11/20/2015. Eighth Biennial Pediatric Sleep Medicine Conference. November 12-15, 2015 Omni Amelia Island Plantation Resort Amelia Island, Florida

Transcription

1 Eighth Biennial Pediatric Sleep Medicine Conference November 12-15, 2015 Omni Amelia Island Plantation Resort Amelia Island, Florida Manisha Witmans, MD, FRCPC, FAASM Associate Clinical Professor, University of Alberta Adjunct Professor, TRU, Kamloops Sponsored by The Warren Alpert Medical School of Brown University Previous sleep and research funded by: AIHW, CIHR Medical Director: Sound Sleep Solutions Consultative Services for Sleep Medicine: Stollery Children s Hospital and Glenrose rehab hospital Peak Medical Consultative Services Braebon Inc Home care companies: home sleep testing for children and adults Review evidence for diagnosis of OSAS using HST or other alternative techniques Discuss evidence for use of auto titrating devices in children Discuss challenges in diagnosing children in different countries Adult data with established morbidity and mortality related to OSAS Emerging data in children also supports morbidity and mortality in children with OSAS Potential childhood origins for adult OSAS warrants early identification and treatment of OSAS Age: 16 Height: 71 (in) 180 (cm) Weight: 335 (lb) (kg) BMI: kg/m 2 1

2 Accurately identify OSAS and treat it in a meaningful fashion that would impact long term morbidity and mortality of the affected individual End organ dysfunction would affect the diagnostic cutoff point To whom and how that child presents may affect access to care and potentially outcome Wrap around care OSAS is a spectrum of disorders ranging in presentation, severity and sequalue Worldwide restricted access to testing, or not available Nocturnal PSG is laborious and cost prohibitive not even accounting for the different nuances that are involved in making the diagnosis 1) symptoms and signs 2) questionnaires 3) abbreviated testing single channel Physiological Oximetry, PAT, etc. Neurocognitive assessment 4) polygraphy 5) polysomnography 6) biomarkers 7)? Machine learning - computer generated algorithms More access to testing facilities and ambulatory equipment Interpretation of results: What rules? Technical components? Understanding of the data what rules? What age? Interpretation of the information? What is critical? The balancing act: positive and negative predictive values, sensitivity and specificity Pediatric Sleep Questionnaire (Chervin) Considers only past month 22 items: yes / no / don t know questions 8 or more yes = positive Dx Validated against PSG Sensitivity: 81-85%; Specificity 87% Caveats: Limited operator curve properties overall ( ) Doesn t account for other factors craniofacial features etc., asthma, atopy No account for seasonal pattern or risk factors May improve when used with other tools De Luca Canto G, JADA 2014: 145: ; Ishman Laryngoscope 2015 Retrospective chart review: n=158, age 10 yrs Tonsil Size (2 fold increased risk of OSA) Mallampati Score sitting and supine (6 fold increased risk) Kumar HV et al, J Clin Sleep Medicine,

3 The quest for optimal tools OSA-18, SDIS PSQ Brazilian-Portuguese SDSC HK-CSQ Children s Sleep Quality Assessment Questionnaire CASQ and Gozal s questionnaire Initial studies: Brouillette et al Used to identify clinical populations with more severe OSAS with clustered desaturations Scholle et al: normative values ODI3% for children: < 2 yrs: 2.2 episodes/hr 2-10 yrs 1.2 episodes/hr yrs: 0.5 episoodes/hr Saito et al: normative values Spruyt et al, Sleep Medicine Reviews, 2011 McGill score: Clustering of desaturation events: 3 drops of desaturations to less than 90%, increasing in score with the severity of the desaturation clusters No night to night variability Expect seasonal variability? As with snoring Low sensitivity (about 40%) for AHI > 1/hr Many children have OSAS with a normal McGill score but that may reflect other conditions Tsai et al: ODI4 > 2 events/hr PPV 98.1%, high sensitivity 77%, and specificity 88.9% for predicting AHI at least 1/hr Other developments: Chang et al ODI4 and symptoms of SBD better PPV but low sensitivity for AHI > 5/hr for TST Attempts to work with this further to improve tool metrics Limited value for children who have good pulmonary reserve Advantages: Inexpensive and simple Objective data Little experience required Disadvantages: Can t distinguish central versus obstructive sleep apnea Doesn t account for those with OSA with little desaturations Doesn t account for other considerations This is used as a surrogate for heart rate variability as a function of respiratory effort, and arousals It appears that it may not be able to detect AHI< 3 events/hr and therefore the sensitivity may not be better 3

4 Nasal flow signals, and mandibular motion are other options Craniofacial profile may be factor Mandibular hypoplasia Micrognathia Neuromotor tone and role of central chemoreceptor response may also vary and affect diagnosis Home polygraphy can be done successfully at home but it still requires substantial resources and expertise which has not been articulated (human power) Acceptable recordings in 93% However, the hpsg underestimates OSAS and limited sensitivity and specificity but area under the curve of 0.88 Alvarez et al, Chest boys and 23 girls, mean age 5.3 yrs (range 3-17 yrs) 66% diagnosed with OSAS based on PSG defined RDI>3 events/hr for total sleep time The AHI on the HRP corresponding to the PSG defined OSAS criterion was > 5.6 events/hr Sensitivity 90.9% and specificity 94.1% These were children referred to a sleep unit for OSAS, pulse averaging time (4 beat), a nurse with training in pediatric sleep techniques and placed sensors May be a role for screening for OSAS but there are limitations for what is can do for children with complex and comorbid conditions This approach can likely be incorporated into a sleep program that is able to direct the patient If end organ dysfunction matters, what should be the defining parameter? CRP too much variability in children Urinary protein biomarkers developed by Gozal et al and shows promising results. Clusters of biomarkers may be helpful in conjunction with genes (single nucleotide polymorphisms) may yield better results in being to predict morbidity Complexity of OSAS in children will involve comprehensive assessments using multiple parameters, with various different considerations for treatment Long term follow up will be required but that also requires further study Machine learning combination of clinical risk factors, objective data, biomarkers and genetic analyses 4

5 There are various tools available for identifying OSAS in children Treatment strategies and modalities of treatment are evolving beyond the traditional adenotonsillectomy Consideration of individual genetics and risk factors for treatment will be necessary to prevent morbidity and mortality Anti-inflammatory therapy CPAP Weight loss Mandibular advancement device? Exercise? Treat comorbid disorders? Nasal expiratory valves Auto PAP Bilevel ventilation Consecutive polygraphy in 26 children who were on CPAP for mean of 10.6 months, mean age 7.8 yrs Partial flow limitation with arousal or desat were most frequent, but not common in children. These were not picked up on polygraphy No normal kids Reported usage by Stanford, Pediatrics 2004 Role in adults is established Role in pediatrics yes, but. Ammaddeo et al, Sleep Medicine, 2014 Treatment trial Adjust pressures Short term or long term Optimize adherence Presurgery Perioperatively Randomized trial, used stardust equipment, n=24, average age 11 yrs, mean use 7.2 hrs Used auto PAP and oxygen if necessary 6 weeks treatment improved cognitive functioning and processing speed Options - Marshall et al, Hematologica,

6 It has and can be used at home and in the lab Familiarity with the technology and insurance coverage may determine the choice PAP adherence is adult and children is similar early use predicts long term use Education is key to its success Randomized, double blind, placebo controlled crossover pilot study Mean age 13.4 yrs, significant improvement in OAHI 4.2 events/hr Variable response older children did better Nasal obstruction -? Septal deviation? Nasal obstruction? Kureshi et al. JCMI, 2014 Polysomnography AHI 39.7 events/hr RDI 41.1 events/hr Hypopneas 76 with a mean duration of 12.9 seconds Total Arousal Index 31.3 events/hr Titration Study: 5-10 cmh20 AHI 5.8 events/hr Hypopneas 12 with a mean duration of 14.5 seconds Incomplete Study due to limited absence of REM Treatment Auto CPAP 6-13 cmh20 How and when should we intervene? What is the treatment in view of everything heard at the conference? Missing gaps: Sleep schedule Sleep timing Timing of interventions? Social determinants of health 6