Marco Zampoli Paediatric Pulmonology Red Cross War Memorial Children’s Hospital University of Cape Town No conflicts of interest; permission for all photos
Aetiology and prevalence Complications Pathophysiology Diagnosis and its challenges Medical interventions Indications and role of surgery Perioperative risks Management approach algorithm
Chest wall indrawing “effort” “ Apnea “ Abdominal effort +Snoring + Arousals With permission from the parents....
Prevalence(%) (95% CI) of habitual snoring reported across 41 studies Age distribution of children reporting questionnaire data for investigate for SDB in large US snoring prevalence centre Prevalence % Age in years Tassig and Landau. Pediatric Resp Medicine Lumeng et al Proc of ATS Feb 2008
Increased upstream airway resistance eg adenoidal hypertrophy Nose Increased inspiratory Nasopharynx effort; “suction pressure” Oropharynx Downstream airway Larynx collapse and Extrathoracic occlusion, worse trachea during REM sleep Arousal, hypoxia, hypercarbia, sleep Diaphragm fragmentation
Adenoidal/tonsillar hypertrophy (ATH) Obesity Micrognathia e.g. Airway/luminal Pierre Robin Allergic rhinitis/Asthma obstruction Craniofacial Foreign body syndromes Deviated septum Down’s Retropharyngeal abscess syndrome Congenital mass/tumour/cysts Other syndromes Skeletal Neuromuscular abnormalities defects Prader Willi Neuromuscular diseases (congenital or acquired) Other medical conditions Cerebral palsy E.g. sickle cell Central hypoventilation Spinal cord defects
Neuromuscular Arousal threshold activation Airway stability Central Ventilatory Anatomical factors control
Intermittent hypoxia, hypercapnea, repeated intrathoracic pressure swings, sleep fragmentation, systemic inflammation , individual genetic susceptibilty, environmental factors e.g. passive smoking, nutrition all contribute to adverse consequences of OSA Growth impairment Excessive daytime sleepiness Impaired concentration Poor Quality of Life Neurobehavioral consequences Cardiovascular consequences Metabolic consequences
Inattention, poor scholastic performance, developmental delay are well known effects of OSA. Hyperactivity, aggressive behaviour and ADHD increasingly recognised as associated with OSA Enuresis and polydipsia “ wild child ”
Cor pulmonale
Apnea Hyponea Index (AHI) AHI< 1 normal AHI 1-5: mild OSA AHI 5-10 : mod OSA AHI> 10 : severe
Technically challenging in children; need overnight supervision by skilled technologist. Need sleep lab facility, or in-patient bed with suitable equipment and software Suitably trained technologist s to perform, analyse and report studies PSG (2-4 hrs per study ! Relatively “invasive “ investigation
The bedside observation Screening questionnaires and scores Overnight oximetry Combining screening questionnaires and oximetry Home polygraphy and portable devices New technologies Urinary biomarkers The bedside “sleep study”
• Simple; cheap; portable; widely available Requirements: • • Oximeter with memory. • 2-3 sec Sats and HR averaging ability. • Sensor that eliminates motion artefact. • Download serial cable. • Compatible download and analysis software..... problem in SA!!
median SpO2 >95% <4 desats / h of >4% no abnormal clusters of desats: >4 / 0.5h of >4%
PSG +ve PSG -ve Oximetry +ve 90 3 93 Oximetry -ve 120 136 256 210 139 • n = 349 snorers – mean age 4.5y [Montreal] • Sensitivity (90/210) = 43% • Specificity (136/139) = 98% • Positive predictive value (90/93) = 97% • Negative predictive value (120/256) = 47% Brouillette et al. Pediatrics 2000
* Nixon et al , Pediatrics 2004 No. No. No No of McGill desats desats desats< desats Score < 90 % < 85% 80% clusters 1 No /mild OSA < 3 0 0 <3 2 Moderate OSA ≥ 3 ≤ 3 0 ≥ 3 severe OSA 3 ≥ 3 > 3 ≤ 3 ≥ 3 4 Very severe OSA ≥ 3 > 3 > 3 ≥ 3
LIMITATIONS ADVANTAGES Cannot distinguish the Quick and simple cause(s) of hypoxia. Cheap Cannot distinguish central Picks up severe spectrum from obstructive events. OSA accurately Sleep/awake states not Excludes severe spectrum established. OSA accurately Motion artefacts. Identifies those at high risk Normal oximetry does not of perioperative exclude OSA, will miss those with mild OSA complications (nadir SaO2) without desaturations
• Multichannel devices gaining popularity but few have yet been validated in children; validated and accepted now as “gold standard” in adults. • Channels: Oximeter, HR, nasal flow, snore, effort (single chest/abdominal band) • Evidence if limited but home polygraphy seems to perform reasonably well compared to laboratory PSG ( Sensitvity 76%, specificty 77%) • Underperforms with diagnosis of mild – moderate OSA (AHI >1 and < 10) Tan et al , CHEST Dec 2015
Combination of urinary biomarkers had sensitivity of 100% and specificity of 95% for predicting PSG-confirmed OSA compared to habitual snorers and healthy controls
Andenotonsillectomy : is it indicated for mild- mod OSA ? Evidence for anti-inflammatory medications for OSA Oromotor exercises for OSA (myofunctional therapy
Excluded children with severe OSA (AHI> 20 or desats < 90% for 2% of Sleep time) Attention and executive functions Behaviour Quality of life scores PSG score
Nearly half of watchful waiting group had normalisation of PSG findings after 7 months., however less in Black and Obese children Risk vs benefits of adeno-tonisillectomy (asphyxia, brain injury and death) must be considered
Intranasal fluticasone vs placebo improved OSA by AHI criteria Intranasal budesonide vs placebo improved AHI Monteleukast vs placebo improved OSA in children 2-10 years ( Kherandish-Gozal et al Ann Am Thorac Soc- Epub July 2016) Monteleukast vs intranasal steroids : trial results pending…. 2011
ORTHODONTIC INTERVENTIONS MYOFUNCTIONAL THERAPY 25 paediatric patients: 62% reduction in AHI
Anti-inflammatories Airway/luminal Decongestants/nasal washes obstruction: Antihistamines Orthodontic treatment AT hypertrophy Allergy Adenotonsillectomy Orthodontic surgery Infections Weight loss CPAP Obesity Bi-level NIV Tracheostomy Skeletal Neuromuscular abnormalities defects Myofunctional therapy CPAP Bi-level NIV
Young children < 2 Syndromes, multifactorial OSA Neuromuscular conditions Obesity Severe OSA AHI> 10 Nadir desaturation < 80%
Suspect OSA Documented severe/life threatening OSA (bedside observation/monitoring Non-severe Severe OSA or cell phone recording) with or without associated life-threatening - Snoring every night - Snoring most complications e.g. Cor pulmonale - Difficulty breathing and witnessed nights - Difficulty apneas every night breathing some - Parents shake child awake or re- position to prevent apnoea's nights - Complications eg PHT, enuresis, Urgent intervention: - no concerning systemic HPT, growth faltering complications CPAP, CIPP, Surgery - Worrying cell phone recording Underlying high risk disorders Optimise medical Severe OSA - Young age < 2 years treatment - Craniofacial and other syndromes - Intranasal - Neuromuscular disorders steroids - Morbid obesity - Montelukast Sleep study: - Request cell Review 3-6 months Oximetry / PSG phone recording Symptom improvement ? No Symptom improvement > 6 months or young child Mild-mod OSA Watchful waiting Continue medical treatment surgery
Childhood snoring and OSA is a common but under recognised public health problem in SA. Persistent snoring and mild OSA is not harmless and requires intervention. A history of snoring should be a routinely obtained. Watchful waiting and anti-inflammatory therapy should be initiated in all children with habitual snoring and mild-moderate OSA before surgical interventions are considered or while awaiting PSG/sleep study Tools other than PSG/ Laboratory studies need to be developed and implemented for use in resource-poor settings. Portable devises and oximetry should become routine on SA setting Awareness and greater access to home CPAP , orthodontic and other interventions is needed as adjunctive treatments for OSA in children
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