Pediatric Sleep-Disordered Pediatric Sleep-Disordered BreathingBreathing

OSA in infants and young children OSA in infants and young children is generally characterized by is generally characterized by

partial, persistent obstruction of the partial, persistent obstruction of the upper airwayupper airway

ContinuumContinuum

Benign primary snoringBenign primary snoring

Upper-airway resistance syndrome Upper-airway resistance syndrome (UARS)(UARS)

Severe OSASevere OSA– Tonsillar hypertrophy most common cause in Tonsillar hypertrophy most common cause in

children 2 – 8 years of agechildren 2 – 8 years of age– Early diagnosis essential to prevent Early diagnosis essential to prevent

complicationscomplications

SIDSSIDS

– Infants (0 – 12 months)Infants (0 – 12 months)Sudden death due to reduced arousabilitySudden death due to reduced arousability

More episodes of obstructive and mixed apneaMore episodes of obstructive and mixed apnea

ALTEALTE– Sleep disordered breathingSleep disordered breathing– Lower heart rate variabilityLower heart rate variability– Altered autonomic controlAltered autonomic control– Increased arousal thresholdsIncreased arousal thresholds– Fewer body movementsFewer body movements

Elective Cesarean sectionElective Cesarean section– More respiratory events in quiet sleepMore respiratory events in quiet sleep

More central apneasMore central apneas– More dangerous than obstructiveMore dangerous than obstructive– Ondine’s curseOndine’s curse

Longer duration of central apneasLonger duration of central apneas

More mixed apneasMore mixed apneas

Longer duration of mixed apneasLonger duration of mixed apneas

SIDSSIDS

Snoring in ChildrenSnoring in Children

7 – 12 % snore7 – 12 % snore

Most common presenting symptom of Most common presenting symptom of OSAOSA

Primary snorersPrimary snorers– Does not progress to OSADoes not progress to OSA

UARSUARSSnore and abnormal sleep histories / Snore and abnormal sleep histories / psg datapsg data

Underrecognized and undertreatedUnderrecognized and undertreated

Common symptoms with OSACommon symptoms with OSA– SleepinessSleepiness– RestlessnessRestlessness– DiaphoresisDiaphoresis– IrritabilityIrritability– SnoringSnoring

DifferencesDifferences– Not predicted well by same clinical variablesNot predicted well by same clinical variables– PSG generally normal except forPSG generally normal except for

Elevation of EEG arousalsElevation of EEG arousals

Characteristic breathing patternsCharacteristic breathing patterns

UARSUARS

OSAOSA

Incidence 1 – 3%Incidence 1 – 3%– More than 2 million childrenMore than 2 million children

Only 20% of pediatricians screen for problemOnly 20% of pediatricians screen for problem

More than one obstructive apnea of any More than one obstructive apnea of any length per hour of sleep should be length per hour of sleep should be considered abnormalconsidered abnormal

Consequences of OSAConsequences of OSARepeated arousals needed to re-establish Repeated arousals needed to re-establish airwayairway– Sleep fragmentationSleep fragmentation– Loss of sleep’s restorative natureLoss of sleep’s restorative nature

Apneic episodes / periods of asphyxiaApneic episodes / periods of asphyxia– HypoxemiaHypoxemia– HypercapniaHypercapnia– AcidemiaAcidemia– Profound hemodynamic alterationsProfound hemodynamic alterations

Cyclical increases in systemic arterial Cyclical increases in systemic arterial pressure with episodes of apneapressure with episodes of apnea– Degree of hypertension correlates withDegree of hypertension correlates with

Apnea indexApnea index

ObesityObesity

– Undiagnosed OSA may lead to increased risk Undiagnosed OSA may lead to increased risk of cardiovascular complications later in lifeof cardiovascular complications later in life

Increases in pulmonary artery pressure Increases in pulmonary artery pressure with each apneawith each apnea– Maximal PAP generated during REMMaximal PAP generated during REM

– Probably reflect hypoxic pulmonary Probably reflect hypoxic pulmonary vasoconstrictionvasoconstriction

– Cor-pulmonale and RHFCor-pulmonale and RHF

Decrease in cerebral blood flowDecrease in cerebral blood flow– Decreased global and regional cerebral Decreased global and regional cerebral

perfusion decreased during wakefulnessperfusion decreased during wakefulness– MRI shows metabolic pattern consistent with MRI shows metabolic pattern consistent with

cerebral ischemiacerebral ischemia

Cognitive ConsequencesCognitive Consequences– Neurodevelopmental ComplicationsNeurodevelopmental Complications

Developmental delayDevelopmental delayPoor school performancePoor school performanceHyperactivityHyperactivityAggressive behaviorAggressive behaviorSocial withdrawalSocial withdrawal

Manifestations occur without frank sleepinessManifestations occur without frank sleepinessSleep deprived children manifest cognitive Sleep deprived children manifest cognitive and behavioral changes mimicking ADHDand behavioral changes mimicking ADHD– 81% of snoring children who have ADHD could 81% of snoring children who have ADHD could

have their ADHD eliminated if the SDB were have their ADHD eliminated if the SDB were effectively treated.effectively treated.

Cognitive impairmentsCognitive impairments– Memory, attention, and visuospatial abilities Memory, attention, and visuospatial abilities

affectedaffected– Sustained attention (vigilance), divergent Sustained attention (vigilance), divergent

intelligence (creativity)intelligence (creativity)

Grades improve with treatmentGrades improve with treatment

Poor growth commonPoor growth common– 50% - Failure to thrive50% - Failure to thrive– Adenotonsillar hypertrophyAdenotonsillar hypertrophy

AnorexiaAnorexia

DysphagiaDysphagia

– Abnormal nocturnal growth-hormone Abnormal nocturnal growth-hormone secretionsecretion

– Lack of end-organ responsiveness to growth Lack of end-organ responsiveness to growth factorsfactors

– Nocturnal hypoxemia, respiratory acidosis, Nocturnal hypoxemia, respiratory acidosis, and increased WOBand increased WOB

Increased weight-gain velocity after Increased weight-gain velocity after correctioncorrection

Clinical ManifestationsClinical Manifestations

Nocturnal symptomsNocturnal symptoms– SnoringSnoring– Restless sleepRestless sleep– Diaphoretic during sleepDiaphoretic during sleep– Abnormal sleeping positionAbnormal sleeping position– Parental anxietyParental anxiety

Daytime symptomsDaytime symptoms– Internalized behavior problemsInternalized behavior problems– Externalized behavior problemsExternalized behavior problems– Overall lower incidence of obvious daytime Overall lower incidence of obvious daytime

somnolence than adultssomnolence than adults

DiagnosisDiagnosisOSA cannot be reliably distinguished from simple OSA cannot be reliably distinguished from simple snoring through clinical assessmentsnoring through clinical assessmentATS Consensus statement on standards and ATS Consensus statement on standards and indications for pediatric sleep studies recommends indications for pediatric sleep studies recommends PSG toPSG to– detect presence and severity of OSAdetect presence and severity of OSA– differentiate between benign snoring, snoring with differentiate between benign snoring, snoring with

partial or complete airway obstruction, hypoxemia and partial or complete airway obstruction, hypoxemia and sleep disruptionsleep disruption

– Evaluate disturbed sleep, EDS, Cor pulmonale, failure Evaluate disturbed sleep, EDS, Cor pulmonale, failure to thrive, unexplained polycythemiato thrive, unexplained polycythemia

– Assess relevant symptoms in children with major risk Assess relevant symptoms in children with major risk factorsfactors

– Assess child with OSA @ increased risk for Assess child with OSA @ increased risk for perioperative and postoperative complicationsperioperative and postoperative complications

– Titrate CPAP therapy in pediatric OSATitrate CPAP therapy in pediatric OSA

ManagementManagement

Supplemental oxygen may depress Supplemental oxygen may depress ventilatory drive and aggravate apneaventilatory drive and aggravate apneaAdenotonsillectomyAdenotonsillectomy– SDB primary indication SDB primary indication

Nasal CPAPNasal CPAP– Patient growth changes CPAP requirementsPatient growth changes CPAP requirements– Pressures = to median pressures for adultsPressures = to median pressures for adults

HFNC (5 – 15 LPM)HFNC (5 – 15 LPM)– Heated to body tempHeated to body temp– Near 100% relative humidityNear 100% relative humidity