Pediatric obstructive sleep apnea

1,430 views

Published on

Published in: Technology, Business
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
1,430
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
80
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Pediatric obstructive sleep apnea

  1. 1. Pediatric obstructive sleep apnea syndrome : time to wake up Veena Arali, Srinivas Namineni, Ch Sampath IJCPD , JAN-APRIL 2012, 5 (1)
  2. 2. Introduction “On Some Causes Backwardness In Children” 11/22/2013 journal club 2
  3. 3. History • OSAS – 1966 • PMC • In 1976 11/22/2013 journal club Guilleminault et al jop 3
  4. 4.  Obstructive Apnea: continued chest and abdominal motion in the absence of airflow during sleep  Obstructive Hypopnea: decreased airflow and alveolar ventilation in the presence of paradoxical motion of chest and abdomen  Apnea-Hypopnea Index: # of events/hour • Used to categorize severity of condition • AHI > 1 abnormal, but clinically significant? • Pathology in a snoring child not yet clearly defined 11/22/2013 journal club 4
  5. 5. Definition • OSAS in childhood, as defined by the American Thoracic Society, is a disorder of breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction, obstructive apnea, that disrupts normal ventilation during sleep and normal sleep patterns. 11/22/2013 journal club 5
  6. 6. Epidemiology • 8-12% • 1-3% • 5-6% 11/22/2013 journal club 6
  7. 7. Physiology of breathing and sleep • Upper air way resistance 11/22/2013 journal club 7
  8. 8. Types of sleep • There are five stages of sleep; four stages are considered non-REM sleep and one stage of REM sleep 11/22/2013 journal club 8
  9. 9. What is REM sleep? • Rapid eye movement..during a sleep period (eyes dart from right to left) stimulates occular muscles; • Called “active sleep” or “paradoxical sleep”; • Respiration is irregular, heart rate is generally faster, blood pressure is higher…brain waves fast and shorter; • Dreaming occurs; 11/22/2013 journal club 9
  10. 10. EPIDEMIOLOGY • 11/22/2013 journal club 10
  11. 11. Pathophysiology 11/22/2013 journal club 11
  12. 12. Pathophysiology • Role of the Tonsils & Adenoids 11/22/2013 journal club 12
  13. 13. Role of upper airway neuromotor tone • Children with OSAS – ventilatory drive • Neuromotor function- abnormal • Accessory muscles- hypoxemia , hypercapnia 11/22/2013 journal club 13
  14. 14. • Role of Arousal • Role of structural factors • Role of genetic factors 11/22/2013 journal club 14
  15. 15. Clinical Symptoms • Vary with the age 11/22/2013 journal club 15
  16. 16. 11/22/2013 journal club 16
  17. 17. Clinical evaluation & diagnosis of SDB 1. The nose, one should look for asymmetry of the nares, a large septal base, collapse of the nasal valves during inspiration, a deviated septum or enlargement of the inferior nasal turbinates. 2. The oropharynx should be examined for the position of the uvula in relation to the tongue. 3. The size of the tonsils should be compared with the size of the airway. 4. The presence of a high and narrow hard palate, overlapping incisors, a crossbite and an important overjet are indicative of a small jaw and or abnormal maxilla-mandibular development 11/22/2013 journal club 17
  18. 18. Objective confirmation of SDB • • • • • Testing during sleeping –SDB Questionnaires Home monitoring Ambulatory monitoring Polysomnography 11/22/2013 journal club 18
  19. 19. • Questionnaires  Brouillette’s OSA questionnaire initially appeared accurate in small sample, but on subsequent studies was indeterminate in 47% » Brouillette, J Pediatr, 1984  Parents cannot predict severity of OSA based on their observations » Preutthipan, Acta Paediatr, 2000 11/22/2013 journal club 19
  20. 20. Home monitering Audiotapes – lack specificity to distinguish OSAS from primary snoring. » Lamm, Ped Pulm 1999 Videotapes – sensitivity 94%, specificity 68% » Sivan, Eur Respir J, 1996 11/22/2013 journal club 20
  21. 21. Diagnosis PSG • Polysomnography = sleep study • “Gold standard” • Only technique that allows comprehensive monitoring of both cardiorespiratory function and sleep noninvasively 11/22/2013 journal club 21
  22. 22. Polysomnography • Polysomnography is the only test that may exclude the diagnosis of SDB. It must always include monitoring of sleep/wake states through electroencephalography (EEG), electrooculography, chin and leg electromyography, electrocardiography, body position and appropriate monitoring of breathing. 11/22/2013 journal club 22
  23. 23. • The American Thoracic Society has defined their criteria for an abnormal PSG in children as follows: • Apnea index (AI) 1/hour • Apnea-hypopnea index 5/hour • Peak end-tidal carbon dioxide 53 mm Hg or • An end-tidal carbon dioxide tension 50 mm Hg for 10% of the sleep period and • A minimum hemoglobin oxygen saturation 92%. 11/22/2013 journal club 23
  24. 24. 11/22/2013 journal club 24
  25. 25. Orofacial implications 11/22/2013 journal club 25
  26. 26. • The most common orofacial characteristics encountered include  a retrognathic mandible,  narrow palate,  large neck circumference,  long soft palate (which leads to dentists’being unable to visualize the entire length of the uvula when the patient’s mouth is open wide), tonsillar hypertrophy,  nasal septal deviation  and relative macroglossia. 11/22/2013 journal club 26
  27. 27. • The following features are found in OSA patients on a cephalogram:  An increased incidence of maxillary retrusion (ANB < 0)  An increased incidence of mandibular retrusion(ANB > 0)  An increased incidence of maxillary and mandibular retrusion (SNA and SNB)  The hyoid was more inferiorly and anteriorly placed  A thicker soft palate  A larger tongue; a longer pharyngeal length. 11/22/2013 journal club 27
  28. 28. Treatment • Adenotonsillectomy • Medical therapies  Nasopharyngeal airway Insufflations of pharynx during sleep Continuous positive airway pressure via nasal mask • Tracheostomy 11/22/2013 journal club 28
  29. 29. • Pharmacological – Topical nasal steroids – Antibiotics – Nasal decongestant – Weight loss • Other surgical therapies – Craniofacial surgical procedures – Mandibular/maxillary plastic surgical procedures – Stenting procedures for nasal stenosis – Cleft palate revision procedures – Uvulopalatopharyngoplasty 11/22/2013 journal club 29
  30. 30. Adenotonsillectomy • Adenotonsillectomy is the most common treatment for childhood OSA • Cure rate = 75-100% » Suen, Arch Otolaryngol Head and Neck Surg, 1995 • Complications – anesthetic – post-op pain, poor oral intake and bleeding – airway edema – pulmonary edema 11/22/2013 journal club 30
  31. 31. • 24 months of age • OSA – 3wks of age • Severe snoring & clinical symptoms- 6-24 months • 6months of age. 11/22/2013 journal club 31
  32. 32. Orthodontic treatment • RMD • SMD • Rapid and slow maxillary distractions are performed between 5 and 11 years of age. • Distraction results in widening of the palate and the nose; thus, these procedure remedies nasal occlusion related to a deviated septum, for which little can be done before 14 to 16 years of age. 11/22/2013 journal club 32
  33. 33. Oral appliances 11/22/2013 journal club 33
  34. 34. Surgical treatment • Surgeries, such as nasal septoplasty and other maxillofacial surgeries, are indicated in some rare cases but not usually seen in the pediatric population. • Orthognathic surgery is normally postponed until 10 to 13 years of age. • Two surgical techniques used in patients with SDB are  mandibular distraction osteogenesis  and maxillomandibular advancement 11/22/2013 journal club 34
  35. 35. CPAP 11/22/2013 journal club Bilevel positive airway pressure 35
  36. 36. Sequelae of OSAS in Children • Cardiopulmonary: – Right ventricular hypertrophy – Left ventricular hypertrophy – Pulmonary hypertension – Systemic hypertension – Cor pumonale – Polycythemia 11/22/2013 journal club 36
  37. 37. • Neurodevelopmental: – Developmental delay – Hypersomnolence – Poor school performance – Leaning problems – Hyperactivity – Mood and behavior problems. 11/22/2013 journal club 37
  38. 38. J. M. Battagel & P R. L'Estrange • lateral cephalometric radiographs of 59 dentate, white, Caucasian males. • 35patients with proven obstructive sleep apnoea (OSA) & • 24 –conrol • Radiograph traced • conventional cephalometric measurements did not differ 11/22/2013 journal club 38 European Journal of Orthodontics 18 (J996) 557-569
  39. 39. • significant reductions were found in the lengths of the mandibular body and cranial base and in cranial base angulation in OSA subjects. • The combination of a short mandible and intermaxillary space, with an enlarged soft palate but decreased pharyngeal airway has relevance to the effective management of OSA. • Inselected patients, advancement of the lower jaw by a nocturnal mandibular repositioning splint may be indicated. 11/22/2013 European Journal of Orthodontics 18 (J996) 557-569 journal club 39
  40. 40. Wilhelmsson B et al • To compare – dental appliance & uvulopalatopharyngoplasty for Rx of OSA • RCT –UPPP or a dental appliance to achieve mandibular advancement of 50% of max protrusive capacity. • Apnea Index (AI) Apnea & Hypoxia Index(AHI) Oxygen Distraction Index(ODI) & Snoring Index(SI). 11/22/2013 journal Acta club oto laryngeal 1999; 119 : 503 -509 40
  41. 41. • Both groups show significant AHI, ODI, & SI . values of AI, • dental appliance - adjunctive 11/22/2013 journal club Acta oto laryngeal 1999; 119 : 503 -509 41
  42. 42. Conclusion 11/22/2013 journal club 42
  43. 43. References • A diagnostic approach to suspected obstructive sleep apnea in children journal of pediatrics Volume 105, Issue 1, July 1984, Pages 10–14. • Can parents predict the severity of childhood obstructive sleep apnoea? Journal of acta pediatrecia vol 89 ,issue 6 june 2000 ,708-712 • The cephalometric morphology of patients with obstructive sleep apnoea European Journal of Orthodontics 18 (J996) 557-569 11/22/2013 journal club 43
  44. 44. 11/22/2013 journal club 44

×