Pediatric Sleep medicine

7/29/2019 Pediatric Sleep medicine

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Pediatric obstructive sleep apneaas a model for the technologists role

in the assessment and management of sleep

problems in children

Dominic B. Gault, M.D.Assistant Professor, University of South Carolina

Medical Director, Division of Pediatric Sleep Medicine

Greenville Hospital System Children's Hospital


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Objectives:

To understand some of the unique issues which

arise in the assessment and management of sleep

disorders in children

To understand the role and importance of the

sleep technologist in the assessment andmanagement of sleep disorders in children


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Children are NOT Little Adults

Continuum across

development

Differences amplified at

younger ages

Additional developmentalissues may arise in association

with specific medical

disorders

www.newline.com (New Line Cinema)


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Different Disorders, Different Assessments,

Different Treatments

Sleep disorders are common in children

Prevalence = 25%Owen, Prim Care Clin Office Pract, 2008; 35: 533-46

Prevalence rates are higher in children with

developmental issues, psychiatric disorders

and chronic medical conditions

Sleep disorders which affect adults can affect

children


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Sleep disorders presenting more commonlyor differently in children

Night Terrors

Sleep Enuresis

Nightmares

Rhythmic Movement Disorder

Kleine-Levin Syndrome Delayed Sleep Phase

ICSD-2, AASM


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Some sleep disorders are unique to

childhood

Apnea of Infancy

Apnea of Prematurity

Behavioral Insomnia of Childhood

Pediatric Obstructive Sleep Apnea

Differences in physiology result in differences in

presentation and adverse effects

Distinct polysomnographic characterization

Prevalence 2%Redline, Am J Respir Crit Care,.1999; 159:1572-32

ICSD-2, AASM


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Assessment ofsleep disorders in children

History and Physical

Sleep Log Actigraphy

Polysomnography

Multiple Sleep Latency Testing (MSLT)

Maintenance of Wakefulness Test (MWT)

Not every child with a sleep complaint requiresassessment in the sleep lab


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Diagnostic Criteria:Pediatric Obstructive Sleep Apnea

A. The caregiver reports snoring, labored or obstructed breathing, or

both snoring and labored or obstructed breathing during the childs

sleep.

B. The caregiver of the child reports observing at least one of the

following:

i. Paradoxical inward rib-cage motion during inspiration

ii. Movement arousals

iii. Diaphoresis

iv. Neck hyperextension during sleep

v. Excessive daytime sleepiness, hyperactivity, or aggressive behavior

vi. A slow rate of growth

vii. Morning headaches

viii. Sleep enuresis ICSD-2, 2005


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Diagnostic Criteria:Pediatric Obstructive Sleep ApneaC. Polysomnographic recording demonstrates one or more scorable

respiratory events per hour (i.e., apnea or hypopnea of at least 2respiratory cycles in duration).

D. Polysomnographic recording demonstrates either i. or ii.i. At least one of the following is observed:

a. Frequent arousals from sleep associated with increased respiratory effort

b. Arterial oxygen desaturation in association with apneic episodes

c. Hypercapnia during sleep

d. Markedly negative esophageal pressures pointsii. Periods of hypercapnia, desaturation or hypercapnia and a desaturation

during sleep associated with snoring, paradoxical inward rib cagemotion during inspiration, and at least one of the following:

a. Frequent arousals from sleep

b. Markedly negative esophageal pressures wings

ICSD-2, 2005


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Diagnostic Criteria:Pediatric Obstructive Sleep Apnea

E. The disorder is not better explained by another current sleep

disorder, medical or neurologic disorder, medication use, orsubstance use disorder

ICSD-2, 2005


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Assessment of obstructive sleep apnea inchildren

Direct Observation

Videotape/Audiotape

Oximetry

Nap Polysomnography

Polysomnography, Gold Standard


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Polysomnography:

Its more than an assessment

of obstructive sleep apnea

Obstructive sleep apnea

Central sleep apnea Central alveolar

hypoventilation syndromes Congenital

Acquired

Sleep-related hypoxemia

Periodic limb movementdisorder

Sleep myoclonus

Narcolepsy

Idiopathic Hypersomulence

Nocturnal seizures

Nocturnal Frontal LobeEpilepsy

REM behavior disorder

Confusional arousals

Sleep ArchitectureAbnormalities

Mood Disturbances Pain Syndromes

Sleep fragmentation

Sleep State Misperception


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Polysomnography is NOT a static test

Full EEG Montage

Multiple Sleep Latency Testing +/- Gastroesophageal Reflux Monitoring

Gastroesophageal reflux as a cause of apnea in children

Issues:

Difficulty correlating reflux with specific respiratory events Increases upper airways resistance, which may increase

obstructive respiratory event frequency

Increases posterior oropharyngeal stimulation, which mayincrease oral secretions and decrease central respiratory eventfrequency


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Performing Polysomnography

in Children The sleep lab

Preparing the child

Running the study

Scoring the study

Interpretation

by Carlton Jemmett

[email protected]


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Sleep lab environment Child Friendly, Child Safe

Child-proofing

outlets, chemicals, equipment Dcor

Distraction objects/Entertainment

Parent space


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Equipment

Do you have the appropriately sized equipment?

Cannula, thermistor, effort belts, oximeter probes,

CPAP masks

Do you have the right equipment?

Crib

CO2 monitoring Videography


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Sleep lab procedures and protocols Lab hours

Staffing

Issues which may arise

pacifier use, bottles, bed-wetting, diapers, emesis

Montages

Bilateral EEG Assessment

Titration

Emergency Protocols Appropriately trained staff (pediatric advanced life support)and appropriate equipment

AAP Safe Sleep Recommendations


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Performing the study

Preparing the child for the study begins prior to the

child arriving in the sleep lab

Books or Videos

Discussions with family and child

Use age/developmentally appropriate language todiscuss the sleep study


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Flexibility Timing of set-up

Order of set-up

Adequate time to perform set-up

Use distraction, comforting and information to youradvantage

Requires understanding the goal of the study BEFOREapproaching the child

If there are any questions about the goal, discuss them with theordering physician


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Sleep technologists observations Important to make an accurate and successful diagnosis

All observations are important

May provide an explanation for events seen in the study May identify other possible sleep disorders

Examples of important observations: Associations

Snoring (patient, caregiver) Timing of feedings

Pacifier use

Patient and caregiver use of cell phones, TV, personal videogames

Parent-Child Interactions


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Scoring of Pediatric Polysomnography

The AASM Manual for the Scoring of Sleep and

Associated Events, 2007

Unique pediatric criteria: Visual Rules

Cardiac Rules

Respiratory Rules

Does not include visual rules for children less than 2months of age post-term (Quiet versus Active)

Pediatric rules can be used for children /= 13 years using adult criteria


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Sleep EEG activity as a developmental

continuum

4 y.o., Stage N2 17 y.o., Stage N2


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Sleep EEG activity as a developmental

continuum

4 y.o., Stage N3 17 y.o., Stage N3


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Arousals

Types of arousals

Spinal/Reflex

Autonomic

Cortical

Children have less cortical arousals with respiratoryevents than adults


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Breathing during sleep Respiratory events

Obstructive Apnea at least 2 missed breaths, 90% decrease in signal with evidence of

respiratory effort

Central Apnea lasts 20 seconds OR lasts at least 2 missed breaths AND is associated

with arousal, awakening or >/= 3% desaturation

Obstructive Hypopnea at least 2 breaths, >/= 50% decrease in signal, associated with an

arousal, awakening or >/= 3% desaturation

Periodic breathing > 3 episodes central apnea lasting > 3 seconds each and seperated by

no more than 20 seconds on normal breathing

Ventilation >25% of total sleep time spent with EtCO2 or TCO2 greater than 50

mm Hg AASM Manual for Scoring of Sleep and Associated Events. 2007


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Interpreting Polysomnography

in Children

Need to take into consideration the unique definition of

obstructive sleep apnea for children

Need to take into consideration differences in

presentation and adverse effects compared to adult

obstructive sleep apnea


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After diagnosis the work just begins

Successful diagnosis does little to help the child

and family other than to make them aware of the

presence of the disorder

Remember, you are treating both the child and the

caregiver

Sleep problems which affect children, also affect thosecaring for them

Both child and caregiver need to be engaged in the

treatment plan


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The Sleep Technologists

Role in Treatment

Must be aware of the wide array of treatmentoptions

Understand that the treatment plan depends onclinical history as well as the pattern and severityof obstructive sleep apnea present onpolysomnography

Understand the adverse effects of obstructivesleep apnea, in order to be able to reinforce theimportance of following through with thephysicians treatment plan


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Treatment Options for


Tonsillectomy and Adenoidectomy

Typically first line treatment

CPAP

Orthodontics

Pharmacologic agents

Weight management Other surgical options in specific cases

Tracheostomy, mandibular advancement,

supraglottoplasty


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Non-Invasive Positive Pressure Ventilation

(CPAP/Bi-Level)

Machines to deliver non-invasive positive pressure

ventilation are FDA approved down to 7 years of age and

for a weight of at least 40 lbs.

There is a non-invasive positive pressure ventilation mask

which has received approval down to 2 years of age

CPAP has been shown to be safe and effective even in

children younger than 2 years of ageDowney, Chest. 2000; 117(6):1608-12


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The Technologists role in CPAP/Bi-Level Fitting

Developing relationships and educating durablemedical equipment providers and home healthcarecompanies

Development of desensitization and transition plans

Titration

Assessment of issues affecting tolerance andcompliance with therapy

Reinforce therapeutic plan


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Mask Fit There are limited mask

options available forchildren

Familiarity with a theavailable mask options,their strengths andlimitations

Comfort andappropriateness of fit ofthe CPAP interface plays asignificant role in thepatients acceptance oftherapy

Massie, Chest. 2003; 123(4);1112-18


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Relationships with DME providers Develop a close relationship with a DME provider who is

comfortable with working with children

Educate them about differences in definitions ofobstructive sleep apnea between children and adults, inorder to prevent delays in initiation of therapy

Educate them about differences in initiation plans, and theuse of desensitization to positive pressure ventilation priorto titration polysomnography, when appropriate

Assure that they are aware of and have ready access toappropriate equipment for pediatric patient


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Desensitization

In fact both adults and children benefit from educationabout CPAP/Bi-Level prior to titration

polysomnography Silva, Sleep Breath. 2008; 12(1):85-9

Desensitization considerations:

Desensitization to mask

Desensitization to headgear

Desensitization to airflow

Individualized treatment planKirk, Sleep Med Rev. 2006; 10:119-27


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Titration

Develop and utilize a protocol for titration, which is

appropriate for pediatric patients, taking into

consideration the definition of pediatric obstructivesleep apnea, and the differences in generation of

arousals, and airway dynamics

Assess hindrances to CPAP

Reinforce importance of therapy


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Differences in children which effect titration:

Airway stability

Airway stability as assessed by the slope of thepressure flow response to subatmospheric pressure

Bandla et al. Sleep. 2008; 31(4):534-41


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Differences in children which effect titration:

Airway size

ResMed Corp.


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Follow-up

Ongoing growth and development results inrequirements for reassessments

CPAP/Bi-Level interface persistence/evolution of sleep-disordered breathing

appropriateness of current therapy and settings

Compliance and hindrances to therapy

compliance and efficacy downloads


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Summary

The sleep technologists role in the assessment and

management of sleep disorders in pediatric patients

begins prior to the child presenting to the sleep lab andcontinues throughout the childs assessment, treatment

and long-term management


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Summary

The sleep technologist plays a critical role in the

assessment and management of sleep disorders inchildren. By being prepared to perform this role, the

sleep technologist can assure the safe and efficacious

assessment and treatment of the pediatric patient


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Thank you!

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Pediatric Sleep medicine

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