ERS Annual Congress Milan September 2017 Meet the expert ME1 Treating obstructive sleep apnoea syndrome in children

Transcription

1 ERS Annual Congress Milan September 2017 Meet the expert ME1 Treating obstructive sleep apnoea syndrome in children Sunday, 10 September :00-14:00 Amber (South) MICO

2 You can access an electronic copy of these educational materials here: To access the educational materials on your tablet or smartphone please find below a list of apps to access, annotate, store and share pdf documents. iphone / ipad Adobe Reader - FREE With the Adobe Reader app you can highlight, strikethrough, underline, draw (freehand), comment (sticky notes) and add text to pdf documents using the typewriter tool. It can also be used to fill out forms and electronically sign documents. MetaMoJi Note Lite - FREE MetaMoJi Note is a cross-platform note taking app, PDF annotation tool, and a digital scrapbook. Sketch your ideas visually with stylish pens and ink, take notes, or annotate imported PDF documents. MetaMoJi Note is a virtual whiteboard for sketching, annotation, scrapbooking or digital mashup. GoodReader GoodReader allows you to view, create and edit PDF annotations. It also provides advanced PDF files organising, reading and editing functionalities, such as inserting or extracting pages, splitting or merging files, etc. Android Adobe Reader - FREE The Android version of Adobe Reader lets you view, annotate, comment, fill out, electronically sign and share documents. It has all of the same features as the ios app like freehand drawing, highlighting, underlining, etc. Xodo - FREE Xodo is an all-in-one PDF reader and PDF editor. With Xodo, you can read, annotate, sign, and share PDFs and fill in PDF forms, plus syncing with Google Drive and Dropbox. ez PDF Reader With ez PDF reader you can add text in text boxes and sticky notes; highlight, underline, or strikethrough texts or add freehand drawings. Add memo & append images, change colour / thickness, resize and move them around as you like.

3 Meet the expert : ME1 Treating obstructive sleep apnoea syndrome in children Aims : To summarise the results of recent multicentre studies (CHAT from the USA and NANOS from Spain) on the efficacy of treatment interventions for OSAS in childhood; to discuss indications for treating OSAS in children, even in settings where polysomnography is not available. Tracks: Acute and chronic respiratory failure/sleep Tags: Paediatric Target audience: Clinician - Fellow - Paediatrician - Pulmonologist - Respiratory physician - Sleep specialist/technologist - Anaesthesiologist - Intensivist/critical care physician - Junior member Neonatologist Chairs : Melania Evangelisti (Rome, Italy) 13:00 Treating OSAS in children Athanasios G. Kaditis (Athens, Greece)

4 THE ERS HANDBOOK OF paediatric respiratory medicine ISBN Edited by Ernst Eber and Fabio Midulla The ERS Handbook of Paediatric Respiratory Medicine comprises more than 100 sections covering the whole spectrum of paediatric respiratory medicine, from anatomy and development to disease, rehabilitation and treatment. The book is structured to tie in with the paediatric HERMES syllabus, making it an essential resource for anyone interested in the field and the ideal training aid for those wishing to take the European Examination in Paediatric Respiratory Medicine. Accredited by EBAP for 18 hours of European CME credit To buy printed copies, visit the ERS Bookshop in the World Village at the ERS International Congress Electronic: Print:

5 Thank you for viewing this presentation. We would like to remind you that this material is the property of the author. It is provided to you by the ERS for your personal use only, as submitted by the author by the author

6 Treating Obstructive Sleep Apnea Syndrome in Children: Lessons from recent multicenter studies Athanasios Kaditis, MD National and Kapodistrian University of Athens School of Medicine and Aghia Sophia Children s Hospital First Department of Pediatrics, Pediatric Pulmonology Unit Sleep Disorders Laboratory

7 Disclosures No conflicts of interest to disclose

8 Specific aims of the presentation To summarise the results of recent multicenter studies (CHAT from USA and NANOS from Spain) on the efficacy of treatment interventions for OSAS in childhood To discuss indications of treating OSAS in childhood based on the recent (2016) ERS Statement To adjust treatment indications for settings where polysomnography is not available

9 Obstructive Sleep-Disordered Breathing (SDB) Spectrum of abnormal respiratory patterns during sleep characterized by snoring and increased respiratory effort Primary snoring Upper airway resistance syndrome Obstructive hypoventilation Obstructive sleep apnea syndrome (OSAS)

10

11 Marcus et al. A Randomized Trial of Adenotonsillectomy for Childhood Sleep Apnea. NEJM 2013;157:57-61 OSAS-Definition 1: obstructive AHI 2 episodes/h or an obstructive apnoea index 1 episode/h in the context of SDB symptoms OSAS-Definition 2: SDB symptoms and an AHI 1 episode/h Sedky et al. Attention deficit hyperactivity disorder and sleep disordered breathing in pediatric populations: A meta-analysis. Sleep Med Rev 2014;18: Scholle et al. The Normative values of polysomnographic parameters in childhood and adolescence: cardiorespiratory parameters. Sleep Med 2011;12: In children without SDB symptoms or morbidity or abnormalities predisposing to SDB, the 90 th percentile for the AHI (AASM 2007 scoring rules) is: 3.2 episodes/h for the 2 nd year of life up to 2.5 episodes/h for ages >2 and 6 years up to 2.1 episodes/h for ages >6 and <18 years

12 Step 1: Recognize the child at risk for obstructive SDB Step 2: Recognition of morbidity and conditions co-existing with SDB (common pathogenesis) Step 3: Recognition of factors predicting longterm persistence of SDB (if not treated) Step 4: Objective diagnosis and assessment of SDB severity Step 5: 5: Indications for Determine treatment of SDB indications for treatment Step 6: Stepwise treatment approach to SDB Step 7: Recognition and management of persistent SDB

13 Patient Case-1 (A) 5 y.o. boy referred by his primary care physician for loud snoring that is present on most nights Mother reports Intermittent complete blockage of breathing with gasping and snorting noises Frequent awakenings from sleep Mouth-breathing day and night even during summer

14 Patient Case-1 (B) Physical examination Wt and Ht steadily on the 50th percentile Nasal congestion American Family Physician

15 2013; 162: Non-snoring Snoring

16 Li et al. Natural History and Predictors for Progression of Mild OSA. Thorax 2010;65: y.o. N=56 (oahi 1-5 episodes/h) F/U 2 years later: oahi >5 in 30% of children. Predictors: Tonsillar hypertrophy, male gender increasing weight circumference

17 Case features 1. Nocturnal SDB symptoms 2. Adenotonsillar hypertrophy 3. No SDB-associated morbidity 4. Risk of persistence or deterioration

18 Step 1: Recognize the child at risk for obstructive SDB Step 2: Recognition of morbidity and conditions co-existing with SDB (common pathogenesis) Step 3: Recognition of factors predicting longterm persistence of SDB (if not treated) Step 4: Objective diagnosis and assessment of SDB severity Step 5: 5: Indications for Determine treatment of SDB indications for treatment Step 6: Stepwise treatment approach to SDB Step 7: Recognition and management of persistent SDB

19 Marcus et al. A Randomized Trial of Adenotonsillectomy for Childhood Sleep Apnea. NEJM 2013;157: children (5-9 y.o.) with obstructive AHI 2 episodes/h and/or obstructive apnea index 1 episode/h Adenotonsillectomy vs. watchful waiting (over 7 months) A T A T Outcome: obstructive AHI <2 episodes/h and obstructive apnea index <1 episode/h If AHI 4.7 episodes/h NNT 5 If AHI >4.7 episodes/h NNT 3

20 How can we assess SDB severity if polysomnography or polygraphy are not available?

21 Cluster of Desaturations At least five D4 over min

22 McGill score Normal Abnormal At least 3 Desaturation Clusters At least 3 D90 Inconclusive AHI may or may not be elevated

23 Frequency of positive oximetry 26.6% Frequency of positive oximetry 22% Frequency of positive oximetry 21.6%

24 Children with positive Sleep Clinical Record Score McGill score 2 Positive predictive value 94% Sensitivity 39.2% for AHI >5 episodes/h

25 Patient Case-1 (C) Polysomnography AHI 19.2 episodes/h

26 Patient Case-2 (A) 5 y.o. boy referred by his primary care physician for loud snoring that is present on most nights Mother reports Intermittent complete blockage of breathing with gasping and snorting noises Frequent awakenings from sleep Irritable and sleepy during the day Has difficulty concentrating at school

27 Patient Case-2 (B) Physical examination Wt and Ht steadily on the 50th percentile Tonsils 2+ Polysomnography AHI 3.4 episodes/h

28 Case features 1. Nocturnal SDB symptoms 2. Adenoidal hypertrophy 3. SDB-associated morbidity: CNS 4. Mild OSAS

29 Step 1: Recognize the child at risk for obstructive SDB Step 2: Recognition of morbidity and conditions co-existing with SDB (common pathogenesis) Step 3: Recognition of factors predicting longterm persistence of SDB (if not treated) Step 4: Objective diagnosis and assessment of SDB severity Step 5: 5: Indications for Determine treatment of SDB indications for treatment Step 6: Stepwise treatment approach to SDB Step 7: Recognition and management of persistent SDB

30 Marcus et al. A Randomized Trial of Adenotonsillectomy for Childhood Sleep Apnea. NEJM 2013;157:57-61

31 Rosen et al. Utility of symptoms to predict treatment outcomes in obstructive sleep apnea syndrome. Pediatrics 2015;135:e Executive functioning pat Attention pat Behavior pat

32 Rosen et al. Utility of symptoms to predict treatment outcomes in obstructive sleep apnea syndrome. Pediatrics 2015;135:e QOL pat OSAS-specific QOL pat Sleepiness pat

33 Patient Case-3 (A) 8 y.o. boy referred by his primary care physician for loud snoring that is present on most nights Mother reports Intermittent complete blockage of breathing with gasping and snorting noises Frequent awakenings from sleep Bedwetting more frequently than one night per week

34 Patient Case-3 (B) Physical examination Wt and Ht steadily on the 50th percentile Tonsils 2+ Polysomnography AHI 4.8 episodes/h

35 Case features 1. Nocturnal SDB symptoms 2. Tonsillar hypertrophy 3. SDB-associated morbidity: enuresis 4. Mild OSAS

36 Jeyakumar et al. The Association Between SDB and Enuresis in Children. Laryngoscope 2012; 122: Systematic review of 7 studies 1360 children (2-18 y.o.) with SDB Preoperative prevalence of enuresis 31% Postoperative prevalence of enuresis 16% (P<0.0002)

37 Patient Case-4 (A) 8 y.o. boy referred by his primary care physician for loud snoring that is present on most nights Father reports Intermittent complete blockage of breathing with gasping and snorting noises Frequent awakenings from sleep Sleepy during the day

38 Patient Case-4 (B) Physical examination Wt >>95th percentile Nasal congestion Flexible nasopharyngocopy: adenoidal hypertrophy Polysomnography AHI 4.4 episodes/h

39 Goodwin et al. Incidence and Remission of SDB and Related Symptoms in 6- to 17-y.o children. J Pediatr 2010;157:57-61

40 Case features 1. Nocturnal SDB symptoms 2. Obesity, adenotonsillar hypertrophy 3. SDB-associated morbidity: CNS 4. Risk factor for OSAS persistence: obesity 5. Mild OSAS

41 Eur Respir J 2015;46: AHI 10 episodes/h BMI BMI OSAS: OAHI 1 episode/h

42 Patient Case-5 (A) 3 y.o. boy referred by his primary care physician for noisy breathing during sleep that is present on most nights Mother reports Persistent nasal congestion Mouth-breathing day and night even during summer

43 Patient Case-5 (B)

44 Patient Case-5 (C)

45 Case features 1. Nocturnal SDB symptoms 2. Adenoidal hypertrophy 3. SDB-associated morbidity: Growth delay 4. Moderate-to-severe OSAS

46 Bonuck et al. Growth and Growth Biomarker Changes after AT. Arch Dis Child 2009;94:83-91 Weight

47 Bonuck et al. Growth and Growth Biomarker Changes after AT. Arch Dis Child 2009;94:83-91 Height

48 Katz et al. Growth after Adenotonsillectomy for OSA: A RCT Pediatrics 2014;134: children (5-9 y.o.) with obstructive AHI 2 episodes/h and/or obstructive apnea index 1 episode/h Adenotonsillectomy vs. watchful waiting (over 7 months) Early adenotonsillectomy: 52% of overweight children became obese Watchful waiting: 21% of overweight children became obese; P<0.05

49 Syndromic Children

50 CSA OSAS CSA+OSAS Neither 44 children with Prader-Willi syndrome ( y.o.); OSAS: 32% CSA: 14% OSAS+CSA:11%

51 88 children and adults with Prader-Willi syndrome ( y.o.); AHI >1.5 episodes/h : 53% of children AHI >5 episodes/h: 41% of adults Pediatr Pulmonol 2015; 50: 1354

52 J Clin Sleep Med 2014; 10: children (1.8 m.o y.o.) with Down syndrome underwent PSG; 50% with OSAS (AHI 2.5 episodes/h) McGill score >2 Positive predictive value 94% Specificity 98%

53 11 children with Down syndrome and 9 controls who underwent adenotonsillectomy (all had moderate-to-severe OSAS) Normal RDI Abnormal RDI

54

55

56 Conclusions Successful treatment of OSAS by adenotonsillectomy is accompanied by better quality of life, increased somatic growth rate, decreased frequency of enuresis, improved sleepiness and behavior Post-adenotonsillectomy, AHI decreases the most among children with moderate-to-severe OSAS, but symptoms and quality of life improve irrespective of initial OSAS severity Obesity or increasing BMI z-score predicts persistence of untreated OSAS or new-onset OSAS