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Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

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Obstructive Sleep Apnea Syndrome Dr. Amir Bar , Bnei-Zion Medical Center , Haifa
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Page 1: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Obstructive Sleep Apnea Syndrome

Dr. Amir Bar,

Bnei-Zion Medical Center,

Haifa

Page 2: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

A “new syndrome”

“PubMed” search (Sleep Apnea; 0-18y):– 1960’ 11

– 1970’ 82

– 1980’ 689

– 1990’ 1012

A common syndrome Has significant complications w/o Tx Can be efficiently treated in the majority of cases

>>Awareness and early diagnosis and Tx

Page 3: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

EEG Non-REM Sleep Stages

Page 4: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

EEGREM sleep

Page 5: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Sleep physiology

REM

EOG M. Tone

WakeRapidNormal

St 1Slow+/-

St 2NoneRelaxation

St 3-4

“SWS”

NoneRelaxationMetabolism , GH secretionPara-sympathetic predominance NoneRelaxation

REMRapidAtoniaDreams, Mental, Memory Sympathetic predominance (MI)Penile- erection REM-Related OSA

Page 6: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Classification

Apnea: a Greek word - “want of breath”– Obstructive – Central – Mixed

m/p the Greeks describe obstructive type

Page 7: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Classification

Respiratory Disturbance Index (RDI)– Normal value <1-2 per hour of sleep

1. Apnea: complete airflow cessation (2 respiratory

cycles) 2. Hypopnea: airflow reduction (2 respiratory cycles) 3. Respiratory Effort Related Arousal (RERA):

prolonged flow limitation with associated arousal (Upper Airways Resistance Syndrome)

• Normal oxygen saturation

Page 8: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Epidemiology

Prevalence: – OSAS: 1-3%– Primary snoring (PS): 3-12%

Gender: – M/F ratio 1:1 (Adults: male predominance)

Age: – From neonates to adolescents – Commonest in preschool children (2-5y)

• (Peak incidence of adenotonsillar hypertrophy)

Race: – More common in African-American children ??

Page 9: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Nocturnal presentation

ApneaDyspneaSnoringMouth breathingRestless sleep

Page 10: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Pathophysiology

Closed AW

Opened AW

Insp. Neg. pressure

•Anatomical factors

Pharyngeal dilators

•Muscle relaxation (Sleep)•Muscle atonia (REM)•Neuromuscular dis

Page 11: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Upper Airways

Page 12: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Anatomical Factors

Page 13: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Anatomical Factors

Page 14: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Neuromuscular Factors

Page 15: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Pathophysiology

Vast majority of cases are associated with adeno-tonsillar hypertrophy (AT-Ht)

Obesity in children is a risk factor for OSAS, and the severity of OSAS is proportional to the degree of obesity– In contrast to adults, most OSAS

children are not obese (may have FTT)

Page 16: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Pathophysiology

Although strongly associated with AT-Ht, childhood OSAS is not caused by AT-Ht alone:

– No obstruction during wakefulness– Adenotonsillar size and OSAS are not correlated

– Deficit in arousal mechanisms • Elevated arousal thresholds in response to

hypercapnia and increased UA resistance

– Abnormal centrally mediated activation of UA muscles

Page 17: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Complications

CVS – systemic and pulmonary HTN

Neurocognitive/behavioral problems

FTTEnuresis

Page 18: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

OSAS: PSG screen

Chin EMG

ECG

Airflow

Peripheral Pulse Volume

BP

Leg Mt.

Oximetry

EEG

Page 19: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Complications: CVS

Cor-pulmonale - used to be a common presentation, but is currently rare – When it does develop-can be reversed by

Tx

Tal, Pediatr Pulmonol, 1988:Ventriculography in children who had

abnormal questionnaire for OSAS:– 37% had Rt. ventricular EF – 67% had abnormal wall motion– All of the 11 pt who had a repeat evaluation

after T&A showed improvement

Page 20: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Complications: CVS

Shiomi, Chest, 1993:Pulsus-paradoxus and leftward

shift of the inter-ventricular septum in 3/6 children with OSAS– Correlated with negative esophageal

pressures but not with oxygen desaturation, reversed with CPAP

Page 21: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Complications: CVS

Am J Respir Crit Care Med. 2004 Apr 24 h ambulatory BP in children with sleep-disordered breathing

Background: OSAS causes intermittent elevation of systemic BP during sleep

Objective: to determine whether obstructive apnea in children has a tonic effect on diurnal BP

Conclusion: OSA in children is associated with 24 h BP dysregulation

Page 22: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Complications: CVS

AAPThe Fourth Report on the Diagnosis,

Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents

PEDIATRICS Vol. 114 No. 2 August 2004

Page 23: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Complications: CVS

Page 24: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Complications: Neurocognitive & Behavioral Guilleminault, Lung, 1981: 50 children with OSAS (PSG)

– 84% - excessive daytime sleepiness– 76% - behavior disturbance– 42% - hyperactive– 16% - school performance

Page 25: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Complications: Neurocognitive & BehavioralGozal, Pediatrics, 1998:297 first graders who were in the lowest

10th academically were evaluated for OSAS by questionnaire combined with home oximetry– 54/297 (18.1%) had positive results

• (recommended T&A)

– 24/54 underwent T&A and improved their grading significantly, with no change in the untreated OSAS group or the non-OSAS group

Page 26: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Complications: Neurocognitive & BehavioralGozal D, Sleep, 2004

Health-related Quality of Life and Depressive Symptoms in Children with Suspected Sleep-Disordered Breathing

Conclusions: Children with suspected OSAS, regardless of the severity of RDI or the presence of obesity, had more impairments in quality of life and depressive symptoms than did children who did not snore

Page 27: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Complications: Neurocognitive & BehavioralPillar, Sleep, 2004 Sleep Disorders and Daytime Sleepiness in Children with

ADHD Of the children with ADHD, 17 (50%) had signs of OSAS,

compared with 7 of the control group (22%, P < .05) Children with ADHD demonstrate objective daytime

somnolence (by MSLT), which may explain the beneficial effects of Tx with stimulants

Primary sleep disorders, especially sleep-disordered breathing and PLMS, should be looked for

Page 28: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Complications:FTT

FTT in OSAS children and reports of growth spurt following T&A

Proposed mechanisms:1. Low caloric intake

• Dysphagia

2. High caloric expenditure • Work of breathing

3. Abnormal GH secretion• Interrupted SWS, post T&A - IGF

Page 29: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Complications: Enuresis

Brooks, J Pediatr, 2003:Children 4 y and older who had suspected

OSAS were asked about enuresis– 160 pt (90/70; M:F)– 41% had enuresis (primary/secondary - 3:1)– RDI <1: significantly lower prevalence of

enuresis (17 vs. 47%)– The prevalence of enuresis is associated to

the OSAS severity (1-5, 5-15, or >15 events per hour)

Page 30: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Complications: Enuresis

Weider, Otolaryngol Head Neck Surg, 1991:

115 enuretic children undergoing T&A– 66% and 77% reduction in enuretic

nights 1m and 6 m Post-T&A– In the group with secondary enuresis,

100% were dry 6 m Post-T&A

Page 31: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Evaluation: Polysomnography (PSG)PSG is the gold STD for diagnosisEstablishment of diagnosis and

severity– Prediction of complications, particularly

in the immediate Post-Op period– Pre-Op baseline for Post-Op further

evaluationHigh costs and shortage of sleep

labs >> screening techniques

Page 32: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Evaluation: Screening

QuestionnairesSnoring audiotapesENT exam

– low sensitivity and specificityNocturnal VideotapesOximetryNap-PSG

– High false-negative rate, indicative if positive

Page 33: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Evaluation: Pulse Oximetry

Brouillette, Pediatrics, 2000:349 children, pulse oximetry

during PSG – OSAS prevalence – 60.2%– PPV - 97% – NPV - 53%

Page 34: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Treatment: T&A Tonsillectomy with or w/o adenoidectomy is

efficient Tx for OSAS Clinical improvement of symptoms and post-Op

complications: CVS, neurocognitive, enuresis, growth

Suen, Arch Otolaryngol Head Neck Surg, 1995: 69 with susp OSAS had PSG, 35/69 had RDI > 5

and referred for T&A, 30/35 had T&A, 26/30 had follow-up PSG– Cure rate 85%– Post-Op snoring: NPV - 100%, and PPV - 57%– A high Pre-Op RDI (>19) was a strong predictor of

abnormal Post-Op residual abnormality

Page 35: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Treatment: T&A

Nieminen, Arch Otolaryngol Head Neck Surg. 2000:– 95% cure rate for a group of 21

children after T&A or tonsillectomy– Postoperative snoring NPV 100%, PPV

20% – 73% of this group had a previous

adenoidectomy, indicating the lack of efficacy of adenoidectomy alone

Page 36: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Treatment: T&A

Post-Op respiratory compromise (16-27%)Causes:

– Upper airway edema– Increased secretions– Respiratory depression – 2nd to

analgesic/anesthetic agentsRisk factors

– Age <3 yr– severe OSAS– Children with additional medical conditions

Page 37: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Treatment: T&A

Follow-up PSG (6–8 wk Post-Op) , to ensure that additional Tx is not required– Children with additional risk factors– Children with a Pre-Op high RDI

Page 38: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Other Tx alternatives

Uvulopharyngopalatoplasty (UPPP): in CP pt and hypotonic upper airway muscles; it has not been studied in the uncomplicated pediatric pt

Oral appliances has not been reported in children (it may adversely affect the facial configuration of the growing child)

In children, CPAP is usually used when T&A is unsuccessful or contraindicated rather than as a primary treatment– Young infants– Medical conditions

Page 39: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

Treatment: Oxygen

Improved oxygenation during sleep, w/o obstruction worsening

PCO2 :– Few individuals show marked increase in PCO2

– With no apparent predictive factors for which pt would develop hypercapnia

Oxygen should never be administered w/o 1st measuring PCO2 response

Oxygen does not address many of the associated pathophysiological features

Page 40: Obstructive Sleep Apnea Syndrome Dr. Amir Bar, Bnei-Zion Medical Center, Haifa.

The end!


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