New Recommendations For Diagnosis and Management By Dr. MAHMOUD
HUSSEIN Childhood Obstructive Sleep Apnea Syndrome
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INTRODUCTION Obstructive sleep apnea syndrome ( OSAS) is a
common condition in childhood and can result in severe
complications if left untreated. OSAS occurs in children of all
ages, from neonates to adolescents. However, it is most common in
preschool-aged children, which is the age when the tonsils and the
adenoids are the largest in relation to the underlying airway size
In August 27, 2012, the American Academy of Pediatrics ( AAP)
published a practice guideline for the diagnosis and management of
uncomplicated childhood OSAS.
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DEFINITION OSAS in children is defined as a disorder of
breathing during sleep characterized by prolonged partial upper
airway obstruction and/or intermittent complete obstruction
(obstructive apnea) that disrupts normal ventilation during sleep
and normal sleep patterns. Prevalence rates of OSAS range from 1.2%
to 5.7% worldwide. in children, the symptoms of OSAS are often
subtle and do not exhibit uniquely specific features that would
make such symptoms immediately recognizable.
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Conditions Associated With OSAS in Children Adenotonsillar
hypertrophy Obesity Allergic Rhinitis, Asthma Micrognathia,Down
syndrome Craniofacial syndromes (Treacher- Collins, midfacial
hypoplasia, Crouzon syndrome, Apert syndrome, Pierre Robin
sequence, etc Achondroplasia, Mucopolysaccharidoses, Macroglossia
Sickle cell disease, Myelomeningocele Neuromuscular disorders
(Duchenne muscular dystrophy, spinal muscular atrophy, etc) Cleft
palate repair and velopharyngeal flap Foreign body, Cerebral palsy
Vascular hemangioma and other tumors Nasoseptal obstruction,
Prematurity
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Pathophysiology Disordered breathing during sleep is a hallmark
of OSAS. Breathing abnormalities include apnea and hypopnea The
ability to maintain upper airway patency during the normal
respiratory cycle is the result of a delicate equilibrium between
the forces that promote airway closure and dilation. The 4 major
predisposing factors for upper airway obstruction are the
following: -Anatomic narrowing -Abnormal mechanical linkage between
airway dilating muscles and airway walls -Muscle weakness -Abnormal
neural regulation
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Recurrent episodes of upper airway obstruction typical of OSAS
will result in intermittent hypoxia, hypercapnia, and significant
swings of intrathoracic pressures, all of which may lead to
disturbances in autonomic function. autonomic dysfunction are one
of major underlying processes ultimately leading to sustained
increases in vasomotor tone in patient s with OSAS, leading to
systemic hypertension.
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Symptoms and Signs of OSAS History Frequent snoring ( 3
nights/wk) Labored breathing during sleep Gasps/snorting
noises/observed episodes of apnea Sleep enuresis (especially
secondary enuresis) Sleeping in a seated position or with the neck
hyperextended Cyanosis Headaches on awakening Daytime sleepiness
Attention-deficit/hyperactivity disorder Learning problems
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Physical examination: Underweight or overweight Tonsillar
hypertrophy Adenoidal facies Micrognathia/retrognathia High-arched
palate Failure to thrive Hypertension
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complications Morbidities can generally be divided into the 4
following immediate consequences of upper airway obstruction during
sleep: Sleep fragmentation Increased work of breathing Alveolar
hypoventilation Intermittent hypoxemia
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A. Cardiovascular Complications Right heart strain Reduced
right ventricular ejection fraction Right ventricular hypertrophy
Leftward shift of the interventricular septum Cor Pulmonale
Systemic hypertension B. Growth poor growth and failure to thrive.
Post treatment, sleeping energy expenditure decreased and weight
increased. Treatment of OSAS results in increases in weight and
height, even in children who were initially obese.
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C. Cognitive and Behavioural The AAP Subcommitee on OSAS pooled
6 cross-sectional studies that examined the cognitive and
behavioural abnormalities in childhood OSAS. Abnormalities include
- decreased school performance, inattention, excessive daytime
sleepiness, aggression, hyperactivity and ADHD. - Young children
who snore loudly and frequently are at higher risk for having lower
grades in school several years after the snoring has resolved.
These findings suggest that the adverse neurocognitive outcome and
diminished academic performance in sleep disordered breathing may
be only partially reversible, - particularly when the sleep
disordered breathing occurs during critical phases of brain growth
and development.
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Differential Diagnoses 1.simple snoring, usually not
accompanied by oxygen desaturation, hypercapnia, or sleep
disruption. Overnight polysomnography can be performed to
differentiate 2.Daytime somnolence: Chaotic sleep schedules with
inconsistent bedtimes and rise times, Narcolepsy. 3.Chronic Fatigue
Syndrome 4.Congenital Stridor 5.Nocturnal Gastroesophageal Reflux
6.Sleep Disorder: Night Terrors, Nightmares
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Effeective strategies for evaluation of OSAS 1. history
2.physical examination 3.testing: - polysomnography - Apnea
Hypopnea Index - Daytime Nap Studies - Overnight Oximetry -
Anteroposterior and Lateral Neck Radiography - Thyroid-Stimulating
Hormone and Thyroxine - Multiple Sleep Latency Test (MSLT)
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Polysomnography Polysomnography remains the criterion standard
for establishing the diagnosis of (OSA) in infants, children, and
adults. Ideally, polysomnography should be performed overnight and
during the patient's usual bedtime. Polysomnography is necessary to
document obstructive sleep apnea and gauge its severity. A history
of snoring alone is not adequate for making a diagnosis of
obstructive sleep apnea or for determining its seriousness.
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Polysomnography provides the following measures: Sleep state (2
EEG leads) Electrooculogram (right and left) Submental
electromyelogram (EMG) Airflow at nose and mouth (thermistor,
capnography, or mask and pneumotachygraph) Chest and abdominal wall
motion (impedance or inductance plethysmography) Electrocardiogram
(preferably with R-R interval derivation technology) Pulse oximetry
(including a pulse waveform channel) End-tidal carbon dioxide
(sidestream or mainstream infrared sensor) Video camera monitor
with sound montage (analog or digital) Transcutaneous oxygen and
carbon dioxide tensions (in infants and children < 8 y)
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Apnea Hypopnea Index polysomnographic-derived index known as
the apnea hypopnea index (AHI). The AHI is the total number of
apneas and hypopneas that occur divided by the total duration of
sleep in hours. An AHI of 1 or less is considered to be normal by
pediatric standards. An AHI of 1-5 is very mildly increased, 5-10
is mildly increased, 10-20 is moderately increased, and greater
than 20 is severely abnormal.
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Daytime Nap Studies Daytime nap studies are specific, but not
sensitive, in detecting sleep apnea. This is because obstructive
events are more likely to occur during rapid eye movement (REM)
sleep than during other sleep stages, and very little (if any) REM
sleep occurs during daytime naps in noninfants. Therefore, children
with symptoms of obstructive sleep apnea who have normal nap study
findings must undergo nocturnal polysomnography to exclude the
diagnosis. Sleep studies should be performed without sedation
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Overnight Oximetry Unattended home overnight oximetry has been
proposed as a screening study. However, it may miss the child with
significant obstructive sleep apnea who does not have marked
episodes of oxygen desaturation. Overnight pulse oximetry by itself
is not adequate for establishing the diagnosis or excluding
obstructive sleep apnea in children because it provides no
information concerning sleep staging/sleep fragmentation or carbon
dioxide.
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Anteroposterior and Lateral Neck Radiography: Neck radiography
for soft tissue detail help define upper airway anatomy and adenoid
size and exclude the possibility of rare nasal pharyngeal
neoplasms. Thyroid-Stimulating Hormone and Thyroxine: Thyroid
function studies are useful to exclude hypothyroidism, which is
associated with tongue enlargement, weight gain, and obstructive
sleep apnea. Multiple Sleep Latency Test (MSLT) If the clinical
history suggests the possibility of narcolepsy, the MSLT should be
ordered in conjunction with overnight polysomnography.
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MRI of the Brain and Brainstem A history of severe snoring,
headaches, neck pain, urinary frequency, or swallowing problems
raises the suspicion of Chiari malformation. Chiari malformations
may occur in otherwise normal children and in association with
congenital myelomeningocele. If brainstem dysfunction is suspected,
MRI is necessary. Cranial CT imaging is not adequate to assess for
brainstem and upper cervical cord lesions.
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Workup The AAP clinical practice guideline focuses on
uncomplicated childhood OSAS associated with adenotonsillar
hypertrophy or obesity in otherwise healthy children in the primary
care setting. The AAP subcommittee was composed of pediatricians
and experts in sleep medicine, pulmonology, otolaryngology, and
epidemiology; and liaison members from the AAP Section on
Otolaryngology-Head and Neck Surgery, the American Thoracic
Society, the American Academy of Sleep Medicine, the American
College of Chest Physicians, and the National Sleep
Foundation.
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Study Synopsis and Perspective As part of a routine health
maintenance visit, clinicians should determine whether a pediatric
patient snores, new guidelines advise. If he or she does snore or
presents with symptoms of OSAS, a more focused evaluation is in
order. These are among the recommendations included in updated
evidence- based guidelines for the diagnosis and management of
childhood OSAS. "Asking about snoring at each health maintenance
visit [as well as at other appropriate times, such as when
evaluating for tonsillitis] is a sensitive, albeit nonspecific,
screening measure that is quick and easy to perform
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Study Highlights The investigators identified 350 articles from
a literature search of relevant studies from 1999 to 2010.
Exclusion criteria were reviews, case reports, letters to the
editor, abstracts, nonEnglish-language studies; animal studies; and
studies of participants younger than 1 year, with central apnea or
hypoventilation syndromes, or with OSAS related to other medical
disorders. The investigators devised 8 key recommendations.
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Recommendation #1 At routine healthcare maintenance visits,
clinicians should ask whether children snore. If children do snore
or have signs or symptoms of OSAS, then a more focused evaluation
is warranted. Screening for snoring is sensitive but
nonspecific.
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Recommendation #2A Children who snore regularly and have any
OSAS signs and symptoms should undergo polysomnography or,
alternatively, be referred to a sleep specialist or to an
otolaryngologist. The gold standard is overnight, attended,
in-laboratory polysomnography. Specific pediatric criteria should
be used. Polysomnography identifies the presence and severity of
OSAS. Specialists might be able to diagnose and determine the
severity of OSAS. Recommendation #2B If polysomnography is not
available, alternative diagnostic tests include nocturnal video
recording, nocturnal oximetry, daytime nap polysomnography, or
ambulatory polysomnography. Alternative tests vs polysomnography
have weaker positive and negative predictive values
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Recommendation #3 The first-line treatment of children with
OSAS, adenotonsillar hypertrophy, and no contraindication to
surgery is adenotonsillectomy. Adenoidectomy or tonsillectomy alone
may be insufficient. The rate of serious complications is low.
Research is needed to identify which obese children are most likely
to benefit from adenotonsillectomy. The benefits and risks
associated with adenotonsillectomy are preferable compared vs those
of other treatment options.
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Recommendation #4 High-risk patients undergoing
adenotonsillectomy should be monitored in the hospital
postoperatively. Risk factors for postoperative respiratory
complications are age younger than 3 years, severe OSAS by
polysomnography, cardiac complications of OSAS, failure to thrive,
obesity, craniofacial anomalies, neuromuscular disorders, and
current respiratory tract infection.
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Recommendation #5 Patients should be reassessed for OSAS signs
and symptoms after therapy to determine if further treatment is
needed. The usual recommended time for re-evaluation is 6 to 8
weeks after treatment. Persistent symptoms should be assessed by
objective testing or by a sleep specialist.
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Recommendation #5B High-risk patients, including those with
significantly abnormal baseline polysomnogram results, sequelae of
OSAS, obesity, or symptoms of OSAS, should be reassessed for
persistent OSAS after adenotonsillectomy by objective testing or by
a sleep specialist. A large proportion of high-risk children have
persistent OSAS postoperatively.
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Recommendation #6 Patients should be referred for CPAP
management if OSAS signs or symptoms or objective evidence persists
after adenotonsillectomy or if adenotonsillectomy is not performed.
CPAP is the most effective treatment of persistent postoperative
OSAS. Alternative treatment is needed if adherence is suboptimal,
even after behavioral modification methods are used.
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Recommendation #7 In addition to other treatment, weight loss
is recommended in children with OSAS who are overweight or obese.
Weight loss relieves OSAS, but it is a slow and unreliable method.
Recommendation #8 Intranasal corticosteroids may relieve mild OSAS
if adenotonsillectomy is contraindicated or if mild postoperative
OSAS is present. Mild OSAS is defined as an apnea-hypopnea index of
less than 5 per hour. Response should be measured objectively after
approximately 6 weeks. Patients should be observed for recurrence
of OSAS and adverse effects of corticosteroids.
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Treatment Adenotonsillectomy: Adenotonsillectomy, along with
weight normalization, is considered the first line of therapy in
children and adolescents with obstructive sleep apnea. Dietary
restrictions: if obesity complicates obstructive apnea
Positive-Pressure Ventilation Oral Appliances :assist in bringing
the lower jaw and tongue forward during sleep, thus improving
obstructive sleep apnea. These devices are expensive, require
special dental expertise, and are associated with frequent adverse
effects such as jaw pain and temporal mandibular joint dysfunction.
Small growing children are likely to outgrow appliances,
necessitating refitting and replacement. Nasal Fluticasone:
administered daily for 6 weeks is shown to ameliorate the frequency
of obstructive events in children with mild-to-moderate obstructive
sleep apnea due to tonsil or adenoid hypertrophy by about one half.
Uvulopalatopharyngoplasty successful in relieving obstructive sleep
apnea only if the major site of obstruction is localized to the
soft palate Tongue Reduction
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Clinical Implications Updated guidelines by the AAP recommend
that all children be screened for snoring. The recommended
diagnostic test for OSAS in children who snore and who have signs
or symptoms of OSAS is polysomnography. The first-line treatment of
childhood OSAS is adenotonsillectomy for children with
adenotonsillar hypertrophy. Other treatments include CPAP if
adenotonsillectomy is not performed or if persistent postoperative
OSAS is present, weight loss for overweight or obese children, and
intranasal corticosteroids for mild OSAS if adenotonsillectomy is
contraindicated or if mild postoperative OSAS is present.