Evaluation & Management of Pediatric Obstructive Sleep Apnea. Objective. Pediatric OSA. Pediatric OSA. #1 Cause of OSA in Children

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1 Evaluation & Management of Pediatric Obstructive Sleep Apnea Stacey Ishman, MD, MPH, FAAP Surgical Director, Upper Airway Center Director, Otolaryngology Outcomes Research Divisions Otolaryngology & Pulmonary Medicine None Acknowledge: Scott Brietzke, MD, MPH 1 Objective 1. To compare guidelines from the AASM, AAO-HNS and AAP for diagnosis/management of OSA 2. To formulate a plan for evaluation and management of children with persistent obstructive sleep apnea (OSA) following adenotonsillectomy (T&A) 3. To understand the options and evidence for sleep surgical procedures currently utilized for treatment of OSA after T&A Pediatric OSA 2 to 4% of pediatric population Two patterns seen in children Complete obstructive apneas Partial upper airway obstruction with hypoventilation Pediatric OSA Higher prevalance in pts with Craniofacial anomalies Pierre-Robin sequence, Apert syndrome Neuromuscular diseases Cerebral palsy Muscular dystrophy Obesity Achondroplasia Mucopolysaccharidoses (Hurlers>Hunters) #1 Cause of OSA in Children

2 Pediatric Sleep Disordered Breathing Clinical Practice Guidelines Committee Composition Otolaryngologist 5 Peds Pulm - 6 Sleep Med - 11 Sleep Medicine 3 Peds Pulm 1 Anesthesia 1 Research - 1 Pediatrician 3 Otolaryngologist 1 Neonatologist 1 Neuropsychologist -1 Oto 2011 Peds 2012 Sleep 2011 Target Audience Otolaryngologist in any practice setting where a child would be evaluated uncomplicated childhood OSAS in an otherwise healthy child...who is being evaluated in the primary care setting pediatric physicians Purpose to define actions that could be taken by otolaryngologists to deliver quality care 1) increase recognition of OSAS by primary care clinicians to minimize delay in diagnosis 2) evaluate diagnostic techniques 3) describe treatment options 4) provide guidelines for follow-up 5) discuss areas requiring further research to evaluate the validity and reliability of PSG and to determine its clinical utility for assessment and management of various respiratory disorders gailforcemarketing.com howtoblogabook.com Methodology OTO Strong Recommendation Benefits> Harm strong evidence Recommendation Benefits>Harm evidence not as strong Option Quality of evidence suspect OR little advantage No Recommendation PSG: Obvious High Risk Cases Obesity Down Syndrome Craniofacial abnormalities Neuromuscular disorders Sickle cell disease Mucopolysaccharidoses GRADE C Not within the scope Obesity Down Syndrome Craniofacial abnormalities Neuromuscular disorders Prader-Willi Chiari malformations Pierre Robin Sequence ALTE STANDARD blog.plista.com high-riskmerchant-account.com

3 PSG: Oto - High Risk Cases PSG: Healthy Child advocate for PSG prior to tonsillectomy for SDB in children for whom the need for surgery is uncertain or when there is discordance between tonsillar size on physical exam and the reported severity of SDB If a child snores on a regular basis and has complaints shown in Table 2 clinicians should either 1) obtain PSG or 2) refer to a sleep specialist or otolaryngologist PSG is indicated when the clinical assessment suggests the diagnosis of OSAS in children GRADE C GRADE B STANDARD PSG: Healthy Child advocate for PSG prior to tonsillectomy for SDB in children for whom the need for surgery is uncertain or when there is discordance between tonsillar size on physical exam and the reported severity of SDB If a child snores on a regular basis and has complaints shown in Table 2 clinicians should either 1) obtain PSG or 2) refer to a sleep specialist or otolaryngologist PSG is indicated when the clinical assessment suggests the diagnosis of OSAS in children GRADE C GRADE B STANDARD History History 12 article identified 11/12 concluded clinical evaluation is inaccurate in diagnosing OSA Level of evidence was B/B+ None had an adequate balance sensitivity & specificity High sensitivity (positive = actually positive) Low specificity (negative = actually negative) Brietzke et al. Otolaryngol Head Neck Surg 2004;131: Brietzke et al. Otolaryngol Head Neck Surg 2004;131:

4 History History A positive history is very reliable BUT cannot tell you the severity Positive predictive value below 1 Overdiagnosis of OSA when compared to PSG Brietzke et al. Otolaryngol Head Neck Surg 2004;131: A negative history is NOT very reliable Poor quality How much are the parents observing? If the risk/consequences are high will need to use objective testing This includes post-operative patients Limitations of the History Does it Matter? Caregiver reports of snoring, witnessed apnea or other nocturnal symptoms may be unreliable if the caregiver does not directly observe the child while sleeping or only observes the child early in the evening the sensitivity and specificity of the history and physical exam are poor Snoring and other nocturnal symptoms showed inconsistent correlations with respiratory parameters of PSG marquelrussell.com Does it Matter?

5 0 Limitations of the Physical Exam tonsil size does not predict the severity of OSAS the size of the tonsils cannot be used to predict the presence of OSAS in an individual child The task force found that clinical evaluation alone does not have sufficient sensitivity or specificity to establish a diagnosis of OSAS Association between subjective pediatric tonsil size (0 to 4+) and PSG OSA Severity Weak at best Conclude subjective tonsil size has limitations for clinical decision making Spearman's rho = Test of Ho: preop_rdi and tonsil are Independent Prob > t = Based on physical examination Preliminary Data Tonsil_Size 28 Tonsillar Staging Modified Mallampati Staging Tonsil Grade Grade 0 Grade I Description No Tonsils 0-24% Filling oropharynx Grade II 25-49% Grade III 50-74% Grade IV % 29 30

6 Results- Pre and Post Surgical RDI Post-Surgical Improvement in RDI Pre-Op RDI Post-Op RDI Average RDI Friedman Staging System Percent Surgical Success Alternatives to PSG 100 Percent Surgical Success Percent Success Friedman Staging System Laboratory-based PSG remains the gold standard for the diagnosis of OSA in children.the panel recommends against the routine use of PM over in laboratory PSG RECOMMENDATION If PSG is not available, then clinicians may order alternative diagnostic test such as nocturnal video recording, nocturnal oximetry, daytime nap PSG, or ambulatory PSG OPTION, GRADE C Nap (abbreviated) PSG is not recommended for the evaluation of OSAS OPTION *Separate statement paper on portable monitors recommends against use in children 33 glimpseofpeace.blogspot.com Adenotonsillectomy Adenotonsillectomy healthy kids Clinicians should counsel caregivers about tonsillectomy as a means to improve health in children with abnormal PSG who also have tonsil hypertrophy and sleep disordered breathing GRADE C If a child has a clinical examination consistent with adenotonsilar hypertrophy, and does not have a contraindication to surgery, the clinician should recommend AT as the first line of treatment GRADE B Adenotonsillectomy (AT) is commonly performed as a firstline treatment of OSAS in children

7 Postoperative Followup Clinicians should counsel caregivers and explain that SDB may persist or recur after tonsillectomy and may require further management GRADE C Clinicians should clinically reassess all patients with OSAS for persisting signs and symptoms after therapy to determine whether further treatment is required. GRADE B Children with mild obstructive sleep apnea syndrome preoperatively should have clinical evaluation following adenotonsillectomy to assess for residual symptoms. If there are residual symptoms of OSAS, PSG should be performed. STANDARD nhstrategicmarketing.com Persistent OSA after T&A No comments Clinicians should refer patients for CPAP management if symptoms/signs (Table 2) or objective evidence of OSAS persists after adenotonsillectomy GRADE C Clinicians may prescribe topical intranasal corticosteroids for children with mild OSAS in whom T&A is contraindicated or for children with mild postoperative OSAS OPTION, GRADE B PSG is indicated for positive airway pressure (PAP) titration in children with obstructive sleep apnea syndrome STANDARD Postoperative Monitoring Clinicians should admit children with OSA documented in results of PSG for inpatient, overnight monitoring after tonsillectomy, if they are under age 3 years or have severe oxygen saturation nadir less than 80%, or both GRADE C Clinicians should monitor high-risk patients (Table 5) undergoing adenotonsillectomy as inpatients postoperatively GRADE B PSG is indicated for positive airway pressure (PAP) titration in children with obstructive sleep apnea syndrome STANDARD Should They Stay or Should They Go? Obvious cases 3 or under, prematurity Obese Craniofacial Syndromes Severe disease Failure to thrive Oto Recommendations PSG for SDB in children in whom the need for surgery is uncertain or discordance between tonsillar size and severity of SDB Communicate PSG results to anesthesia Oto Recommendations Admit children with OSA if: < 3 years AHI>10 events/hour Oxygen saturation nadir <80% Non-CPAP therapies in obstructive sleep apnoea. Eur Respir J May; 37(5): Non-CPAP therapies in obstructive sleep apnoea. Eur Respir J May; 37(5):

8 AAP Recommendations Admit children with OSA if: < 3 years AHI 24 events/hour Oxygen saturation nadir <80% Peak end tidal CO2 >60mmHg Putting the Puzzle Together. Clinical Evaluation Verify the quality of the history Remember that the specificity is low Get a 3D impression of the tonsils (gag) Marcus C et al. Pediatrics. 2012; 130:576. allthingsd.com Putting the Puzzle Together. Putting the Puzzle Together. Use of PSG Diagnostic uncertainty Higher operative risk Bleeding dyscrasia Malignant hyperthermia allthingsd.com Pros of PSG Recognize nonobstructive disease to avoid surgery Negative study allow high risk children to defer or delay surgery Baseline to compare with future results Assist with perioperative planning admission, cardiac evaluation, preoperative CPAP, opioids procondebaters.wordpress.com Putting the Puzzle Together. Cons of PSG High cost Limited availability Delay in treatment Does not change admission for high-risk children Putting the Puzzle Together. Post-op Monitoring Outpatient with observation period 2 vs 4 hours as a minimum Inpatient 3 or under (10 kg), history of prematurity Obese, craniofacial syndrome, neuromuscular copyfight.corante.com allthingsd.com

9 Putting the Puzzle Together. Post-op PSG When there is any doubt Persistent symptoms of SDB/OSA High risk for persistent OSA Obesity Down s Syndrome Management of Persistent Pediatric OSA dchawks.com 50 Options Non-surgical treatment Weight loss/sleep Hygiene Pharmacotherapy Palate expansion/dental appliances CPAP Surgical treatments Adenoidectomy Tonsillectomy vs. tonsillotomy Nasal treatments Tongue/tongue base procedures Non-surgical modalities Weight loss Sleep hygiene Pharmacotherapy Oral appliances/rapid Maxillary Expansion Nasal continuous positive airway pressure Medical Weight Loss 10yr Counseled behavior & dietary approach 34% had 20% weight loss 30% were no longer obese Meta-analysis: 342 adults after surgery BMI decreased 57.6 to 37.7 kg/m 2 AHI decreased 54.7 to 15.8 events/hour Many still with moderate to severe OSA 34 adolescents Mean weight loss 58kg OSA in 19/34 10 underwent repeat PSG (9.1 to 0.7/hr) resolved Weight Loss Medical Weight loss (10-18yo; N=132) 49 with SDB, 42 with RDI>2/hour (14>5/hr) Overall Mean preop RDI=1.9 events/hr 71% resolved with weight loss 32% decrease in BMI Pretreatment SDB ODI<2 ODI 2-5 ODI>5 Karla M et al. Obes Res 2005;13(7): Hoorenbeeck K,et al. Obesity 2012;20(1):172.

10 5 Guidelines/Recommendations 2007 Health Care organization 4 stage model Convened by AMA and CDC 2007 Canadian clinical practice guidelines 2008 Endocrine Society recommendations 2009 Obesity Management 7 step model 2010 U.S. Preventive Task Force recs Weight Loss Bariatric Surgery ASMBS best practice guidelines mounting body of evidence supports the use of modern surgical weight loss procedures for carefully selected, extremely obese adolescents BMI of 40 kg/m 2 with other co-morbidities HTN, INS resistance, glucose intolerance, OSA with AHI 5, dyslipidemia, substantially impaired QOL/ADL BMI > 35 kg/m 2 with major co-morbidities Type 2 DM, mod-svr OSA (AHI 15),pseudotumor cerebri, or severe NASH Kirschenbaum DS et al. J Consult Clin Psychol 2013, 81(2): Michalsky M, et al. Surgery for Obesity & Related Diseases 2012;8(1):1-7. Bariatric Surgery Bariatric Surgery Prospective trial (N=50) 14-18yo, BMI >35 Medically supervised lifestyle vs gastric banding 2 years postoperatively lifestyle surgery Mean %EWL 13% 79% Metabolic synd (B) 40% 36% Metabolic syndr(2yr) 44% 0% Surgery group: 33% reop rate in 2 years Band slippage, pouch dilation, injury to port side tubing Prospective cohort study (N=226) 5-21 yo, BMI >35 kg/m Pre and post gastric sleeve baseline 3yr BMI (mean) OSA present 43% 7% (15/16 improved) Ibele AR, Mattar SG. Surgery Clin NA, (2011) 91(6) Alqahtani AR. Surgery Obesity Related Dz. 2014;10:842. Pharmacotherapy Steroids Oral Steroids 5D trial (1mg/kg) no reduction Nasal Steroids 6 wk course in 25 pts decreased RDI from 11 to 6/hr Pharmacotherapy Leukotriene Modifiers Increased # leukotriene receptors in tonsils of sleep apnea patient Demonstrated a specific topographic pattern of expression Al-Ghamdi AS et al. Laryngoscope (1997) 107: Brouillette RT et al. J Pediatr (2001) 138: Goldbart AD et al. Chest (2004) 126: Goldbart AD et al. AM J Resp Crit Care Med (2005) 172:

11 Leukotriene Modifiers Montelukast daily use x 16 wks in 24 mild osa pts Improvement in hypercarbia and AHI Decrease in adenoid size Combo Montelukast/Nasal Steroid Montelukast daily use x 12 wks in 752 mild osa pts Normalization PSG in 62% Less likely to work in children > 7 years or obesity pretreatment posttreatment Goldbart AD. Pediatrics Sep;130(3):e Kheirandish-Gozal L. Chest. 2014;146(1): Oral Appliances Most effective in nonobese patients with retro or micrognathia Better for mild to moderate cases 20 healthy kids versus 20 with mild to moderate OSA Reduced mandibular length Overbite Superior hyoid bone position Smaller dental arch Cozza et al. Eur J Orthod (2004) 26: Evaluation for Surgery Physical examination Cine MRI Sleep endoscopy Villa MP et al. Sleep Med. 2007;8(2):128. Villa MP et al. Sleep Breath. 2011;15:179. Cine MRI children with and without OSA Airway measurement/collapsibility differ children with Down Synd Relative macroglossia 74% Glossoptosis 63% Recurrent/enlarged adenoids 63% Enlarged lingual tonsils 30% Hypopharyngeal collapse 22% 2008/2010 reproduced results Hypopharyngeal collapse Glossoptosis Cine MRI - Axial Lane F et al. Radiology. 2003;227:239. Shott S et al. Laryngoscope. 2004;114(10):1724. Guimaraes C et al. Ped Radiology. 2008;38:1062. Schaaf WE et al. Am J on Roentgenology. 2010;194(5):120.

12 Cine MRI Indications for DISE Indications currently under debate Original papers focused on syndromic children Evolution to: Persistent pediatric OSA Children without obvious area of obstruction Children with significant comorbidities State-dependent laryngomalacia Drug induced sleep endoscopy Drug induced sleep endoscopy Anesthesia to approximate natural sleep Look at the dynamic movement of the airway Use flexible laryngoscopy or bronchoscopy Sher - syndromic children with PRS Reported Glossoptosis & pharyngeal collapse Sleep endoscopy was described by Croft and Pringle Croft CB. Sleep nasendoscopy: a technique of assessment in snoring and obstructive sleep apnoea. Clin Otolaryngol Allied Sci. 1991;16(5):504. Sher A et al. IJPO. 1986;11(2):135. DISE Drug induced sleep endoscopy Then mentioned recently in pediatric literature as a valuable tool in management of persistent pediatric OSA by identifying site of obstruction % 80% 70% 60% 50% 40% 30% * * * * tongue base supraglottic collapse 20% 10% 0% * = persistent OSA Lin AC, Koltai PJ. Sleep Endoscopy in the Evaluation of Pediatric OSA. IJPO 2012; 2012:576719

13 Occult Laryngomalacia Severe OSA Surgical Treatment Beyond T&A Adenoidectomy revision Completion Tonsillectomy Palatal surgery (UPPP) Nasal surgery Maxillary expansion Tongue/tongue base procedures Supraglottoplasty Adenoidectomy Long-term follow-up (3-5 years) Snoring 88%, Obstructed breathing 44% 32 no improvement /worsening Adenoid hypertrophy seen in 50% (16/32) 174 with improved symptoms 11% (20/174) Joshua B. Otolaryngology Head and Neck Surgery (2006) 135, 576. Adenoidectomy Retrospective (n=48 sdb, 52 no sdb) Likelihood of future tonsillectomy or revision adenoidectomy 38% with sdb underwent subsequent surgery versus 19% of those with nonobstructive Tonsillotomy Retrospective study 1,731 partial tonsillectomy group vs 1,212 patients traditional tonsillectomy Tonsillotomy Decreased posttonsillectomy hemorrhage (1.1% vs. 3.4%, p < 0.001) Decreased severe pain or dehydration requiring medical attention (3.0% vs. 5.4%, p = 0.002) 0.64% required revision completion tonsillectomy for tonsillar hypertrophy Brietzke S. Otolaryngology Head and Neck Surgery (2006) 134, 979. Schmidt R. Arch OtoHNS. 2007;133(9):925

14 Tonsillotomy Risk of tonsillar regrowth (0.5-17%): 17% (7/42) Krespi 1-10 year results (laser) 2-4% cited for symptomatic evaluation only Most studies with low numbers are 1 year follow-up or less Risk factors for tonsil tissue recurrence? Young age at the time of surgery Acute tonsillitis during the recovery period UPPP UPPP proposed in neurologically impaired, obese and Downs kids All retrospective studies Nasopharyngeal stenosis at increased risk when performed along with adenoidectomy Krespi YP. J Otolaryngol1994;23:325. Celenk F. Int J Pediatr Otorhinolaryngol Jan;72(1):19 Kerschner JE. IJPO. 2002;62(3):229. Kostko J. IJPO. 1995;32:241. Nasal / Nasopharyngeal Nasal/Nasopharyngeal Adenoidectomy Nasal turbinate reduction Septoplasty concern about nasal growth Nasal Surgery Nasal obstruction = potential OSA contributor Several studies have shown that Nasal obstruction alone may cause or exacerbate apnea in some children Children with turbinate hypertrophy are more likely to have persistent OSA after T&A No data on treatment of nasal obstruction alone for treatment of SDB in children Morita T et al. Am J Otolaryngol. 2004;25(5): Sullivan S, et al. Ann Acad Med Singapore. 2008;37: Nasal Surgery Meta-analysis: Effect of nasal surgery on OSA Reduction 11 events/hour Nasal Surgery Randomized, controlled trial on effect of RF turbinate ablation on NAO in adults Improves NAO and nasal CPAP compliance? Consider nasal turbinate reduction routinely in children with inferior turbinate hypertrophy? Wait as turbinate hypertrophy noted to be commonly improved after adenoidectomy & suggests that many will benefit from adenoidectomy alone Ishii L, et al. OtoHNS. 2015; Epub ahead of print. Powell NB, et al. Laryngoscope. 2001;111(10):

15 Nasal Turbinate Reduction Nasal turbinate reduction Retrospective case review 28 T&A, 23 with T&A/Turb Rapid Maxillary Expansion Device fitted to the molars with expansion of the maxilla Carried out over 12 months or less With Turbinate Reduction Without Turbinate Reduction Preop Postop Preop Postop p AHI 15.6 (5.2-28) 0.8 ( ) 15.0 (5.4-26) 3.5 ( ) <0.01 Min Sat 84 (76-94) 94 (92-97) 83 (75-92) 93 (91-96) <0.05 Min xsec area 0.16 ( ) 0.31 ( ) 0.15 ( ) 0.16 ( ) <0.01 Cheng PW. Laryngoscope Oct 15 Rapid Maxillary Expansion 2006 Study of 14 children Snoring & AHI reduced ( 5.8 to 1.5 events/hr) Daytime symptoms (sleepiness, tiredness, and oral breathing) significantly improved Mean expansion mm for the intercanine mm for the inter pre-molar 2011 Follow-up of 10/14 Repeat PSG in 12 and 24 months 24 months later, improvement in AHI and clinical symptoms persisted Villa MP et al. Sleep Med. 2007;8(2):128. Villa MP et al. Sleep Breath. 2011;15:179. Rapid Maxillary Expansion children (4 month followup ) day expansion; 6-12 months of consolidation AHI reduced ( 12.2 to <1 events/hr) Mean expansion mm for the intermolar mm for the interincisive Pirelli P et al. Sleep. 2004;27(4):761. Procedures Tongue/Tongue Base Macroglossia Lingual tonsillectomy Glossoptosis, tongue base obstruction treatment including surgery Tongue suspension suture Radiofrequency ablation Hyoid suspension Partial Midline Glossectomy Genioglossal advancement Lingual Tonsillectomy Radiology studies and flexible endoscopy show hypertrophy in Down Syndrome and Obesity Flex scope showing hypertrophy Fricke. Pediatr Radiol. 2006;36:518.

16 Lingual Tonsillectomy Author N Mean age Resolution O2 Sat pre/post AHI pre/post Abdul-Aziz 16 NR 68% 84/ /3.2 Chen % 89/ /5.7 Truong 31 7 NR NR 18.3/9.7 Lin % 89/ /8.1 Wootten % 83/84 8.5/4.1 Tongue Suspension Suture Case reports showing variable success Wooten/Shott patients with RFA BOT Mean age = 11 years; 9/31 Downs Success = 61% (66% no DS) Manickam et al. Laryngoscope. 2015; Epub ahead of print. Radiofrequency Ablation Safety with tongue lymphatic malformation Study combined with tongue suspension Meta-analysis in adults Mean treatments = 4.3 ( range) Long-term changes ESS 32% reduction at 24m (OR 0.68, ) RDI 45% reduction at 24m (OR.55, ) Partial Midline Glossectomy Submucosal lingual excision (SMILE) Pediatric cadaver studies only Endoscopic guidance with coblation Equivalent to RF BOT 55% change in AHI (2008) RCT: UPPP with 1)RF vs 2)SMILE-RF vs 3)SMILE-harmonic Farrar. Laryngoscope. 2008;118:1878. Babademez et al. OtoHNS. 2011;145(5):858. Friedman M. Oto HNS. 2008;139:378. Maturo SC. Ann Otol Rhinol Laryngol ;115(8):624. Partial Midline Glossectomy PMG Clark/Shott 2011 ASPO 22 Patients Success in 59% Current treatment protocol includes PMG with tongue suspension if needed Supraglottoplasty after T&A Author N Mean age Resolution O2 Sat pre/post AHI pre/post Chen % 88/ /4.9 Chen & Truong 9 NR NR NR 10.4/2.9 Truong 8 NR NR NR 9.7/5.7 Digoy % 83/ /4.1 Shott S. Curr Opin Otolaryngol Head Neck Surg Dec;19(6):449. Manickam et al. Laryngoscope. 2015; Epub ahead of print.

17 Additional Procedures Genioglossal advancement Pediatric case reports Adults - 70% reduction in RDI With multiple adjunctive procedures Consider older kids with well-developed mandible Procedures Mandibular & craniofacial procedures Tongue-lip adhesion Mandibular distraction osteogenesis Tracheostomy Miller FR. Oto HNS. 2004;130:73. Other Procedures Tracheostomy Highly effective Useful in kids with multiple levels of obstruction or neurologic impairment Increased risk of perioperative complications COMPLICATIONS Respiratory Complications pts 16 (23%) with complications Retrospective chart review Complications associated with: Younger than 3 Severe OSA Weight <5%ile Craniofacial abnormalities Recommended hospitalization postop for all Respiratory pts 10 with complications Retrospective chart review Complications McColley SA et al. Arch OtoHNS. (1992) 118(9):940. Rosen G et al. Pediatrics. (1994) 93(5):784.

18 Respiratory Complications 1994 Recommended selected admission after T&A Complications Effect of Anesthesia on Sleep healthy volunteers (20s)-isoflurane (3hr) Reduction in slow-wave sleep first night Sleep after surgery is low in REM and slow-wave sleep Poor sleep in the immediate postoperative period Analgesic drugs Pain Environmental noise Disturbance by nursing interventions Anxiety in unfamiliar environment Rosen G et al. Pediatrics. (1994) 93(5):784. Moote CA, Knill RL. Anesthesiology. (1988) 69:327. Sleep after T&A Complications 2005 PSG 1 st postop night after T&A for OSA (N=10) 5 mild OSA (1-10 events/hr) All 3 to 5 years old 5 severe OSA (>10 events/hr) Complications Sleep after T&A 2005 PSG 1 st postop night after T&A for OSA (N=10) preop 1 st night postop 6 weeks postop Nixon G et al. Ped Pulm. (2005) 39:332. Nixon G et al. Ped Pulm. (2005) 39:332. Complications Analgesic Sensitivity in OSA 2004 Age and preoperative sat nadir correlated with total opioid dose (N=46) Complications Analgesic Sensitivity in OSA 2006 Children with preoperative sat nadir <85% required ½ opioid after surgery than those 85% (N=22) Mean age = 43±19 months Mean age = 43±19 months Brown K et al. Anesthesiology. (2004) 100:806. Concluded: Recurrent hypoxemia in OSA associated with increased opioid sensitivity Brown K et al. Anesthesiology. (2006) 105:665.

19 Complications Postoperative Pain Management 2006 Children with preoperative sat nadir <85% required ½ opioid after surgery than those 85% (N=22) Mean age = 43±19 months Concluded: Recurrent hypoxemia in OSA associated with increased opioid sensitivity Brown K et al. Anesthesiology. (2006) 105:665. Morbidly obese 13yo with sleep apnea T&A, UPPP and SMR turbinate resection 12/9/13 Planned admission to the PICU Severe bleeding, transfusions Cardiac arrest & anoxic brain death Declared dead POD3 - eval that included 2 EEG Goldman et al M&M after T&A AAO newsletter, 552 respondents 51 mortalities reported 4 with anoxic brain injury Sales Pediatric Adult Unknown Goldman et al M&M after T&A Mechanism Medication 22% Pulmonary/CV factors 20% Hemorrhage 16% Perioperative events 7% Progression of underlying disease 5% Unexplained (All but 1 outside) 31% Goldman et al M&M after T&A Preop OSA dx NOT associated with increased risk of death or anoxic brain injury Timing 55% in the first 2 days after surgery Events unrelated to bleeding accounted for the preponderance of deaths & anoxic brain injury Hill, Hartnick et al Risk factors for airway complications in T&A for severe osa N=83 with AHI>10 all admitted Major complications 4.8% Increased level of care CPAP/BIPAP use Pulmonary edema Reintubation Minor Complications 19.3% Oxygen sat < 90% Hill et al. IJPO. 2011;75(11):1385.

20 Hill, Hartnick et al Risk factors for airway complications in T&A for severe osa Independent predictors of complications Age < 2 years AHI >= 24 events/hour Intraop laryngospasm requiring treatment Oxygen sats <90% on RA in PACU PACU stay > 100 mins Any of these factors 38% complications (vs 2%) Dalesio, Smith, Ishman et al. CO2 driver of complications Unadjusted Modeling Sat nadir Peak CO2 < Adjusted model Age significant and correlated with sat nadir/peak CO2? Confounder of the relationship between CO2 and complications Hill et al. IJPO. 2011;75(11):1385. Dalesio, Smith, Ishman et al. CO2 driver of complications Unadjusted Modeling Sat nadir Peak CO2 < Adjusted model Age significant and correlated with sat nadir/peak CO2? Confounder of the relationship between CO2 and complications Gaps: Who needs to be admitted? What level of admission is necessary? Floor, ICU, stepdown What is appropriate and safe pain control in these children? Thank You Stacey Ishman, MD, MPH Surgical Director, Upper Airway Center Multidisciplinary Treatment of Children with Persistent #8 Sleep Apnea Stacey.ishman@cchmc.org