • Decreased cerebral blood flow • Regular HR RR BP • Increased upper airway resistance • NREM sleep is divided into stages by EEG criteria which parallel depth of sleep

  7. Sleep cycles

  8. Respiration during sleep • Increased upper airway resistance • Relaxed pharyngeal muscles (dilator) • Probably decreased central respiratory drive • Decrease in lung volumes during REM

  9. Sleep disordered breathing • Partial or complete collapse at the elvel of extrathoracic airway • Caused by • Small upper airway – smaller in those with OSA • Decreased tone of pharyngeal dilators during sleep • SUbvstantial change in dimensions of airway between inspiration and expiration

  10. Predisposing factors • Peak age 2-8 years old • Coincides with peak age of lymphoid tissue – ie tonsils and adenoids • Enlarged tonsils and adenoids • Obesity • Mucopolysaccharidoses • Children with airway or facial abnormalities • Midface hypoplasia • Retro or micrognathia Acutely angled skull base • Narrow maxillary arch • Nueromuscular factors – hypotonia or hypertonia

  11. Predisposing factors • Genetic factors • Both obese and non-obese populations • Drugs • Alcohol • Chloral hydrate • Benzodiazepines • GA • Opioids

  12. Pathology • Decreased upper airway patency • Adenotonsillar hypertrophy • Allergies causing rhinitis, nasal obstruction • Reduced capacity to maintain airway • Obesity • Neuromuscular disorder • Decreased drive to breathe • Brain stem injury

  13. Patterns • REM sleep • Hypoventilation • Significant oxygen desaturations • NREM sleep • Relatively protected

  14. What are the symptoms and signs?

  15. Symptoms – night time • Snoring • 12% of children snore • Most of children with OSA snore • Pauses in snoring with apnoea • Sleeping • Mouth breathing or unusual positions • Nighttime sweating • Restless or agitated sleep • Parasomnias – sleep terror, sleep walking • Nocturnal enuresis

  16. Symptoms – day time • Growth deviations • Failure to thrive • Obesity is predisposing factor • Mouth breathing and hyponasal speech • Sleepiness • Daytime napping • Inattention, learning problems, behavioural problems

  17. On examination – head and neck • Craniofacial anomalies – midface hypoplasia, retrognathia • Obstructive septal deformity • Macroglossia • Hyponasal speech • Mouth breathing – adenoidal hypertrophy • Mucosal or turbinate swelling suggestive of chronic nasal congestion • Suggestive of allergy if dark circles under eyes, swollen eyes, transverse nasal crease

  18. Examination • Growth • Neuromuscular tone • Mallampati classification of oropharyngeal crowding • BP (hypertension)

  19. How is OSA diagnosed • Sleep study – polysomnography • What is measured • Airflow – apnoea and hypopnoea • Abdominal and chest wall movements to indicate respiratory effort • End tidal CO2 – adequacy of ventilation • Saturations • EEG – stage of sleep • ECG – cardiac rate and rhythm • EMG – arousals and leg movement • Snore microphone

  20. Measurements made • Apnoeas • >90% decrease in ariflow that lasts >0% of the duration of 2 normal breaths • Obstructive – continued or increased respiratory effort during period • Central – no respriatory effort during period, event lasts > 20 seconds • Can be mixed • Hypopnoea • Respiratory effort related arousal

  21. What is measured • Apnoea hyponoea index – total number occurring during 1 hour • Other measures • End tidal CO2 • If CO2 exceeds 50 for > 25% of ttoal sleep time – hypoventilation • Hypoexmia < 92%(lowest nadir in normal children)

  22. Diagnostic criteria • History of snoring, laboured breathing or obstructed breathing during sleep • History of arousals, sweating, neck hyperextension, excessive daytime sleepiness, aggressive or irritable behaviour, slow growth, morning headaches, secondary enuresis • PSG – AHI>1 or frequent arousals with icnreased respriatory effrot, desaturations, hypercapnia • Not explained otherwise

  23. Severity • Mild • AHI – 1-4, sats nadir 86-91%, CO2 peak > 53 • Moderate • AHI 5-10, sats nadir 76-85, CO2 > 60 • Severe • AHI > 10, sats nadir < 75, CO2 > 65

  24. Management • Adenotonsillectomy • Based on clinical experience, difficult to randomize • Known adenotonsillar hypertrophy • CPAP or BiPAP • If adenotonsillectomy too risky or already done • Other • Weight loss, maxillofacial surgery to correct anomalies, nasal steroids, oral appliances

  25. Adenotonsillectomy • Meta-analysis of 355 children with OSA and adenotonsillar hypertophy • Post adenotonsillectomy 83% had normalized PSG and reduced AHI • If obese, less successful outcomes – AHI>2 persisted in about 76% (compared to 28% lean children

  26. Positive airway pressure • CPAP • Constant level of positive airway pressure throughout cycle • BiPAP • Higher pressures during inspiration than expiration • Pressures are determined by sleep study • Very poor compliance

  27. Oxygen • Supplemental oxygen useful in short term if severely hypoxemic until definitive therapy provided • Rarely used • For those who cannot tolerate PPV • Does not improve episodic upper airway obstruction or hypercapnia or sleep fragmentation • May suppress ventilatory drive and worsen hypercapnia

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