Gonzalo Pin ArboledasUnidad de Pediatría Integral Q ValenciaUnidad Valenciana del Sueño.Hospital Quirón Valenciawww.upiqwe...
VAS:Respuesta conservada a pr. Subatmosférica e hipercapnea                                       J Appl Physiol 2004;97:9...
A: incremento gradual de la pr B: Incremento intermitente
Mecanismo compensatorio de la mayor estrechez :  VAS menos colapsable.  Respuesta más dinámica tanto al CO2 como a la pres...
“The heart is the chief feature of a functioning mind”. Frank Lloyd Wright (1868-1959) ‘‘The brain runs away with the hear...
Repeated complete upper airway obstruction during sleep might be amajor contributor to the observed behavioral phenotype a...
children with OSA require more time and an    increased number of learning opportunities to reach     immediate and long-t...
Miano S, Paolino MC, Urbano A, Parisi P, Massolo AC, Castaldo R, Villa MPNeurocognitive assessment and sleep analysis in c...
Baumert M, Kholer M, Kabir M, Sanders P, Kennedy D, Martin J, Pamula Y . Altered cardio-respiratory response tospontaneous...
…. that the behavioral consequences and cellular losses are produced,at least in part, by the episodic hypoxia-reoxygenati...
TRS: Porcentajes significativamente elevados de disfuncion global ejecutiva
Pr. de conducta e indicaciones de pr. atencionales en los tres grupos de TRS
PubMed:“ADHD”, “attention-deficit/hyperactivity disorder”, “sleep”, sleep disorder” y “children” OR “pediatrics ”.1994 a M...
N= 11.000Sleep-Disordered Breathing in a Population-Based Cohort: Behavioral Outcomes at 4 and 7 Years.Pediatrics 2012;129...
Pediatrics 2012;129;e857N= 11.000
Sleep-Disordered Breathing in a Population-Based Cohort: Behavioral Outcomes at 4 and 7Years. Pediatrics 2012;129;e857 SDB...
EDAD: 6.5±4.0 a.   IAH : >1 < 10
DSM-IV Diagnoses and                                                                 DSM-IV Diagnoses andJ ,DILLON; S, BLU...
… existing studies of SDB’s effects are primarily cross-sectional, andlimited by poor sampling, insufficient consideration...
Snoring is not associated with adverse effects on blood pressure, arterialstructure or function in 8-year-old children: Th...
Changes in Heart Rate Variability After Adenotonsillectomy in Children With Obstructive Sleep Apnea. Chest.2011; 139 (5)  ...
TA - DISTENSIBILIDAD ARTERIAL EN         RH.      9,5 +/- 2 a. RONCADORES NO RONCADORES                   p      T. SISTOL...
“aumento de la actividad basal simpática durante lavigilia y mayor reactividad ante estímulos fisiológicos…dependiente de ...
DM O’Driscoll, Horne R, Davey M, Hope S, Anderson V, Trinder J, Walker A, Nixon G. Increased sympathetic activity in child...
DM O’Driscoll, Horne R, Davey M, Hope S, Anderson V, Trinder J, Walker A, Nixon G. Increased sympathetic activity in child...
Acute Cardiovascular changes with obstructive eventsin children with sleep disordered breathing Sleep.2009;32,10:12651271
ODriscoll D.M., Horne R.S., Davey M.J., Hope S.A., Anderson V., Trinder J.,  Walker A.M., Nixon G.M. Increased sympathetic...
Baroreflex Sensitivity is Associated with Sleep-Related Breathing Problems inAdolescentsJ Pediatr 2012;160:610-4SRBPs were...
Effects of Sleep Patterns and Obesity on Increases in Blood Pressure in a 5-Year Period:Report from the Tucson Childrens A...
Regeneración neuronal        “Second best ”hipótesis                                                  paliativa previa a m...
Consecuencias del SAHS infantil
Consecuencias del SAHS infantil
Consecuencias del SAHS infantil
Consecuencias del SAHS infantil
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Consecuencias del SAHS infantil

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Presentación del Dr. Gonzalo Pin en NeumoMadrid.

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Consecuencias del SAHS infantil

  1. 1. Gonzalo Pin ArboledasUnidad de Pediatría Integral Q ValenciaUnidad Valenciana del Sueño.Hospital Quirón Valenciawww.upiqweb.es
  2. 2. VAS:Respuesta conservada a pr. Subatmosférica e hipercapnea J Appl Physiol 2004;97:98-108
  3. 3. A: incremento gradual de la pr B: Incremento intermitente
  4. 4. Mecanismo compensatorio de la mayor estrechez : VAS menos colapsable. Respuesta más dinámica tanto al CO2 como a la presión negativa. Factores que facilitan el colapso: Vías aéreas altas más estrechas, Posición más alta de la laringe, Mayor laxitud de los tejidos y Mayor flexibilidad cartilaginosa de las estructuras de soporte .Gryczynska D., Powajbo K., Zakrzewska A.The influence of tonsillectomy on obstructive sleepapnea children with malocclusion Int J Pediatric Otorhinolaryngol, 1995; 32 (Suppl) S225-S228
  5. 5. “The heart is the chief feature of a functioning mind”. Frank Lloyd Wright (1868-1959) ‘‘The brain runs away with the heart’s best blood.’‘ Jean Ingelow… existing studies of SDB’s effects are primarily cross-sectional, andlimited by poor sampling, insufficient consideration of confounders, andimprecise use of statistical tools. The few longitudinal studies are eitherbefore or after tonsillectomy or follow children for ≤ 2 years.
  6. 6. Repeated complete upper airway obstruction during sleep might be amajor contributor to the observed behavioral phenotype amongchildren at the low end of the SDB severity spectrum. Gozal D et al.Sleep-Disordered Breathing Affects Auditory Processing in 5–7 Year-Old Children: Evidence From Brain Recordings. Dev Neuropsychol. 2009 September ; 34(5): 615–628. doi:10.1080/87565640903133608
  7. 7. children with OSA require more time and an increased number of learning opportunities to reach immediate and long-term recall performances that are reduced compared with controls acquisition and retention of newly learned material are compromisedKheirandish-Gozal L, De Jong MR, Spruyt K, Chamuleau SA, Gozal D. Obstructive sleep apnoea isassociated with impaired pictorial memory task acquisition and retention in children. Eur Respir J.2010;36(1):164-9.
  8. 8. Miano S, Paolino MC, Urbano A, Parisi P, Massolo AC, Castaldo R, Villa MPNeurocognitive assessment and sleep analysis in children with sleep-disorderedbreathing. Clin Neurophysiol. 2011;122(2):311-9.. sleep fragmentation and cognitive function IQ : Controls > SDB ADHD rating scale scores: SDB > Controls. SDB: % of wakefulness after sleep onset N1 Global intelligence correlated positively A2 Arousal A2 index Hyperactivity scores correlated positively : A2 index. CONCLUSIONS: Arousal is a defensive mechanism that may preserve cognitive function.
  9. 9. Baumert M, Kholer M, Kabir M, Sanders P, Kennedy D, Martin J, Pamula Y . Altered cardio-respiratory response tospontaneous cortical arousals in children with upper airway obstruction. Sleep Medicine.2011 (12): 230-238 Número de arousals corticales: no diferencias. Duración del arousal: • Más corto en TRS en N2 y REM. • AA: sin diferencias. Cambios FC en el a.espontáneo: > en TRS en N2
  10. 10. …. that the behavioral consequences and cellular losses are produced,at least in part, by the episodic hypoxia-reoxygenation cycles duringsleep that characterize OSA. Excessive NADPH oxidase activity may play a role in IH-induced CNS dysfunction Nair D, Dayyat EA, Zhang SX, Wang Y, Gozal D (2011) Intermittent Hypoxia-Induced Cognitive Deficits Are Mediated by NADPH Oxidase Activity in a Murine Model of Sleep Apnea. PLoS ONE 6(5): e19847. doi:10.1371/journal.pone.0019847
  11. 11. TRS: Porcentajes significativamente elevados de disfuncion global ejecutiva
  12. 12. Pr. de conducta e indicaciones de pr. atencionales en los tres grupos de TRS
  13. 13. PubMed:“ADHD”, “attention-deficit/hyperactivity disorder”, “sleep”, sleep disorder” y “children” OR “pediatrics ”.1994 a Marzo 2012.
  14. 14. N= 11.000Sleep-Disordered Breathing in a Population-Based Cohort: Behavioral Outcomes at 4 and 7 Years.Pediatrics 2012;129;e857
  15. 15. Pediatrics 2012;129;e857N= 11.000
  16. 16. Sleep-Disordered Breathing in a Population-Based Cohort: Behavioral Outcomes at 4 and 7Years. Pediatrics 2012;129;e857 SDB effects may only become apparent years later. The most significant long-term effects occurred in children with the greatest overall levels of snoring, apnea, and mouth breathing throughout, peaking at 30 months. Even very early symptom peaks at 6 and 18 months are associated with 40% and 50%, respectively, increased behavioral morbidity at 7 years of age.
  17. 17. EDAD: 6.5±4.0 a. IAH : >1 < 10
  18. 18. DSM-IV Diagnoses and DSM-IV Diagnoses andJ ,DILLON; S, BLUNDEN; D,RUZICKA; K,GUIRE; D,CHAMPINE; R,WEATHERLY; E, HODGES;B,GIORDANI; R,CHERVIN. J ,DILLON; S, BLUNDEN; D,RUZICKA; K,GUIRE; D,CHAMPINE; R,WEATHERLY; E, HODGES;B,GIORDANI; R,CHERVIN.Obstructive Sleep Apnea in Children Before and 11Year After Adenotonsillectomy. Journal ofoftheObstructive Sleep Apnea in Children Before and Year After Adenotonsillectomy. Journal theAmerican Academy of Child & Adolescent Psychiatry.2007 46(11):1425-1436, November 2007 American Academy of Child & Adolescent Psychiatry.2007 46(11):1425-1436, November 2007 Edad: 5 – 12.9 años Pre-intervención: Controles Pacientes Alt. Conducta: 11.1% 36,7% p<.05 p<.05 Síntomatol. TDAH: 7.4% 27.8% 1 año postintervención: No diferencias significativas
  19. 19. … existing studies of SDB’s effects are primarily cross-sectional, andlimited by poor sampling, insufficient consideration of confounders, andimprecise use of statistical tools. The few longitudinal studies are eitherbefore or after tonsillectomy or follow children for ≤ 2 years. “The heart is the chief feature of a functioning mind”. Frank Lloyd Wright (1868-1959)‘‘The brain runs away with the heart’s best blood.’‘ Jean Ingelow
  20. 20. Snoring is not associated with adverse effects on blood pressure, arterialstructure or function in 8-year-old children: The Childhood Asthma PreventionStudy (CAPS). Journal of Paediatrics and Child Health. Article first published online: 29 APR 2011 DOI: 10.1111/j.1440-1754.2011.02014.x Parentally reported snoring was not independently associated with adverse measurements ofmetabolic markers, vascular structure or function in8-year-old children.
  21. 21. Changes in Heart Rate Variability After Adenotonsillectomy in Children With Obstructive Sleep Apnea. Chest.2011; 139 (5) Edad: 4.9 ± 2.4 PRE AA POST AAIAH 31.9±24.8 4.1±3.7FC sueño profundo 100.2±15.4 80.5±12.4FC sueño REM 106.9±16.4 87.0±12.5Variabilidad BF/AF s. profundo 1.2±1.6 0.5±0.6Variabilidad BF/AF s. REM 30.0±5.4 1.4±1.7AA: Asociada a la mejoría la actividad simpática disminuye.
  22. 22. TA - DISTENSIBILIDAD ARTERIAL EN RH. 9,5 +/- 2 a. RONCADORES NO RONCADORES p T. SISTOLICA 112 +/- 10 105 +/- 8 0.001 T.DIASTOLICA 60 +/- 7 53 +/- 9 0.004 T.MEDIA 81 +/- 7 71 +/- 8 < 0.001RH:RH: Mayor TA diurna Mayor TA diurna Menor distensibilidad arterial. Menor distensibilidad arterial. Único determinante identificado de la distensibilidad. Único determinante identificado de la distensibilidad.
  23. 23. “aumento de la actividad basal simpática durante lavigilia y mayor reactividad ante estímulos fisiológicos…dependiente de la intensidad del SAHS” Correlación positiva TAS - TAD / IAH Montesano M; Miano S; Paolino MC; Massolo AC; Ianniello F; Forlani M; Villa MP. Autonomic cardiovascular tests in children with obstructive sleep apnea syndrome. SLEEP 2010;33(10):1349-1355.
  24. 24. DM O’Driscoll, Horne R, Davey M, Hope S, Anderson V, Trinder J, Walker A, Nixon G. Increased sympathetic activity in children with obstructive sleep apnea:cardiovascular implications. Sleep Medicine.2011;12: 483-488
  25. 25. DM O’Driscoll, Horne R, Davey M, Hope S, Anderson V, Trinder J, Walker A, Nixon G. Increased sympathetic activity in children with obstructive sleep apnea:cardiovascular implications. Sleep Medicine.2011;12: 483-488
  26. 26. Acute Cardiovascular changes with obstructive eventsin children with sleep disordered breathing Sleep.2009;32,10:12651271
  27. 27. ODriscoll D.M., Horne R.S., Davey M.J., Hope S.A., Anderson V., Trinder J., Walker A.M., Nixon G.M. Increased sympathetic activity in children with obstructive sleep apnea: Cardiovascular implications. Sleep Medicine. 2011;12(5): 483-488... significant associations between noradrenaline and: - AHI (r=0.32) and age (r=-0.20, p<0.05 for both). - Systolic/ diastolic BP z-score (r=0.22 and r=0.20, p<0.05 for both ).These data indicate that children with OSA haveincreased sympathetic tone that may contribute to thecardiovascular consequences.
  28. 28. Baroreflex Sensitivity is Associated with Sleep-Related Breathing Problems inAdolescentsJ Pediatr 2012;160:610-4SRBPs were associated with attenuated BRS in adolescents,and this relationship was exacerbated by higher BMI. “ Although we did not examine the sensitivity and specificity of either BMI or SRBP scores, our study suggests that the clinical cut-offs in screening for SRBP may need to be stratified based on children’s BMI.”
  29. 29. Effects of Sleep Patterns and Obesity on Increases in Blood Pressure in a 5-Year Period:Report from the Tucson Childrens Assessment of Sleep Apnea Study. J Pediatr 2012increases in BMI and reductions in TST wereassociated with higher levels of BP in adolescents,with a trend for an effect from SDB.
  30. 30. Regeneración neuronal “Second best ”hipótesis paliativa previa a maduración NADPH-oxidasa¿? lóbulo frontal (3-5 a) Hipoxemia ▲ Resistencia vasc. periférica Hipercapnia Activación simpática Las imágenes doppler son capaces de detectar Re-oxigenación BNP ▼ Tono vagal Menor distensibilidad arter.S los cambios subclínicos cardiacos que ocurren SNA ▲ Catecolaminas Remodelación VI ▼ Variabilidad (<edad)A durante el intratorácica ▲ Presión SAHS. Estos cambios generalmente cardiacaH son reversibles tras la AA ▲ Resistencia Pediatr Cardiol. 2010 vascular sistémica ▲ RGES 8 m:Arousal relacionados con ronquido en ausencia de VD Remodelación apnea o (IAH,CO ,arousal) hipopneas se correlacionan negativamente con score mental. Pediatrics Stress oxidativo: 2 2006; 117:e496-e502 ▲ reactive oxygen species ▲ IL 6- IL1 Hipertensión ▲ TNFα,MRP8/14 ▲ Fac. adhesión -Disfunción Microdespertares Inflamación (p-selectina) endotelial. ▲PCR Alt. Conducta Disf. Cerebral + -Aterogénesis ▲ Adipocitos TDAH-like fragmentación -Obesidad. ▲ LeptinaBNP: Péptido Cerebral Natriurético Adaptado por Dr. G. Pin y revisada la adaptación por Dr. D. Gozal. (Sleep Medicine 2009;10: S12-S16)

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