Obstructive Sleep Apnea

Syndrome

Dr. Amir Bar,

Bnei-Zion Medical Center,
Haifa
A new syndrome

PubMed search (Sleep Apnea; 0-18y):

1960 11
1970 82
1980 689
1990 1012

A common syndrome
Has significant complications w/o Tx
Can be efficiently treated in the majority of cases
>>Awareness and early diagnosis and Tx
EEG
Non-REM Sleep Stages
EEG
REM sleep
 EOG M. Tone
Wake Rapid Normal
St 1
Sleep
Slow
physiology
+/-
St 2 None Relaxation
St 3-4 None Relaxation Metabolism , GH secretion
SWS None Relaxation Para-sympathetic predominance
REM Rapid Atonia Dreams, Mental, Memory
Sympathetic predominance (MI)
Penile- erection
REM-Related OSA

REM
Classification

Apnea: a Greek word - want of breath

Obstructive
Central
Mixed
m/p the Greeks describe obstructive type
Classification

Respiratory Disturbance Index (RDI)

Normal value <1-2 per hour of sleep
1. Apnea: complete airflow cessation (2 respiratory
cycles)
2. Hypopnea: airflow reduction (2 respiratory cycles)
3. Respiratory Effort Related Arousal (RERA):
prolonged flow limitation with associated
arousal (Upper Airways Resistance Syndrome)
Normal oxygen saturation
Epidemiology

Prevalence:
OSAS: 1-3%
Primary snoring (PS): 3-12%
Gender:
M/F ratio 1:1 (Adults: male predominance)
Age:
From neonates to adolescents
Commonest in preschool children (2-5y)
(Peak incidence of adenotonsillar hypertrophy)
Race:
More common in African-American children ??
Nocturnal presentation

Apnea
Dyspnea
Snoring
Mouth breathing
Restless sleep
Pathophysiology
Muscle relaxation (Sleep) Anatomical factors
Muscle atonia (REM)
Neuromuscular dis

Pharyngeal dilators Insp. Neg. pressure

Opened AW

Closed AW
Upper Airways
Anatomical Factors
Anatomical Factors
Neuromuscular Factors
Pathophysiology

Vast majority of cases are associated

with adeno-tonsillar hypertrophy (AT-
Ht)
Obesity in children is a risk factor for
OSAS, and the severity of OSAS is
proportional to the degree of obesity
In contrast to adults, most OSAS children are
not obese (may have FTT)
Pathophysiology

Although strongly associated with AT-Ht,

childhood OSAS is not caused by AT-Ht
alone:
No obstruction during wakefulness
Adenotonsillar size and OSAS are not correlated
Deficit in arousal mechanisms
Elevated arousal thresholds in response to
hypercapnia and increased UA resistance
Abnormal centrally mediated activation of UA
muscles
Complications

CVS systemic and pulmonary HTN

Neurocognitive/behavioral problems
FTT
Enuresis
 EEG
OSAS: PSG screen
ECG

Chin EMG

Airflow

Peripheral Pulse
Volume

BP

Leg Mt.

Oximetry
Complications:
CVS
Cor-pulmonale - used to be a common
presentation, but is currently rare
When it does develop-can be reversed by Tx
Tal, Pediatr Pulmonol, 1988:
Ventriculography in children who had
abnormal questionnaire for OSAS:
37% had Rt. ventricular EF
67% had abnormal wall motion
All of the 11 pt who had a repeat evaluation after
T&A showed improvement
Complications:
CVS

Shiomi, Chest, 1993:

Pulsus-paradoxus and leftward shift of
the inter-ventricular septum in 3/6
children with OSAS
Correlated with negative esophageal
pressures but not with oxygen
desaturation, reversed with CPAP
Complications:
CVS
Am J Respir Crit Care Med. 2004 Apr
24 h ambulatory BP in children with sleep-
disordered breathing
Background: OSAS causes intermittent
elevation of systemic BP during sleep
Objective: to determine whether obstructive
apnea in children has a tonic effect on diurnal BP
Conclusion: OSA in children is associated with
24 h BP dysregulation
Complications:
CVS
AAP
The Fourth Report on the Diagnosis, Evaluation,
and Treatment of High Blood Pressure in
Children and Adolescents
National High Blood Pressure Education Program
Working Group on High Blood Pressure in Children
and Adolescents
PEDIATRICS Vol. 114 No. 2 August 2004
Complications:
CVS
Complications:
Neurocognitive & Behavioral
Guilleminault, Lung, 1981:
50 children with OSAS (PSG)
84% - excessive daytime sleepiness
76% - behavior disturbance
42% - hyperactive
16% - school performance
Complications:
Neurocognitive & Behavioral
Gozal, Pediatrics, 1998:
297 first graders who were in the lowest 10th
academically were evaluated for OSAS by
questionnaire combined with home oximetry
54/297 (18.1%) had positive results
(recommended T&A)
24/54 underwent T&A and improved their grading
significantly, with no change in the untreated
OSAS group or the non-OSAS group
Complications:
Neurocognitive & Behavioral
Gozal D, Sleep, 2004
Health-related Quality of Life and Depressive
Symptoms in Children with Suspected Sleep-
Disordered Breathing
Conclusions: Children with suspected OSAS,
regardless of the severity of RDI or the presence of
obesity, had more impairments in quality of life
and depressive symptoms than did children who
did not snore
Complications:
Neurocognitive & Behavioral
Pillar, Sleep, 2004
Sleep Disorders and Daytime Sleepiness in Children with
ADHD
Of the children with ADHD, 17 (50%) had signs of
OSAS, compared with 7 of the control group (22%,
P < .05)
Children with ADHD demonstrate objective daytime
somnolence (by MSLT), which may explain the
beneficial effects of Tx with stimulants
Primary sleep disorders, especially sleep-disordered
breathing and PLMS, should be looked for
Complications:
FTT
FTT in OSAS children and reports of growth
spurt following T&A
Proposed mechanisms:
1. Low caloric intake
Dysphagia
2. High caloric expenditure
Work of breathing
3. Abnormal GH secretion
Interrupted SWS, post T&A - IGF
Complications:
Enuresis
Brooks, J Pediatr, 2003:
Children 4 y and older who had suspected
OSAS were asked about enuresis
160 pt (90/70; M:F)
41% had enuresis (primary/secondary - 3:1)
RDI <1: significantly lower prevalence of enuresis
(17 vs. 47%)
The prevalence of enuresis is associated to the
OSAS severity (1-5, 5-15, or >15 events per
hour)
Complications:
Enuresis
Weider, Otolaryngol Head Neck Surg,
1991:
115 enuretic children undergoing T&A
66% and 77% reduction in enuretic nights
1m and 6 m Post-T&A
In the group with secondary enuresis,
100% were dry 6 m Post-T&A
Evaluation:
Polysomnography (PSG)
PSG is the gold STD for diagnosis
Establishment of diagnosis and
severity
Prediction of complications, particularly in
the immediate Post-Op period
Pre-Op baseline for Post-Op further
evaluation
High costs and shortage of sleep
labs >> screening techniques
Evaluation:
Screening
Questionnaires
Snoring audiotapes
ENT exam
low sensitivity and specificity
Nocturnal Videotapes
Oximetry
Nap-PSG
High false-negative rate, indicative if
positive
Evaluation:
Pulse Oximetry
Brouillette, Pediatrics, 2000:
349 children, pulse oximetry during
PSG
OSAS prevalence 60.2%
PPV - 97%
NPV - 53%
Treatment:
T&A
Tonsillectomy with or w/o adenoidectomy is efficient
Tx for OSAS
Clinical improvement of symptoms and post-Op
complications: CVS, neurocognitive, enuresis,
growth
Suen, Arch Otolaryngol Head Neck Surg, 1995:
69 with susp OSAS had PSG, 35/69 had RDI > 5
and referred for T&A, 30/35 had T&A, 26/30 had
follow-up PSG
Cure rate 85%
Post-Op snoring: NPV - 100%, and PPV - 57%
A high Pre-Op RDI (>19) was a strong predictor of
abnormal Post-Op residual abnormality
Treatment:
T&A
Nieminen, Arch Otolaryngol Head Neck
Surg. 2000:
95% cure rate for a group of 21 children
after T&A or tonsillectomy
Postoperative snoring NPV 100%, PPV
20%
73% of this group had a previous
adenoidectomy, indicating the lack of
efficacy of adenoidectomy alone
Treatment:
T&A
Post-Op respiratory compromise (16-27%)
Causes:
Upper airway edema
Increased secretions
Respiratory depression 2nd to
analgesic/anesthetic agents
Risk factors
Age <3 yr
severe OSAS
Children with additional medical conditions
Treatment:
T&A
Follow-up PSG (68 wk Post-Op) , to
ensure that additional Tx is not
required
Children with additional risk factors
Children with a Pre-Op high RDI
Other Tx alternatives

Uvulopharyngopalatoplasty (UPPP): in CP
pt and hypotonic upper airway muscles; it
has not been studied in the uncomplicated
pediatric pt
Oral appliances has not been reported in
children (it may adversely affect the facial
configuration of the growing child)
In children, CPAP is usually used when T&A
is unsuccessful or contraindicated rather
than as a primary treatment
Young infants
Medical conditions
Treatment: Oxygen

Improved oxygenation during sleep, w/o

obstruction worsening
PCO2 :
Few individuals show marked increase in PCO2
With no apparent predictive factors for which pt
would develop hypercapnia
Oxygen should never be administered w/o
1st measuring PCO2 response
Oxygen does not address many of the
associated pathophysiological features
The end !