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Pediatric OSA, what
cannot we see?!S. SHAHZEIDI, MD, FAAP, FCCP, FAASM
GRAND HEALTH INSTITUTE
Objectives
� Understanding of
Physiology of the upper
airways in pediatrics
� Etiology of OSA in
pediatrics
� Control of breathing &
upper airway patency in
pediatrics
Outcome
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Airway shape in pediatric
and growth
Upper airway muscles in
OSA
Awake NREM
� Genioglosus (Normal)
� Tensor palatini
� Air flow
� Genioglosus (OSA)
� Tensor palatini
� Air flow
Tongue position in airway
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Airway patency in Normal
and OSA during sleep
Hypoglossal N:
Orexin
Alpha 1 B R (Norepinephrine)
5HT2 alpha R (Serotonin)
Glosso-pharyngeal N:
Hypopharyngeal proprioception
(– ve pressure)
Control of upper airway
Infantile airway
disadvantages� Upper airway
� Greater difficulty switching from nasal to oral breathing
� Laryngeal reflexes with cardio- respiratory depressant responses
� Chest wall properties impairing load compensation
� Increased chest wall compliance
� Circular “barrel‐shaped” chest wall with horizontal rib position
� Smaller diaphragmatic zone of apposition
� Sober, cartilaginous ribs
� Greater REM sleep time with inhibition of stabilizing intercostal muscles
� Lower resting functional residual capacity; low specific lung compliance
� Higher metabolic rate
� Immature respiratory control
� • Respond to ↓ pH or ↓ Cl‐ at
laryngeal entrance
� • Laryngeal chemoreflex
� Startle, rapid swallowing, laryngnealconstriction,
� hypertension, and bradycardia
� Via superior laryngeal nerve (X)
� Blunted with maturation
Laryngeal
Chemoreceptors
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Chemo-reflex
dysfunction
Central breathing instability
High loop gain is
required
Central Breathing Control
Instability CompSA and the Apneic
Threshold
Central apneas occur
CompSA patient not treated
CompSA patienton Servo
Respiratory Effort Related
Arousal (RERA)
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EEG in RERA
OSA demographics
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� 1. Some children have a pattern of persistent partial upper airway obstruction associated with gas exchange abnormalities, rather than discrete, cyclic apneas (“obstructive hypoventilation”2).
� 2. These children will not manifest pauses and gasps in their snoring, and therefore, the condition may be misdiagnosed as PS
� Study Conclusions:
� 1. In the pediatric age range, abnormalities include oxygen desaturation under 92%, more than one obstructive apnea per hour, and elevations of ET CO2 measurements of more than 50 mm Hg for more than 9% of sleep time or a peak level of greater than 53 mm Hg.
� Goh DY, Galster P, Marcus CL. Sleep architecture and respiratory disturbances in children with obstructive sleep apnea. Am J Respir C rit Care Med.2000;162 :682– 686
Task force conclusions:
� 1. AHI of 1.5 is normal, 1.5-3 is mild, 3-5 is moderate and >5 is severe (CHOPS)
� Note:3 RERA for <12 years or 5 RERA for>12 years are equal to 1 obstructive event.
� 2. There is the option of using adult respiratory scoring rules for children ≥ 13 years.
� AASM Task force, 2012
Diagnostic criteria of OSA
in children
Consequences of untreated
Disordered breathing in
children� Behavioral disorders
(ADHD, ADD, dyslexia, memory ditch)
� Metabolic disorders (
Obesity, diabetes )
� Cardiovascular disorders
(Hypertension)
Common presentation of sleep problems in school age
children
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Mouth breathingPalatne & Adenoidal
tonsils Tonsillar hypertrophy Normal
Crowded oropharynx Adenoids +&-
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� Neurobehavioral Implications of Habitual Snoring in Children
� Louise M. O’Brien, Carolyn B. Mervis, Cheryl R. Holbrook, Jennifer L. Bruner, Carrie J. Klaus, Jennifer Rutherford, Troy J. Raffield, David Gozal
� Behavior Problems Associated with Sleep Disordered Breathing in School-Aged Children—the Tucson Children’s Assessment of Sleep Apnea Study
� Shelagh A. Mulvaney, PhD 1 , James L. Goodwin, PhD 2 Wayne J. Morgan, MDGerald R. Rosen, MD 4 Stuart F. Quan, MD 5 Kristine L. Kaemingk, PhD 6
� Neurocognitive and behavioral impact of sleep disordered breathing in children†
� Judith A. Owens MD, MPH*
� Version of Record online: 20 APR 2009
� DOI: 10.1002/ppul.20981
� Sleep-Disordered Breathing, Behavior, and Cognition in Children Before and After Adenotonsillectomy
� Ronald D. Chervin, Deborah L. Ruzicka, Bruno J. Giordani, Robert A. Weatherly, James E. Dillon, Elise K. Hodges, Carole L. Marcus, Kenneth E. Guire
Key articles Questions?