Diagnosis and Treatment

Obstructive Sleep Apnea Syndrome

(OSAS)
in Children
dr. Dian Permatasari
dr. Dewa Gede Arta Eka Putra Sp. THT-KL
 INTRODUCTION
Sleeping Affecting children growth and development process.
Adverse effects on health, physical problems, altering habits,
increase morbidity & mortality rate

OSAS characterized by snoring, restless sleep, morning

headaches, apnea or hipopnea, impaired emotional or mental
functioning

OSAS in children different than in adult. Highest prevalention in

pre-school age

Children with OSAS giving Night and Day symptoms

 INTRODUCTION

OSAS assesment : Subjective and Objective

OSAS management in children : Invasif and

Non-Invasif Management

Non invasif : habitual intervention, oral

appliances (OA) & CPAP (Continuous Positive
Airway Pressure)

Invasif : Surgical management

LITERATURE REVIEW
OSAS : DEFINITION

Typified by recurrent
episodes of partial or
A respiratory sleep complete upper airway
disorder obstruction that cause
cessation of airflow

These episodes Due to the various

causes repeated anatomic &
arousals & physiologic
fragmented sleep dysfunctions
 OSAS : DEFINITION
Hypopnea
Partially decreased inspiration condition due to shallow
breathing or low respiratory rate with optimum breathing
effort for at least 10 sec.
Many criteria included,, mostly involved decreased air flow
untill 30% from normal with decreased of oxygen saturation
for 4% or more.

Apnea
Complete cessation of breating for 10 sec. or more. Divided
into central apnea, obstructive apnea, and mixed apnea

OSAS
Apnea periode with breathing effort involving abdominal and
thoracical breathing muscles
Prevalention

OSAS happened in all age groups including

neonatus

Highest age group affected : pre-school

4-6 yo

(Adenoid and Tonsils hypertrophy)

In adult mostly affected male (M : F =8 :1)

SLEEP PHYSIOLOGY
Hobson dan McCarley Interaction between REM (Rapid
Eye Movement) dan non REM (NREM) sleeping cycle.

NREM cycle is 80% of sleeping periode. Divided to 4 phases

due to the depth of sleep, physiological changes, endocrines
and EEG (Electro Encephalography)

REM cycle is a 1 phase related to dream.

Rem to NREM cycle takes 70-100 min. Repeated 4-6 cycles

per sleeping periode (depends on the age).

Sleeping hours depend on age : Neonatus (16-20 hrs),

Children (10-12 hrs), Adults (7-8 hrs)
 SLEEP PHYSIOLOGY
Phase I
Muscles relaxations, slow
breathing, eye closed and side
moving. EEG = low voltage
with mixed wave replacing
alpha
Phase II
no movement of the eye,
muscle tonus remains. EEG =
sleep spindle (1214 Hz),
vertex sharp wave, high
amplitude sharp slow wave
complexes

Phase III NREM Phase IV NREM

low muscle tonus movement, EEG = slow wave without
EEG = high amplitude delta sleep spindle
waves (12 Hz) with rarely
sleep spindle

REM cycle
Increasing muscle tonus, rapid eye movement, blood pressure and
respiratory rate changing. Eeg = low voltage fast frequency waves.
SLEEP PHYSIOLOGY

Hobson dan McCarley :

Monoaminorgenik neurons activations oscilations process
less active in NERM and non active in REM. Activated
cholinergic neurons supporting REM cycle.

Sherin dan Saper :

Ventrolateral preoptik neuron (VLPO) is the main trigger
of a sleeping process. Activated VLPO in sleeping process
inhibits aroussal mechanism (noradrenergic, serotonergic
and histaminergic neuron) in brainstem resulting NREM.
Decreased activated VLPO supporting cholinergic neurons
activation resulting REM.
PREDISPOSING FACTORS FOR OSAS
Factors in airway patency :
Short big neck (congenital or acquired obesity), abnormal structur
of head and neck (longer uvula, nasal polip, septum deviation,
chonca hipertrofi, mikrognathia, retrognathia, narrow upper jaw,
makroglosia, tonsil enlargment, palatum mole condition and
airway muscles disturbances.

OSAS in children :

head and neck abnormalities (brachicephali), adenoid and tonsils

enlargement, neuromuscular abnormalities.

OSAS in adults :
happens more often in male, age 40-60, afro-american, family
history with OSAS, obesity, smoker and alcohol drinker.
PATOPHYSIOLOGY OF OSAS

In normal In sleeping
condition : condition :

Posterior airway Muscles relaxation

tract is soft and but not blocking the
tended to collapse airway. Patients with
inside when OSAS have a
breathing. Dilating blocking airways
muscles againts this reducing air flow to
process. the lungs.
PATOPHYSIOLOGY OF OSAS
OSAS Over relaxation and collapsed of the
upper respiratory tract blocking in certain
times, resulting apneu periode in sleeping,
oftenly not realized even though involved wake
up periode due to breath efforth. Blocking or
narrowing airway involving neuromuscular
tonus system, airway muscles synchronization
and sleeping phase.
PATOPHYSIOLOGY OF OSAS
Abnormal anatomy built and physiological
disturbances take major role in upper respiratory
tract collapse resulting apneu periode.
Small airways size, negatif pressure inspiration,
ekstraluminal tissue pressure, small jaws, supine
position, inflamation involved in collapsing
airway while pharingeal dilating muscles, bigger
size of jaws and airways, and bigger lungs
volume supporting patent airway.
PATOPHYSIOLOGY OF OSAS
Venturi efect :
if the air flowing through a narrow space, the
speed will increase.
Bernoulli principal :
For an inviscid flow, an increase in the speed of
the fluid occurs smultaneously with a decrease
in the fluids potential energy.
OSAS pressure needed is lower than 25 cm
H2O
Snoring airway blocking between pressure -2
untill -10 cm H2O
DIAGNOSIS OF OSAS
History :

very important esp. in high risk population

Anamnesis :

evaluating snoring, apnea, gasping/choking

episodes, sleepy or drowsiness (based on
Epworth Sleepness Scale), sleeping hours and
sleeping fregmentation.
DIAGNOSIS OF OSAS
Clinical manifestation :
Oesophageal refluks, nocturia, over sweat,
morning headache, dryness in mouth, sexual
disfunction, emotional disturbances, short
memories, hipogenic halutination.
Spesific symptomps in children : longer nap in
daytime, abnormal motoric activities, over sweat,
stronger breathing effort when sleeping, wet bed,
abnormal sleeping position, nightmares, morning
headache, inatention hyperactivities, poor school
achievement, sleepy or drowsiness, wight and
growth disturbances.
DIAGNOSIS OF OSAS
Physical examinations :
Respiration system, cardiovaskular system,
neurologic system, obesity (BMI), upper airway
track and several other factors.
(BMI) = body mass divided by the square of their
height, with the value universally being given in
units of kg/m2. (Normal BMI : 1825 kg/m 2;
overweight 2530 kg/m2; obesity 30 kg/m2
Neck measurement (obesity in male >17 inches
and female >16 inches)
retrognathia, mikrognathia, peritonsilar narrowing,
makroglosia, tonsilar hipertrofi, bigger uvula,
narrow hard pallate, nasal abnormalities (polip,
septum deviation, chonca hypertrophi).
DIAGNOSIS OF OSAS
Mullers Maneuver (MM)
Flexible optic fibers laringoscop examination into
hypofaring. Interpretation to airway tract
collapse. 0 if no collapse; 1 if collapse arround
25% kolaps; 2 if collapse arround 50%; 3 if
collapse arround 75% ; 4 if totally collapsed.

Friedman Classification based on palate

position, tonsil size and BMI (evatualion on
surgical management on OSAS).
 DIAGNOSIS OF OSAS

Modified Malampati Airway Classification (MMAC)

to descrideb OSAS degree and management on it, based on
tongue size related to oropharyng.
Class I : the soft palate, fauces, uvula, anterior and
posterior pillar are visualized
Class II : the soft palate, fauces, uvula are visualized
Class III : the soft palate and basal of the uvula are
visualized
Class IV : the soft palate is not visualized
DIAGNOSIS OF OSAS
Laboratory Findings :
Non spesific
Polisitemia due to chronic hypoxia.
Blood gas analysis in patients with cor
pulmonale according to hypoxia and
hyperkapneu state.
Tyroid hormones check
DIAGNOSIS OF OSAS
Radiographic Imaging (Rarely done) :
Skull lateral soft tissue setting
Head CT Scan and MRI (expensive)
DIAGNOSIS OF OSAS
Night time oxymetri
Oxygen saturation is 92% (CT 92) or 90% (CT
90) is a high indication for PSG.
CT 92 must be less than 2% from total sleeping
hours.
CT 90 must be less than 1% from total sleeping
hours.
DIAGNOSIS OF OSAS
PSG is golden standard examination for OSAS
diagnosis in adults and children.
EEG, EOG, air flow, oxygen saturation, breathing
efforts, heart rate, ECG and EMG are recorded in
PSG.

AHI calculation :
Normal AHI <5 /hours, Mild AHI 514/ hours,
Moderate AHI 1530/hours; dan AHI >30/hours.
DIAGNOSIS OF OSAS
Portable monitor (PM)
Examinations on several parameters including
oxygen saturation, cardiovascular and
respiratory system, sleeping and awake
activities,
Inadequate or failure examination on patients
PSG has to be done in labs.
Polisomnogram in OSAS
DIAGNOSIS OF OSAS
PSG is golden standard examination for OSAS
diagnosis in adults and children.
EEG, EOG, air flow, oxygen saturation, breathing
efforts, heart rate, ECG and EMG are recorded in
PSG.

AHI calculation :
Normal AHI <5 /hours, Mild AHI 514/ hours,
Moderate AHI 1530/hours; dan AHI >30/hours.
DIAGNOSIS OF OSAS
Portable monitor (PM)
Examinations on several parameters including
oxygen saturation, cardiovascular and
respiratory system, sleeping and awake
activities,
Inadequate or failure examination on patients
PSG has to be done in labs.
MANAGEMENT OF OSAS
Invasif and Non-Invasif management.
Non invasif :
habitual intervention, oral appliances (OA) &
CPAP (Continuous Positive Airway Pressure).
Invasif :
surgical management.

Good prognosis in patients with AHI 15

decreased oxygen saturation of 4% more than 10
times per hour. (Scottish Intercollegiate Guidelines
Network)
MANAGEMENT OF OSAS
Habitual intervention :
Body weight loss
No smoking, alcohol, coffee before bed time,
sedatif and hypnotic medicine
Higher head position and lying to one side
improve better sleep and reducing apneu risk.
MANAGEMENT OF OSAS
Medicamentosa less efficacy
(Modafinil, thyroid hormones, intranasal
corticosteroid).
AASM (American Academy of Sleep Medicine)
recommend an OA for patients with simple
snoring and mild sleep apnea.
OA : Mandibular Advancement Device (MAD and
Tongue Retaining Device (TRD)
 MANAGEMENT OF OSAS
CPAP is a standard therapy for OSAS. Consist of a
electronic tools placed near patients head and
connected with air pipe to the nose, giving a constant
air flow with certain pressure (16 cmHg O2)

Indications :
Patients with AHI > 15 or AHI between 5-14 with
symptomps drowsiness, cognitif disturbance,
emotional disturbances, insomnia, hypertention,
ischemic heart disease, CVA history.
MANAGEMENT OF OSAS
Primary surgical intervention : mild OSAS with
corectable condition with surgical management.
(adenotonsilectomy in childhren,
adenotonsilectomy with UPPP in adults)
Secondary surgical intervention : alternative
manegement after CPAP failure.
MANAGEMENT OF OSAS
UPPP Surgical procedures :
Laser assisted uvuloplasty (LAUP)

Radio frequency uvuloplasty (RFUP)

Uvulopalatopharyngoplasty (UPPP)

____________________________________________

UPPP is a surgical management taking away soft

tissues behind the throat, partially or totally uvula, soft
palate, tonsil and adenoid.
MANAGEMENT OF OSAS
Advancement procedures (AP)
After surgical mangement failed to give best
result.
Efficacy 40-70%
Genioglossus, hyoid and suture tongue
advencement, bimaxillary advancement,
Maxillary-mandibular advancement
MANAGEMENT OF OSAS
Tongue resection
Multispet procedure (UPPP, genioglossus
advancement and hyoid advancement, followed
by bimaxillary advancement).
Palatal implantation dan cautery assisted palatal
stiffning operation (CAPSO) outcome patient
DISCUSSION
 DISCUSSION

Clinical symptoms in children leading to OSAS :

Prolonged sleeping hours, abnormal motoric activities,
over-sweat, stronger effort when sleeping, bed wet,
abnormal sleeping position, frequently awake, nightmares,
morning headache, hyperactivities, inattention, low school
achievment, sleepy, growth and body weight disturbances.
 DISCUSSION
Supporting Examination :

Vary spesifity and sensitifity

Gold Standard Polysomnography (PSG)

PSG is golden standard examination for OSAS diagnosis in adults

and children. Examination including EEG, EOG, air flow, oxygen
saturation, breathing efforts, heart rate, ECG and EMG (Recorded
in PSG).
AHI calculation :
Normal AHI <5 /hours, Mild AHI 514/ hours, Moderate AHI 15
30/hours; dan AHI >30/hours.
 DISCUSSION
UPPP is most frequent surgical procedures :
Laser assisted uvuloplasty (LAUP)

Radio frequency uvuloplasty (RFUP)

Uvulopalatopharyngoplasty (UPPP)

UPPP is a surgical management taking away soft

tissues behind the throat, partially or totally uvula, soft
palate, tonsil and adenoid.
 DISCUSSION
UPPP 41%-52,3% efficacy.

Surgical approach when Non-Invasif treatment

didnt give any optimum result or anatomy
abnormality indicated as the main cause in OSAS.
CONCLUSION
 CONCLUSION
OSA is a sleep breathing disorder breathing
characterized by snoring, restless sleep, morning
headaches, apnea, impaired emotional or mental
functioning.
Adverse effects on health, physical problems, altering
habits, increase morbidity & mortality rate
OSAS in children : 1%3 % of population; in Adult esp.
with obesity, age 40 & older, male, smokers
 CONCLUSION
OSAS Over relaxation and collapsed of the upper
respiratory tract blocking in certain times, resulting
apneu periode in sleeping.
PSG is the gold standard for diagnosis.

Management : Non invasif (habitual intervention, oral

appliances (OA) & CPAP/Continuous Positive Airway
Pressure) and Invasif (surgical management).
UPPP is the most common procedure.
 CONCLUSION
UPPP procedure including standard and modification
technique.
Complications of UPP : bleeding, infections, nasopharyngeal
stenosis, nelopharingeal insuficient, open wound post
operative, globus sensation, respiratory distress and death.
Efficacy depends on patients selection (based on palate
posisition, tonsil size and BMI)
Efficacy 90% or more : UPPP combined with genioglossus
advancement dan maxillary-mandibular advancement in
multistep surgical manegement.
Thank you!