Consultant for Pediatricians.
Obstructive Sleep Apnea in Children: Accurate Diagnosis, Effective Treatment
By DENNIS ROSEN, MD
Harvard Medical School |
April 5, 2010
Dr Rosen is Instructor in Pediatrics at Harvard Medical School in Boston and Associate Medical Director of the Sleep Laboratory at Children’s Hospital Boston.
Adenotonsillectomy. In most children with OSA, however, the firstline treatment is adenotonsillectomy. This is curative in 79% to 92% of children,31 although some series have demonstrated complete resolution of obstruction in smaller numbers. Adenotonsillectomy is less likely to be successful in older and obese children32,33 and in children who have underlying chromosomal or craniofacial abnormalities.
When a decision is made to treat OSA surgically, both the adenoids and the tonsils should be removed, barring a compelling reason not to do so.34 Even though the tonsils may appear small on inspection, differences in muscle tone between wakefulness and sleep, especially REM sleep, may result in otherwise small-appearing tonsils having a significant impact on the caliber of the upper airway during sleep.
Following adenotonsillectomy, some children may require extubation to continuous positive airway pressure (CPAP) and/or admission to the ICU until postoperative swelling has receded and the upper airway is stable. In 2002, the American Academy of Pediatrics published guidelines recommending postoperative hospital admission and close monitoring of children at high risk for perioperative complications, including those with severe OSA; children younger than 3 years; and children with cardiac complications of OSA, failure to thrive, obesity, prematurity, recent respiratory infection, craniofacial abnormalities, or neuromuscular disorders.35 In children identified before surgery as having severe OSA, and in those with other underlying risk factors, such as obesity or craniofacial, chromosomal, or muscle tone abnormalities, consider obtaining a follow-up PSG about 8 weeks after surgery to check for full resolution.
Positive airway pressure (PAP). This is the second most common treatment for OSA in children. The pressurized air is generated by a compressor and is delivered through an air hose via an interface: a nasal mask with or without a chinstrap, a full-face mask, or nasal pillows. The amount of pressure required is determined during a titration PSG in which PAP is administered at increasing increments until no further obstruction is seen. Either CPAP or bi-level PAP (BiPAP) can be used. CPAP is used more often, but in children in whom high pressure is required, BiPAP may prove to be more comfortable. PAP is used either until testing shows it is no longer needed or until further surgical or orthodontic interventions can be tried.36 Although PAP is very effective, its success depends greatly on regular use. For a description of an approach to introducing children to PAP and monitoring its use afterward that may increase the odds of success, see the Box.
Less common treatment options. Additional surgical interventions, such as midface advancement, mandibular distraction and advancement,37 tongue reduction, and uvulopalatopharyngoplasty,38 are also used to treat OSA, albeit rarely. These interventions are usually attempted when adenotonsillectomy and CPAP have not succeeded in resolving the obstruction or in children in whom there is a clear indication for a surgical or orthodontic procedure, eg, a high-arched and narrow palate or retromicrognathia; in cases such as these, CPAP is used as a bridge. Although rarely performed for this purpose, tracheostomy can also be used to bypass the upper airway, thereby eliminating obstruction.
Although dental appliances are used to treat mild to moderate OSA in adults, their use is not common in children because of the potential for alteration of the bite and for temporomandibular joint disease.39 Orthodontic interventions, such as maxillary expansion, have been shown to be very successful, both as standalone procedures and in conjunction with adenotonsillectomy, in treating OSA in children.40,41
Children's Hospital Boston: One Model of How Pediatric PAP Is Initiated and Monitored
At Children's Hospital Boston, children in need of positive airway pressure (PAP) meet with one of the sleep technologists in advance of the titration so that they can be fitted with a comfortable and suitable mask. The mask-fitting sessions generally last for 20 to 30 minutes, during which the children are engaged, with the parents present, and the placement and removal of the interface is introduced in a playful and non-threatening way.
The majority of children are able to proceed immediately to a titration study after meeting with the technologist. Others, however, require a period of acclimatization and desensitization at home. In these cases, the families are given the mask to take home and are encouraged to work on getting the child to adapt to the mask at his or her own pace, first by having the child wear it while playing, then while watching television or being read to, and finally by putting it on before falling asleep. A number of parents have reported that they incorporated the headgear for the mask into a game (eg, a mask with mesh-like headgear was referred to as a "Spiderman costume" by one of the children). The habituation process is highly specific, depends on many factors, and can range in duration from a few days to weeks. The families are asked to contact the sleep lab once they feel their child is comfortable wearing the mask; the titration study is then scheduled.
First follow-up visit: a time to review treatment details. Following the titration study, the PAP is ordered with downloadable compliance and efficacy capacity so that adherence can be monitored longitudinally. The child and parent(s) are asked to return in 1 to 2 weeks for follow-up and to bring the mask and machine with them. The machine is checked to make sure it is programmed to the correct settings, and the mask is applied to make sure that the fit is appropriate—not loose enough to cause an air leak, not so tight as to cause skin abrasion or breakdown. The use of the heated humidifier is reviewed, and the family is taught that its use results in diminished nasal stuffiness. Other issues typically discussed at the first follow-up visit include the following:
|• ||Ways to avoid water condensation in the air hose. |
|• ||Possible need for adjuvant medications such as nasal corticosteroids, antihistamines, or montelukast(Drug information on montelukast). |
|• ||How frequently to expect to need to replace the mask and tubing. |
|• ||Cleaning instructions. |
Monitoring for compliance, effectiveness, and accommodation to growth and change. The downloadable compliance data are monitored at varying intervals. At Children's Hospital Boston, the downloadable compliance data are reviewed 2 weeks, 6 weeks, and 3 months after initiation and, if all is going well, every 3 months thereafter. This helps not only to alert providers to any compliance problems patients may be having that they are not reporting (or that the parents may not even be aware of) but also to meet insurance requirements of documented use.
Because children, especially younger children, are constantly growing, leading to changes in airway caliber and compliance, muscle tone, and body mass index, it is important to restudy those receiving PAP therapy on a regular basis. There have been reports of midface hypoplasia developing in infants with longterm PAP delivered via mask42; thus, it is important to watch for this and to discontinue PAP once it is no longer necessary, especially in very young children. Conversely, children who gain a significant amount of weight or who experience a recurrence of symptoms such as snoring, excessive daytime sleepiness, or behavioral disturbances despite documented use of PAP may require higher pressures.
At Children's Hospital Boston, most children younger than 2 years who are receiving PAP are restudied every 3 to 6 months to determine whether PAP is still necessary and whether the settings are appropriate. Children older than 2 years are restudied every 1 to 2 years (unless there are clinical reasons to do so more often).
1. Lumeng JC, Chervin RD. Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc. 2008;5:242-252.
2. Kalra M, Inge T, Garcia V, et al. Obstructive sleep apnea in extremely overweight adolescents undergoing bariatric surgery. Obes Res. 2005;13:1175-1179.
3. Rosen CL. Obstructive sleep apnea syndrome (OSAS) in children: diagnostic challenges. Sleep. 1996;19(10 suppl):S274-S277.
4. Wilson SL, Thach BT, Brouillette RT, Abu-Osba YK. Upper airway patency in the human infant: influence of airway pressure and posture. J Appl Physiol. 1980;48:500-504.
5. Arens R, Marcus CL. Pathophysiology of upper airway obstruction: a developmental perspective. Sleep. 2004;27:997-1019.
6. Arens R, McDonough JM, Corbin AM, et al. Upper airway size analysis by magnetic resonance imaging of children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med. 2003;167:65-70.
7. Ievers-Landis CE, Redline S. Pediatric sleep apnea: implications of the epidemic of childhood overweight. Am J Respir Crit Care Med. 2007;175:436-441.
8. Arens R, McDonough JM, Costarino AT, et al. Magnetic resonance imaging of the upper airway structure of children with obstructive sleep apnea syndrome. Am J Respir Crit Care Med. 2001;164:698-703.
9. Redline S, Tishler P, Aylor J, et al. Prevalence and risk factors for sleep disordered breathing in children [abstract]. Am J Respir Crit Care Med. 1999;155:A843.
10. Gozal D, Kheirandish-Gozal L. Obesity and excessive daytime sleepiness in prepubertal children with obstructive sleep apnea. Pediatrics. 2009;123:13-18.
11. Li AM, Au CT, Sung RY, et al. Ambulatory blood pressure in children with obstructive sleep apnoea—a community based study. Thorax. 2008;63:803-809.
12. Tamura A, Kawano Y, Watanabe T, Kadota J. Relationship between the severity of obstructive sleep apnea and impaired glucose metabolism in patients with obstructive sleep apnea. Respir Med. 2008;102:1412-1416.
13. Parish JM, Somers VK. Obstructive sleep apnea and cardiovascular disease. Mayo Clin Proc. 2004;79:1036-1046.
14. Nishibayashi M, Miyamoto M, Miyamoto T, et al. Correlation between severity of obstructive sleep apnea and prevalence of silent cerebrovascular lesions. J Clin Sleep Med. 2008;4:242-247.
15. Halbower AC, Degaonkar M, Barker PB, et al. Childhood obstructive sleep apnea associates with neuropsychological deficits and neuronal brain injury. PLoS Med. 2006;3:e301.
16. Karpinski AC, Scullin MH, Montgomery-Downs HE. Risk for sleep-disordered breathing and executive function in preschoolers. Sleep Med. 2008;9:418-424.
17. Montgomery-Downs HE, Gozal D. Snore-associated sleep fragmentation in infancy: mental development effects and contribution of secondhand cigarette smoke exposure. Pediatrics. 2006;117:e496-e502.
18. Gozal D. Sleep-disordered breathing and school performance in children. Pediatrics. 1998;102(3, pt 1):616-620.
19. Chervin RD, Ruzicka DL, Giordani BJ, et al. Sleep-disordered breathing, behavior, and cognition in children before and after adenotonsillectomy. Pediatrics. 2006;117:e769-e778.
20. Freezer NJ, Bucens IK, Robertson CF. Obstructive sleep apnoea presenting as failure to thrive in infancy. J Paediatr Child Health. 1995;31:172-175.
21. Hogan AM, Hill CM, Harrison D, Kirkham FJ. Cerebral blood flow velocity and cognition in children before and after adenotonsillectomy. Pediatrics. 2008;122:75-82.
22. Kheirandish-Gozal L, Capdevila OS, Tauman R, Gozal D. Plasma C-reactive protein in nonobese children with obstructive sleep apnea before and after adenotonsillectomy. J Clin Sleep Med. 2006;2:301-304.
23. Mahboubi S, Marsh RR, Potsic WP, Pasquariello PS. The lateral neck radiograph in adenotonsillar hyperplasia. Int J Pediatr Otorhinolaryngol. 1985;10:67-73.
24. Chesson AL Jr, Ferber RA, Fry JM, et al. The indications for polysomnography and related procedures. Sleep. 1997;20:423-487.
25. Hoban TF. Polysomnography should be required both before and after adenotonsillectomy for childhood sleep disordered breathing. J Clin Sleep Med. 2007;3:675-677.
26. Friedman NR. Polysomnography should not be required both before and after adenotonsillectomy for childhood sleep disordered breathing. J Clin Sleep Med. 2007;3:678-680.
27. Rosen D. Many parents report their child's breathing and sleep patterns during overnight sleep study as atypical. Clin Pediatr (Phila). In press.
28. Mitchell RB, Pereira KD, Friedman NR. Sleepdisordered breathing in children: survey of current practice. Laryngoscope. 2006;116:956-958.
29. Kheirandish L, Goldbart AD, Gozal D. Intranasal steroids and oral leukotriene modifier therapy in residual sleep-disordered breathing after tonsillectomy and adenoidectomy in children. Pediatrics. 2006;117:e61-e66.
30. Goldbart AD, Goldman JL, Veling MC, Gozal D. Leukotriene modifier therapy for mild sleep-disordered breathing in children. Am J Respir Crit Care Med. 2005;172:364-370.
31. Mitchell RB, Kelly J. Outcomes and quality of life following adenotonsillectomy for sleep-disordered breathing in children. ORL J Otorhinolaryngol Relat Spec. 2007;69:345-348.
32. Tauman R, Gulliver TE, Krishna J, et al. Persistence of obstructive sleep apnea syndrome in children after adenotonsillectomy. J Pediatr. 2006;149:803-808.
33. Mitchell RB, Kelly J. Outcome of adenotonsillectomy for obstructive sleep apnea in obese and normal-weight children. Otolaryngol Head Neck Surg. 2007;137:43-48.
34. Smith E, Wenzel S, Rettinger G, Fischer Y. Quality of life in children with obstructive sleeping disorder after tonsillectomy, tonsillotomy, or adenotomy [in German]. Laryngorhinootolgie. 2008;87:490-497.
35. American Academy of Pediatrics. Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2002;109:704-712.
36. Kushida CA, Chediak A, Berry RB, et al; Positive Airway Pressure Titration Task Force, American Academy of Sleep Medicine. Clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea. J Clin Sleep Med. 2008;4:157-171.
37. Lye KW, Waite PD, Meara D, Wang D. Quality of life evaluation of maxillomandibular advancement surgery for treatment of obstructive sleep apnea. J Oral Maxillofac Surg. 2008;66:968-972.
38. Donaldson JD, Redmond WM. Surgical management of obstructive sleep apnea in children with Down syndrome. J Otolaryngol. 1988;17:398-403.
39. Kushida CA, Morgenthaler TI, Littner MR, et al; American Academy of Sleep. Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances: an update for 2005. Sleep. 2006;29:240-243.
40. Villa MP, Malagola C, Pagani J, et al. Rapid maxillary expansion in children with obstructive sleep apnea syndrome: 12-month follow-up. Sleep Med. 2007;8:128-134.
41. Monini S, Malagola C, Villa MP, et al. Rapid maxillary expansion for the treatment of nasal obstruction in children younger than 12 years. Arch Otolaryngol Head Neck Surg. 2009;135:22-27.
42. Li KK, Riley RW, Guilleminault C. An unreported risk in the use of home nasal continuous positive airway pressure and home nasal ventilation in children. Chest. 2000;117:916-918.
43. Sher AE. Mechanisms of airway obstruction in Robin sequence: implications for treatment. Cleft Palate Craniofac J. 1992;29:224-231.
44. Johnston C, Taussig LM, Koopmann C, et al. Obstructive sleep apnea in Treacher-Collins syndrome. Cleft Palate J. 1981;18:39-44.
45. Leighton SE, Papsin B, Vellodi A, et al. Disordered breathing during sleep in patients with mucopolysaccharidoses. Int J Pediatr Otorhinolaryngol. 2001;58:127-138.
46. Suen JS, Arnold JE, Brooks LJ. Adenotonsillectomy for treatment of obstructive sleep apnea in children. Arch Otolaryngol Head Neck Surg. 1995;121:525-530.
47. Mitchell RB, Call E, Kelly J. Diagnosis and therapy for airway obstruction in children with Down syndrome. Arch Otolaryngol Head Neck Surg. 2003;129:642-645.
48. Mortimore IL, Marshall I, Wraith PK, et al. Neck and total body fat deposition in nonobese and obese patients with sleep apnea compared with that in control subjects. Am J Respir Crit Care Med. 1998;157:280-283.
49. Spitzer AR, Boyle JT, Tuchman DN, Fox WW. Awake apnea associated with gastroesophageal reflux: a specific clinical syndrome. J Pediatr. 1984;104:200-205.
50. Corbo GM, Forastiere F, Agabiti N, et al. Snoring in 9- to 15-year-old children: risk factors and clinical relevance. Pediatrics. 2001;108:1149-1154.
51. Kaditis AG, Finder J, Alexopoulos EI, et al. Sleep-disordered breathing in 3,680 Greek children. Pediatr Pulmonol. 2004;37:499-509.
52. Marcus CL, Keens TG, Bautista DB, et al. Obstructive sleep apnea in children with Down syndrome. Pediatrics. 1991;88:132-139.
53. O'Donoghue FJ, Camfferman D, Kennedy JD, et al. Sleep-disordered breathing in Prader-Willi syndrome and its association with neurobehavioral abnormalities. J Pediatr. 2005;147:823-829.
54. Finnimore AJ, Roebuck M, Sajkov D, McEvoy RD. The effects of the GABA agonist, baclofen, on sleep and breathing. Eur Respir J. 1995;8:230-234.
55. Rosen D. Severe hypothyroidism presenting as obstructive sleep apnea. Clin Pediatr (Phila). 2010 Jan 28. [Epub ahead of print]. doi:10.1177/ 0009922809351093.
FROM PHYSICIANS PRACTICE
How Physicians Can Manage Unexpected Free Time Jennifer Frank, MD,
October 22, 2013
Whether you have an unexpected patient no-show, or two hours before bed, figuring out how to spend spurts of free time can be a work-life balance stressor.