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 abnormalities Cortical arousals leading to sleep
fragmentation Autonomic arousals leading to systemic fragmentation
Diagnosed by presenting symptoms (night and day) and sleep study
Naturally occurring model of sleep fragmentation Primary Snoring
OSAS UARS
Slide 3
Notes about SDB in children Breathing worse in sleep,
especially REM Less cortical input overall Smaller lung volumes Low
muscle tone upper airway collapse, decreased amount of air exchange
Relative immaturity of the respiratory system particularly in
infants Blunted hypoxic and hypercapnic responses Smallest airway
to pharyngeal structure ratio is during childhood (3- 6 years of
age) Craniofacial abnormalities most impactful in infancy
Slide 4
Case Study Pete 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.
Slide 5
BEARS B: bedtime problems Has to be rocked to sleep or have a
bottle? No consistent routine? E: excessive sleepiness/dysfunction
Fussy, no nap/sleep routine? Essentially difficult to assess in an
infant A: awake after sleep onset? Night time awakenings R: sleep
routine Really non-existent S: snoring
Quality/quantity/frequency/positional/witnessed apnea
Slide 6
Physical Exam Pete 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.
Slide 7
What next? Would you refer? Would you get any imaging? Sleep
clinic or OTO?
Slide 8
How OSAS can present in infants Slam dunk Otherwise healthy
Loud, obstructive snoring BIG tonsils and/or adenoids Abnormal
sleep study History/exam dont really match: snoring, but no tonsil
hyperplasia Neuromuscular abnormalities/syndromes
Slide 9
Adenoid film
Slide 10
Case Study Lily 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.
Slide 11
BEARS B: 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 predictable S: snores every night, described as scary
when she is sick.
Slide 12
Physical Exam Lily 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.
Slide 13
What next? Would you refer? Would you get any imaging? Sleep
clinic or OTO?
Slide 14
How OSAS presents in toddlers/preschoolers Slam dunk Otherwise
healthy Loud, obstructive snoring BIG tonsils and/or adenoids
Abnormal sleep study Behavior concerns: moody, emotionally labile
Fatigue, daytime lethargy OR hyperactivity Cognitive
impairment-concentration focus, attention
Slide 15
Case Study Jose 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.
Slide 16
BEARS B: 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: doesnt awaken at night, often
wets the bed. R: occasionally irregular bedtime, but typically
predictable S: parents say he snores sometimes but are not
concerned about it. They deny any history of pausing, gasping or
dyspnea in sleep.
Slide 17
Physical Exam Jose 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.
Slide 18
What next? Would you refer? Would you get any imaging? Sleep
clinic or OTO?
Slide 19
How OSAS presents in school aged kids Slam dunk Otherwise
healthy Loud, obstructive snoring BIG tonsils and/or adenoids
Abnormal sleep study Behavior concerns: moody, emotionally labile,
impulsivity, non-compliance Fatigue, daytime lethargy OR
hyperactivity Cognitive 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
Slide 20
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 its pretty severe 80-90% cured with T & A
Clinically resolved SDB Oftentimes sleep studies still with
residual abnormalities
Slide 21
Case Study Shayla 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.
Slide 22
BEARS B: 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 doesnt snore as bad as dad and she has always
been very highly functional.
Slide 23
Physical Exam Shaylas 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 cant be the problem.
Slide 24
What Next? Would you refer? Would you get any imaging? Sleep
clinic or OTO?
Slide 25
How OSAS presents in adolescents Slam 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 solving
Risk taking behaviors Use of stimulants, e.g. caffeine, borrowed
Ritalin, etc School failure
Slide 26
SDB: Clinical Presentations New (but the old Pickwickian
model), Type II adolescents Obesity with variable, even minimal
adenotonsillar hypertrophy Early metabolic syndrome (borderline
HTN, acanthosis) Tend to be sleepy and inattentive as opposed to
hyper and distractable