Child with “OSA”
Eid Ali Gumaa
Assist. Professor of Anesthesia
Faculty of Medicine
1837: Charles Dickens, in the
Posthumous Papers of the Pickwick Club,
described an obese boy named Joe with
excessive daytime somnolence.
Joe has become the prototype of the obesity-
hypoventilation syndrome, and probably
suffered from obstructive sleep apnea.
1918: Sir William Osler, was
subsequently coined the word „Pickwickian‟ to
describe such obese, hypersomnolent
1928: Berger, Human EEG alpha waves.
1937: Loomis, EEG Sleep stages described.
1965: Gastaut et al. documented the
presence of repetitive obstructive apneas
during polysomnographic recording of an
obese Pickwickian patient.
The link between obesity, hypoventilation,
daytime somnolence, and upper airway
obstruction was now established.
1972: Guilleminault – coined the term
1990: International Classification of Sleep
What is Sleep?
“a reversible behavioral state of
perceptual disengagement from and
unresponsiveness to the environment”
75% in Non-REM sleep
25% REM sleep –muscle atonia,
Normal muscle tone
Four stages of NREM sleep based on
Stage 1-small amplitude high
frequency waves resembling awake
Stage 4-large amplitude and lowest
frequency waves approaching REM
Rapid eye movements.
Generalized hypotonia of muscles.
Irregular rate and depth of respiration.
Marked suppression of hypothalamic
regulation of homeostasis.
OSAS: describe a person with specific
symptoms and signs (daytime sleepiness,
cognitive dysfunction, snoring,
hypertension, and a narrow upper airway),
and a polysomnogram showing upper
associated symptoms have frequently been
described, including gastro-esophageal
reflux, nocturnal or unusually enuresis,
abnormal motor activity, and sweating
Apnea is cessation of airflow >10 sec,
ends in arousal
OSA- apnea with continued
Hypopnea –reduction in airflow of
50% with 4% desaturation, ends in
Apnea / Hypopnea Index (AHI)
OSAS: AHI >5/ h. on polysomnography.
UARS: AHI <5/ h., excessive daytime
somnolence, elevated intra-thoracic
Primary Snoring: no polysomnogram
OSA severity scoring
Severe OSAModerate OSAMild OSA
respiratory effort, loud
snoring and „snorting‟,
Mouth breathing with
moderate increase in
respiratory effort, +/-
snoring or „snorting‟,
Mouth breathing, slight
effort, +/- snoring,
sleeps quietly at night
episodes of paradoxical
Normal baseline SpO2,
to mid 80s
SpO2 in normal limits,
+/- minor dips
Upper airway resistance syndrome:
A group of children with:
Symptoms of (OSAS) excessive daytime somnolence but
Without polygraphic apnea and hypopneas.
Rather repeated central nervous system arousals, during
However, these children were found to have increased
respiratory efforts during sleep.
Using esophageal manometry as a measure of respiratory
effort, it was noted that such arousals were preceded
by increased respiratory effort.
The typical presentation of UARS
May or may not snore,
But typically has a narrowed upper
postural hypotension, seems to be a
common finding in such patients, in
contrast to OSAS where hypertension is
the usual finding.
Diagnosis may be wrong in 50 % cases
Loud snoring + witnessed apneas
identified OSAHS with sensitivity 78%
and specificity 67%
Neck circumference <37cm , >48 cm
are associated with low and high risk
Obesity (BMI>30) independent risk
factor but ~ 50% cases are not obese
Obstructive apnea: Complete cessation of
airflow despite efforts to breathe
Hypopnea:Reduction in airflow compared
to baseline, associated with desaturation:
2% of children
Boys = Girls
Peak at age 2:5 years
Peak OSA =Peak ATH
Snoring- severity not predictive
Many are mouth breathers (Adenoid
facies 15% have OSA)
Excessive daytime sleepiness
Obesity Vs. Fatty
Increased respiratory effort
* Possible impairment of release or end-
organ response to GH
* Increased caloric effort with respiration
* Difficulty with eating
Associated with GERD
Clinical features of OSA in children and adults
ObeseFailure to thriveWeight
Poor school performance
Adults and Children
Type II OSA
Type I OSA
Middle age2-6 yearsPeak age
High rate of comorbidity (COPD, CAD,
Short, obese neck / retrognathia –
setup for disaster unless prepared
Post-obstructive pulmonary edema
Identification of children at high risk for
complications after adenotonsillectomy
Age < 3 years or Weight < 15 Kg.
Failure to thrive
Children with OSA with a cold should be
postponed for 4 weeks.
Children with signs and symptoms
suggestive of severe OSA with cardiac
involvement need to be assessed by a
cardiologist prior to surgery
The improvement is not immediate, but
children are dramatically improved in
the weeks after surgery.
Sedative premedication should be
avoided for children with OSA.
Parents to accompany the child to the
anaesthetic room to reduce the child‟s
May be gaseous or intravenous, depending
on the child and the preference of the
Immediately after induction” with the loss
of pharyngeal tone “ airway almost
obstruct & may be relieved by jaw thrust
and the application of CPAP.
As soon as the child is deep enough an oral
airway should be inserted and effectively
relieves the obstruction.
Children with severe micrognathia (expected will
not be easy to intubate) a cautious gas
induction is sensible in this situation.
Intubation and electively ventilation of children
with severe OSA, usually using a short acting
Intubation under deep anesthesia without muscle
relaxant is unwise in this situation.
Suxamethonium should be used if non depolarising
agents are not available.
Children with severe OSA have been
estimated to require 50% less opioid than
normal children due to increased opioid
Analgesia should be carefully titrated to effect,
Simple analgesics should be used.
Awake Extubation at the end of surgery.
Opioid analgesia should be kept to a minimum
in the postoperative period.
Insertion of a nasopharyngeal prong airway
(NP airway) for these children at the end of
Airway obstruction is not relieved immediately after
surgery in children undergoing adenotonsillectomy for
severe OSA. This is mainly due to edema and swelling
at the operation site, which improves in the first 24-
48 hours after surgery.
The child is nursed on the high dependency area (HAD)
with the NP airway in position for the first night at
least – it is very important to regularly do suction the
airway with soft suction catheter.
Careful overnight observation, using saturation
monitoring as part of routine monitoring on the ward /
HAD , but do not administer oxygen to those with
severe OSA unless required.