CHALLENGES IN PEDIATRIC OBSTRUCTIVE SLEEP APNEA Amy S. Whigham, MD Assistant Professor
Disclosures I have nothing to disclose.
Outline Epidemiology Diagnosis Adenotonsillectomy Failure Treatment of Refractory OSA Identification of Sites of Airway Obstruction Additional Upper Airway Procedures
Epidemiology Pediatric obstructive sleep apnea (OSA) was first reported in 1976 1. Prevalence of pediatric OSA is 1.2 to 5.7% 2. Increased risk of OSA with: obesity craniofacial deformity genetic syndrome metabolic disease www.capitaltmjcenter.com
Obstructive Adenotonsillar Disease google.com entcare.files.wordpress.com openi.nlm.nih.gov
Challenge 1 Diagnosis Exam and history not concordant Family would like objective data prior to treatment
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
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%
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.
Challenge 2 T&A Failure https://www.sciencedirect.com/
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 https://leadingwithtrust.com/
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 www.ortodoncia.ws
Severity of OSA 13
Comorbidities 2009 - 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 2009 - Obese children had a 51% failure 6 Failure defined as AHI > 5 Cure was obtained in 12% (AHI <1)
Influence of Weight on OSA Prevalence of OSA Overall pediatric population - 1.2 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
Pediatric Obesity in the US - 2011
Challenge 3 Treatment compliance https://www.webmd.com
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 www.momjunction.com N Postop T&A PSG (Mean obstructive AHI ± SD) 12+ week PSG (Mean obstructive AHI ± SD) M/B group 22 3.9 ± 1.2 0.3 ± 0.3 (p <.001) Control 14 3.6 ± 1.4 4.7 ± 1.5
CPAP Mask fitting issues are a major challenge for children CF anomalies Industry focuses on adults Air leaks, irritation, pain 1800CPAP.com
RAD3D Journey from CT image of a patient, to the perfectly fitting 3D printed head and mask
Personalized Device
Challenge 4 Identifying Site of Obstruction
What methods exist to identify site of obstruction? 2016 Review 23 24 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
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 - 1991 7 Children - 2000 8
DISE Evaluation
DISE - Concerns Necessary tool? - Gillespie, MUSC, 2013 25 38 adult patients with SDB or OSA 1 patient combative, unable to perform Awake endoscopy and DISE were significantly different p=0.0001 Surgical plan was changed in 62% Appropriate Planning? Consent Coordination with Anesthesiologists Instrumentation OR Time Postoperative planning
DISE - Findings Durr et al UCSF, 2012 11 13 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%)
DISE - Findings Systematic Review Cincinnati 2016 23 24 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
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
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
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
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