CHALLENGES IN PEDIATRIC OBSTRUCTIVE SLEEP APNEA. Amy S. Whigham, MD Assistant Professor

Transcription

1 CHALLENGES IN PEDIATRIC OBSTRUCTIVE SLEEP APNEA Amy S. Whigham, MD Assistant Professor

2 Disclosures I have nothing to disclose.

3 Outline Epidemiology Diagnosis Adenotonsillectomy Failure Treatment of Refractory OSA Identification of Sites of Airway Obstruction Additional Upper Airway Procedures

4 Epidemiology Pediatric obstructive sleep apnea (OSA) was first reported in Prevalence of pediatric OSA is 1.2 to 5.7% 2. Increased risk of OSA with: obesity craniofacial deformity genetic syndrome metabolic disease

5 Obstructive Adenotonsillar Disease google.com entcare.files.wordpress.com openi.nlm.nih.gov

6 Challenge 1 Diagnosis Exam and history not concordant Family would like objective data prior to treatment

7 OSA Terminology (Pediatric) Apnea = cessation/near cessation of ventilation for 10 seconds or two breath cycles Hypopnea = 50% decrease in airflow for 10 seconds or two breath cycles associated with a desaturation or arousal

8 OSA Terminology Primary Snoring: 10-12% prevalence in kids AHI <1, SpO2>90% OSA: 1-6% prevalence in kids Mild OSA: AHI > 1 and <5, SpO2 < 90% Moderate OSA: AHI >5 and <10 Severe OSA: AHI >10, SpO2 < 80%

9 Upper Airway Sizes Arens, R, McDonough, JM, Costarino, A, 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.

10 Challenge 2 T&A Failure

11 Adenotonsillectomy (T&A) Failure AAP 3 (2002) and AAO- HNS 4 (2011) recommend T&A for the primary treatment of OSA in healthy children over 2 years of age. Failure rate of 20-40% 14

12 Young Age Surgical failure after T&A (AHI >/= 5) Less than 5 yrs 35% 15 (2005) Less than 3 yrs 65% 16 (2008) Excluding comorbidities 14 (2013) Less than 3 yrs 21% Normal AHI (<1) 59% Predictors of Failure Severity of OSA by AHI Patients with lower weight

13 Severity of OSA 13

14 Comorbidities Surgical failure after T&A (RDI >/= 5) 5 Overall up to 34% Uncomplicated children - 26% Children with comorbidities 61% i.e., morbid obesity, severe OSA, age < 3 yrs Obese children had a 51% failure 6 Failure defined as AHI > 5 Cure was obtained in 12% (AHI <1)

15 Influence of Weight on OSA Prevalence of OSA Overall pediatric population to 5.7% 2 Overweight children 4 to 22% 12 Obese children more likely to have severe SDB and postop respiratory complications. 9 ICU setting should be considered after T&A with obesity alivenewspaper.com

16 Pediatric Obesity in the US

17 Challenge 3 Treatment compliance

18 Medical Treatment Options Medications Nasal steroids (i.e., fluticasone, mometasone) Allergy treatment (i.e., antihistamines) Combination therapy budesonide and montelukast 17 Devices Mouth guards CPAP/BiPAP Lifestyle Modifications diet, exercise, weight loss N Postop T&A PSG (Mean obstructive AHI ± SD) 12+ week PSG (Mean obstructive AHI ± SD) M/B group ± ± 0.3 (p <.001) Control ± ± 1.5

19 CPAP Mask fitting issues are a major challenge for children CF anomalies Industry focuses on adults Air leaks, irritation, pain 1800CPAP.com

20 RAD3D Journey from CT image of a patient, to the perfectly fitting 3D printed head and mask

21 Personalized Device

22 Challenge 4 Identifying Site of Obstruction

23 What methods exist to identify site of obstruction? 2016 Review articles Modalities Drug induced sleep endoscopy (DISE) 11/24 Identified site of obstruction in 100% of children Cine MRI 3/24 Identified site of obstruction in 33-93% of children Alternative imaging 3/24

24 Drug-Induced Sleep Endoscopy (DISE) Utilized to characterize the pattern of upper airway obstruction: T&A failure complicated upper airway OSA without ATH Upper airway fiberoptic endoscopic evaluation during sedation Adults Children

25 DISE Evaluation

26 DISE - Concerns Necessary tool? - Gillespie, MUSC, adult patients with SDB or OSA 1 patient combative, unable to perform Awake endoscopy and DISE were significantly different p= Surgical plan was changed in 62% Appropriate Planning? Consent Coordination with Anesthesiologists Instrumentation OR Time Postoperative planning

27 DISE - Findings Durr et al UCSF, pts, aged 3-15 years with persistent OSA or history of SDB after T&A 6/13 obese/overweight 85% (11/13) multi-level obstruction Diagnoses: Tongue base obstruction (85%), Adenoid regrowth (69%), and inferior turbinate hypertrophy (54%)

28 DISE - Findings Systematic Review Cincinnati extant articles on evaluating pediatric patients with refractory OSA 4 articles discussed DISE findings of multiple levels of obstruction Most common sites: Tongue base Adenoids secondary to regrowth Inferior turbinates Velum Lateral oropharyngeal walls

29 Additional Procedures Nasal cavity/pharynx Septoplasty Turbinate reduction Revision adenoidectomy Palate Pillarplasty Uvulopalatopharyngoplasty Palatoplasty Tongue Lingual tonsillectomy Midline posterior glossectomy Genioglossus stabilization Craniofacial Mandibular advancement Airway Supraglottoplasty Epiglottopexy Tracheostomy

30 Outcomes of DISE Most common procedures performed 2016 Review 23 Lingual tonsillectomy (alone) 6 studies Combined N = 141 Mean age 9.7 years Pooled mean AHI improved from 13.9 to 8.0 Success (AHI < 5) of 57-88% Supraglottoplasty - 4 studies Combined N = 77 Mean age 5.7 years Pooled mean AHI improved from 12.1 to 4.4 Success of 58-72% Multilevel surgery in several studies

31 Key Points T&A is the recommended initial surgical treatment for OSA in healthy children T&A has a significant failure rate Patients with obesity are rarely cured with T&A Medical and surgical options exist beyond T&A Treatment compliance is a concern DISE is best method to guide procedure selection

32 References 1. Guilleminault C, Eldridge FL, Simmons FB, et al. Sleep apnea in eight children. Pediatrics 1976; 58: Ishman SL. Evidence Based Practice: Pediatric Obstructive Sleep Apnea. Otolaryngol Clin N Am 2012; 45: American Academy of Pediatrics. Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2002; 109(4): Baugh RF, Archer SM, Mitchell RB, et al. Clinical practice guideline: tonsillectomy in children. American Academy of Otolaryngology-Head and Neck Surgery Foundation. Otolaryngol Head Neck Surgery 2011; 144(Suppl 1):S Friedman M, Wilson M, Lin HC, et al. Update systematic review of tonsillectomy and adenoidectomy for treatment of pediatric obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg 2009; 140(6): Costa DJ, Mitchell R. Adenotonsillectomy for obstructive sleep apnea in obese children: a meta-analysis. Otolaryngol Head Neck Surg 2009; 140: Croft CB, Pringle M. Sleep nasoendoscopy: a technique of assessment of snoring and obstructive sleep apnoea. Clin Otolaryngol Allied Sci 1991; 16(5): Myatt HM, Beckenham EJ. The use of diagnostic sleep nasendoscopy in the management of children with complex upper airway obstruction. Clin Otolaryngol Allied Sci 2000; 25(3): Roland PS et al. AAO-HNS Clinical Practice Guideline: Polysomnography for Sleep-Disordered Breathing Prior to Tonsillectomy in Children. Ot0 HNS 145(IS): S1-S15, Lin AC, Koltai PJ. Persistent pediatric obstructive sleep apnea and lingual tonsillectomy. Otolaryngol Head Neck Surg 2009; 141(1): Durr ML, Meyer AK, Kezirian EJ, et al. Drug-Induced Sleep Endoscopy in Persistent Pediatric Sleep-Disordered Breathing After Adenotonsillectomy. Arch Otolaryngol Head Neck Surg 2012; 138(7): Verhulst SL, Schrauwen N, Haentjens D, et al. Sleep-disordered breathing in overweight and obese children and adolescents: prevalence, characteristics and the role of fat distribution. Arch Dis Child 2007;92: Imanguli M, Ulualp SO. Risk Factors for Residual Obstructive Sleep Apnea after Adenotonsillectomy in Children. Laryngoscope 2016; 126: Nath A, Emani J, Suskind DL, Baroody FM. Predictors of persistent sleep apnea after surgery in children younger than 3 years. JAMA Otolaryngology Head Neck Surg 2013;139(10): MitchellRB,KellyJ.Outcomeof adenotonsillectomy for obstructive sleep apnea in children under 3 years. Otolaryngol Head Neck Surg. 2005;132(5): Walker P, Whitehead B, Gulliver T. Polysomnographic outcome of adenotonsillectomy for obstructive sleep apnea in children under 5 years old. Otolaryngol Head Neck Surg. 2008;139(1): KheirandishL,GoldbartAD,GozalD.Intranasal steroids and oral leukotriene modifier therapy in residual sleep-disordered breathing after tonsillectomy and adenoidectomy in children. Pediatrics. 2006;117(1):e61-e Childhood Obesity Facts. In Centers for Disease Control and Prevention, Merrell J, Shott S. OSAS in Down syndrome: T&A versus T&A plus lateral pharyngoplasty International Journal of Pediatric Otorhinolaryngology (2007) 71, Sied AB, Martin PJ, Pransky SM, et al. Surgical therapy of obstructive sleep apnea in children with severe mental insufficiency. Laryngoscope (1990)100(5): Wooten CT, Shott SR. Evolving therapies to treat retroglossal and base-of-tongue obstruction in pediatric obstructive sleep apnea. Arch Otolaryngol Head Neck Surg (2010)136: Manickam PV, Shott SR. Boss EF, et al. Systematic review of site of obstruction identification and non-cpap treatment options for children with persistent pediatric obstructive sleep apnea. Laryngoscope (2016); 126(2); Wootten CT, Chinnadurai S and Goudy SL. Beyond adenotonsillectomy: Outcomes of sleep endoscopy-directed treatments in pediatric obstructive sleep apnea. International Journal of Pediatric Otorhinolaryngology (2014); 78(7): Gillespie MB, Reddy RP, White DR, et al. A Trial of Drug-Induced Sleep Endoscopy in the Surgical Management of Sleep-Disordered Breathing. Laryngoscope 2013; 123: Arens, R, McDonough, JM, Costarino, A, 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.