Faculty Disclosure. Casey J. Burg, MD. Dr. Burg has listed no financial interest/arrangement that would be considered a conflict of interest.

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1 Faculty Disclosure Casey J. Burg, MD Dr. Burg has listed no financial interest/arrangement that would be considered a conflict of interest. Pediatric Asthma & Sleep Apnea Casey Burg, MD Pediatric Pulmonology & Sleep Medicine 1

2 Objectives: Define the recommendations for well asthma care in terms of spirometry and assessment of asthma control Describe the evaluation and treatment for pediatric sleep apnea Define the role of overnight trend oximetry in management of pediatric sleep disordered breathing 2

daily with a 3L syringe x3 trials (use different flow rates) need to be ± 3.5% Sit upright, nose clip on Test procedure: 1.

3 Clinic-Based Spirometry Portable handheld device Calibrated to 3L daily Would recommend Global Lung Initiative reference set Option of setting to 3-6 sec test (need ability to switch this for pediatrics) ATS Spirometry Guidelines Calibrate daily with a 3L syringe x3 trials (use different flow rates) need to be ± 3.5% Sit upright, nose clip on Test procedure: 1. Maximal inspiration 2. Blast of exhalation 3. Continued complete exhalation t end of test Incentive screens recommended for kids 3

4 End of Test Criteria The volume time curve shows no change in volume(<0.025 L) for 1 s, and the subject has tried to exhale for 3 s in children aged <10 yrs and for 6 s in subjects aged >10 yrs. Need 3 acceptable FVC maneuvers Highest 2 FVCs and FEV1s are within 0.150L of each other Usually max of 8 maneuvers Unacceptable Tests Any coughing Glottis closure or hesitations Leaks from nose or mouth Early termination Sub-maximal effort throughout Obstruction of the mouthpiece (tongue) Collapsing the mouthpiece (biting) 4

5 Selected Values Flow-volume and volume-time displays recommended Largest FVC and largest FEV1 recorded (may be from different maneuvers) FEV1/FVC and FEF25-75 is taken from the blow with the largest sum of FEV1 and FVC Post-BD Testing No short-acting beta-agonists or anticholinergics for 4 hrs prior No long-acting beta-agonists for 12h prior 4 puffs of albuterol given via valved holding chamber (hold for 5-10 seconds and then repeat at 30 second intervals) Repeat spirometry 10 min and up to 15 min 5

6 Interpretation Machine interpretation is usually OK MILD MODERATE SEVERE Significant BD Response FEV1 < 80% < 70% < 60% -12% FVC < 80% < 70% < 60% -12% FEV1/FVC < 0.80 < 0.70 < 0.60 NA FEF25-75 < 75% < 65% < 55% -25% Comment of shape of flow-volume loops Use of Z-scores gives a better interpretation Typical spirometric tracings Volume Normal Flow FEV 1 Asthma (after BD) Asthma (before BD) Normal Asthma (after BD) Asthma (before BD) Time (seconds) 6 Volume Note: Each FEV 1 represents the highest of three reproducible measurements GINA

7 Loop Interpretation scooped appearance of expiratory loop blunted appearance of inspiratory loop 7

IMPRESSION: Mild obstruction based on reduced FEF25-75. Inspiratory loop appears normal. Expiratory loop is "scooped" to suggest obstruction.

8 IMPRESSION: Mild obstruction based on reduced FEF Inspiratory loop appears normal. Expiratory loop is "scooped" to suggest obstruction. Significant improvement noted in FEV1 and FEF25-75 after bronchodilator to suggest reversibility. Exhaled NO level is normal. These results are decreased from previous. How to Check Adherence Use the Medication Dispense Report EPIC report that is also available on other EMRs Comes from a 3 rd party (Surescripts) that looks at both claims data and participating pharmacy data Verify with family if the report is accurate Use the actual use over the last 4 weeks to determine risk score and if a step up or correction to regular use is required 8

9 Obviously not filling medication regularly Coding basic spirometry with no flow-volume loop comment wrvu 0.17, Nebraska Medicaid $24.60 (global $43) pre-post spirometry wrvu 0.27, Nebraska Medicaid = $24.60 (global $82) spirometry with flow-volume loops wrvu 0.31, Nebraska Medicaid = $20.50 (global $61.50) 9

10 CASI Score Composite Asthma Severity Index (CASI) Free, open-source tool Developed into EPIC at no cost Incorporates and replaces the Asthma Control Test (ACT) Quantifies disease severity by taking into account: Impairment Risk Medication needed for control -Wildfire, J Allergy Clin Immunol, 2011 CASI Components Day symptoms and albuterol use (last 2 weeks) Night symptoms and albuterol use (last 2 weeks) Controller medication usage (current) Lung function measures (current) Exacerbations (in last 2 months) 10

11 Scorecard Controller medications are ¼ of score Exacerbations are 30% of score 11

12 Controller Meds (hardest piece to sort out) Tracking Results 12

asthma severity Unsure what to add if unable to do PFTs 0 points vs 1 point for

13 Interpreting Scores Maximum score is 20 (high score = high severity) Score of 3 or less = mild asthma A change of 1 point, suggests a change in the individual s asthma severity Unsure what to add if unable to do PFTs 0 points vs 1 point for Lung Function Section Note: No questions about exercise impairment on the CASI 13

Step Up Therapies (Step 3 decision) If allergy/eczema component -> increase inhaled steroids or leukotriene blocker If no significant allergy/eczema -> long-acting bronchodilator (LABA) If unsure if

14 Step Up Therapies (Step 3 decision) If allergy/eczema component -> increase inhaled steroids or leukotriene blocker If no significant allergy/eczema -> long-acting bronchodilator (LABA) If unsure if allergy present LABA is 1.5 times as likely to produce the best response (not as significant in Black race though) -Lemanske, NEJM, 2010 GINA Pocket Guidebook is a link to download current pocket guide for asthma management and prevention 14

15 Asthma Healthy Planet MyPanel Metrics % of asthma patients with annual Asthma Visit % of asthma patients with < 1 ED visit in past year % of asthma patients with Asthma admit in past year % of asthma patients with a current AAP % of asthma patients with ACT > 19 % of asthma patients with FEV1 < 80%tile % of asthma patients who received annual flu shot -GOALS are > 80% for all -Attribution is difficult (specialist vs PCP) Pediatric Sleep Disorders Medical Sleep Apnea Central & Obstructive Periodic limb movements & restless leg syndrome Narcolepsy Ventilator management Behavioral Sleep hygiene Insomnia Parasomnias Circadian rhythm CPAP adherence 15

16 Behavioral Sleep Medicine Brett R. Kuhn, PhD, C.BSM Certified in behavioral sleep medicine (C.BSM) by the American Academy of Sleep Medicine Treats behavioral sleep insomnia, parasomnias, circadian rhythm abnormalities, sleep hygiene techniques, sleep fears and CPAP adherence Childhood Sleep-Disordered Breathing SDB in children occurs in all age groups, including neonates Present in 1-6% of children Peak incidence in children is 2-7 years of age Habitual snoring seen in up to 27% -AAP Guidelines, Pediatrics,

17 Symptoms of OSA in Children Difficulty breathing during sleep Loud habitual snoring Mouth breathing Grunting, snorting or gasping without snoring Morning headaches Retractions and increased respiratory effort Sleep with hyperextension of neck Diaphoresis / cyanosis Bedwetting Daytime sleepiness / hyperactivity Behavioral problems (ADHD-like) Diagnosis Questionnaires Helpful in taking a structured history but unlikely to replicate polysomnogram reliably Pediatric Sleep Questionnaire (PSQ), Sleep Disturbance Scale for Children (SDSC), Sleep Disorders Inventory for Students (SDIS) Epworth Sleepiness Scale Revised for Children (ESS) -Spruyt, Sleep Med Reviews, 2011 (review) Ambulatory polysomnogram Not evaluated in children for clinical use Difficult to maintain quality of signals Audio and video monitoring Helpful but poor specificity when used alone -AAP Guidelines, Pediatrics, 2012 Oximetry studies Not all events associated with hypoxia 17

18 Overnight Polysomnography Gold standard to diagnose sleep disordered breathing Includes more monitoring than is typical for adults Smaller person = more channels 36 18

EEG studies during the day Sleep studies at night Room big enough for child and parent Also have separate parent room so their snoring doesn t mess up the sleep study

arousal index Include hypnogram to give a good overview Agreement on what constitutes normal is debated Clinically, an obstructive AHI > 1.

0 Central apneas in children can be normal and decrease with age Up to 4 events per hour normal in 1-2 year olds By around 15 yo, < 1 per hour is normal 1-2 yo 2-4 yo 4-6

19 EEG studies during the day Sleep studies at night Room big enough for child and parent Also have separate parent room so their snoring doesn t mess up the sleep study Reporting Physician reviews all epochs and verifies scoring Highly important as just a few events can determine if surgery or CPAP is needed oahi, cahi, ODI, PLMS index, arousal index Include hypnogram to give a good overview Agreement on what constitutes normal is debated Clinically, an obstructive AHI > 1.0 is abnormal Practically, no significant treatment until > 2.0 to 3.0 Central apneas in children can be normal and decrease with age Up to 4 events per hour normal in 1-2 year olds By around 15 yo, < 1 per hour is normal 1-2 yo 2-4 yo 4-6 yo 6-10 yo yo yo yo yo Total AHI Central AHI Obstructive AHI Scholle, Sleep Medicine,

20 Severity of OSA Severity of OSA Adult AHI Pediatric oahi None 0-5 <1.0 Mild OSA Moderate OSA Severe OSA >40 >10 Definition of when Adult starts can vary between yo In MY practice, I would probably use an age cutoff of 16 yo Overnight monitoring following adenotonsillectomy if: Age < 3 yo OR Severe OSA (oahi > 10) Continuous SpO2 overnight -Practice Guidelines, Anesth, Roland, Otolaryngology,

21 Treatment of OSA in Children Adenotonsillectomy resolves 27-80% of childhood sleep disordered breathing 71-87% when an AHI cutoff of 5.0 used This percentage increases in absence of craniofacial disorders, dental misalignment, obesity, nasal obstruction CPAP is not typically 1 st line therapy in kids Long-term CPAP vs. 1-time surgical procedure with small but real risk of complications Treatment of OSA in Children Role of watchful waiting 46% of mild OSA in school aged children resolved with no intervention after 7 months (79% in early adenotonsillectomy group) Executive functioning and attention not significantly improved with early adenotonsillectomy, Quality of life, symptoms, behavior and polysomnogram values improved in early adenotonsillectomy group -Marcus, N Engl J Med, 2013 (CHAT study) Nasal Steroid +/- Singulair Can treat mild OSA (obstructive AHI 1-5) Improvement noted in 62-80% of children aged 2-14 years Younger and non-obese children did better -Kheirandish-Gozal, Chest,

CPAP & Titrations Non-resolved OSA after adenotonsillectomy Split nights are unusual Full night diagnostic Eval in clinic and decide if CPAP candidate Fit mask in clinic vs.

22 CPAP & Titrations Non-resolved OSA after adenotonsillectomy Split nights are unusual Full night diagnostic Eval in clinic and decide if CPAP candidate Fit mask in clinic vs. through DME Limited by pediatric masks available Desensitization process When tolerating falling asleep with 4 cmh2o, then sleep study is scheduled We work closely with home health companies for mask fitting/selection, machine selection and desensitization Use auto-titrating machines with remote monitoring (modems) to determine compliance, leak, AHI prior to titration study Auto-titrating CPAP Limited research in pediatrics Pediatrics 2004 showed utility when used in a sleep lab setting Felt was adequate until in-lab titration available Many times used to determine the fixed CPAP pressure Common adult practice to do auto-titrating at 4-20 cwp following home sleep testing CPAP download can give you an AHI number based on proprietary algorithms Seems to work on children also, but algorithm is attempting to get AHI below 5.0, which is still elevated for pediatrics My experience shows good resolution of symptoms and ability to rely on downloads in most instances 22

Devices Used Most companies have a download capability Integrated modems are ideal Patient/parent portal also helps with compliance Kids like

waveform views Algorithm for adults sometimes identifies CSA as OSA in children Likely due to small airways and pressure pulse bouncing off the

23 Devices Used Most companies have a download capability Integrated modems are ideal Patient/parent portal also helps with compliance Kids like reviewing data on iphone/ipad Parents (and myself) like to point out children that are lying about their CPAP use I prefer a report that allows waveform views Algorithm for adults sometimes identifies CSA as OSA in children Likely due to small airways and pressure pulse bouncing off the carina (my explanation anyway) Use this data to determine need for mask re-fit Acts as a lie-detector for parents Data can be sent to an app on your mobile device 23

24 Clinic vs Telemedicine Use data to generate reports via a telemed type visit to avoid frequent travel and to guide therapy Helps limit the need for surveillance sleep studies Despite parent/patient protests Trend Oximetry Not a replacement for a sleep study Can help decide if referral straight to ENT vs obtain a PSG Many times use it to monitor for resolution of desaturations following an intervention Post T&A vs medical treatment with nasal steroids +/- Singulair More helpful when sleep study verifies that ODI was main determinant of events scored (i.e. events not scored due to arousals) Look more at the desaturation index than I do at the overall oxygen saturations Currently doing research to compare the sleep study derived ODI with a home trend oximetry equipment derived ODI Preliminary data shows good correlation Average of the ODI from the combined 3% and 4% desaturation report 24

Laryngomalacia at 6 mo S/p supraglottoplasty but still with OSA on repeat sleep study

0 averaged) Children s Sleep Lab Currently 4 beds 5-6 nights per week Moving to 6 beds 7

Part or full time positions Every 3 rd weekend Sign-on bonus Relocation Tuition

25 Laryngomalacia at 6 mo S/p supraglottoplasty but still with OSA on repeat sleep study Symptoms improved since sleep study Desat index decreased from 10.4 to 4.9 (3.0 averaged) Children s Sleep Lab Currently 4 beds 5-6 nights per week Moving to 6 beds 7 nights per week Posting for 4 sleep technician positions 12 hour shifts 6pm to 6:30 am) Part or full time positions Every 3 rd weekend Sign-on bonus Relocation Tuition reimbursement Open to negotiation Careerlink.com (Children s Hospital Omaha) Call Megan Black, RRT/SDS

26 Thank You!! Casey Burg, MD Pediatric Pulmonology Children s Hospital & Med Center Sleep Disorders Center 8200 Dodge ST (402) (phone) (402) (fax) sleep@childrensomaha.org Mark Wilson, MD Pediatric Pulmonology Matthew Dennis, MD Pediatric Sleep -Amber Widstrom, PA (Sleep Medicine) -Brett Kuhn, PhD (Pediatric Psychology) 51 26

Questions: What tests are available to diagnose sleep disordered breathing? How do you calculate overall AHI vs obstructive AHI?

Questions: What tests are available to diagnose sleep disordered breathing? How do you calculate overall AHI vs obstructive AHI? Pediatric Obstructive Sleep Apnea Case Study : Margaret-Ann Carno PhD, CPNP, D,ABSM for the Sleep Education for Pulmonary Fellows and Practitioners, SRN ATS Committee April 2014. Facilitator s guide Part