Download Sleep Disordered Breathing - Texas Children`s Hospital

Evaluation and
Management of Sleep
Disordered Breathing
Kathy Shelly, PA-C
Texas Children’s Hospital Department of Surgery:
Otolaryngology
Learning Objectives
1.
Review the anatomy of the pediatric
nasopharyngeal and oropharyngeal cavity
2.
Analyze information obtained from PSG and
the indications for surgical and medical
management of SDB
3.
Recognize typical adenotonsillectomy recovery
expectations
What is Sleep Disordered Breathing?
Sleep disordered breathing (SDB) is a general term for
breathing difficulties occurring during sleep.
This can range from primary snoring and mouth
breathing all the way up to obstructive sleep apnea
(OSA).
There are many other types of sleep issues that may not
have anything to do with breathing issues.
10% of children snore regularly.
Snoring alone can disturb the sleep pattern depriving the
snorer of adequate rest. However, when the breathing is
disrupted, the body perceives this as a choking event and
results in the following physiological ways:
 the heart rate slows
 the blood pressure rises
 the brain is aroused
 sleep is interrupted
 the oxygen level in the blood may
drop increasing the work of the heart.
Sleep Disordered Breathing
Snoring
Upper
Airway
Resistance
Obstructive
Sleep
Apnea
The disruption of the normal sleep cycle can make one feel
poorly despite spending an adequate amount of time in
bed. The snorer stays in a lighter phase of sleep to keep
the throat muscles more tense in order to keep the airflow
to the lungs open.
In adults, this has been well studied, and this has been
shown to affect daytime sleepiness/somnolence, complaint
of fatigue and job performance. It is more dangerous to
drive and operate heavy equipment. There is an increased
risk of having an MI, CVA, diabetes and one is more likely
to be involved in a MVA. In children, the are noted to have
fewer cortical arousals and preservation of the sleep
architecture but varied manifestations of sleepiness.
Potential Consequences of untreated SDB/OSA



behavior/learning – a hallmark of adult OSA is
excessive daytime somnolence/sleepiness. This is
common in adolescents also, but children may have
issues with being moody/grumpy, hyperactive,
inattentive, impaired learning and diminished academic
performance, aggressive becoming disruptive both at
home and at school. They may also be more likely to
have sleep walking and night terrors.
cardiovascular – long term, can be associated with an
increased risk of high blood pressure or right ventricular
dysfunction and elevated pulmonary arterial pressure
growth – secondary to impaired growth hormone
secretion, there is a higher risk of failure to thrive and
impairment of growth development



obesity – SDB may cause the body to have increased
resistance to insulin contributing to obesity and daytime
fatigue may decrease physical activity participation
social – loud snoring can become a significant problem
if the child shares a room with sibling(s) or is at a
sleepover/summer camp
enuresis – SDB can cause increased night time urine
production from decreased release of anti-diuretic
hormone
Often times, the diagnosis of sleep disordered breathing
can be made based on parental history only and is then
supported by the physical exam.
In special cases, such as in a child with a craniofacial
syndrome, morbid obesity, sickle cell disease, seizures or a
neuromuscular disorder and for children less than 3 years
of age, additional testing may be recommended.
Overweight children are at an increased risk for SDB
because of the fat deposits around the neck and throat
narrowing the airway. Extra weight on the frame interferes
with the ability of the chest and abdomen to fully expand
during breathing hindering the intake of air and increasing
the risk of sleep apnea.
Overweight is anyone with a BMI of 25 or above. Obesity
is having a BMI of 30 or above. Morbid obesity is a BMI of
40 or above with “morbid” indicating that the risk of obesity
related illness is increased dramatically at this degree of
obesity.
What is OSA?
Obstructive Sleep Apnea (OSA) is a condition involving
repeated episodes of partial or complete blockage of the
airway during sleep as detected by a polysomnography
(PSG, also referred to as a sleep study or SS). There are
other types of sleep issues that may be diagnosed by PSG
not associated with obstruction.
The prevalence of OSA is estimated to be between 1-4% in
preschool and school-aged children. Recently, the
estimated prevalence has increased due to better
monitoring techniques during PSG.
OSA viscous cycle
Sleep
Disturbance
Caregiver
Concerns
Daytime
Function
Physical
Symptoms
Emotional
Distress
So, what exactly are the tonsils and adenoids?
The tonsils and adenoids are similar to the lymph
nodes/glands found in the neck, groin and armpits. The
tonsils are the 2 round lumps located in the back of the
throat and they are enclosed in a fibrous capsule.
Adenoids are high in the throat at the very back of the nose
and are not visible on typical exam with out the use of
special instruments. The 2 most common issues with the
tonsils and adenoids is infections and enlargement. The
adenoids may be enlarged producing mouth breathing and
a chronic runny nose. Recurrent sinusitis and recurrent
ear infections are also common.
In order to understand how adenotonsillar
hypertrophy(ATH) can impact SDB/OSA in children, a
review of the pediatric airway anatomy and how the airway
is affected during SDB/OSA is important to understand.
The disorder is most common between the ages of 2-10
years of age and correlates to the age of lymphoid
hyperplasia during childhood.
Blood supply of the tonsil
Nasal Obstruction – Adenoid Hypertrophy
Turbinate
Hypertrophy
Nasal Polyps
Tonsil Grading
Mallampati score – this is an
anestheisology assessment
of the “crowdedness” of the
oral airway
Mallampati Score
Sleepy Kids
=
Sleepy Parents
History: Bedtime behaviors


Describe events from dinner time until sleep onset
Is their a a set bedtime?

Is it developmentally appropriate?
 Is it consistent from night to night?
 Is it enforced?

What are the child’s evening activities?




Is there a bedtime routine?
Are there any sleep associations present?



Heavy meals not w/in 1-2 hours before bedtime?
Any high energy activities w/in hour before bedtime?
What is happening at sleep onset?
Where is it occurring?
Any bedtime refusal?
Falling asleep

What is happening at the time child is falling asleep?

What is the time from lights out to sleep onset?


> 20 minutes indicates difficulty falling asleep
Asking the child/adolescent directly is important



What is the level of sleepiness?


Sleep anxiety?
Restless leg syndrome symptoms?
Does the child really feel sleepy at a later bedtime indicating a possible
delayed phase in circadian rhythm?
Where is sleep onset occurring and is there then transfer after sleep
onset?


Is the location of sleep onset variable?
Does the child fall asleep on the couch watching TV and is then
moved?
Sleep Environment

Bedroom and bed location

Bedroom or bed sharing may increase night wakenings
 If location of child’s bedroom far from parents room may increase child’s
anxiety

Light

May interfere with melatonin secretion
 Need for bright light may be indicative of anxiety issues

Bed type


Moving a child from crib to bed prematurely may exacerbate sleep
problems
Bedding


No data on advantage of different sleeping surfaces and sleep quality
Infants who sleep on soft surfaces are at increased risk for suffocation
and SIDS
Morning awakening

Is it difficult to wake the patient in the morning?


Does it take multiple attempts?
When would the child spontaneously wake if allowed?




Best elicited during vacation or summer days
Helps determine their preferred time of sleep and average sleep need.
Difficulty waking despite seemingly adequate amount of sleep may
indicate the quality of sleep is affected
Are there consequences to difficulty waking?

Habitual tardiness
Daytime behaviors

Indicative of significant daytime sleepiness
 Morning waking difficulties
 Daytime sleepiness
 Fatigue
 Daytime dysfunction
Presence of unplanned napping at all ages and the need
for planned naps in a child after 5-6 years of age is
suggestive of insufficient sleep and/or poor quality sleep.
A brief Sleep screening tool for sleep - BEARS
Bedtime
Excessive
Awakenings Regularity Snoring
issues
daytime
sleepiness
at night
and duration
of sleep
Resistance
Onset Delay
Fears
Special
needs
Difficulty
waking
Sleepiness
Naps
Inattention/
Hyperactivity
Parasomnias
Nightmares
Call outs
Special needs
Total sleep
Bedtime
Waketime
Schedule
Frequency
Pauses
Dry mouth
Headaches
Mindel, JA, & Owens, JA. (2003) A Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems.
Lippincott, Williams & Wilkins. Philadelphia, PA.
Consistent and Positive Routines


Keep the same exact routine every night
Use a regular series of positive, relaxing behaviors
and interactions that replace frustration and conflict
prior to sleep:








Sleep in the same place every night
Engage in relaxing nighttime activities
Go to bed and get up at the same time
No caffeine after lunch
Create a dark, cool sleep environment
Take away the clock
Avoid daytime napping
Useful at all ages
History, continued

Medical Hx


Developmental Hx


Repeating a grade in school
Familial Factors


Repeating a grade in school Any other developmental
delays
Academic Hx


GERD; seizures; allergies/eczema/asthma
Genetics; culture; conflicts
Psychiatric/Behavioral Hx
Anxiety; mood; inattention; making friends
Psychosocial History

Family functioning

Effectiveness of parenting
 Family schedule





Discrepancies in parenting styles
Consistency of sleep patterns at 2 different households
Significant life events


Psychologic status of parent
Parental divorce


Shift work
Moving to own room
Family culture
How are the child’s sleep problems impacting the family?


Is the parent having daytime dysfunction?
Falling asleep while driving
20-30% of children have sleep problems at some time
during their life. In the neurologically/developmentally
challenged children, this increases to 40-100%. “Good
sleep” has to do with the timing and the amount of sleep in
addition to the continuity of sleep.
Sleep Requirements of Typically Developing
Children
0-2 months: 16-20 h; no night/day pattern
 2-12 months: 9-12 h; 4-1 naps (2-5h)
 1-3 yr: 12-13 h per 24 h; 2-1 naps
 3-5 yr: 11-12 h per 24 hr; 1-0 naps
 6-12 yr: 10-11 h; 0 naps
 12-18 yr: 9-9.5 hr; 0 naps

Total Sleep Duration in 24 hours
The average
10 year old
child needs 10
hours of sleep
Iglowstein, I. et al. Pediatrics 2003;111:302-307
Copyright ©2003 American Academy of Pediatrics
Difficulty Sleeping
Poor sleep hygiene, OSA, RLS, PLMD,
Parasomnias, Circadian Rhythm Disorders
0-5 years
• Behavioral
Insomnia of
Childhood
6-12 years
13+ years
• Depression
or Anxiety
• Delayed
Sleep Phase
Syndrome
Excessive
InsufficientSleepiness
Sleep, Circadian Rhythm Disorders,
Narcolepsy, Hypersomnia
Other challenges
Caregivers may be less attuned to sleep
issues beyond the early childhood period.
 Some caregivers may not regard some
symptoms as problematic
 Often differences between child and
parent perspective
 Not uncommon for parents to say that their
child has “never slept well”

Sleep and Anxiety Center for Kids
SACK is a clinical research center in the Department of Psychology at the
University of Houston offering research opportunities and low-cost
treatment services for children based on the latest scientific evidence. U.S.
military families services are offered services at no charge.
4505 Cullen Blvd.
Houston, TX 77204
Phone: 713-743-3400
Fax: 713-743-8633
Email: [email protected]
Physical Exam

Physical exam is normal in many children with sleep disorders

Growth parameters


FTT and obesity are both associated with SDB/OSA
Tanner stage in patient with recent onset sleep initiation insomnia

Onset of puberty is associated with normal biological shift in sleep-wake cycles

Do they fall asleep during the examination or are they
hyperactive/irritable/dis-inhibited

Significant sleep disruption or inability to self soothe may be an early
indication of developmental delay
Physical Exam

Otolaryngologic examination

Assessing for risk factors for OSA




Tonsillar hypertrophy
Narrowed/small oropharynx
Nasal congestion
Neurologic exam



Concern for excessive sleepiness or nocturnal seizures
Brainstem dysfunction if suspecting central sleep apnea
Abnormal sensation if suspecting secondary restless leg
syndrome
A couple of key points
Large tonsils and adenoids does not
always indicate the presence of OSA
 Loudness of snoring does not correlate
with degree of OSA
 A formal sleep study remains the gold
standard in diagnosing OSA and other
sleep related disorders.

Polysomnography (PSG) or
Sleep Study (SS)
This is an objective test in which wires are attached to the head
and body that monitor brain waves, muscle tension, eye
movement, breathing and level of oxygen in the blood. The test is
not painful and is generally performed in a sleep lab or hospital.
The role of PSG includes the following:






Meet diagnostic criteria of pediatric OSA according to ICSD 2
Differentiate OSA from primary snoring
Define severity of OSAS
Evaluate excessive daytime sleepiness (i.e. narcolepsy)
Evaluate for periodic limb movement disorder
Evaluate success of treatment
Clinical Practice Guidelines
PSG for SDB prior to tonsillectomy in children 2-18 years of
age – improving referral patterns for PSG:




Complex medical conditions such as obesity, Down
syndrome, craniofacial abnormalities, neuromuscular
disorders and sickle cell disease.
When there is discordance between tonsillar size on
physical exam and reported severity of breathing.
Results of PSG should be communicated to the
anesthesiologist prior to the induction of anesthesia.
Children admitted with OSA younger than 3 years of age
or if severe AHI or 10 or more obstructive events per
hour or with an O2 nadir <80%.
EEG
Nasal EtCO2
EOG
Nasal Oral Airflow
Chin EMG (2)
Microphone
Sao2
EKG
Tech Observer
Video Camera
Respiratory
Effort
Leg
Documents arousals,
parasomnias, abnormal
sleeping position, and attends
to any technical problem
EMG (2)
Record behavior
Courtesy of Dr. Carol Rosen
“First-night Effect” with PSG






 sleep onset latency
 wake after sleep onset
 sleep efficiency
 REM latency
 amount of REM sleep
No significant difference in NREM sleep
Despite the first-night effect, the diagnosis of Obstructive Sleep Apnea in
children can usually be reliably confirmed by one night of PSG
Obstructive Apnea
2 missed breaths
 > 90% fall in signal amplitude
 Continued respiratory effort
 Duration: Last normal breath to the
beginning of the first breath that achieves
the pre-event baseline inspiratory
excursion

Mixed Apnea
2 missed breaths
 > 90% fall in signal amplitude
 No inspiratory effort initially, but toward
end of the event, the effort returns

Central Apnea
Absent inspiratory effort throughout event
 1 of the following

Lasts longer than 20 seconds
‐ Lasts at least 2 missed breaths and is
associated with an arousal, awakening, or a >
3% desaturation.
‐
Obstructive Hypopnea



> 50% drop in amplitude of the nasal
pressure
2 breaths
Associated with

Arousal
 Awakening
 >3% desaturation
Respiratory Effort
Related Arousal (RERA)


Nasal pressure sensor
Must meet following criteria





< 50% decrease in amplitude
Flattening of the wave form
Assoc with snoring, noisy breathing,
increased pCO2, or increased work of
breathing
Lasts 2 breaths
Associated with arousal
Hypoventilation
> 25% of the total sleep time has pCO2 >
50mmHg
 Can be prominent in patients with
neuromuscular disease
 Concern for underlying cardiopulmonary
factors

Apnea/Hypopnea Index
(Obstructive Apneas + Central Apneas
Mixed Apneas + Hypopneas) per hour of
sleep.
 Mild >1 to 5
 Moderate >5 to 15
 Severe = > 15

Respiratory Disturbance Index
(Obstructive Apneas + Central Apneas
Mixed Apneas + Hypopneas +RERAs) per
hour of sleep.
 Mild >1 to 10
 Moderate >10 to 20
 Severe >20

RESPIRATORY ANALYSIS:
The patient was recorded while sleeping in the supine, prone, and side positions. Snoring was recorded. During wakefulness
the respiratory rate was 12-14 breaths per minute. During sleep the respiratory rate was 12-18 breaths per minute. The
baseline oxygen saturation was 99%. The oxygen nadir was 74%. The patient spent 1.3% of the total sleep time with oxygen
saturation values less than 90%. The transcutaneous pCO2 values were elevated to as high as 51 mmHg. During 1.6% of the
monitoring time pCO2 values were elevated above 50 mmHg (significant values > 25%).
During sleep, 9 obstructive apneas, 1 mixed apneas, 6 central apneas (8.7-15.3 seconds), 110 obstructive hypopneas, and 13
RERAs were recorded. The apnea hypopnea index was 16.60. The obstructive apnea hypopnea index was 15.81. The
respiratory disturbance index was 18.31 (17.52 obstructive respiratory events per hour of sleep). Respiratory events were
more frequent during REM sleep (44.42 respiratory events per hour of REM sleep). Of note, there were intermittent episodes
of thoracoabdominal asynchrony.
CARDIAC ANALYSIS:
The heart rate was typically in the range of 69-113 beats per minute. No significant cardiac arrhythmias were recorded.
LIMB MOVEMENT ANALYSIS:
During sleep, there were 0.0 periodic limb movements recorded (0.0 per hour of sleep; significant values greater than 5.0 per
hour of sleep).
EEG CHARACTERISTICS:
The occipital dominant rhythm was 7-8 Hz. There were no focal or lateralizing features. No epileptiform abnormalities were
recorded.
IMPRESSION:
During this sleep evaluation, severe obstructive sleep apnea (17.52 obstructive events per hour of sleep and snoring) was
recorded. Respiratory events were more frequent during REM sleep (44.42 respiratory events per hour of REM sleep). The
minimum oxygen value was 74%; pCO2 values were mildly elevated but did not meet the criteria for sleep related
hypoventilation.
ECG and EEG findings were normal on this overnight sleep evaluation.
RECOMMENDATIONS:
1. Evaluation of the upper airway for anatomic abnormalities, including chronic nasal congestion, is recommended.
2. If the patient undergoes surgery, then a follow up study in 6-8 weeks after surgery is recommended.
3. If the patient is not a surgical candidate and has significant daytime impairment, then other therapeutic options include
a trial of positive airway pressure (PAP). This would require a second night titration study.
4. Repeat sleep study in 12 months is recommended, sooner if clinically indicated, in order to reassess the severity of sleep
disordered breathing.
RESPIRATORY ANALYSIS:
The patient was recorded while sleeping on the back and sides. Minimal snoring was recorded. During wakefulness the respiratory
rate was 17-25 breaths per minute. During sleep the respiratory rate was 16-26 breaths per minute. The baseline oxygen saturation
was 98%. The oxygen nadir was 93%. The patient spent 0% of the total sleep time with oxygen saturation values less than 90%.
The transcutaneous pCO2 values were elevated to as high as 42mmHg. During 0% of the monitoring time pCO2 values were
elevated above 50 mmHg (significant values > 25%).
During sleep, 0 obstructive apneas, 0 mixed apneas, 3 central apneas (8.9-10.2 seconds), 3 obstructive hypopneas, and 18 RERAs
were recorded. The apnea hypopnea index was 0.72. The obstructive apnea hypopnea index was 0.36. The respiratory
disturbance index was 2.87 (2.51 obstructive respiratory events per hour of sleep). Respiratory events were more frequent during
REM sleep (4.94 respiratory events per hour of REM sleep).
CARDIAC ANALYSIS:
The heart rate was typically in the range of 53-120 beats per minute. Rare PVCs were recorded. In addition, there were
intermittent episodes of elevation of the ST segment. Of note, there was a significant amount of ECG artifact.
LIMB MOVEMENT ANALYSIS:
During sleep, there were 0.0 periodic limb movements recorded (0.0 per hour of sleep; significant values greater than 5.0 per hour
of sleep).
EEG CHARACTERISTICS:
The occipital dominant rhythm was 7-8 Hz. There were no focal or lateralizing features. No epileptiform abnormalities were
recorded. Few episodes of bruxism was recorded.
IMPRESSION:
This patient was previously diagnosed with mild OSA on 4/2013. The current study was performed to reassess the severity of sleep
disordered breathing.
During this sleep evaluation, mild obstructive sleep apnea (2.51obstructive events per hour of sleep and snoring) was recorded.
The minimum oxygen value was 93%; pCO2 values were not significantly elevated.
ECG findings were abnormal (rare PVCS, ST segment elevation); however, there was a significant amount of artifact on the single
lead EKG monitor.
EEG findings were normal on this overnight sleep evaluation. Few episodes of bruxism was recorded.
RECOMMENDATIONS:
1. Evaluation of the upper airway for anatomic abnormalities, including chronic nasal congestion, is recommended.
2. If the patient undergoes surgery, then a follow up study in 6-8 weeks after surgery is recommended.
3. If the patient is not a surgical candidate and has significant daytime impairment, then other therapeutic options
include a trial of positive airway pressure (PAP). This would require a second night titration study.
4. ECG showed rare PVCs and intermittent episodes of ST segment elevation in the setting of significant amounts of artifact.
This was recorded on a one lead EKG monitor. Clinical correlation and/or follow up with a 12 lead EKG is strongly
recommended.
5. For the bruxism, dental evaluation is recommended.
6. Repeat sleep study in 12 months is recommended, sooner if clinically indicated, in order to reassess the severity of sleep
disordered breathing.
Treatment for SDB/OSA
1st line treatment is adenotonsillectomy (T&A). Of the over
500,000 pediatric T&As performed in the US each year, the
majority are done to treat SDB. Many children with
SDB/OSA show both short and long term improvement in
their sleep after T&A but not EVERY child with snoring
should undergo T&A as the procedure does have risks.
If the SDB/OSA is mild or intermittent, academic
performance and behavior are not concerns, the tonsils are
small, or the child is near puberty, it may be recommended
that they should be conservatively monitored.
Tonsillectomy indications for OSA
T&A is typically performed on an out-patient basis. The procedure
takes about 35-45 minutes and is performed under general anesthesia.
Post-operative observation lasts for several hours, but children under
the age or 3 years of age, those that have severe OSA per sleep study
and those with other medical issues are typically kept overnight for
monitoring of their respiratory status.
Types of T&As




Coblation (involves using cool electrical current to
remove tonsillar tissue; may produce less postoperative
pain and a faster recovery)
Dissection (most common method; involves removing
the tonsils using a scalpel)
Electrocauterization (involves using hot electrical current
to remove the tonsils; may cause damage to surrounding
tissue that increases postoperative pain)
Harmonic scalpel (involves using a scalpel that vibrates;
minimizes bleeding and damage to surrounding tissue)
Types of T&As (contined)



Laser ablation (involves using a hand-held laser to
vaporize tonsillar tissue)
Microdebridement (involves using a rotary "shaving"
device to remove tissue from enlarged tonsils
Radiofrequency ablation (also called somnoplasty;
involves using energy transferred through probes
inserted into the tonsils)
Types of T&As (contined)

Partial tonsillectomy (intracapsular tonsillectomy) with
the use of power instruments that produce
radiofrequency energy or coblation or laser has been
advocated because the procedure has been shown to
result in less post-op pain and an earlier return to normal
diet and daily activity. The capsule is not disturbed
therefore the underlying muscle is not encountered.
3.2% of children who underwent this technique
experienced tonsillar regrowth and recurrence of snoring
during a 2 year period following the first procedure.
Recovery after T&A



Average recovery is 7-10 days.
Post-operative problems: swallowing, vomiting, fever,
throat/ear pain, bleeding from the nose/mouth.
Drinking is the most important part of recovery and
starts immediately after surgery. Dehydration is a
common issue for children in the post-operative period.
Eating is typically a soft diet but the sooner the child
eats/chews, the quicker the recovery. Weight loss
during the recovery is not uncommon.
Recovery after T&A


A low grade fever may be observed the first night after
surgery and even continue for a day or 2 but the
surgeon’s office should be contacted if it is greater
than 101.0° F.
Nearly all children will have mild to severe throat pain
after surgery. Ear pain, stiff neck or jaw pain are also
frequently reported. The type of pain medication has
changed since the findings regarding codeine
metabolism. Rectal suppositories and liquid
medications are recommended instead of
tablets/capsules and pills.
Recovery after T&A



Activity may be increased slowly with a return to
school after a return to normal eating and drinking and
pain medications are no longer required and the child
is back to sleeping through the night.
Snoring and mouth breathing due to the swelling in the
throat is not uncommon during the recovery period but
should subside within 10-14 days after the procedure.
Scabs look like thick, white discharge and causes bad
breath and is often mistaken as an infection. Most
scabs will fall off in small pieces 5-10 days after
surgery. Bleeding of bright red blood should not be
seen.
Immediate
Post Tonsillectomy Complications
Hemorrhage
 Protracted vomiting
 Severe Pain
 Decreased PO Intake/Dehydration
 Postoperative pulmonary edema
 Postoperative airway obstruction

Delayed
Post Tonsillectomy Complications
Hemorrhage (post 24 hours)
 NP/choanal stenosis
 Pharyngeal stenosis
 Velopharyngeal insufficiency
 Grisel’s syndrome (atlantoaxial
subluxation)

Postoperative bleeding risk factors
The UK National Prospective Tonsillectomy
Audit demonstrated that there was a higher
risk of postoperative bleeding with:
Increasing patient age
 Male gender
 History of recurrent acute tonsillitis (3.7%)
 Previous peritonsillar abscess

Rate for quinsy patients (5.4%) compared with
patients with pharyngeal obstruction and OSA
(1.4%)
Primary hemorrhage range from 0.2% to 2.2%
of patients. Secondary hemorrhage 0.1% to
3%.
T&A Outcomes
T&A results in significant improvement in the QOL based on validated
questionaires measuring sleep disturbance, physical and emotional
symptoms, hyperactivity and daytime functioning. Pulmonary HTN has
normalized based on ECHO assessment. School performance is
improved. Health care utilization is reduced. Abnl PSG measurement
including respiratory disturbance index (RDI), oxygen saturation and
arousal index have resolved.
However, many children continue to have residual SDB/OSA after
surgery. Factors contributing to residual sleep concerns include the
severity of OSA prior to T&A, obesity, +FH as well as African American
descent. Untreated nasal obstruction and maxillofacial deformity
contributing to diminished airway dimension are also frequent findings
in those inadequately treated by T&A. Additional surgery may be
warranted such as jaw expansion by orthodontics, maxillofacial surgery
or nasal airway reconstruction. Some children will benefit from PAP
titration. Tracheotomy is reserved for the most severe of cases.
Tracheotomy



Bypasses areas of airway obstruction during
sleep
Generally reserved for most severe cases of
OSA
Patient refractory to other therapies
Risk Factors for persistent OSA after T&A
Obesity
 Older age at time of surgery (varies per
article >7 y/o)
 More severe sleep apnea preoperatively
 Asthma in nonobese children
 Craniofacial & mandibular anomalies
 Cerebral palsy
 Genetic disorders- Down Syndrome

When to consider PAP therapy

Confirmed moderate to severe OSA
 Surgery
is not an option
 Morbid obesity
 Post-operative T&A with residual OSA
 Poor surgical candidate
 Craniofacial syndromes
 Comoribidities such as ADHD and ESS
 To stabilize patient prior to surgery

In children with milder OSA?
PAP compliance in children







Wide age range
Symptoms improve
Safe effective treatment
Labor intensive
 >20% drop out
 Only 50% with immediate acceptance
 Delayed acceptance in 1 year- 80% in 3 months
 School age >teens >toddlers
Full face harder to accept
Compliance varies greatly
 objective measures important
Monitor craniofacial growth
CPAP and BIPAP for Children

Best practices require
 Child/family focused therapy
 Health management team approach
 Coordination of care through RN/RT, sleep lab, DME,
and physicians
MASKS AND MACHINES
… AND to all a good night.
References
















1.Baldassari C, Kepchar J, et al. Changes in Central Apnea Index following Pediatric Adenotonsillectomy. Otolaryngol Head and Neck Surgery 2012;
146(3) 487–490.
2.Bhattacharjee R, Kheirandish-Gozal L, Spruyt K, et al. Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children: a multicenter
retrospective study. Am J Resp Crit Care Med 2010; 182:676–683.
3.Darrow DH. Surgery for Pediatric Sleep Apnea. Otolaryngol Clin N Am 2007; 40: 855–875.
4.Kerschner J,Lynch JB, et al. Uvulopalatopharyngoplasty with tonsillectomy and adenoidectomy as a treatment for obstructive sleep apnea in neurologically
impaied children. International Journal of Pediatric Otorhinolaryngology 2002; 62: 229–235.
5.Lin AC, Koltai PJ. Persistent pediatric obstructive sleep apnea and lingual
tonsillectomy. Otolaryngol Head Neck Surg 2009; 141:81–85.
6.Mitchell RB. Adenotonsillectomy for obstructive sleep apnea in children:outcome evaluated by pre and postoperative polysomnography. Laryngoscope
2007; 117:1844–1854.
7.O’Brien LM, Sitha S, Baur LA, Waters KA. Obesity increases the risk for persisting obstructive sleep apnea after treatment in children. Int J Pediatr
Otorhinolaryngol 2006; 70:1555–1560.
8.Richter G.T., Rutter M.J, et al. Late-onset laryngomalacia: a variant of disease, Arch. Otolaryngol. Head Neck Surg 2008; 134(1) (2008) 75–80.
9.Shott SR. Evaluation and management of pediatric obstructive sleep apnea beyond tonsillectomy and adenoidectomy. Current Opinion in Otolaryngology &
Head and Neck Surgery 2011; 19:449–454.
10.Tauman R, Gulliver TE, Krishna J, et al. Persistence of obstructive sleep apnea syndrome in children after adenotonsillectomy. J Pediatr 2006; 149:803–
808.
11.Wooten CT, Shott SR. Evolving therapies to treat retroglossal and base-of tongue obstruction in pediatric obstructive sleep apnea. Arch Otolaryngol Head
Neck Surg 2010; 136:983–987.
Thank You!
[email protected]